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Fazio M, Jabbour E, Patel S, Bertelle V, Lapointe A, Lacroix G, Gravel S, Cabot M, Piedboeuf B, Beltempo M. Association of Shift-Level Organizational Factors with Nosocomial Infection in the Neonatal Intensive Care Unit. JOURNAL OF PEDIATRICS. CLINICAL PRACTICE 2024; 13:200112. [PMID: 38948384 PMCID: PMC11214522 DOI: 10.1016/j.jpedcp.2024.200112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 07/02/2024]
Abstract
Objective To evaluate the association between shift-level organizational data (unit occupancy, nursing overtime ratios [OTRs], and nursing provision ratios [NPRs]) with nosocomial infection (NI) among infants born very preterm in the neonatal intensive care unit (NICU). Study design This was a multicenter, retrospective cohort study, including 1921 infants 230/7-326/7 weeks of gestation admitted to 3 tertiary-level NICUs in Quebec between 2014 and 2018. Patient characteristics and outcomes (NIs) were obtained from the Canadian Neonatal Network database and linked to administrative data. For each shift, unit occupancy (occupied/total beds), OTR (nursing overtime hours/total nursing hours), and NPR (number of actual/number of recommended nurses) were calculated. Mixed-effect logistic regression models were used to calculate aOR for the association of organizational factors (mean over 3 days) with the risk of NI on the following day for each infant. Results Rate of NI was 11.5% (220/1921). Overall, median occupancy was 88.7% [IQR 81.0-94.6], OTR 4.4% [IQR 1.5-7.6], and NPR 101.1% [IQR 85.5-125.1]. A greater 3-day mean OTR was associated with greater odds of NI (aOR 1.08, 95% CI 1.02-1.15), a greater 3-day mean NPR was associated lower odds of NI (aOR 0.96, 95% CI 0.95-0.98), and occupancy was not associated with NI (aOR, 0.99, 95% CI 0.96-1.02). These findings were consistent across multiple sensitivity analyses. Conclusions Nursing overtime and nursing provision are associated with the adjusted odds of NI among infants born very preterm in the NICU. Further interventional research is needed to infer causality.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Quebec investigators of the Canadian Neonatal Network (CNN)∗
- McGill University, Montréal, QC, Canada
- Université de Sherbrooke, Sherbrooke, QC, Canada
- Université de Montréal, Montréal, QC, Canada
- Université Laval, Quebec, QC, Canada
- CHU Sainte-Justine, Montréal, QC, Canada
- CHU de Québec, Québec, QC, Canada
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Gawronski O, Parshuram CS, Cecchetti C, Tiozzo E, Szadkowski L, Ciofi Degli Atti ML, Dryden-Palmer K, Dall'Oglio I, Raponi M, Joffe AR, Tomlinson G. Evaluating associations between patient-to-nurse ratios and mortality, process of care events and vital sign documentation on paediatric wards: a secondary analysis of data from the EPOCH cluster-randomised trial. BMJ Open 2024; 14:e081645. [PMID: 38964797 PMCID: PMC11227805 DOI: 10.1136/bmjopen-2023-081645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVE To describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation. DESIGN Secondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial. SETTING 22 hospitals caring for children in Canada, Europe and New Zealand. PARTICIPANTS Eligible hospitalised patients were aged>37 weeks and <18 years. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care. RESULTS A total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8-3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77-1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53-1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57-1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs. CONCLUSIONS The data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios. TRIAL REGISTRATION NUMBER EPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Corrado Cecchetti
- Critical Care, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Leah Szadkowski
- Biostatistics Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Karen Dryden-Palmer
- Paediatric Intensive Care Unit, Hospital for Sick Children, Barrie, Ontario, Canada
| | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Ari Robin Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Dye ME, Runyan P, Scott TA, Dietrich MS, Hatch LD, France D, Alrifai MW. Workload In Neonatology (WORKLINE): Validation and feasibility of a system for measuring clinician workload integrated into the electronic health record. J Perinatol 2023; 43:936-942. [PMID: 37131049 DOI: 10.1038/s41372-023-01678-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE The purpose of the study was to validate WORKLINE, a NICU specific clinician workload model and to evaluate the feasibility of integrating WORKLINE into our EHR. STUDY DESIGN This was a prospective, observational study of the workload of 42 APPs and physicians in a large academic medical center NICU over a 6-month period. We used regression models with robust clustered standard errors to test associations of WORKLINE values with NASA Task Load Index (NASA-TLX) scores. RESULTS We found significant correlations between WORKLINE and NASA-TLX scores. APP caseload was not significantly associated with WORKLINE scores. We successfully integrated the WORKLINE model into our EHR to automatically generate workload scores. CONCLUSION WORKLINE provides an objective method to quantify the workload of clinicians in the NICU, and for APPs, performed better than caseload numbers to reflect workload. Integrating the WORKLINE model into the EHR was feasible and enabled automated workload scores.
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Affiliation(s)
- M Eva Dye
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Patti Runyan
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Theresa A Scott
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary S Dietrich
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - L Dupree Hatch
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mhd Wael Alrifai
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Genna C, Thekkan KR, Raymakers-Janssen PAMA, Gawronski O. Is nurse staffing associated with critical deterioration events on acute and critical care pediatric wards? A literature review. Eur J Pediatr 2023; 182:1755-1770. [PMID: 36763191 DOI: 10.1007/s00431-022-04803-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Abstract
UNLABELLED Pediatric and neonatal patients admitted to acute and critical care wards may experience critical deterioration events that may lead to unexpected deaths if unrecognized and untreated promptly. Adequate levels and skill-mix of nurse staffing are essential for the quality of patient monitoring and response to deteriorating patients. Insufficient staffing may have an impact on the occurrence of missed care and consequently on critical deterioration events, increasing the risk of mortality and failure-to-rescue. To review the literature to explore the association between nurse staffing levels or skill-mix and pediatric and neonatal critical deterioration events, such as mortality, pediatric intensive care unit (PICU)/neonatal intensive care unit (NICU) unplanned admissions, cardiac arrests, and failure-to-rescue. A structured narrative literature review was performed. Pubmed, Cinhal, and Web of Science were searched from January 2010 to September 2022. Four independent reviewers conducted the study screening and data extraction. The quality of the studies included was evaluated using the Joanna Briggs Institute critical appraisal tools. Out of a total of 2319 studies, 15 met the inclusion criteria. A total of seven studies were performed in PICU, six in NICU, and two in general pediatric wards. Nurse staffing measures and outcomes definitions used were heterogeneous. Most studies suggested nursing skill-mix, increased working experience, or higher nursing degrees were associated with increased survival in PICU. Decreased nursing staffing levels were associated with increased mortality in NICU and mechanically ventilated patients in PICU. CONCLUSION Evidence on the association of nurse staffing and critical deterioration events in PICU and NICU is limited, while there is no evidence reported for pediatric wards. Future research is needed to determine adequate levels of nurse/patient ratios and proportion of registered nurses in the skill-mix for pediatric acute and critical care nursing to improve outcomes on in-patient wards. WHAT IS KNOWN • Adult nursing skill-mix, staffing ratios, and level of education are associated with patient mortality and failure to rescue. • In children, nurse staffing levels are associated with clinical outcomes. WHAT IS NEW • Evidence on the association of nurse staffing levels or skill-mix with pediatric or neonatal mortality is limited. • There is some evidence regarding the association of nursing work experience, certification, higher level degree with in-hospital survival in PICU.
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Affiliation(s)
- Catia Genna
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Kiara Ros Thekkan
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paulien A M A Raymakers-Janssen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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Neonatal intensive care unit occupancy rate and probability of discharge of very preterm infants. J Perinatol 2023; 43:490-495. [PMID: 36609482 DOI: 10.1038/s41372-022-01596-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/05/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess the association of NICU occupancy with probability of discharge and length of stay (LOS) among infants born <33 weeks gestational age (GA). STUDY DESIGN Retrospective study of 3388 infants born 23-32 weeks GA, admitted to five Level 3/4 NICUs (2014-2018) and discharged alive. Standardized ratios of observed-to-expected number of discharges were calculated for each quintile of unit occupancy. Multivariable linear regression models were used to assess the association between occupancy and LOS. RESULTS At the lowest unit occupancy quintiles (Q1 and Q2), infants were 12% and 11% less likely to be discharged compared to the expected number. At the highest unit occupancy quintile (Q5), infants were 20% more likely to be discharged. Highest occupancy (Q5) was also associated with a 4.7-day (95% CI 1.7, 7.7) reduction in LOS compared Q1. CONCLUSION NICU occupancy was associated with likelihood of discharge and LOS among infants born <33 weeks GA.
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Alle YF, Akenaw B, Seid S, Bayable SD. Parental satisfaction and its associated factors towards neonatal intensive care unit service: a cross-sectional study. BMC Health Serv Res 2022; 22:1266. [PMID: 36261864 PMCID: PMC9583552 DOI: 10.1186/s12913-022-08645-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/24/2022] [Accepted: 10/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Parental satisfaction is a well-established outcome indicator and tool for assessing a healthcare system’s quality, as well as input for developing strategies for providing acceptable patient care. This study aimed to assess parental satisfaction with neonatal intensive care unit service and its associated factors. Method A cross-sectional study design was conducted on parents whose neonates were admitted to the neonatal intensive care unit at Debre Tabor Comprehensive Specialized Hospital, in North Central Ethiopia. Data were collected by adopting an EMPATHIC-N instrument during the day of neonatal discharge, after translating the English version of the instrument to the local language (Amharic). Both Bivariable and multivariable logistic analyses were done to identify factors associated with parental satisfaction with neonatal intensive care unit service. P < 0.05 with 95% CI was considered statistically significant. Results The data analysis was done on 385 parents with a response rate of 95.06%. The overall average satisfaction of parents with neonatal intensive care unit service was 47.8% [95% CI= (43.1–52.5)]. The average parental satisfaction of neonatal intensive care unit service in the information dimension was 50.40%; in the care and treatment dimension was 36.9%, in the parental participation dimension was 50.1%, in the organization dimension was 59.0% and the professional attitude dimension was 48.6%. Gender of parents, residency, parental hospital stay, birth weight, and gestational age were factors associated with parental satisfaction. Conclusion There was a low level of parental satisfaction with neonatal intensive care unit service. Among the dimensions of EMPATHIC-N, the lowest parental satisfaction score was in the care and treatment while the highest parental satisfaction score was in the organization dimension.
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Affiliation(s)
- Yewlsew Fentie Alle
- Departement of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, 272, Ethiopia.
| | - Bantigegn Akenaw
- Departement of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, 272, Ethiopia
| | - Shimelis Seid
- Departement of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, 272, Ethiopia
| | - Samuel Debas Bayable
- Departement of Anesthesia, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Le Blanc G, Jabbour E, Patel S, Kazantseva O, Zeid M, Olivier F, Shalish W, Beltempo M. Organizational Risk Factors and Clinical Impacts of Unplanned Extubation in the Neonatal Intensive Care Unit. J Pediatr 2022; 249:14-21.e5. [PMID: 35714965 DOI: 10.1016/j.jpeds.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the association between organizational factors and unplanned extubation events in the neonatal intensive care unit (NICU) and to evaluate the association between unplanned extubation event and bronchopulmonary dysplasia (BPD) among infants born at <29 weeks of gestational age. STUDY DESIGN This is a retrospective cohort study of infants admitted to a tertiary care NICU between 2016 and 2019. Nursing provision ratios, daily nursing overtime hours/total nursing hours ratio, and unit occupancy were compared between days with and days without unplanned extubation events. The association between unplanned extubation events (with and without reintubation) and the risk of BPD was evaluated in infants born at <29 weeks who required mechanical ventilation using a propensity score-matched cohort. Multivariable logistic regression analysis was used to assess the association between exposures and outcomes while adjusting for confounders. RESULTS On 108 of 1370 days there was ≥1 unplanned extubation event for a total of 116 unplanned extubation event events. Higher median nursing overtime hours (20 hours vs 16 hours) and overtime ratios (3.3% vs 2.5%) were observed on days with an unplanned extubation event compared with days without an unplanned extubation event (P = .01). Overtime ratio was associated with higher adjusted odds of a unplanned extubation event (aOR, 1.09; 95% CI, 1.01-1.18). In the subgroup of infants born at <29 weeks, those with an unplanned extubation event who were reintubated had a longer postmatching duration of mechanical ventilation (aOR, 13.06; 95% CI, 4.88-37.69) and odds of BPD (aOR, 2.86; 95% CI, 1.01-8.58) compared with those without an unplanned extubation event. CONCLUSIONS Nursing overtime ratio is associated with an increased number of unplanned extubation events in the NICU. In infants born at <29 weeks of gestational age, reintubation after an unplanned extubation event is associated with a longer duration of mechanical ventilation and increased risk of BPD.
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Affiliation(s)
| | - Elias Jabbour
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Olga Kazantseva
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Marco Zeid
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Francois Olivier
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Wissam Shalish
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Marc Beltempo
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada; McGill University Health Center Research Institute, Montreal, Quebec, Canada; Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.
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