In the UK an “intensive care” day for a newborn is defined as a day where the baby is intubated and ventilated, or is on non-invasive respiratory support (CPAP of non-invasive ventilation) AND parenteral nutrition, or on the day of surgery, or on the day of death, or a day when they have any of the following:
- Presence of an umbilical arterial line
- Presence of an umbilical venous line
- Presence of a peripheral arterial line
- Insulin infusion
- Presence of a chest drain
- Exchange transfusion
- Therapeutic hypothermia
- Prostaglandin infusion
- Presence of replogle tube
- Presence of epidural catheter
- Presence of silo for gastroschisis
- Presence of external ventricular drain
- Dialysis (any type)
The next level of care is referred to as “high-dependency” and includes for example CPAP with full enteral feeds, or parenteral nutrition without positive pressure respiratory support.
The British Association of Perinatal Medicine standards state that on an intensive care day a baby should have a 1:1 nurse ratio, on a high-dependency day they should have 1 nurse per 2 babies.
A new publication from a group in the UK has found that in 2008 only 9% of intensive care days had 1:1 staffing, and in 2012 that had fallen to 6%, when examining data from 30 to 40 NICUs around the country. As you are all aware, the severity of illness of babies who would be classified as “intensive care” using the BAPM criteria varies hugely. In order to determine whether there is an impact of nursing ratios on outcomes, it is necessary to try to adjust for this severity. But just crudely, if the reduction of days of 1:1 ratio is because the babies are less sick (and someone thought they didn’t really need 1:1) then mortality should have fallen. In fact it increased. Over the years where the proportion of days with less 1:1 nursing was falling mortality increased from 4 out of every 100 babies receiving intensive care to 4.5, passing a peak of 5.3 in 2010 and 2011.
Of course the authors have much more sophisticated analysis than that, and after doing all the adjustments that they could, they calculate that, from a median mortality rate of 4.5, every time you decrease the proportion of 1:1 days by 10% you increase mortality by 0.6, that is, to 5.1, then to 5.7… An accompanying editorial says it all:
..there is already a sufficient body of evidence to justify a renewed focus on working towards achieving the national standards set for one-to-one nurse staffing in neonatal intensive care. If not now, when?
The data may not be directly applicable to other health care systems, where some of the roles of NICU nurses in the UK are covered by other professionals, in the UK, for example they do not have respiratory therapists, and it is the nurses who do the tasks that RTs do in our NICU. Nevertheless I am convinced that the same principle applies in North American NICUs, when the workload is higher, and we can provide fewer 1:1 nurse assignments, then infection rates are higher, and probably, mortality also.
I also think that maybe the BAPM should rethink their criteria. Does every child with an Umbilical Venous Line really need 1:1 nursing? A full term baby with hypoglycemia who has a UVC placed for glucose administrator would be classified as “intensive care” and would be supposed to have 1:1. A nurse could probably safely look after 2 babies whose only criteria for “intensive care” was the presence of a chest tube. If you could rationalize the criteria you would probably be able to put more pressure on the system to provide 1:1 for those babies that really need it.
On the other hand a baby who no longer needs parenteral nutrition, but who has just been extubated to CPAP would not be “intensive care” but really needs expert dedicated nursing at a high ratio to prevent re-intubation, and should maybe be considered “intensive care” if they are under 28 weeks for the first 48 hours at least.
I have said many times that I think the most important factor in mortality and morbidity of the extremely immature babies is the quality of the nursing care they receive. In order to give care of good quality, as this study shows, you need adequate quantity.