A study in the April 25 edition of JAMA shows that very low-birth-weight infants that were born in hospitals recognized for nursing excellence (RNE), compared with those that had not, had a substantially lower rate of hospital infection, severe intraventricular hemorrhage and death at 7-days, but no lower rates of death at 28-days or hospital stay mortality. The study included over 72,000 very low-birth-weight infants.
Background information in the article states:
“One in 4 very low-birth-weight (VLBW) infants (less than 1,500 grams [3.3 lbs.]) dies in the first year of life; nearly all deaths (87 percent) occur in the first month. Infants born at VLBW require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known.”
Eileen T. Lake, Ph.D., R.N., of the University of Pennsylvania School of Nursing in Philadelphia, her team decided to examine the link between hospitals with and without RNE status and VLBW infant outcomes. From January 2007 to December 2008, they assessed 72,235 VLBW infants that weighed between 501 to 1,500 grams and were born in 558 Vermont Oxford Network hospital neonatal intensive care units. The team determined the hospital’s RNE, which is awarded when nursing care achieves exemplary practice or leadership in 5 areas, from the American Nurses Credentialing Center.
The team says:
“Recognition for nursing excellence is uncommon. Only 7 percent of U.S. hospitals achieve this.”
The primary endpoints were determined as 7-day, 28-day, and hospital stay mortality, severe intraventricular hemorrhage (SIVH), as well as nosocomial (hospital) infection defined as an infection in blood or cerebrospinal fluid culture that occurred later than 3 days after birth.
According to the team:
“The 7-day mortality was 7.0 percent in RNE hospitals vs. 7.4 percent in non-RNE hospitals; 28-day mortality was 10.0 percent in RNE hospitals vs. 10.5 percent in non-RNE hospitals; and hospital stay mortality was 12.4 percent in RNE hospitals vs. 13.1 percent in non-RNE hospitals. The incidence of SIVH was 7.2 percent in RNE hospitals and 7.8 percent in non-RNE hospitals. Infection occurred in 16.7 percent of VLBW infants in RNE hospitals and 18.3 percent in non-RNE hospitals.”
The adjusted absolute decrease in risk of outcomes between RNE hospitals and non-RNE hospitals ranged from 0.9 to 2.1%. All five outcomes proved important together. The outcome also showed that the odds ratio for RNE for all 3 mortality outcomes and infection were statistically important in a subgroup of 68,253 infants that had a gestational age of 24 weeks or older.
The team indicates that the better outcomes observed in VLBW infants in RNE hospitals could be due to higher-quality neonatal intensive care unit (NICU) and obstetric care, stating:
“Perhaps RNE hospitals have a broad, long-standing commitment to quality care that is reflected in other aspects of care, such as excellent physician care, respiratory care, or infection control, that are not directly related to RNE but that may independently contribute to better outcomes for VLBW infants. Thus, RNE status may serve as a marker for an institution-wide commitment to optimizing outcomes.”
The researchers state that the practical significance of their findings depends on the accessibility of existing RNE hospitals to mothers at high risk of preterm birth, explaining: “Currently, access is limited because only 1 in 5 hospitals with a NICU has RNE. This is a particular source of concern for racial and ethnic minorities because disproportionately few minority infants are born in hospitals with RNE.”
Wanda D. Barfield, M.D., M.P.H., of the Centers for Disease Control and Prevention in Atlanta, writes in a linked editorial that the authors of this study “appropriately conclude that the components of hospital RNE, including exemplary professional practice, structural empowerment, new knowledge, transformational leadership, and empirical outcomes, helped these hospitals to achieve high-quality care and decreased infant mortality and severe morbidity.”
“These principles may not only make better nurses but also better physicians, respiratory therapists, laboratory technicians, social workers, and hospital executives. Recognition for nursing excellence status may serve as a proxy for the hospital’s commitment to quality care and available resources because members must pay for the program, and RNE status ensures’ a work environment to pursue quality improvement. It would be useful to understand which specific components of RNE status may have contributed to the reduction of VLBW mortality and morbidity because it may not be RNE status that is critical.
In addition, general characteristics of the RNE facilities, such as teaching status, not-for-profit status, large size, and high NICU patient volumes may be related to improved outcomes. The challenge lies in disentangling the ‘black box’ of NICU care and the provision of timely and effective interventions and care models in ways that can be efficiently replicated by others.”
Written By Petra Rattue