Association Between Hospital Recognition for Nursing Excellence and Outcomes of Very Low-Birth-Weight Infants | Cerebrovascular Disease | JAMA | JAMA Network
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Original Contribution
April 25, 2012

Association Between Hospital Recognition for Nursing Excellence and Outcomes of Very Low-Birth-Weight Infants

Author Affiliations

Author Affiliations: Center for Health Outcomes and Policy Research, School of Nursing, Department of Sociology, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Dr Lake); Department of Economics, Dartmouth College, Hanover, New Hampshire (Dr Staiger); National Bureau of Economic Research, Cambridge, Massachusetts (Drs Staiger and Rogowski); Departments of Pediatrics (Dr Horbar) and Medical Biostatistics (Mr Kenny), University of Vermont, and Vermont Oxford Network (Dr Horbar), Burlington; UK Healthcare Enterprise, Lexington, Kentucky (Dr Cheung); College of Nursing, Ohio State University, Columbus (Dr Patrick); and Department of Health Systems and Policy, School of Public Health, University of Medicine and Dentistry of New Jersey, Piscataway (Dr Rogowski).

JAMA. 2012;307(16):1709-1716. doi:10.1001/jama.2012.504

Context Infants born at very low birth weight (VLBW) require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known.

Objective To examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes.

Design, Setting, and Patients Cohort study of 72 235 inborn VLBW infants weighing 501 to 1500 g born in 558 Vermont Oxford Network hospital neonatal intensive care units between January 1, 2007, and December 31, 2008. Hospital RNE was determined from the American Nurses Credentialing Center. The RNE designation is awarded when nursing care achieves exemplary practice or leadership in 5 areas.

Main Outcome Measures Seven-day, 28-day, and hospital stay mortality; nosocomial infection, defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage.

Results Overall, the outcome rates were as follows: for 7-day mortality, 7.3% (5258/71 955); 28-day mortality, 10.4% (7450/71 953); hospital stay mortality, 12.9% (9278/71 936); severe intraventricular hemorrhage, 7.6% (4842/63 525); and infection, 17.9% (11 915/66 496). The 7-day mortality was 7.0% in RNE hospitals and 7.4% in non-RNE hospitals (adjusted odds ratio [OR], 0.87; 95% CI, 0.76-0.99; P = .04). The 28-day mortality was 10.0% in RNE hospitals and 10.5% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.80-1.01; P = .08). Hospital stay mortality was 12.4% in RNE hospitals and 13.1% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.81-1.01; P = .06). Severe intraventricular hemorrhage was 7.2% in RNE hospitals and 7.8% in non-RNE hospitals (adjusted OR, 0.88; 95% CI, 0.77-1.00; P = .045). Infection was 16.7% in RNE hospitals and 18.3% in non-RNE hospitals (adjusted OR, 0.86; 95% CI, 0.75-0.99; P = .04). Compared with RNE hospitals, the adjusted absolute decrease in risk of outcomes in RNE hospitals ranged from 0.9% to 2.1%. All 5 outcomes were jointly significant (P < .001). The mean effect across all 5 outcomes was OR, 0.88 (95% CI, 0.83-0.94; P < .001). In a subgroup of 68 253 infants with gestational age of 24 weeks or older, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant.

Conclusion Among VLBW infants born in RNE hospitals compared with non-RNE hospitals, there was a significantly lower risk-adjusted rate of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage but not of 28-day mortality or hospital stay mortality.