Nurse staffing in relation to risk-adjusted mortality in neonatal care

Objective: To assess whether risk-adjusted mortality in very low birthweight or preterm infants is associated with levels of nursing provision. Design: Prospective study of risk-adjusted mortality in infants admitted to a random sample of neonatal units. Setting: Fifty four UK neonatal intensive care units stratified by: patient volume; consultant availability; nurse:cot ratios. Patients: A group of 2585 very low birthweight (birthweigkt < 1500 g) or preterm (<31 weeks gestation) infants. Main Outcome Measure: Death before discharge or planned deaths at home, excluding lethal malformations, after adjusting for initial risk 12 hours after birth using gestation at birth and measures of illness severity in relation to nursing provision calculated for each baby's neonatal unit stay. Results: A total of 57% of nursing shifts were understaffed, with greater shortages at weekends. Risk-adjusted mortality was inversely related to the provision of nurses with specialist neonatal qualifications (OR 0.67; 95% CI 0.42 to 0.97). Increasing the ratio of nurses with neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality of 48% (OR: 0.52, 95% CI: 0.33, 0.83). Conclusions: Risk-adjusted mortality did not differ across neonatal units. However, survival in neonatal care for very low birthweight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. The findings could be used to support specific standards of specialist nursing provision in neonatal and other areas of intensive and high dependency care.