Overall Evidence Table
Reference
Hugonnet et
al., 2007a [1]
Sample and
Setting
Sample:
1,883
Setting:
Medical ICU in
Geneva
Hugonnet et
al., 2007b [2]
Mark et al.,
2007 [3]
Stone et al.,
2007 [4]
Berney &
Needleman,
Sample:
2,470 patients
Setting:
Medical ICU in
Geneva
Sample:
3.65 million
pediatric patients
Setting:
286 general and
children’s
hospitals in
California
Sample:
15,846 patients in
51 adult ICUs in
31 hospitals
1095 nurses
Setting:
NNIS hospitals
Sample:
161 hospitals
Design and Unit
of analysis
Design:
Prospective
cohort
Unit of analysis:
Patient
Design:
Prospective
cohort
Unit of analysis:
Patient
Design:
Retrospective
longitudinal
Unit of analysis:
Hospital
Design:
Observational
study
Unit of analysis:
Unit
Design:
Longitudinal
Adjustment for
confounding
Demographic
characteristics, admission
diagnosis and severity
score, comorbidities, daily
exposure to devices and
selected drugs
Staffing variable(s)
Staffing variable:
Nurse to patient ratio
Infection and
Operational definition
Infection:
ICU acquired infection
Operational Definition:
CDC criteria
Patient characteristics,
admission diagnosis,
severity of illness, commorbidities, exposure to
invasive devices
Staffing variable:
Nurse to patient ratio
Resource demand scale,
which includes ages, sex,
comorbid conditions,
emergency admission
Size, teaching status,
metropolitan area, inpatient
days, presence of pediatric
and neonatal ICU,
Fixed effect analytic model
Severity of illness,
comorbidity, gender, age,
socioeconomic status,
hospital size and teaching
status
Staffing variable:
HPPD (RN, LPN,
aides)
Staffing variable:
RN HPPD
Infection:
Early on-set VAP
Late on-set VAP
Operational Definition:
CDC criteria
Infection:
Postoperative
infections
Postoperative
pneumonia
Postoperative UTI
Operational Definition:
ICD-9-codes
Infection:
CLBSI
VAP
CAUTI
Operational Definition:
CDC definition
Diagnostic related groups,
age, payer, comorbidity,
Staffing variable:
RN HPPD
Infection:
Urinary tract infection
2006 [5]
Setting:
New York State
hospitals
Cimiotti et
al., 2006 [6]
Sample:
2,675 patients
Dancer et al.,
2006 [7]
Setting:
2 level III-IV
neonatal ICUs
Sample:
174 patients
Halwani et
al., 2006 [8]
Geubbels et
al., 2005 [9]
Setting:
United Kingdom
ICU
Sample:
430 patients and
3947 patient-days
Setting:
Adult ICU of a
tertiary care
hospital in the
United Kingdom
Sample:
13,680 patients
Setting:
36 acute care
Unit of analysis:
Hospital
Design:
Prospective
cohort
Unit of analysis:
Patient
Design:
Retrospective
investigation
Unit of analysis:
Patient
Design:
Longitudinal
urban or rural hospital,
size, teaching status,
unionization and margin.
Patient acuity, birth weight, Staffing variable:
use of devices, surgery
RN HPPD
Not reported
Staffing variable:
Nurse staffing levels
for trained, agency and
auxiliary nurses and
weekly workload
Hospital acquired
pneumonia
Hospital acquired
sepsis
Operational Definition:
ICD-9 codes
Infection:
BSI
Operational Definition:
CDC criteria
Infection:
MRSA
Operational Definition:
Microbiologic data
Not reported
Staffing variable:
Infection:
Understaffing: less than Nosocomial pathogen
one nurse per patient
during a 24h period
Operational Definition:
CDC definition
Patient characteristics
including: age, American
Society of
Anasthesiologists score,
duration of postoperative
Staffing variable:
Full time-equivalent
employees per 250
beds for prevention and
control of infection
Unit of analysis:
Patient
Design:
Prospective,
multi-center
cohort study
Overtime as percent of
RN HPPD
Infection:
Surgical-site infection
Operational Definition:
CDC definition
Sujijantararat
et al., 2005
[10]
The UK
Neonatal
Staffing
Study Group,
2005 [11]
Mark et al.,
2004 [12]
hospitals in the
Dutch
surveillance
network for
Nosocomial
infections
(PREZIES)
Unit of analysis:
Sample:
10 medical and 9
surgical wards;
389 patients and
513 full-time
nursing personnel
Design:
Prospective,
descriptive
correlational
research design
Setting:
Thai University
hospital
Sample:
13334 infants
Setting:
54 NICUs in the
UK
Sample:
Hospitalized
patients
Setting:
422 hospitals in
hospital care); Hospital
characteristics: including
wound contamination
class, type of surgery,
duration of surgery,
whether surgery was
emergent of elective);
teaching status
Not reported
Full time-equivalent
employees per 250
beds for prevention and
control of SSIs
Number of surgeons
Staffing variable:
Nursing HPPD and
percentage of RNs (of
each ward)
Infection:
UTI
Staffing variable:
Presence of an
appointed NICU
infection control nurse
or a link NICU
infection control nurse
at the unit
Infection:
Nosocomial bacteremia
Staffing variable:
RN FTE per 1,000
patient days
LPN FTE per 1,000
patient days
Non-nurse FTE per
Infection:
Pneumonia
complication
UTI complication
Operational Definition:
Other: urine culture
Unit of analysis:
Unit
Design:
Prospective,
observational
study
Illness severity
Unit of analysis:
patient
Design:
Longitudinal
Unit of analysis:
Hospital
Hospital characteristics
including: high technology
services, region, calendar
year, ownership, payer
mix, HMO penetration,
patient risk adjustment
Operational Definition:
Other
Operational Definition:
11 states
McGillis et
al., 2004 [13]
AlonsoEchanove et
al., 2003 [14]
Cho et al.,
2003 [15]
Needleman et
al., 2003 [16]
Sample:
77 adult medical,
surgical, and
obstetric units
Setting:
19 urban
hospitals in
Ontario, Canada
Sample:
4,535 patients
Setting:
8 ICUs
Sample:
124,204 patients
in 20 surgical
diagnosis related
groups
Design:
Cross sectional
Unit of analysis:
Unit
Design:
Cohort
Unit of analysis:
Patient
Design:
Cross sectional
Unit of analysis:
Patient
Setting:
California
Sample:
Design:
Medicare patients Cross sectional
Setting:
Hospitals in 11
states
Patient complexity and age
Unit of analysis:
Hospital
Patient age, gender,
weight, height, diagnosis,
comorbidity
1,000 patient days
Interactions among
these variables
Staffing variable:
Staffing models
defined as:
RN/RPN staff mix
All RN staff mix
Proportion of regulated
to unregulated staff
RN/RPN/URW staff
mix
Staffing variable:
Patient cared for by
float nurse day > 60%
Age, sex, race, primary
payer, diagnosis related
group, number of
diagnoses at admission,
scheduled admission,
hospital ownership, size,
teaching status,
Staffing variable:
All nursing hours
RN hours
RN proportion
Diagnosis, age, sex,
comorbidity, emergency
admission, hospital
location, size, occupancy
rate, teaching status, casemix
Staffing variable:
Nursing HHPD (RN,
LPN, Aide, licensed
and total)
Proportion of total
hours of care by RN
Proportion of total
hours by LPN
ICD-9 codes
Infection:
Wound infections
UTI
Operational Definition:
Not stated in report
Infection:
CVC-associated BSI
Operational Definition:
CDC criteria
Infection:
Pneumonia
Urinary tract infection
Sepsis
Wound infection
Operational Definition:
ICD-9-codes
Infection:
Urinary tract infection
Hospital acquired
pneumonia
Hospital acquired
sepsis
Operational Definition:
Richet et al.,
2003 [17]
Unruh, 2003
[18]
Yang, 2003
[19]
Sample:
90 healthcare
facilities
Setting:
Hospitals from
30 countries
participating in
the International
Network for the
Study and
Prevention of
Emerging
Antimicrobial
Resistance
(INSPEAR)
Sample:
211 hospitals
Setting:
Acute care
hospitals in
Pennsylvania
Sample:
21 medicalsurgical nursing
units
Setting:
1394-bed
medical center in
Design:
Cross-sectional
RN hours as a
proportion of LPN
hours
Staffing variable:
Number of infection
control nurses per
number of beds
ICD-9 codes
Patient age, gender, race,
acuity, hospital ownership,
board certified doctors,
number of patients
annually, capacity
utilization
Staffing variable:
Licensed nurse FTE
Total nurse FTE
Proportion of licensed
nurse FTE
Infection:
Pneumonia
Post surgical infection
Urinary tract infection
Patient acuity level
Staffing variable:
Daily average hours of
care, ratio of RNs to
average patient census,
skill-mix
Not reported
Unit of analysis:
Hospital
Design:
Longitudinal
Unit of analysis:
Hospital
Design:
Correlational
Unit of analysis:
Unit
Infection:
MRSA
Operational Definition:
Laboratory reports of
MRSA isolates
Operational Definition:
ICD-9 codes
Infection:
Respiratory and urinary
tract infections
Operational Definition:
Other
Barkell et al.,
2002 [20]
Taiwan
Sample:
59 patients in
staffing model A
37 patients in
staffing model B
Design:
Retrospective
pre-post test
Not reported
Staffing variable:
Increase in budgeted
ratio of RN to aide in
staffing model B
Unit of analysis:
Patient
Setting:
Surgical unit
Grundmann
et al., 2002
[21]
Kovner et al.,
2002 [22]
Sample:
Design:
331 patients
Cohort study
followed for
3067 patient-days Unit of analysis:
Patient
Setting:
Adult ICU in a
tertiary-care
hospital in the
United Kingdom
Design:
Sample:
Surgical patients Longitudinal
Setting:
Unit of analysis:
530-570 hospitals Hospital
from 6 to 13
states depending
on year
Needleman et
al., 2002 [23]
Sample:
5,075,969
medical patients
1,104,659
Design:
Cross sectional
Unit of analysis:
Infection:
Pneumonia
UTI
Operational Definition:
Pneumonia verified by
chest x-ray
UTI defined per CDC
criteria
Infection:
MRSA
Operational Definition:
Microbiological
identification
Age, APACHE II scores
Staffing variable:
Relative staff deficit =
a ratio of <1 of nurse
staffing level/daily bed
occupancy
Hospital size, location,
teaching status, affiliation
with HMO or PPO,
hospital owned nursing
school, ownership,
Medicare case-mix,
proportion of Medicare and
Medicaid, source of
admission
Diagnosis, age, sex,
comorbidity, emergency
admission, hospital
location, size, occupancy
Staffing variable:
RN hours per adjusted
patient day
LPN hours per adjusted
patient day
Infection:
Pneumonia
UTI
Staffing variable:
Nursing HHPD (RN,
LPN, Aide, licensed
and total)
Infection:
Urinary tract infection
Hospital acquired
pneumonia
Operational Definition:
ICD-9 codes
surgical patients
Hospital
rate, teaching status, casemix
Setting:
799 hospitals in
11 states
Stegenga et
al., 2002 [24]
Sample:
2929 patients
Tucker, 2002
[25]
Setting:
General
pediatrics ward
of a Canadian
hospital
Sample:
13,334 infants
Whitman et
al., 2002 [26]
Setting:
54 Neonatal
ICUs in the
United Kingdom
Sample:
95 specialty units
Dimick et al.,
2001b [27]
Setting:
10 adult acute
care hospitals in
eastern United
States
Sample:
569 patients
Design:
Retrospective
descriptive study
Not reported
Proportion of total
hours of care by RN
Proportion of total
hours by LPN
RN hours as a
proportion of LPN
hours
Staffing variable:
Patient-to-nurse ratio
and nursing HPPD
Unit of analysis:
Patient
Design:
Prospective
cohort
Unit of analysis:
Patient
Operational Definition:
ICD-9 codes
Infection:
Nosocomial viral
gastrointestinal
infections
Operational Definition:
CDC definition
Volume of neonatal ICU,
consultant availability,
birth weight, gestation,
mode of delivery, mother
had antenatal steroids, sex,
Apgar scores
Design:
Not reported
Secondary
analysis of
prospective,
observational data
Unit of analysis:
Specialty unit
Design:
Cohort Study
Hospital acquired
sepsis
Wound infection
Patient age, sex, nature of
admission, type of
operation, comorbidity,
Staffing variable:
High and low nurse-topatient ratios
Staffing variable:
WHPPD
Infection:
Nosocomial bacteremia
Operational Definition:
First positive blood
culture more than 48
hours after birth
Infection:
Central line infection
Operational Definition:
NNIS definition
Staffing variable:
Nurse to patient ratio
Infection:
Pneumonia
Septicemia
Dimick et al.,
2001a [28]
Setting:
25 hospitals in
Maryland
Unit of analysis:
Patient
Sample:
366 patients
Design:
Retrospective
cohort
Amaravadi et
al., 2000 [30]
Dorsey et al.,
2000 [31]
Postoperative Infection
Unit of analysis:
Patient
Operational Definition:
ICD-9 CM codes
Infection:
Complications after
esophageal infection
including pneumonia,
septicemia,
postoperative infection
Sample:
Abdominal
Aortic surgery
patients
Setting:
All nonfederal
ICUs in
Maryland
Sample:
366 patients
Design:
Cross sectional
Operational Definition:
ICD-9 CM codes
Infection:
Septicemia
Setting:
32 non-federal
acute care
hospitals in
Maryland
Sample:
52 patients in a
SICU
Unit of analysis:
Patient
Setting:
35 hospitals in
Maryland
Pronovost et
al., 2001[29]
hospital and surgeon
volumes
Unit of analysis:
unit
Design:
Cohort study
Design:
Retrospective
cohort study
Patient case-mix and other
hospital characteristics
Staffing variable:
Presence vs. absence of
daily rounds by ICU
physicians
Patient age, sex, race,
emergency admission, type
of aneurysm, comorbid
conditions, size of hospital,
volume of surgery
Staffing variable:
Nurse to patient ratios
of 1:1 or 1:2
Nurse to patient ratios
of 1:3 or 1:4
Patient age, sex, nature of
admission, type of
operation, comorbid
disease and hospital and
surgeon volume, clustering
of outcomes within a
hospital
Staffing variable:
NNPR
Monthly patient-days
Staffing variable:
Nurse to patient
staffing ratio defined
as: number of nurses-
Operational Definition:
ICD-9 codes
Infection:
Pneumonia
Septicemia
Postoperative infection
Operational Definition:
ICD9CM codes
Infection:
E. cloacae and S.
marcescens
Robert et al.,
2000 [32]
Harbarth et
al., 1999 [33]
Setting:
Hospital in San
Francisco, CA
Sample:
28 cases and 99
randomly
selected controls
Setting:
20-bed surgical
ICU
Sample:
60 infants
Setting:
NICU of a 1500bed healthcare
center in Geneva,
Switzerland
Lichtig et al.,
1999 [34]
Vicca, 1999
[35]
Unit of analysis:
Patient
Design:
Case-control
Age, diagnosis,
comorbidity, length of stay
Unit of analysis:
Patient
Design:
Retrospective
cohort (outbreak)
Unit of analysis:
Patient
Sample:
478 hospitals in
1992
426 hospitals in
1994
Design:
Cross-sectional
(Hospital cost
reports)
Setting:
California and
New York
hospitals
Sample:
50 new incident
Unit of analysis:
Hospital
Design:
Cohort
Gender, birth weight,
gestational age, length of
stay in NICU and exposure
factors including
indwelling devices,
medication and nutrition
Nursing intensity weights
based on patients’
characteristics, teaching
status and location
[(1:1 patients X 1)+(1:2 Operational Definition:
patients X 0.5)]
Microbiologic
identification
Staffing variable:
Infection:
Regular permanently
Bloodstream infections
assigned staff
Pool staff
Operational Definition:
CDC criteria
Nurse to patient ratio
Staffing variable:
Understaffing (lack of
more than eight nursing
staff per shift)
Staffing variable:
Nursing hours/ NIWs
and RN hours as a
percentage of total
nursing hours
Infection:
E. cloacae infection at
any site including:
bacteremia, pneumonia,
soft-tissue infection
and respiratory
colonization
Operational Definition:
CDC criteria
Infection:
Urinary tract infection
Pneumonia
Surgical wound
infection
Operational Definition:
ICD-9 CM codes
Not reported
Staffing variable:
Number of trained
Infection:
MRSA carriage
cases
Setting:
Intensive therapy
unit of a hospital
in Leicestershire
Blegen et al.,
1998 [36]
Sample:
42 general
nursing units
Setting:
1 hospital
Kovner &
Gergen, 1998
[37]
Archibald et
al., 1997 [38]
Fridkin et al.,
1996 [39]
Sample:
589 hospitals
Setting:
Acute-care
hospitals in 10
states
Sample:
782 pediatric
patients
Setting:
Cardiac intensive
care unit
Sample:
1760 patients
Unit of analysis:
Patient
Design:
Cross sectional
Patient severity of illness
Nursing acuity system
Unit of analysis:
Nursing unit
Design:
Cross-sectional
nursing staff per 8 h
shift, number of
extra/agency staff per 8
h shift, number of
patients per 8 h shift,
dependency score per 8
h shift (number of
nurses needed at
bedside)
Staffing variable:
All HPPD
Case mix (patient age, sex,
and comorbidity), hospital
teaching status, ownership,
bed size, region
Staffing variable:
FTE
RNAPD
Operational Definition:
Not defined, data
abstracted from patient
charts.
Infection:
Urinary tract infection
pneumonia
Operational Definition:
ICD-9 diagnosis codes
Not reported
Staffing variable:
Monthly nurse hours
Nursing HPPD
Unit of analysis:
Monthly unit
rates of infection
Design:
Case-control and
Infection:
Urinary tract and
respiratory infections
RN HPPD
Unit of analysis:
Hospital
Design:
Cross sectional
Operational Definition:
Not reported
Infection:
Nosocomial infection
rate
Operational Definition:
CDC criteria
Patient age, gender, length
of stay, primary diagnosis,
Staffing variable:
Average monthly SICU
Infection:
CVC-BSI
Setting:
SICU in a
Universityaffiliated VA
medical center
Grillo-Peck & Sample:
Risner, 1995
71 patients
[40]
Setting:
1 neuroscience
unit
Haley et al.,
Sample:
1995 [41]
NICU
Taunton et
al., 1994 [42]
Setting:
Public hospital in
Dallas
Sample:
Hospitalized
patients
Setting:
4 large
Midwestern
urban hospitals
cohort study (preand post- a
protracted
outbreak)
Unit of analysis:
Patient
Design:
Pre-post
severity of illness
Operational Definition:
Laboratory-confirmed
or CDC definition
Not reported
Unit of analysis:
Patient
Design:
Outbreak
investigation
Unit of analysis:
Unit
Design:
Cross sectional
correlation study
patient-to-nurse ratio
Time and intensity of care
Not reported
Unit of analysis:
Unit
APACHE II = Acute physiology and chronic health evaluation II
BSI = Bloodstream infections
CAUTI- Catheter-associated urinary tract infections
CDC = Center for Disease Control and Prevention
Staffing variable:
Change in staffing to
increased aides and
decreased RN
Infection:
Nosocomial infection
Staffing variable:
Daily infant to nurse
ratio
Daily work load to
staffing ratio
Infection:
MRSA
Staffing variable:
RN absenteeism
Required RN hours
/actual RN hours
Infection:
UTI
BSI
Operational Definition:
Not given
Operational Definition:
Microbiology results
Operational Definition:
CDC criteria
CLBSI = Central line-related bloodstream infections
CVC = Central venous catheter
FTE = Full-time equivalent
HMO = Health Maintenance Organization
HPPD = Hours per patient day
ICD-9 = International classification of diseases, 9th Edition
ICD-9 CM = International classification of diseases, 9th Edition, Clinical Modification
ICU = Intensive care unit
LPN = Licensed practical nurse
MRSA = Methicillin-resistant Staphylococcus aureus
NICU = Nosocomial intensive care unit
NIW = Nursing intensity weights
NNIS = National Nosocomial Infections Surveillance System
NNPR = Night-time nurse to patient ratio
PPO = Preferred Provider Organization
RN = Registered nurse
RNAPD = RNs per adjusted inpatient day
RPN = Registered Practical Nurse
SICU = Surgical intensive care unit
SSI = Surgical site infections
URW = Unregulated Staff
UTI = Urinary tract infections
VAP = Ventilator-associated pneumonia
WHPPD = Worked hours per patient day
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