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PICO Assignment
Amanda G. White
University of Arizona
I. Clinical problem: Calling out of work in any field seems to be a problem. Nurses will call out
of work because they are sick, for a family emergency, they are exhausted and other reasons.
Trying to find another nurse to come in on their day off can be tough; and if no one is able to
come, more work and patient load is assigned to the nurses already there. A high patient-to-nurse
ratio can add to an already stressful environment. When under high stress, quality of care and
safety diminish. In the category of safety, hospital acquired infections (HAIs) are of high
concern; especially to pediatric patients who don’t have the best immune system. Also, for
newborns they are relying on their maternal antibodies for protection. So nurses must intervene
to reduce risk of harm from HAIs in pediatric patients.
II. PICO
 Population: hospitalized pediatric patients
 Intervention: low patient-to-nurse ratio
 Comparison: high patient-to-nurse ratio
 Outcome: incidence of hospital acquired infections
PICO question: In hospitalized pediatric patients, does a low patient-to-nurse ratio compared to a
high patient-to-nurse ratio affect the incidence of hospital acquired infections?
III. Search strategy.
Terms: children, pediatric, infections, hospital acquired infection, nurse staffing, patient-tonurse ratio, NICU, and understaffing
Limiters: linked full text, publication within the last five years, English language, article types
(research, meta-analysis, systemic review) and human species.
 All of these limiters were important for this PICO question. I wanted to make sure that I
would be able to get access to the full article and not just the abstract. Also, recent
research can have more accurate and relevant information. I wanted to exclude any other
research besides human and make sure that the article was in a language that I would be
able to read. Article type was also important because higher levels of evidence articles
are better to use for clinical relevance and to elicit change.
Databases: I started my research process with Google scholar. Google scholar gives me ideas
and is a good starting point. Then I searched for articles on CINAHL. This database kept giving
me articles that weren’t truly related to my PICO question. I went to PubMed and got the most
results. This database is helpful because when there is an article of relevance, there is a tab
underneath the article that states “related citations” and will direct you even further to articles
you are searching for.
IV. Identify three articles
“Nurse staffing and NICU infection rates”
In this research by Rogowski et al. (2013), NICU nurse staffing was investigated on its
association with infant outcomes. Research was conducted using the Vermont Oxford Network
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database. The network provided information about 67 hospitals with infants born between 2008
and 2009. Web survey was used to collect data on the nurses in 2008. The data for 2009 was
based on four complete nursing shifts. The ratio for patients to nurses was calculated by acuity of
the NICU patients. In 2008, 16.4% of infants had HAIs and 13.9% in 2009. In 2008, on average
each infant had 0.4 of a nurse. In other words, 4046 nurses were assigned to 10,394 infants. In
2009, 3645 nurses were assigned to 8804 infants (Rogowski et al., 2013). According to the
United States national guidelines, hospitals understaffed 47% of NICU patients in 2008 and 31%
in 2009. The odds ratio for understaffing was translated into a predicted infection rate
graphically and showed an increase in infection as understaffing amount also increased. For
example, with no understaffing, there is a predicted infection rate of 9%, but with 0.11 of a nurse
per infant, there is a predicted infection rate of 14%. This study concluded that understaffing in
the NICU unit was associated with an increased risk for nosocomial infections (Rogowski et al.,
2013).
This article by Rogowski et al. (2013) supports the intervention of patient to nurse ratios
affecting the incidence of nosocomial infections. Nurse understaffing or high patient-to-nurse
ratios, are shown in this article to increase the risk of HAIs in NICU patients. According to the
University of Wisconsin levels of evidence (2014), this article would be classified as level four.
Out of a possible seven levels, one being held the highest quality of evidence, four makes this
article not as clinically relevant and is lacking in rigor.
“Impact of staffing on bloodstream infections in the neonatal intensive care unit”
In this research article by Cimiotti et al. (2006), the association between nurse staffing
and hospital associated bloodstream infections in the NICU was investigated. Research took
place at two level III-IV NICUs in New York from March of 2001 through January of 2003.
Information on the nurse staffing was provided by the files at each hospital. During the infants
stay in the NICU, the study only examined the first episode of healthcare associated bloodstream
infections (Cimiotti et al., 2006). Clinical data was obtained from the infant’s medical records.
Risk factors associated with bloodstream infections were birth weight, intravascular
catheterization, major surgery, and total parenteral nutrition. Then, a Cox proportional hazards
regression model was used to identify these risk factors associated with infection. The risk of
infection was modeled for each individual infant. During the study, 2675 admissions were
examined and only 224 infants had a total of 298 bloodstream infections. Most common
pathogen at 45% was coagulase-negative staphylococci (Cimiotti et al., 2006). The incidence
rate of infection was 6.11 per 1000 patient days and 16.56 per 1000 catheter days. Sixteen infants
that had bloodstream infections died. The mean number of nurse hours per infant per day was
10.8. From the Cox regression model, it was shown that in one of the hospitals, the number of
hours of care by a nurse was significantly associated with a decreased risk of infection. In other
words, increased staffing had a hazard rate of 0.21 with a 95% confidence interval. However, in
the other hospital the amount of nurse hours was not associated with bloodstream infection.
Overall, this study concluded that nurse staffing is associated with the risk of bloodstream
infections in NICU patients (Cimiotti et al., 2006).
This article was designed as a cohort study, classifying it as a level four on the evidence
pyramid. Level four is lower on the pyramid making this research not as clinically relevant. This
research partially supports the intervention. One of the hospitals in their data supported the claim
that nurse staffing affects the incidence of hospital acquired bloodstream infections. Their results
showed that as nurse staffing increased the hazard rate of infection was small. The other hospital
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showed no correlation. Authors attributed this result due to those hospital patients being smaller,
more acutely ill, and less nurse hours overall compared to the second hospital.
“The effect of nurse staffing on clinical outcomes of children in hospital: A systematic review”
In this article by Wilson et al. (2011), the association between nurse staffing and clinical
outcomes in hospitalized children was identified. Quantitative studies measuring nurse staffing
through nurse hours per patient day, nurse-to-patient ratio, skill mix and nurse characteristics
were searched for using the Cochrane database and Joanna Briggs Institute Libraries of
Systematic Reviews. Eight studies (six cohort, one case-control, and one cross sectional) were
included in this research. Participants from the studies were hospital children aged 0-18 years of
age. For healthcare-associated infections, different studies looked at fourteen different clinical
outcomes (Wilson et al., 2011). Data from Archibald et al. (1997) reported an inverse linear
relationship between monthly nosocomial infection rates and nurse hours. The slope indicated a
fall of two infections per 1000 patient days for each extra nurse hour. In research from Cimiotti
(2004), evidence showed that infants who had less RN hours than the average had 1.5 times more
of a chance of developing an infection. For postoperative urinary tract infections, research by
Mark et al. (2007) concluded that with a one hour increase in RN hours per patient day there was
an associated 3% decrease in UTIs (Wilson et al., 2011). Overall, from the fourteen clinical
outcomes relating to HAIs, nine of the articles demonstrated an association between nurse
staffing and infection rates. Evidence points to nurse staffing associated with HAIs, but the
authors believe that further research on hours per patient day and the proportion of nurses in the
skill mix that maximizes children’s clinical outcomes is still needed (Wilson et al., 2011).
This article is classified as a systematic review giving it a level one on the Wisconsin
evidence pyramid (2014). A level one is the highest level on the evidence pyramid; thus this
research is most clinically relevant. The research by Wilson et al. (2011) supports the
intervention of interest. Overall, nine out of the fourteen articles investigated showed a
correlation between nurse-to-patient ratio and infection.
V. Reflection
All three articles used for this assignment met the criteria for the pediatric population.
The research for Wilson et al. (2011) investigated the ages of hospitalized children between 0-18.
The other two articles focused primarily on NICU patients. All of the evidence was based off on
large sample sizes and was quantitative. However, Cimiotti et al. (2006) and Rogowski et al.
(2013) only did two years for their research. Additional quality results would be achieved with
the use of a larger time span. Only one article was classified at a high level on the evidence
pyramid. The article by Wilson et al. (2011) is a level one which makes it of rigor and more
clinically relevant. The fact that this article was published within the last five years also means
that it is more relevant and accurate. Overall, the work by Wilson et al. (2011) is of quantity,
quality and generalizability. The other two articles by Rogowski et al. (2013) and Cimiotti et al.
(2006) are at level four on the pyramid. A level four classifies an article as not as clinically
significant. The evidence from Cimiotti et al. (2006) was also contradictory. Half of the evidence
supported the intervention and half did not. To support change for this intervention, better
evidence needs to be provided. For that reason, evidence from Cimiotti et al. (2006) should be
eliminated and new articles should be investigated for stronger proof. The research by Rogoswki
et al. (2013) can be used to provide more information, but should not be the main source of
evidence. Using all of this evidence is not sufficient enough to support change. Further articles of
value need to be researched to change patient-to-nurse ratios in the pediatric setting.
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References
Cimiotti, J. P., Haas, J., Saiman, L., & Larson, E. L. (2006). Impact of staffing on bloodstream
infections in the neonatal intensive care unit. Archives of Pediatrics & Adolescent Medicine,
160(8), 832-836.
Rogowski, J.A., Staiger, D., Patrick, T., Horbar, J., Kenny, M., & Lake, E.T. (2013). Nurse
staffing and NICU infection rates. JAMA Pediatrics, 167(5), 444-450.
doi:10.1001/jamapediatrics.2013.18 [doi]
University of Wisconsin (2014). Levels of Evidence (I-VII). Retrieved from
http://researchguides.ebling.library.wisc.edu/content.php?pid=325126&sid=2940230
Wilson, S., Bremner, A., Hauck, Y., & Finn, J. (2011). The effect of nurse staffing on clinical
outcomes of children in hospital: A systematic review. International Journal of EvidenceBased Healthcare, 9(2), 97-121. doi:10.1111/j.1744-1609.2011.00209.x [doi]
“I have reviewed the Code of Academic Integrity and can attest that this document is consistent
with the provisions of the code and represents my own original work.”
Signed: Amanda G. White