By Eileen Lake and Thelma Patrick
Health and Human Services Secretary Kathleen Sebelius recently called nurses critical in the
fight against lethal hospital- acquired infections.
Sebelius is right: Nurses are on the front lines of this battle.
Nowhere is that battle more urgent than in a hospital neonatal intensive care unit (NICU), where
a baby weighing less than two pounds can swiftly develop a potentially deadly infection.
Secretary Sebelius has urged hospitals to reduce HAIs and has promised $50 million in stimulus
money to achieve that goal.
That’s a tough call to action that CEOs can’t afford to ignore: They can start making changes
now in hospital units like the NICU, where infection rates are often high and a nurse is the
principal caregiver keeping a tiny patient alive.
Our research, which we presented in June at the Academy Health Annual Research Meeting in
Chicago, gives hospital managers a blueprint for improvements in the NICU. In preliminary
findings from a national study of 104 hospital NICUs funded by the Robert Wood Johnson
Foundation we found that babies in units where nurses have less support and limited professional
practice are at higher risk of developing infections.
What’s a NICU with inadequate support for nurses? We define it as a unit that comes up short
when it comes to staffing and other resources. Nurses on such units are often caring for too many
critically ill infants. In addition, they’re often pulled away from direct nursing care and are
juggling too many non-nursing duties, like answering the phone, running to pick up a
prescription or transporting a patient.
A sub-optimal unit is also one where nurses’ authority doesn’t match their responsibility. When
they speak up with an urgent concern about a tiny baby, they may not get a rapid response or
credit for their assessment. In some cases, nurses delay calling doctors because they’re
concerned about getting an angry response: Over time, such strained relationships can lead to
inefficient or suboptimal care.
NICU babies, especially the very tiny ones, often need constant nursing care just to prevent
complications like infections or bleeding in the brain. But hospital managers struggling to stay
afloat in a deepening recession might be tempted to cut nursing staff or other services.
In fact, a June survey by the Association for Professionals in Infection Control and
Epidemiology suggests that many hospitals have cut back on infection control. More than 40%
of infection control professionals in hospitals said they’d experienced cuts in staffing or other
resources in the last year and a half.
But this research, and other evidence, suggests that infection control cutbacks are a short-sighted
solution that might cost managers more in the long run. As Medicare and other payers stop
paying for preventable infections, the NICU might be one area they’ll home in on for payment
reductions.
This study isn’t the only one to link nursing care to outcomes in the NICU. For example, a 2007
study found that 65 percent of the NICUs in the United Kingdom were understaffed and the lack
of nursing care put babies at risk of death.
Another study by Jeannie Cimiotti, a nurse researcher at the University of Pennsylvania, also
makes the case that, at least in some NICUs, babies who get less nursing care are at greater risk
of developing infections.
So what should hospitals do?
CEOs should fully staff the NICU and other hospital service units so that nurses aren’t called
away from a critically ill infant to answer the phone. Fully staffing a NICU might mean hiring
more RNs to make sure that critically ill infants have one-on-one nursing care. Or managers
might have to keep support staff, like secretaries, on duty—even at night or on the weekend.
Hospitals should also make sure they don’t leave lots of relatively young nurses on duty without
support, including a seasoned supervisor. Without adequate supervision, a short-staffed young
nurse might turn too quickly from one very sick newborn to another—and fail to wash up.
That one misstep can mean a lethal bug gets passed from one baby to the next.
Managers must also work to create a professional atmosphere in the NICU so that nurse and
doctors work together as a team. They must include nurses in hospital rounds and encourage
nurses to speak up when they have concerns about a patient.
For example, in a professional well-run NICU a nurse might notice subtle signs that could be an
infection and won’t hesitate to call the doctor on call. The baby gets prompt attention and a crisis
is averted.
Hospitals that put such steps in place will get results in the form of fewer infections. And they’re
likely to have fewer cases of complications like bleeding in the brain. Such complications are
expensive to treat, lead to long-term developmental problems, and can push up hospital costs if
insurers like Medicaid don’t pay the entire bill.
Hospitals with a well-staffed and efficient NICU will earn a reputation for keeping the tiniest
babies alive, and that’s nothing short of a modern miracle.
Eileen Lake is associate director of the Center for Outcomes and Policy Research at the
University of Pennsylvania in Philadelphia and is the lead researcher of a study on infants and
nursing care under a grant from the Interdisciplinary Nursing Quality Research Initiative, a
Robert Wood Johnson Foundation project to improve the quality of patient care.
Thelma Patrick is a co-author of the INQRI study and a nurse researcher at the Ohio State
University in Columbus
Contact Information:
Eileen Lake, PhD, RN, FAAN
Associate Professor, School of Nursing
Associate Director, Center for Health Outcomes and Policy Research
University of Pennsylvania
418 Curie Boulevard
Philadelphia, PA 19104-6096
Office phone: 215-898-2557
e-mail: elake@nursing.upenn.edu