A team of researchers from the Universities of Aberdeen, Sheffield and Sydney have carried out a comprehensive study of UK neonatal intensive care units (NICUs), which highlights that high staff workload poses a threat to outcome of infants in intensive care.
There is conflicting evidence about the optimal way to organise and configure neonatal intensive care. Expert recommendations in the UK have suggested that large NICUs perform better than smaller units, but this remains unproven. The research team and colleagues from the UK Neonatal Staffing Study Group compared risk-adjusted outcomes of units with small, medium and large numbers of infants, units with high and low nursing provision, and units with high and low specialist consultant availability, and with unit workload, costs and staff well-being.
The main results are published in today’s medical journal The Lancet, (Friday, January 11, 2002).
One hundred and eighty six UK NICUs were categorised according to volume of patients, proportion of nursing provision, and neonatal consultant provision. The primary outcome measures were death in hospital, death or cerebral damage, and nosocomial bacteraemia (hospital-based bacterial infection). Around 13,500 infants who were admitted to 54 NICUs (randomly selected from each category type and throughout England, Wales, Northern Ireland and Scotland) were involved in the study. The aim was to find out if there were differences in outcomes in different types of unit.
After taking close account of initial illness severity in the infants, the study found no differences in adjusted outcomes of mortality or brain damage by size of unit or measures of staffing establishment levels.
However the study found, in all types of units, that infants born and admitted as units became busier (with consequently lower nurse to infant ratios) were at greater risk of mortality than infants born when the unit was less busy. For example, infants born and admitted at times when units approached full versus half-capacity were about 50% more likely to die.
Dr Janet Tucker, Senior Research Fellow, University of Aberdeen, said: “In the first phase of our study, we had found nursing provision was consistently below (about 90%) of the national recommended standards in all unit types. Further improvement of outcomes for infants may be brought about by improving nurse staffing levels; especially avoiding occasions when units become very busy and the availability of skilled nurses to care for infants falls.”
Dr Gareth Parry, Senior Research Fellow, University of Sheffield, said: “UK neonatal intensive care appears to be organised in mostly informal networks. The sickest infants were often transferred from smaller units to larger units. Infants had a similar chance of an optimal outcome regardless of where they were born.”
“The study found no evidence that larger units are more efficient than smaller units. Gains in efficiency may be possible by ensuring that the care of the sickest infants is centralised. However, great caution will be required to avoid incurring potentially high costs associated with any change, and avoid exacerbating the workload effect.”
UK policy makers will need to balance the demands of providing a service that is in keeping with a Patient Centred NHS (for example, one that implies services are provided locally), with the important training demands of clinicians for the future service. The current consensus is that training may be best provided by exposing trainees to large numbers of infants, implying greater centralisation of care.
The authors recommend more formal development of hierarchical perinatal networks with locally agreed protocols for appropriate levels of care, acknowledging and avoiding wherever possible problems of access for parents and their newborn infants.
Members of the media interested in interviewing researchers involved in this study should contact Angela Begg, Media Relations Officer, University of Aberdeen, on: (01224) 272960, or email: a.begg@abdn.ac.uk