Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation.
BACKGROUND
UK recommendations suggest that large neonatal intensive-care units (NICUs) have better outcomes than small units, although this suggestion remains unproven. We assessed whether patient volume, staffing levels, and workload are associated with risk-adjusted outcomes, and with costs or staff wellbeing.


METHODS
186 UK NICUs were stratified according to volume of patients, nursing provision, and neonatal consultant provision. Primary outcomes were hospital mortality, mortality or cerebral damage, and nosocomial bacteraemia. We studied 13515 infants of all birthweights consecutively admitted to 54 randomly selected NICUs. Multiple logistic regression analyses were done with every primary outcome as the dependent variable. Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 questionnaires.


RESULTS
Data were available for 13334 (99%) infants. High-volume NICUs treated the sickest infants and had highest crude mortality. Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision; however, nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision (odds ratio 0.65, 95% CI 0.43-0.98). Mortality was raised with increasing workload in all types of NICUs. Infants admitted at full capacity versus half capacity were about 50% more likely to die, but there was wide uncertainty around this estimate. Most staff had MHI-5 scores that suggested good mental health.


CONCLUSIONS
The implications of this report for staffing policy, medicolegal risk management, and ethical practice remain to be tested. Centralisation of only the sickest infants could improve efficiency, provided that this does not create excessive workload for staff. Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate.
Tucker
Janet
J
Dugald Baird Centre for Research on Women's Health, Department of Obstetrics and Gynaecology, University of Aberdden, UK. j.s.tucker@abdn.ac.uk
D016470:Bacteremia / Q000453:epidemiology / Q000209:etiology; D001509:Bed Occupancy / Q000706:statistics & numerical data*; D001930:Brain Injuries / Q000453:epidemiology / Q000209:etiology; D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology; D017598:Efficiency, Organizational; D006302:Health Services Research; D017721:Hospital Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration*; D009741:Nursing Staff, Hospital / Q000600:supply & distribution*; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D010343:Patient Admission / Q000706:statistics & numerical data*; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D020379:Risk Adjustment; D012307:Risk Factors; D016019:Survival Analysis; D006113:United Kingdom / Q000453:epidemiology; D000078329:Workforce; D016526:Workload