title: Association between hospital recognition for nursing excellence and outcomes of very low-birth-weight infants.
abstract: BACKGROUND
  Infants born at very low birth weight (VLBW) require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known.
  
  
  OBJECTIVE
  To examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes.
  
  
  METHODS
  Cohort study of 72,235 inborn VLBW infants weighing 501 to 1500 g born in 558 Vermont Oxford Network hospital neonatal intensive care units between January 1, 2007, and December 31, 2008. Hospital RNE was determined from the American Nurses Credentialing Center. The RNE designation is awarded when nursing care achieves exemplary practice or leadership in 5 areas.
  
  
  METHODS
  Seven-day, 28-day, and hospital stay mortality; nosocomial infection, defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage.
  
  
  RESULTS
  Overall, the outcome rates were as follows: for 7-day mortality, 7.3% (5258/71,955); 28-day mortality, 10.4% (7450/71,953); hospital stay mortality, 12.9% (9278/71,936); severe intraventricular hemorrhage, 7.6% (4842/63,525); and infection, 17.9% (11,915/66,496). The 7-day mortality was 7.0% in RNE hospitals and 7.4% in non-RNE hospitals (adjusted odds ratio [OR], 0.87; 95% CI, 0.76-0.99; P = .04). The 28-day mortality was 10.0% in RNE hospitals and 10.5% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.80-1.01; P = .08). Hospital stay mortality was 12.4% in RNE hospitals and 13.1% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.81-1.01; P = .06). Severe intraventricular hemorrhage was 7.2% in RNE hospitals and 7.8% in non-RNE hospitals (adjusted OR, 0.88; 95% CI, 0.77-1.00; P = .045). Infection was 16.7% in RNE hospitals and 18.3% in non-RNE hospitals (adjusted OR, 0.86; 95% CI, 0.75-0.99; P = .04). Compared with RNE hospitals, the adjusted absolute decrease in risk of outcomes in RNE hospitals ranged from 0.9% to 2.1%. All 5 outcomes were jointly significant (P < .001). The mean effect across all 5 outcomes was OR, 0.88 (95% CI, 0.83-0.94; P < .001). In a subgroup of 68,253 infants with gestational age of 24 weeks or older, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant.
  
  
  CONCLUSIONS
  Among VLBW infants born in RNE hospitals compared with non-RNE hospitals, there was a significantly lower risk-adjusted rate of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage but not of 28-day mortality or hospital stay mortality.
authors.affiliation: Center for Health Outcomes and Policy Research, School of Nursing, Department of Sociology, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104-6096, USA. elake@nursing.upenn.edu
authors.forename: Eileen T
authors.initials: ET
authors.lastname: Lake
authors.forename: Douglas
authors.initials: D
authors.lastname: Staiger
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Horbar
authors.forename: Robyn
authors.initials: R
authors.lastname: Cheung
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Kenny
authors.forename: Thelma
authors.initials: T
authors.lastname: Patrick
authors.forename: Jeannette A
authors.initials: JA
authors.lastname: Rogowski
mesh_terms: D002543:Cerebral Hemorrhage / Q000453:epidemiology; D015331:Cohort Studies; D003406:Credentialing / Q000592:standards*; D003428:Cross Infection / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals / Q000145:classification* / Q000592:standards; D006801:Humans; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D008297:Male; D009732:Nursing Care / Q000592:standards*; D017063:Outcome Assessment, Health Care; D014707:Vermont / Q000453:epidemiology