title: Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study.
abstract: BACKGROUND
  Nurse understaffing is frequently hypothesized as a potential risk factor for healthcare-associated infections (HAI). This study aimed to evaluate the role of nursing workload in the occurrence of HAI, using Nursing Activities Score (NAS).
  
  
  METHODS
  This prospective cohort study enrolled all patients admitted to 3 Medical ICUs and one step-down unit during 3 months (2009). Patients were followed-up until HAI, discharge or death. Information was obtained from direct daily observation of medical and nursing rounds, chart review and monitoring of laboratory system. Nursing workload was determined using NAS. Non-compliance to the nurses' patient care plans (NPC) was identified. Demographic data, clinical severity, invasive procedures, hospital interventions, and the occurrence of other adverse events were also recorded. Patients who developed HAI were compared with those who did not.
  
  
  RESULTS
  195 patients were included and 43 (22%) developed HAI: 16 pneumonia, 12 urinary-tract, 8 bloodstream, 2 surgical site, 2 other respiratory infections and 3 other. Average NAS and average proportion of non compliance with NPC were significantly higher in HAI patients. They were also more likely to suffer other adverse events. Only excessive nursing workload (OR: 11.41; p: 0.019) and severity of patient's clinical condition (OR: 1.13; p: 0.015) remained as risk factors to HAI.
  
  
  CONCLUSIONS
  Excessive nursing workload was the main risk factor for HAI, when evaluated together with other invasive devices except mechanical ventilation. To our knowledge, this study is the first to evaluate prospectively the nursing workload as a potential risk factor for HAI, using NAS.
authors.affiliation: Humanization Technical Division, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil.
authors.forename: Renata M
authors.initials: RM
authors.lastname: Daud-Gallotti
authors.forename: Silvia F
authors.initials: SF
authors.lastname: Costa
authors.forename: Thais
authors.initials: T
authors.lastname: Guimarães
authors.forename: Katia Grillo
authors.initials: KG
authors.lastname: Padilha
authors.forename: Evelize Naomi
authors.initials: EN
authors.lastname: Inoue
authors.forename: Tiago Nery
authors.initials: TN
authors.lastname: Vasconcelos
authors.forename: Fernanda
authors.initials: F
authors.lastname: da Silva Cunha Rodrigues
authors.forename: Edizângela Vasconcelos
authors.initials: EV
authors.lastname: Barbosa
authors.forename: Walquíria Barcelos
authors.initials: WB
authors.lastname: Figueiredo
authors.forename: Anna S
authors.initials: AS
authors.lastname: Levin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology*; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009729:Nursing / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012307:Risk Factors; D016526:Workload / Q000706:statistics & numerical data*; D055815:Young Adult