title: What we talk about when we talk about NICUs: infants' acuity and nurse staffing.
abstract: OBJECTIVE
  Organizational features of neonatal intensive care influence the care of sick neonates. We estimated the acuity-adjusted nurse-to-patient ratio (NPR) in a national sample of Italian NICUs and factors influencing it.
  
  
  METHODS
  Twelve monthly cross-sectional surveys were prospectively carried out in 63 NICUs. Number and acuity of infants, and number of nurses were recorded. Infants' acuity was assessed by Rogowki's 2013 and British Association for Perinatal Medicine 2001 classifications.
  
  
  RESULTS
  We collected 702 reports regarding 11 082 infants. Non-intensive infants represented about 75% of NICU residents. Very preterm infants (<1501 g birth weight or <30 weeks gestation) represented 10.8% of admissions, but 44% of all infants surveyed. Average acuity-adjusted NPR was 0.31 (interquartile range 0.28-0.38); NPR depended on case-mix (proportion of intensive infants), size of the unit (larger units had a lower NPR) and was higher during morning shifts (+18%). Clustering on hospitals, reflecting shared components within each hospital, explained 47% of the variability of NPR.
  
  
  CONCLUSIONS
  The majority of infants cared for in NICUs are not intensive. NPR is influenced by acuity of infants, size of units, shifts, but is largely due to other unobserved hospital-related organizational features.
authors.affiliation: a Woman and Child Health Department , Ospedale Versilia , Viareggio , Italy .
authors.forename: Luigi
authors.initials: L
authors.lastname: Gagliardi
authors.affiliation: b International Centre on Birth Defects and Prematurity , Rome , Italy .
authors.forename: Carlo
authors.initials: C
authors.lastname: Corchia
authors.affiliation: c Neonatal Intensive Care Unit, Alessandro Manzoni Hospital , Lecco , Italy .
authors.forename: Roberto
authors.initials: R
authors.lastname: Bellù
authors.affiliation: d Neonatologia Universitaria, Città Della Salute E Della Scienza , Torino , Italy .
authors.forename: Alessandra
authors.initials: A
authors.lastname: Coscia
authors.affiliation: e Chair of Public Management, Department of Economics, Parma University , Parma , Italy , and.
authors.forename: Antonello
authors.initials: A
authors.lastname: Zangrandi
authors.affiliation: f Woman and Child Health Department , Azienda Ospedaliera Della Provincia Di Lecco , Lecco , Italy.
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Zanini
mesh_terms: D006801:Humans; D007223:Infant; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal; D007558:Italy; D017283:Neonatal Nursing; D009741:Nursing Staff, Hospital / Q000600:supply & distribution*; D062072:Patient Acuity; D010561:Personnel Staffing and Scheduling / Q000592:standards*; D011446:Prospective Studies; D012044:Regression Analysis; D000078329:Workforce; D016526:Workload
keywords: Intensive care; nurse workload; nurse-to-patient ratio; organization of care