Misfortune at Birth

This blog post originally appeared on the RWJF Human Capital Blog.

 

Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, are co-principal investigators of a study, supported by the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative, that generated evidence linking nurse staffing and work environments to infant outcomes in a national sample of neonatal intensive care units.* A new documentary, “Surviving Year One,” examines infant mortality in Rochester, N.Y. and nationwide. It is being shown on PBS and World Channel stations (check local listings). Read more about it on the RWJF Culture of Health Blog here and here.



Are some premature babies simply born in the wrong place? Premature babies are fragile at birth and most infant deaths in this country are due to prematurity.  It is well established that blacks have poorer health than whites in our country, but the origin of these disparities is still a mystery.  It’s possible that the hospital in which a child is born may tell us why certain population groups have poorer health.

A new study by University of Pennsylvania and Rutgers investigators that I led shows that seven out of ten black infants with very low birth weights (less than 3.2 lbs.) in the United States have the simple misfortune of being born in inferior hospitals. What makes these hospitals inferior?  A big component is lower nurse staffing ratios and work environments that are less supportive of excellent nursing practice than other hospitals.  Our study, which was funded by the RWJF Interdisciplinary Nursing Quality Research Initiative, indicates that the hospitals in which infants are born can affect their health all their lives. 

A Brighter Future

What can be done to make these hospitals better?  A first step would be to include nurses in decisions at all levels of the hospital, as recommended by the Institute of Medicine to position nursing to lead change and advance health. Laws in seven states require hospitals to have staff nurses participate in developing plans for safe staffing levels on all units.

Another solution would be to require hospitals to publicly report their neonatal unit staffing levels or work environment ratings (which are determined from a standard survey of nurses about features of their job, such as whether there is teamwork between nurses and doctors) so that pregnant women can make informed decisions about birth options in their communities. Five states require staffing levels to be displayed on nursing units.  Colorado already publicly reports work environment ratings on all hospitals with more than 100 beds.

It would also be a good idea to require the use of a patient acuity tool in staffing plans. We developed a five-level acuity tool for critically ill babies that is ready for use.  Our research using this acuity tool revealed substantial understaffing in neonatal intensive care nursing units was related to higher infection rates.

Previously, there was very little research evidence about the role of nurses in improving outcomes for premature babies, despite nurses being the main caregivers for infants in hospitals.  Our work filled in these gaps. We showed that in hospitals recognized for excellent nursing standards, premature infants have lower rates of death, infection, and severe brain hemorrhage. These standards include the active participation of nurses in hospital policies and decision making.

Among the premature infants who are fortunate enough to survive, the birth hospital is where they receive their first nutrition. Nurses are the principal caregivers and assist new mothers in developing supplies of breast milk, which the U.S. Surgeon General recommends for all newborns. Breast milk is particularly beneficial for premature infants because their immune systems are not completely developed, and it provides both nutrition and immunity protection. In hospitals where disproportionately more black infants are born, 47 percent more infants were discharged without receiving breast milk than in hospitals where the proportion was low. Nurses also play a great role in supporting and guiding mothers through breast-feeding. They commit a large amount of time to instructing and encouraging breast-feeding mothers, but if a neonatal intensive care unit (NICU) is understaffed, nurses have less time to devote to these activities. This in turn may affect infants’ access to breast milk.

Premature newborns often require life-saving interventions and central venous catheters.  Especially in a unit as nurse-intensive as a NICU, nurses play a significant role in preventing infection. They must remember to carefully use sterile techniques while performing procedures and be diligent about detecting early signs of infection. Although these tasks are crucial, they can also be time consuming. They may also be unintentionally overlooked in an understaffed unit. In hospitals where disproportionately more black infants are born, infections were 29 percent more frequent.

Improving Quality

These two perinatal care standards, breast milk and infection prevention, build a foundation for an infant’s lifelong health. Infections can affect neurological development and growth during childhood. In addition, the optimal nutrition provided by breast milk has a lasting impact on a person’s health. Breast-feeding is particularly important for premature infants because it reduces the chance an infant will develop a potentially fatal condition known as necrotizing enterocolitis, in which part of the bowel dies.  The study showed that one-third to one-half of the poorer health outcomes suffered by these premature infants were related to a lack of nursing resources.

Most importantly, if safe staffing helps to improve nurses’ resources in the NICU, the outcomes of those seven of ten black very low birth weight infants may be improved.  Health as a newborn builds a foundation for a healthier life.

*Lake is the Jessie M. Scott Term Chair in Nursing and Health Policy at the University of Pennsylvania School of Nursing and associate director of the Center for Health Outcomes & Policy Research. She leads a program of research on the contributions of the nurse's work environment and clinical nursing expertise to patient outcomes. She has developed an instrument to measure the work environment that is endorsed by the National Quality Forum as a nursing care performance standard that is used internationally.

Rogowski is the University Professor in Health Economics at the Rutgers School of Public Health. For more than two decades, her research has focused on access to care, quality and treatment costs for infants with very low birth weights. Rogowski has served as a member of the Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes and is currently a member of the National Advisory Committee for the RWJF Investigator Awards in Health Policy Research.

INQRI Study Shows Nursing Improvements Could Boost Outcomes for 7 Out of 10 Critically Ill Black Babies

Identifying the reasons for racial health disparities and ways to address them is a significant, complex challenge in health care. A new INQRI-funded study led by Eileen T. Lake, PhD, RN, FAAN and Jeannette A. Rogowski, PhD, provides insight into the issue of very low birth weight (VLBW) infants, who are disproportionately black, and finds that it’s not just their race that’s a factor in their health outcomes, it’s the quality of care at the hospitals where they’re born. The study was published in the journal Health Services Research.

The research team examined data on 8,252 VLBW infants in 98 Vermont Oxford Network member neonatal intensive care units (NICUs) throughout the country and the results of a survey of 5,773 NICU nurses. They found that nurse understaffing and practice environments were worse at hospitals with higher concentrations of black patients, contributing to adverse outcomes for VLBW infants born in those facilities.

Since 7 out of 10 black VLBW infants are born in hospitals with a high concentration of black patients, researchers concluded that improvements in nursing at such hospitals have the potential to boost the quality of care for many black VLBW infants. The study looked at two nurse-sensitive perinatal quality standards—hospital-acquired infection and discharge without having started breast milk, which have long-term health implications for VLBW infants—and found higher rates of both in high-black-concentration hospitals. NICU nursing features ultimately accounted for one-third to one-half of hospital-level health disparities.

“Very low birth weight infants are at a high risk for a lifetime of health challenges,” said Lake. “The birth hospitalization is the starting point.  With a high number of black infants born in relatively few hospitals, tackling a previously unaddressed question—do infants cared for in hospitals with a high concentration of black infants have poorer perinatal quality outcomes?—gives us an opportunity to make a positive impact on population-level health disparities.”

The study highlights dramatic differences in the distribution of care for black infants, with nearly three-fourths of black VLBW infants born in a third of hospitals that care for critically ill newborns. Only 1 in 20 black infants are born in hospitals with better nursing characteristics, and odds of adverse outcomes related to nurse-sensitive perinatal quality standards are at least 60 percent higher for infants born in disproportionately black hospitals.

The team also included Jeffrey Horbar, MD, chief executive and scientific officer, Vermont Oxford Network and  professor of pediatrics, University of Vermont; Michael Kenny, MS, research biostatistician, University of Vermont; Thelma Patrick, PhD, RN, associate professor, the Ohio State University College of Nursing; and Douglas Staiger, PhD, professor of economics, Dartmouth College.

Study Links RN Perception of Work Environment to Rates of Infection

Healthcare-associated infections (HAIs) are less likely to occur in favorable critical care work environments, according to a study of more than 3,200 nurses, Nurse.com reports. The principal investigators for the study were INQRI NAC member Linda H. Aiken and INQRI researcher Eileen Lake.

HAIs cost the health care system billions of dollars each year, according to background information for the study, which was published in the November issue of the American Journal of Critical Care. The study found nurses working in favorable critical care environments were 36 to 41 percent less likely than nurses in poor work environments to report that urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections occurred more than once a month. The study also finds that critical care nurses are well-positioned to reduce the prevalence and prevention of HAIs in critically ill patients.

An INQRI team led by Eileen Lake and Jeannette Rogowski demonstrated the impact of nurse staffing and the professional practice environment in preventing infection among infants in neonatal intensive care units (NICUs). Their findings show that babies in units where nurses have less support and limited professional practice are at higher risk of developing infections. Higher levels of NICU experience are associated with better infant outcomes.