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Several preemie outcomes better at Magnet hospitals

Tuesday April 24, 2012
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In a study that included more than 72,000 very low-birth-weight infants, those born in hospitals with Magnet recognition had significantly lower rates of hospital infection, death at seven days and severe intraventricular hemorrhage than those born at other hospitals, according to a study.

However, the infants born at Magnet hospitals did not have significantly lower rates of death at 28 days or hospital-stay mortality, according to the study, which appears in the April 25 issue of JAMA.

In background information for the article, researchers wrote that one in four very low-birth-weight (VLBW) infants — those weighing less than 3.3 pounds, according to criteria in the study — dies in the first year of life, with 87% of deaths occurring in the first month. "Infants born at VLBW require high levels of nursing intensity," the authors wrote. "The role of nursing outcomes for these infants in the United States is not known."

Eileen T. Lake, RN, PhD, of the University of Pennsylvania School of Nursing in Philadelphia, and colleagues conducted a study to examine the association of Magnet status — whether the hospital was "recognized for nursing excellence [RNE]," according to the authors’ terminology — with VLBW infant outcomes. The study included 72,235 VLBW infants weighing between 1.1 and 3.3 pounds who were born in 558 Vermont Oxford Network hospital NICUs between January 2007 and December 2008.

The primary outcomes measured for the study were 7-day, 28-day, and hospital-stay mortality; nosocomial infection, defined as an infection in blood or cerebrospinal fluid culture occurring more than three days after birth; and severe intraventricular hemorrhage.

Analysis of the data indicated that overall, the percentage of eligible infants with each outcome was: seven-day mortality, 7.3%; 28-day mortality, 10.4%; hospital stay mortality, 12.9%; SIVH, 7.6%; and infection, 17.9%.

The authors wrote that the seven-day mortality rate was 7% in Magnet hospitals vs. 7.4% in non-Magnet hospitals; the 28-day mortality rate was 10% in Magnet hospitals vs. 10.5% in non-Magnet hospitals; and hospital stay mortality was 12.4% in Magnet hospitals vs. 13.1% in non-Magnet hospitals. The differences in rates for 28-day mortality and hospital-stay mortality were not considered statistically significant based on the authors' analysis.

The incidence of SIVH was 7.2% in Magnet hospitals and 7.8% in non-Magnet hospitals. Infection occurred in 16.7% of VLBW infants in Magnet hospitals and 18.3% in non-Magnet hospitals.

In a subgroup of 68,253 infants with gestational age of 24 weeks or older, the odds ratios for Magnet hospitals for all three mortality outcomes and infection were considered statistically significant.

The better outcomes observed in VLBW infants in Magnet hospitals may reflect higher-quality NICU and obstetric care, the authors suggested. "Perhaps RNE hospitals have a broad, longstanding commitment to quality care that is reflected in other aspects of care, such as excellent physician care, respiratory care or infection control, that are not directly related to RNE but that may independently contribute to better outcomes for VLBW infants," they wrote.

"Thus, RNE status may serve as a marker for an institution-wide commitment to optimizing outcomes."

The researchers said the practical importance of their findings is influenced by the accessibility of existing Magnet hospitals to mothers at high risk of preterm birth. "Currently, access is limited because only one in five hospitals with a NICU has RNE," they wrote. "This is a particular source of concern for racial and ethnic minorities because disproportionately few minority infants are born in hospitals with RNE."

In an accompanying editorial, Wanda D. Barfield, MD, MPH, of the Centers for Disease Control and Prevention, wrote that the study authors "appropriately conclude that the components of hospital RNE, including exemplary professional practice, structural empowerment, new knowledge, transformational leadership and empirical outcomes, helped these hospitals to achieve high-quality care and decreased infant mortality and severe morbidity.

"These principles may not only make better nurses but also better physicians, respiratory therapists, laboratory technicians, social workers and hospital executives. Recognition for nursing excellence status may serve as a proxy for the hospital’s commitment to quality care and available resources because members must pay for the program, and RNE status ensures a work environment to pursue quality improvement."

Barfield noted that because Magnet status in itself may not be a critical factor, "it would be useful to understand which specific components of RNE status may have contributed to the reduction of VLBW morbidity and mortality. … General characteristics of the RNE facilities, such as teaching status, not-for-profit status, large size and high NICU patient volumes may be related to improved outcomes. The challenge lies in disentangling the 'black box’ of NICU care and the provision of timely and effective interventions and care models in ways that can be efficiently replicated by others."

The study was supported by grants from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and the National Institute of Nursing Research, which is part of the National Institutes of Health. To view the study data and access the study via subscription or purchase, visit http://bit.ly/HZDddf.

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