Association Between Hospital Recognition for Nursing Excellence and Outcomes of Very Low-Birth-Weight Infants

Approximately 1 in 4 infants born at very low birth weight (VLBW) die, and most do so in the first month of life. Such VLBW infants require intensive nursing care in a neonatal intensive care unit (NICU). The American Nurses Credentialing Center has developed a program that recognizes hospitals and other health care organizations for quality patient care and nursing excellence. Only 7% of US hospitals are awarded the nursing excellence (RNE) designation; approximately 20% of hospitals with a NICU have achieved this recognition. The outcomes for VLBW infants in the United States born at RNE hospitals are unknown. This cross-sectional cohort study was designed to examine the association of hospital RNE status with VLBW infant outcomes. The study population was composed of 72,235 infants weighing between 501 and 1500 g who were born in the NICUs of 558 Vermont Oxford Network hospitals between 2007 and 2008. The primary study outcome measures included mortality within 7 or 28 days of birth; hospital stay mortality; nosocomial infection, defined as occurrence of an infection in blood or cerebrospinal fluid culture more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage. Multivariable logistic regression models were used to control for potential confounders. Joint significance tests were used to summarize the overall pattern for the 5 outcome measures. The percentage of infants with each outcome was as follows: 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 rates for the 5 outcomes in the RNE and non-RNE hospitals were as follows: 7-day mortality {7.0% in RNE hospitals vs 7.4% in non-RNE hospitals [adjusted odds ratio (aOR), 0.87; 95% confidence interval, 0.76-0.99; P = 0.04]}, 28-day mortality [10.0% in RNE hospitals vs 10.5% in non-RNE hospitals (aOR, 0.90; 95% CI, 0.80-1.01; P = 0.08)], hospital stay mortality [12.4% in RNE hospitals vs 13.1% in non-RNE hospitals (aOR, 0.90; 95% CI, 0.81-1.01; P = 0.06)], severe intraventricular hemorrhage [7.2% in RNE hospitals vs 7.8% in non-RNE hospitals (aOR, 0.88; 95% CI, 0.77-1.00; P = 0.045)], and infection [16.7% in RNE hospitals vs 18.3% in non-RNE hospitals (aOR, 0.86; 95% CI, 0.75-0.99; P = 0.04)]. The adjusted absolute decrease in risk of outcomes in RNE hospitals compared with non-RNE hospitals ranged from 0.9% to 2.1%. The differences between the RNE and non-RNE hospitals for all 5 outcomes were jointly significant (P < 0.001). The mean effect across all 5 outcomes was also significant (OR, 0.88; 95% CI, 0.83-0.94; P < 0.001). In an older-gestational-age subgroup of 68, 253 infants with gestational age of 24 weeks or longer, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant, with P values ranging from 0.01 to 0.03. These findings show that hospital RNE status in VLBW infants is associated with significantly lower rates of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage compared with non-RNE hospitals. However, birth in RNE hospitals does not improve rates of 28-day mortality or hospital stay mortality.