JAMA：出生于提供优质护理的医院中的极低体重婴儿拥有一些良好的测量指标

据4月25日刊《美国医学会杂志》上的一项研究披露，在一项包括了72,000多个出生体重非常低的婴儿的研究中，那些出生于以优质护理而闻名（recognized for nursing excellence, RNE）的医院中的婴儿与出生在非RNE医院的婴儿相比，他们的医院内感染率、出生7天时的死亡率及重症脑室内出血发生率都显著偏低，而出生28天时的死亡率或住院死亡率则没有降低。

根据文章的背景资料：“每4个极低出生体重(VLBW)的婴儿（低于1,500克[3.3磅]）中有1个会在出生头1年中死亡；这些死亡几乎都发生的头1个月中（87%）。VLBW婴儿要求高强度的护理。在美国，护理作用对这些婴儿的结果是未知的。”

费城宾夕法尼亚大学护理学院的Eileen T. Lake, Ph.D., R.N.及其同事们开展了一项研究，旨在调查医院的RNE状态与VLBW婴儿的结果之间的关系。这项研究包括了72,235名VLBW婴儿，他们是在2007年1月至2008年12月间在558个佛蒙特州牛津医院网的新生儿重症监护病房中出生的，其出生体重在501克至1,500克之间。医院的RNE是由美国护士资格认证中心决定的。RNE的称号是在5个领域中的护理实践或领导能力达到杰出水平时授予的。文章的作者写道：“获得优质护理并不常见。只有7%的美国医院获得了这一称号。”

这一研究中所检测的主要结果为7天死亡率、28天死亡率及住院死亡率；院内（医院内）感染——其定义为出生3天以后在血液或脑脊液培养中发现感染；以及重症脑室内出血（SIVH）。

数据分析表明，总体来说，每种结果的符合资格的婴儿百分比为： 7天死亡率, 7.3% (n = 5,258/71,955); 28天死亡率, 10.4% (n = 7,450/71,953); 住院死亡率, 12.9% (n = 9,278/71,936); SIVH 7.6% (4,842/63,525); 以及感染率17.9% (11,915/66,496)。文章的作者写道：“7天死亡率在RNE医院中为7.0% vs.非RNE医院中的7.4%；28天死亡率在RNE医院中为10.0% vs.非RNE医院中的10.5%；及住院死亡率在RNE医院中为12.4% vs. 非RNE医院中的13.1%。SIVH发生率在RNE医院中为7.2% vs. 非RNE医院中的7.8%。VLBW婴儿在RNE医院中的感染率为16.7%，在非RNE医院中则为18.3%。”

研究人员指出，与RNE医院相比，RNE医院中的不良后果风险的校正后的绝对下降幅度范围在0.9%至2.1%之间。所有5种后果的差别都具有显著性。在一个有68,253名胎龄在24周或以上的亚组中，对所有3种死亡率结果和感染来说，RNE的优势比都具有统计学上的显著性。

文章的作者提示，在RNE医院内的VLBW婴儿中所看到的较好的结果可能反映的是品质较高的新生儿重症监护病房（NICU）和产科的护理。“也许RNE医院有着广泛、长期的对高品质治疗的承诺，它反映在其他的治疗方面，诸如优异的医生治疗、呼吸系统护理或感染控制，而这些方面虽与RNE不直接相关，但却能各自独立地促成VLBW婴儿的较好的结果。因此，RNE地位可作为某一机构范围内对最佳结果承诺的一个标志。”

doi:10.1038/nbt.2149
PMC:
PMID:

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

Eileen T. Lake, PhD, RN; Douglas Staiger, PhD; Jeffrey Horbar, MD; Robyn Cheung, PhD, RN; Michael J. Kenny, MS; Thelma Patrick, PhD, RN; Jeannette A. Rogowski, PhD

Context Infants born at very low birth weight (VLBW) require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known.

Objective To examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes.

Design, Setting, and Patients Cohort study of 72 235 inborn VLBW infants weighing 501 to 1500 g born in 558 Vermont Oxford Network hospital neonatal intensive care units between January 1, 2007, and December 31, 2008. Hospital RNE was determined from the American Nurses Credentialing Center. The RNE designation is awarded when nursing care achieves exemplary practice or leadership in 5 areas.

Main Outcome Measures Seven-day, 28-day, and hospital stay mortality; nosocomial infection, defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage.

Results Overall, the outcome rates were as follows: for 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 7-day mortality was 7.0% in RNE hospitals and 7.4% in non-RNE hospitals (adjusted odds ratio [OR], 0.87; 95% CI, 0.76-0.99; P = .04). The 28-day mortality was 10.0% in RNE hospitals and 10.5% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.80-1.01; P = .08). Hospital stay mortality was 12.4% in RNE hospitals and 13.1% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.81-1.01; P = .06). Severe intraventricular hemorrhage was 7.2% in RNE hospitals and 7.8% in non-RNE hospitals (adjusted OR, 0.88; 95% CI, 0.77-1.00; P = .045). Infection was 16.7% in RNE hospitals and 18.3% in non-RNE hospitals (adjusted OR, 0.86; 95% CI, 0.75-0.99; P = .04). Compared with RNE hospitals, the adjusted absolute decrease in risk of outcomes in RNE hospitals ranged from 0.9% to 2.1%. All 5 outcomes were jointly significant (P < .001). The mean effect across all 5 outcomes was OR, 0.88 (95% CI, 0.83-0.94; P < .001). In a subgroup of 68 253 infants with gestational age of 24 weeks or older, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant.

Conclusion Among VLBW infants born in RNE hospitals compared with non-RNE hospitals, there was a significantly lower risk-adjusted rate of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage but not of 28-day mortality or hospital stay mortality.