Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Article
  • Published:

Association of unit size, resource utilization and occupancy with outcomes of preterm infants

Journal of Perinatology volume 35, pages 522–529 (2015)Cite this article

Subjects

Abstract

Objective:

Assess association of NICU size, and occupancy rate and resource utilization at admission with neonatal outcome.

Study Design:

Retrospective cohort study of 9978 infants born at 23–32 weeks gestation and admitted to 23 tertiary-level Canadian NICUs during 2010–2012. Adjusted odds ratios (AOR) were estimated for a composite outcome of mortality/any major morbidity with respect to NICU size, occupancy rate and intensity of resource utilization at admission.

Results:

A total of 2889 (29%) infants developed the composite outcome, the odds of which were higher for 16–29, 30–36 and >36-bed NICUs compared with <16-bed NICUs (AOR (95% CI): 1.47 (1.25–1.73); 1.49 (1.25–1.78); 1.55 (1.29–1.87), respectively) and for NICUs with higher resource utilization at admission (AOR: 1.30 (1.08–1.56), Q4 vs Q1) but not different according to NICU occupancy.

Conclusion:

Larger NICUs and more intense resource utilization at admission are associated with higher odds of a composite adverse outcome in very preterm infants.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1

Similar content being viewed by others

References

  1. Swyer PR . The regional organisation of special care for the neonate. Pediatr Clin North Am 1970; 17: 761–776.

    Article  CAS  PubMed  Google Scholar 

  2. Yu VY, Dunn PM . Development of regionalized perinatal care. Semin Neonatol 2004; 9: 89–97.

    Article  PubMed  Google Scholar 

  3. Ohlsson A, Fohlin L . Reproductive medical care in Sweden and the Province of Ontario, Canada. A comparative study. Acta Paediatr Scand Suppl 1983; 306: 1–15.

    CAS  PubMed  Google Scholar 

  4. Sinclair JC . The neonatal intensive care unit: organization of care of the low-birthweight infant. Birth Defects Orig Artic Ser 1988; 24: 11–21.

    CAS  PubMed  Google Scholar 

  5. Investigators of the Vermont-Oxford Trials Network Database Project. The Vermont-Oxford Trials Network: very low birth weight outcomes for 1990. Pediatrics 1993; 91: 540–545.

  6. Draper ES, Zeitlin J, Fenton AC, Weber T, Gerrits J, Martens G et al. Investigating the variations in survival rates for very preterm infants in 10 European regions: the MOSAIC birth cohort. Arch Dis Child Fetal Neonatal Ed 2009; 94: F158–F163.

    Article  CAS  PubMed  Google Scholar 

  7. Isayama T, Lee SK, Mori R, Kusuda S, Fujimura M, Ye XY et al. Comparison of mortality and morbidity of very low birth weight infants between Canada and Japan. Pediatrics 2012; 130: e957–e965.

    Article  PubMed  Google Scholar 

  8. Kusuda S, Fujimura M, Sakuma I, Aotani H, Kabe K, Itani Y et al. Morbidity and mortality of infants with very low birth weight in Japan: center variation. Pediatrics 2006; 118: e1130–e1138.

    Article  PubMed  Google Scholar 

  9. Lee SK, McMillan DD, Ohlsson A, Pendray M, Synnes A, Whyte R et al. Variations in practice and outcomes in the Canadian NICU network: 1996-1997. Pediatrics 2000; 106: 1070–1079.

    Article  CAS  PubMed  Google Scholar 

  10. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126: 443–456.

    Article  PubMed  Google Scholar 

  11. Synnes AR, Chien LY, Peliowski A, Baboolal R, Lee SK . Variations in intraventricular hemorrhage incidence rates among Canadian neonatal intensive care units. J Pediatr 2001; 138: 525–531.

    Article  CAS  PubMed  Google Scholar 

  12. Synnes AR, Macnab YC, Qiu Z, Ohlsson A, Gustafson P, Dean CB et al. Neonatal intensive care unit characteristics affect the incidence of severe intraventricular hemorrhage. Med Care 2006; 44: 754–759.

    Article  PubMed  Google Scholar 

  13. Bartels DB, Wypij D, Wenzlaff P, Dammann O, Poets CF . Hospital volume and neonatal mortality among very low birth weight infants. Pediatrics 2006; 117: 2206–2214.

    Article  PubMed  Google Scholar 

  14. Lorch SA, Baiocchi M, Ahlberg CE, Small DS . The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics 2012; 130: 270–278.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Neogi SB, Malhotra S, Zodpey S, Mohan P . Does facility based newborn care improve neonatal outcomes? A review of evidence. Indian Pediatr 2012; 49: 651–658.

    Article  PubMed  Google Scholar 

  16. Phibbs CS, Bronstein JM, Buxton E, Phibbs RH . The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996; 276: 1054–1059.

    Article  CAS  PubMed  Google Scholar 

  17. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH . Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007; 356: 2165–2175.

    Article  CAS  PubMed  Google Scholar 

  18. Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Gregory KD et al. Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling. J Perinatol 2011; 31: 770–775.

    Article  CAS  PubMed  Google Scholar 

  19. Horbar JD, Badger GJ, Lewit EM, Rogowski J, Shiono PH . Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Vermont Oxford Network. Pediatrics 1997; 99: 149–156.

    Article  CAS  PubMed  Google Scholar 

  20. Tucker J . Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet 2002; 359: 99–107.

    Article  PubMed  Google Scholar 

  21. Hamilton K, Gould C, Tarnow-Mordi W . Hospital mortality in relation to staffing levels in the first three days of neonatal care. Proceedings of the 4th Annual Congress of the Perinatal Society of Australia and New Zealand 2000; 109 (abstract).

  22. Hamilton KE, Redshaw ME, Tarnow-Mordi W . Nurse staffing in relation to risk-adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed 2007; 92: F99–F103.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Haley RW, Bregman DA . The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145: 875–885.

    Article  CAS  PubMed  Google Scholar 

  24. Parry GJ, Tucker JS, Tarnow-Mordi WO . Relationship between probable nosocomial bacteraemia and organisational and structural factors in UK neonatal intensive care units. Qual Saf Health Care 2005; 14: 264–269.

    Article  CAS  PubMed  Google Scholar 

  25. Canadian Neonatal Network. Abstractor's Manual v2.1.2. 2014. Available from http://www.canadianneonatalnetwork.org/portal/CNNHome/Publications.aspx Last accessed: March 18th, 2014.

  26. Gray JE, Richardson DK, McCormick MC, Workman-Daniels K, Goldmann DA . Neonatal therapeutic intervention scoring system: a therapy-based severity-of-illness index. Pediatrics 1992; 90: 561–567.

    CAS  PubMed  Google Scholar 

  27. Papile LA, Burstein J, Burstein R, Koffler H . Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92: 529–534.

    Article  CAS  PubMed  Google Scholar 

  28. International Committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol 2005; 123: 991–999.

    Article  Google Scholar 

  29. Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM . Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics 1988; 82: 527–532.

    CAS  PubMed  Google Scholar 

  30. Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978; 187: 1–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Kramer MS, Platt RW, Wen SW, Joseph KS, Allen A, Abrahamowicz M et al. A new and improved population-based Canadian reference for birth weight for gestational age. Pediatrics 2001; 108: E35.

    Article  CAS  PubMed  Google Scholar 

  32. Richardson DK, Corcoran JD, Escobar GJ, Lee SK . SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001; 138: 92–100.

    Article  CAS  PubMed  Google Scholar 

  33. Marlow N, Bennett C, Draper ES, Hennessy EM, Morgan AS, Costeloe KL . Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study. Arch Dis Child Fetal Neonatal Ed 2014; 99: F181–F188.

    Article  CAS  PubMed  Google Scholar 

  34. Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ . Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356: 185–189.

    Article  CAS  PubMed  Google Scholar 

  35. Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G et al. Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med 1993; 21: 40–51.

    Article  CAS  PubMed  Google Scholar 

  36. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995; 23: 294–300.

    Article  CAS  PubMed  Google Scholar 

  37. Clark K, Normile L . Nursing informatics and data collection from the electronic medical record: Study of characteristics, factors and occupancy impacting outcomes of critical care admissions from the Emergency Department. Health Informatics J 2012; 18: 309–319.

    Article  PubMed  Google Scholar 

  38. Boyle J, Zeitz K, Hoffman R, Khanna S, Beltrame J . Probability of severe adverse events as a function of hospital occupancy. IEEE J Biomed Health Inform 2014; 18: 15–20.

    Article  PubMed  Google Scholar 

  39. Volpe FM, Magalhaes AC, Rocha AR . High bed occupancy rates: Are they a risk for patients and staff? Int J Evid Based Healthc 2013; 11: 312–316.

    Article  PubMed  Google Scholar 

  40. Whitfield M, Chessex P . The need for public involvement when operating a regionalized neonatal care system at maximum capacity. Paediatr Child Health 2010; 15: 573–575.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Howell EM, Richardson D, Ginsburg P, Foot B . Deregionalization of neonatal intensive care in urban areas. Am J Public Health 2002; 92: 119–124.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Caveney AF, Silbergleit R, Frederiksen S, Meurer WJ, Hickenbottom SL, Smith RW et al. Resource utilization and outcome at a university versus a community teaching hospital in tPA treated stroke patients: a retropsective cohort study. BMC Health Serv Res 2010; 10: 44.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We thank the staff of the Canadian Neonatal Network (CNN) Coordinating Centre, Mr Junmin Yang for statistical support, and Dr Ruth Warre for editorial help during manuscript preparation. Although no funding was received specifically for this study, the CNN Coordinating Centre is based at the Maternal-Infant Care Research Centre (MiCare) at Mount Sinai Hospital, Toronto, Ontario, Canada. MiCare is supported by grant funding from the Canadian Institutes of Health Research and in-kind support from Mount Sinai Hospital, Toronto. Although no funding was received specifically for this study, the CNN Coordinating Centre is based at the Maternal-Infant Care Research Centre (MiCare) at Mount Sinai Hospital, Toronto, Ontario, Canada. MiCare is supported by grant funding from the Canadian Institutes of Health Research and in-kind support from Mount Sinai Hospital, Toronto.

Author Contributions

Dr Shah had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Shah, Mirea. Acquisition, analysis or interpretation of data: all authors. Drafting of the manuscript: Shah. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Mirea with assistance from Yang (additional contributor). Study supervision: Shah, Lee.

Disclosure

The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Site Investigators for the Canadian Neonatal Network (Collaborators):

Prakesh S Shah, MD, MSc (Director, Canadian Neonatal Network), Mount Sinai Hospital, Toronto, Ontario, Canada; Adele Harrison, MD, MBChB, Victoria General Hospital, Victoria, British Columbia, Canada; Anne Synnes, MDCM, MHSC, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada; Todd Sokoran, MD, Royal Columbian Hospital, New Westminster, British Columbia, Canada and Surrey Memorial Hospital, Surrey, British Columbia, Canada; Wendy Yee, MD, Foothills Medical Centre, Calgary, Alberta, Canada; Khalid Aziz, MBBS, MA, MEd, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Zarin Kalapesi, MD, Regina General Hospital, Regina, Saskatchewan, Canada; Koravangattu Sankaran, MD, MBBS, Royal University Hospital, Saskatoon, Saskatchewan, Canada; Mary Seshia, MBChB, Winnipeg Health Sciences Centre, Winnipeg, Manitoba, Canada; Ruben Alvaro, MD, St Boniface General Hospital, Winnipeg, Manitoba, Canada; Sandesh Shivananda, MBBS, MD, DM, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Orlando Da Silva, MD, MSc, London Health Sciences Centre, London, Ontario, Canada; Chuks Nwaesei, MD, Windsor Regional Hospital, Windsor, Ontario, Canada; Kyong-Soon Lee, MD, MSc, Hospital for Sick Children, Toronto, Ontario, Canada; Michael Dunn, MD, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Nicole Rouvinez-Bouali, MD, Children’s Hospital of Eastern Ontario and Ottawa General Hospital, Ottawa, Ontario, Canada; Kimberly Dow, MD, Kingston General Hospital, Kingston, Ontario, Canada; Ermelinda Pelausa, MD, Jewish General Hospital, Montréal, Québec, Canada; Keith Barrington, MBChB, Hôpital Sainte-Justine, Montréal, Québec, Canada; Christine Drolet, MD, Centre Hospitalier Universitaire de Québec, Sainte Foy Québec, Canada; Patricia Riley, MD, MDCM, BSc, Montréal Children’s Hospital, Montréal, Québec, Canada and Royal Victoria Hospital, Montréal, Québec, Canada; Valerie Bertelle, MD, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada; Rody Canning, MD, Moncton Hospital, Moncton, New Brunswick, Canada; Barbara Bulleid, MD, Dr Everett Chalmers Hospital, Fredericton, New Brunswick, Canada; Cecil Ojah, MBBS, and Luis Monterrosa, MD, Saint John Regional Hospital, Saint John, New Brunswick, Canada; Akhil Deshpandey, MD, MBBS, Janeway Children’s Health and Rehabilitation Centre, St John’s, Newfoundland; Jehier Afifi, MB BCh, MSc, IWK Health Centre, Halifax, Nova Scotia, Canada; Andrzej Kajetanowicz, MD, Cape Breton Regional Hospital, Sydney, Nova Scotia, Canada; Shoo K Lee, MBBS, PhD (Chairman, Canadian Neonatal Network), Mount Sinai Hospital, Toronto, Ontario, Canada.

Author information

Authors and Affiliations

  1. Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada

    P S Shah, L Mirea & S K Lee

  2. Department of Pediatrics, University of Toronto, Toronto, ON, Canada

    P S Shah, E Ng & S K Lee

  3. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

    L Mirea

  4. Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

    A Solimano

Authors
  1. P S Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L Mirea
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. E Ng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A Solimano
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S K Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of the Canadian Neonatal Network

Corresponding author

Correspondence to P S Shah.

Ethics declarations

Competing interests

Dr Prakesh Shah holds an Applied Research Chair in Reproductive and Child Health Services and Policy Research awarded by the Canadian Institutes of Health Research. The remaining authors declare no conflict of interest.

Additional information

A full list of Site Investigators for the Canadian Neonatal Network (Collaborators) is given before References.

Supplementary Information accompanies the paper on the Journal of Perinatology website

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shah, P., Mirea, L., Ng, E. et al. Association of unit size, resource utilization and occupancy with outcomes of preterm infants. J Perinatol 35, 522–529 (2015). https://doi.org/10.1038/jp.2015.4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2015.4

This article is cited by

Search

Advanced search

Quick links