Association of Nurse-to-Patient Ratios in the First 72 Hours of Admission and Outcomes of Very Preterm Infants: A Multicentre Cohort Study

Background: Very preterm infants born at <33 weeks Gestational Age (GA) are at high risk of short- and long-term complications. Neonatal Intensive Care Unit (NICU) organizational factors such as Nurse-to-Patient Ratios (NPRs) may contribute to patient outcomes. This study aimed to assess the association of NPRs received in the first 72 hours of admission with mortality and/or major morbidity among very preterm infants born <33 weeks GA.Methods: This was a multicentre cohort study of inborn infants <33 weeks in 14 Level 3 NICUs in Canada between January 2020 and December 2021. Data on infant characteristics, NPRs and outcomes were obtained from the Canadian Neonatal Network database. NPR was recorded for the shift of admission, and a mean NPR was calculated for the first 24 hours, and first 72 hours of admission. Analysis was stratified by GA group to account for the differences in recommended NPR which are GA based (<29 and 29-32 weeks). Primary outcome was mortality and/or major morbidity. Three multivariable logistic regression models were fitted to estimate odds ratios adjusted for patient covariates with Generalized Estimating Equations to account for clustering within each site. Results: The rate of mortality/major morbidity was 66% (633/952) among infants <29 weeks, and 19% (280/1501) among infants 29-32 weeks. The median NPR (Interquartile Range [IQR]) on shift of admission, first 24 hours, and first 72 hours were 1.00 [IQR 1.00-1.00], 1.00 [IQR 0.50-1.00], and 0.83 [IQR 0.53-1.00] for infants <29 weeks, and were 0.50 [IQR 0.50-0.50], 0.50 [IQR 0.50-0.75], and 0.50 IQR [0.50-0.58] for infants 29-32 weeks. In <29 week infants, there was insufficient precision and no evidence of an effect between higher NPRs received on the shift of admission (adjusted Odds Ratio (aOR); 0.63, 95% Confidence Interval (CI) 0.34-1.18), in the first 24 hours (aOR; 0.74, 95% CI 0.25-2.22), and in the first 72 hours (aOR; 0.82, 95% CI 0.24-2.76) of admission with mortality and/or major morbidity. Among infants born 29-32 weeks, higher NPR in the first 24 (aOR; 2.18, 95% CI 1.06-4.45) and 72 hours (aOR; 6.07, 95% CI 3.08-11.96) of admission were associated with higher odds of mortality and/or major morbidity. Conclusion: Among infants born 29-32 weeks, higher NPRs in the first 24 and 72 hours of admission were associated with worse outcomes, which likely highlights confounding by indication as sicker infants are more likely to receive higher NPRs. In the <29 week infants, we were unable to estimate a precise association between higher NPRs and mortality and/or major morbidity. Further intervention studies are required to evaluate if active interventions to improve NPRs and organizational care are associated with outcomes in the NICU

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