FETAL AND MEDICINE
NEONATAL RichardE. Behrman,Editor
Diurnal variation in the quality and outcome o f newborn intensive care Variables related to both the process and the outcome o f neonatal intensive care were studied to compare care given during the day (0901-2100 hours) with that at night (2101-0900 hours). A t night, intravenous infiltrations occurred more often, and the tidal volume o f respirator-treated infants was verified less often. Blood p H values less than 7.20, excluding values within 12 hours o f admission, were recorded more often and in more patients at night. During a 12-month period, there were significantly more deaths among infants less than 1,500 gm during the night than during the day. The deterioration o f infants at night may result in part from current nursery staffing practices.
Jon Tyson, M.D.,* Karoly Schultz, M.D., John C. Sinclair, M.D., and Gerald Gill, M . D . ,
Hamilton,
Ont., C a n a d a
TrIE NUMBER of medical and nursing staff in many neonatal units is reduced at night. There may also be a decline in their supervision and in the ability of individual nurses and physicians to provide care at night. We undertook a review of variables related to both the process and the outcome of neonatal intensive care, contrasting performance and outcome during the day (0901-2100 hours) With that at night (2101-0900 hours).
METHODS The McMaster Neonatal Unit is a 22-bed referral center for high-risk babies. Three pediatric residents and two to four clinical fellows work in the unit between 0900 and 1800 hours on weekdays, and 0900 and 1200 hours on weekends. At all other hours, one resident and one fellow care for all infants. Residents and fellows take call in the hospital every second to fourth night during a continuous period of duty lasting 28 to 32 hours. Each resident is closely supervised by a fellow, and all newly admitted or unstable patients are discussed in detail with one of three neonatologists who take call from home. Nursing staff routinely work 12-hour shifts, which change at 0730 and
From McMaster University "Medical Center. Presented to the American Pediatric Society and Society for Pediatric Research, Denver, Colorado, April, 1975. *Reprint address: Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75235.
0022-3476/79/080277+04500.40/0 9 1979 The C. V. Mosby Co.
1930 hours. Each shift is staffed by a team of eight to 11 nurses, frequently there being one less nurse after 1930 hours. Each of the four teams works for two or three consecutive days or nights followed by an equal period withcut duty. By changing shifts every two weeks, each team works seven days and seven nights of each fourweek period. (Our laboratory technicians also rotate shifts so that the same group of technicians perform neonatal blood gas determinations during the night as during the day. The laboratory is adjacent to our unit, with immediate access both day and night.) The periods designated as "day" (0901-2100 hours) and "night" (2101-0900 hours) were selected prior to data collection as the two 12-hour periods most likely to differ in quality of care. The process selected for study measures were (1) maintenance of intravenous infusions: incidence of infiltration, and elapsed time before infusions were restarted; and (2) determination of tidal volume. Tidal volume, as used here, refers to the gas volume delivered into the infant by the Bourns LS i50 respirator. At the same volume setting of the respirator, the infant's tidal volume will be affected by replacement of tubing (ordinarily performed daily between 0745 and 0830 hours), variation in the nebulizer water level, and changes in lung compliance. All residents were instructed to calculate tidal volume every four to six hours for acutely ill infants, and every eight to 12 hours for relatively stable infants requiring respirator therapy. These calculations The Journal o f P E D 1A T R I C S Vol. 95, No. 1, pp. 277-280
277
278
Tyson et al.
The Journal of Pediatrics August 1979
Table I. Process measures, day vs night
No. patient] Night 12-hr [ Day periods I mean mean
Intravenous infiltrations/ patient/12 hr Hours to restart/infusion Hours without infusion/ patient/12 hr Calculations of tidal volume/patient/12 hr
P
NEONATAL RichardE. Behrman,Editor
Diurnal variation in the quality and outcome o f newborn intensive care Variables related to both the process and the outcome o f neonatal intensive care were studied to compare care given during the day (0901-2100 hours) with that at night (2101-0900 hours). A t night, intravenous infiltrations occurred more often, and the tidal volume o f respirator-treated infants was verified less often. Blood p H values less than 7.20, excluding values within 12 hours o f admission, were recorded more often and in more patients at night. During a 12-month period, there were significantly more deaths among infants less than 1,500 gm during the night than during the day. The deterioration o f infants at night may result in part from current nursery staffing practices.
Jon Tyson, M.D.,* Karoly Schultz, M.D., John C. Sinclair, M.D., and Gerald Gill, M . D . ,
Hamilton,
Ont., C a n a d a
TrIE NUMBER of medical and nursing staff in many neonatal units is reduced at night. There may also be a decline in their supervision and in the ability of individual nurses and physicians to provide care at night. We undertook a review of variables related to both the process and the outcome of neonatal intensive care, contrasting performance and outcome during the day (0901-2100 hours) With that at night (2101-0900 hours).
METHODS The McMaster Neonatal Unit is a 22-bed referral center for high-risk babies. Three pediatric residents and two to four clinical fellows work in the unit between 0900 and 1800 hours on weekdays, and 0900 and 1200 hours on weekends. At all other hours, one resident and one fellow care for all infants. Residents and fellows take call in the hospital every second to fourth night during a continuous period of duty lasting 28 to 32 hours. Each resident is closely supervised by a fellow, and all newly admitted or unstable patients are discussed in detail with one of three neonatologists who take call from home. Nursing staff routinely work 12-hour shifts, which change at 0730 and
From McMaster University "Medical Center. Presented to the American Pediatric Society and Society for Pediatric Research, Denver, Colorado, April, 1975. *Reprint address: Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75235.
0022-3476/79/080277+04500.40/0 9 1979 The C. V. Mosby Co.
1930 hours. Each shift is staffed by a team of eight to 11 nurses, frequently there being one less nurse after 1930 hours. Each of the four teams works for two or three consecutive days or nights followed by an equal period withcut duty. By changing shifts every two weeks, each team works seven days and seven nights of each fourweek period. (Our laboratory technicians also rotate shifts so that the same group of technicians perform neonatal blood gas determinations during the night as during the day. The laboratory is adjacent to our unit, with immediate access both day and night.) The periods designated as "day" (0901-2100 hours) and "night" (2101-0900 hours) were selected prior to data collection as the two 12-hour periods most likely to differ in quality of care. The process selected for study measures were (1) maintenance of intravenous infusions: incidence of infiltration, and elapsed time before infusions were restarted; and (2) determination of tidal volume. Tidal volume, as used here, refers to the gas volume delivered into the infant by the Bourns LS i50 respirator. At the same volume setting of the respirator, the infant's tidal volume will be affected by replacement of tubing (ordinarily performed daily between 0745 and 0830 hours), variation in the nebulizer water level, and changes in lung compliance. All residents were instructed to calculate tidal volume every four to six hours for acutely ill infants, and every eight to 12 hours for relatively stable infants requiring respirator therapy. These calculations The Journal o f P E D 1A T R I C S Vol. 95, No. 1, pp. 277-280
277
278
Tyson et al.
The Journal of Pediatrics August 1979
Table I. Process measures, day vs night
No. patient] Night 12-hr [ Day periods I mean mean
Intravenous infiltrations/ patient/12 hr Hours to restart/infusion Hours without infusion/ patient/12 hr Calculations of tidal volume/patient/12 hr
P
