Skip to main content

The Influence of the Composition of the Nursing Staff on Primary Bloodstream Infection Rates in a Surgical Intensive Care Unit

  • Jérôme Robert (a1) (a2), Scott K. Fridkin (a2), Henry M. Blumberg (a3) (a4), Betsy Anderson (a3), Nancy White (a4), Susan M. Ray (a3) (a4), Jinlene Chan (a2) and William R. Jarvis (a2)...

To determine the risk factors for acquisition of nosocomial primary bloodstream infections (BSIs), including the effect of nursing-staff levels, in surgical intensive care unit (SICU) patients.


A nested case-control study.


A 20-bed SICU in a 1,000-bed inner-city public hospital.


28 patients with BSI (case-patients) were compared to 99 randomly selected patients (controls) hospitalized ≥3 days in the same unit.


Case- and control-patients were similar in age, severity of illness, and type of central venous catheter (CVC) used. Case-patients were significantly more likely than controls to be hospitalized during a 5-month period that had lower regular-nurse-to-patient and higher pool-nurse-to-patient ratios than during an 8-month reference period; to be in the SICU for a longer period of time; to be mechanically ventilated longer; to receive more antimicrobials and total parenteral nutrition; to have more CVC days; or to die. Case-patients had significantly lower regular-nurse-to-patient and higher pool-nurse-to-patient ratios for the 3 days before BSI than controls. In multivariate analyses, admission during a period of higher pool-nurse-to-patient ratio (odds ratio [OR]=3.8), total parenteral nutrition (OR=1.3), and CVC days (OR=1.1) remained independent BSI risk factors.


Our data suggest that, in addition to other factors, nurse staffing composition (ie, pool-nurse-to-patient ratio) may be related to primary BSI risk. Patterns in intensive care unit nurse staffing should be monitored to assess their impact on nosocomial infection rates. This may be particularly important in an era of cost containment and healthcare reform.

Corresponding author
Hospital Infections Program, Mailstop E-69, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333
Hide All
1.Pittet D. Nosocomial bloodstream infections. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:512555.
2.Banerjee SN, Emori TG, Culver DH, Gaynes RP, Jarvis WR, Horan T, et al. Secular trends in nosocomial primary bloodstream infections in the United States, 1980-1989. Am J Med 1991;91:86S89S.
3.Craven DE, Kunches LM, Lichtenberg DA, Kollisch NR, Barry MA, Heeren TC, et al. Nosocomial infection and fatality in medical surgical intensive care unit patients. Arch Intern Med 1988;148:11611168.
4.Daschner FD, Frey P, Wolff G, Baumann PC, Suter P. Nosocomial infections in intensive care wards: a multicenter prospective study. Intensive Care Med 1982;8:59.
5.Donowitz LG, Wenzel RP, Hoyt JW. High risk of hospital-acquired infection in the ICU patient. Crit Care Med 1982;10:355357.
6.Duggan JM, Oldfield GS, Ghosh HK. Septicaemia as a hospital hazard. J Hosp Infect 1985;6:406412.
7.Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1994;271:15981601.
8.Rose R, Hunting KJ, Towsend TR, Wenzel RP. Morbidity/mortality and economics of hospital-acquired bloodstream infections: a controlled trial. South Med J 1977;70:12671269.
9.Smith RL, Meixler SM, Simberkoff MS. Excess mortality in critically ill patients with nosocomial bloodstream infections. Chest 1991;100:164167.
10.Maki DG. Nosocomial bacteremia: an epidemiologic overview. Am J Med 1981;70:719732.
11.Bjornson HS, Colley R, Bower RH, Duty VP, Schwartz-Fulton JT, Fischer JE. Association between microorganism growth at the catheter insertion site and colonization of the catheter in patients receiving total parenteral nutrition. Surgery 1982;92:720726.
12.Kelsey MC, Gosling MA. A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices. J Hosp Infect 1984;5:313321.
13.Snydman DR, Pober BR, Murray SA, Gorbea HF, Majka JA, Perry LK. Predictive value of surveillance skin cultures in total-parenteral-nutrition-related infection. Lancet 1982;2:13851388.
14.Faubion WC, Wesley JR, Khalidi N, Silva J. Total parenteral nutrition catheter sepsis: impact of the team approach. J Parenter Enteral Nutr 1986;10:642645.
15.Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA 1980;243:19061908.
16.Puntis JWL, Holden CE, Smallman S, Finkel Y, George RH, Booth IW. Staff training: a key factor in reducing intravascular catheter sepsis. Arch Dis Child 1990;65:335337.
17.Fridkin SA, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996;17:150158.
18.Garner JS, Jarvis WR, Emori TG, Horan TC, Hugues JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16:128140.
19.Greenman RL, Schein RM, Martin MA, Wenzel RP, MacIntyre NR, Emmanuel G, et al. A controlled clinical trial of E5 murine monoclonal IgM antibody to endotoxin in the treatment of gram-negative sepsis. The XOMA Sepsis Study Group. JAMA 1991;266:10971102.
20.Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1995;13:818829.
21.Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med 1977;296:13051309.
22.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;145:875885.
23.Haley RW, Cushion NB, Tenover FC, Bannerman TL, Dryer D, Ross J, et al. Eradication of endemic methicillin-resistant Staphylococcus aureus infections from a neonatal intensive care unit. J Infect Dis 1995;171:614624.
24.Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes. N Engl J Med 1981;305:731735.
25.Li J, Birkhead GS, Strogatz DS, Coles FB. Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York state nursing homes. Am J Epidemiol 1996;143:10421049.
26.Arnow PM, Allyn PA, Nichols EM, Hill DM, Pezzlo M, Bartlett RH. Control of methicillin-resistant Staphylococcus aureus in a burn unit: role of nurse staffing. J Trauma 1982;22:954959.
27.Mayhall CG, Lamb VA, Gayle WE, Haynes BW. Enterobacter cloacae septicemia in a burn center: epidemiology and control of an outbreak. J Infect Dis 1979;139:166171.
28.Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182205.
29.Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126130.
30.Delgado-Rodriguez M, Bueno-Cavanillas A, Lopez-Gigosos R, de Dios Luna-Castillo J, Gufflen-Solvas J, Moreno-Abril O, et al. Hospital length of stay as an effect modifier of other risk factors for nosocomial infection. Eur J Epidemiol 1990;6:3439.
31.Tess BH, Glenister HM, Rodrigues LC, Wagner MB. Incidence of hospital-acquired infection and length of hospital stay. Eur J Clin Microbiol Infect Dis 1993;12:8186.
32.Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) study. EPIC International Advisory Committee. JAMA 1995;274:639644.
33.Soufir L, Timsit J-F, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999;20:396401.
34.Girou E, Stephan F, Novara A, Safar M, Fagon J-Y. Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients. Am J Respir Crit Care Med 1998;157:11511158.
35.Gilbert M, Gallagher SC, Eads M, Elmore MF. Microbial growth patterns in a total parenteral nutrition formulation containing lipid emulsion. J Parenter Enteral Nutr 1986;10:494497.
36.Jarvis WR, Highsmith AKBacterial growth and endotoxin production in lipid emulsion. J Clin Microbiol 1984;19:1720.
37.Shiro H, Muller E, Takeda S, Tosteson TD, Goldmann DA, Pier GB. Potentiation of Staphylococcus epidermidis catheter-related bacteremia by lipid infusions. J Infect Dis 1995;171:220224.
38.Snydman DRMurray SA, Kornfeld SJ, Majka JA, Ellis CA. Total parenteral nutrition-related infections. Prospective epidemiologic study using semiquantitative methods. Am J Med 1982;73:695699.
39.Beck-Sague CM, Jarvis WR, the National Nosocomial Infections Surveillance System. Secular trends in the epidemiology of nosocomial fungal infections in the United States, 1980-1990. J Infect Dis 1993;167:12471251.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 5 *
Loading metrics...

Abstract views

Total abstract views: 353 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd February 2018. This data will be updated every 24 hours.