A CONTROLLED TRIAL OF NURSE PRACTITIONERS IN NEONATAL INTENSIVE-CARE

Objective. To compare a clinical nurse specialist/neonatal practitione r (CNS/NP) team with a pediatric resident team in the delivery of neon atal, intensive care. Design. Randomized, controlled trial. Setting. A 33-bed tertiary-level neonatal intensive care unit. Patients. Of 821 infants admitted to the neonatal intensive core unit between September 1991 and September 1992, 414 were randomized to care by the CNS/NP te am, and 407 were randomized to care by the pediatric resident team. In tervention. Infants assigned to the CNS/NP team were cared for by CNS/ NPs during the day and by pediatric residents during the night. Infant s assigned to the pediatric resident team were cared for by pediatric residents around the clock. Neonatologists supervised both teams. Meas ures. Outcome measures included mortality; number of neonatal complica tions; length of stay; quality of care, as assessed by a quantitative indicator condition approach; parent satisfaction with care, measured using the Neonatal Index of Parent Satisfaction; long-term outcomes, m easured using the Minnesota Infant Development Inventory; and costs. R esults. There were 19 (4.6%) deaths in the CNS/NP group and 24 (5.9%) in the resident group (relative risk [RR], 0.78; confidence interval [ CI], 0.43 to 1.40). In the CNS/NP group, 230 (55.6%) neonates had comp lications, in comparison with 220 (54.1%) in the resident group (RR, 1 .03; CI 0.91 to 1.16). Mean lengths of stay were 12.5 days in the CNS/ NP group and 11.7 days in the resident group (difference in means, 0.8 days; CI, -1.1 to 2.7). The performance on the indicator conditions w as comparable in the two groups except for two instances, jaundice and charting, both of which favored the CNS/NP group. Mean scores on the Neonatal Index of Parent Satisfaction were 140 in the CNS/NP group and 139 in the resident group (difference in means, 1.0; CI, -3.6 to 5.6) . In the CNS/NP group, 6 (2.6%) infants performed 30% or more below th eir age level in the Minnesota Infant Development Inventory, in compar ison with 2 (0.9%) in the resident group (RR, 2.87; CI, 0.59 to 14.06) The cost per infant in the CNS/NP group was $14 245 and in the reside nt group $13 267 (difference in means, $978; CI, -1303.18 to 3259.05). Conclusions. CNS/NP and resident teams are similar with respect to al l tested measures of performance. These results support the use of CNS /NPs as an alternative to pediatric residents in delivering care to cr itically ill neonates.