Medical staffing in Ontarioneonatal intensive care units

Bosco Paes, MDAlba Mitchell, Reg N, MScMabel Hunsberger, Reg N, MSNSusan Blatz, Reg N, MEdJohn Watts, MDPeter Dent, MDJohn Sinclair, MDDoris Southwell

Advances in technology have improved thesurvival rates of infants of low birth weight.Increasing service commitments together withcutbacks in Canadian training positions havecaused concerns about medical staffing in neo-natal intensive care units (NICUs) in Ontario. Todetermine whether an imbalance exists betweenthe supply of medical personnel and the de-mand for health care services, in July 1985 wesurveyed the medical directors, head nurses andstaff physicians of nine tertiary level NICUs andthe directors of five postgraduate pediatric resi-dency programs. On the basis of current guide-lines recommending an ideal neonatologist:pa-tient ratio of, 1:6 (,assuming an adequate numberof support personnel) most of the NICUs wereunderstaffed. Concern about the heavy workpatterit and resulting lifestyle implications hasmade Canadian graduates reluctant to enter thissubspecialty. We propose strategies to correctstaffing shortages in the context of rapidly in-creasing workloads resulting from a continuingcutback of pediatric residency positions andrestrictions on immigration of foreign trainees.

Les progres dans les techniques en perinatologieont permis d'ameliorer les taux de survie desnouveau-nes de faible poids. Vu l'augmentationdes soins qu'ils exigent et la diminution dunombre de postes de formation au Canada, on sedemande avec inquietude s'il y a suffisammentde specialistes dans les pouponnieres de soinsintensifs (PSI) en Ontario par rapport aux be-

From the departments of Pediatrics, Clinical Epidemiology andBiostatistics, and Nursing and the School of Nursing, Faculty ofHealth Sciences, McMaster University and Children's Hospitalat Chedoke-McMaster, Hamilton, Ont.

Reprint requests to: Dr. Bosco Paes, Department of Pediatrics,Faculty of Health Sciences, McMaster University, 1200 Main St.W, Hamilton, Ont. L8N3Z5

soins. Afin de repondre a cette question, nousavons sonde en juillet 1985 les medecins-chefs,infirmieres-chefs et me'decins traitants de neufPSI de niveau tertiaire et les directeurs de cinqprogrammes de formation postdoctorale enpediatrie. Si on se fonde sur la norme reconnueactuellement, soit tin neonatologue pour sixmalades (pourvu que le personnel de soutiensoit suffisant), la plupart des PSI n'en ont pasassez. Les nouveaux dipl6mds au Canada sontpeu enclins a embrasser cette sous-spdcialite,craignant la somme excessive de travail qu'ellecomporte et la repercussion de celle-ci sur leurmode de vie. Nous proposons un plan d'attaqueafin de pourvoir les postes vacants devant l'aug-mentation rapide des taches individuelles ame-nee par la diminution constante du nombre depostes de residence en pediatrie et la restric-tion de l'immigration de mddecins formes 'al'etranger.

egionalization of perinatal care1 togetherR{ with advances in technologic expertise and

therapeutic interventions have increasedthe survival rates for infants of extremely low birthweight.2 To reduce the incidence of neurologic andfunctional impairment, newer diagnostic and mon-itoring techniques coupled with therapeutic inter-ventions have been implemented in neonatal in-tensive care units (NICUs).3 Increasingly complexequipment and improved treatment of pathophysi-ologic states have increased the workload of care-givers within NICUs.

A multidisciplinary research group at McMas-ter University, Hamilton, Ont., conducted a de-scriptive study to evaluate the factors affecting thesupply of medical personnel and the demand forhealth care services in Ontario NICUs for theperiod 1980-84. The primary aim of the study wasto determine whether an imbalance exists betweenworkload and the supply of medical personnel inOntario level III NICUs. A level III NICU is

CMAJ, VOL. 140, JUNE 1, 1989 1321- For prescribing information see page 1386

defined as a central referral unit for high-riskperinatal problems whose assessment and manage-ment require more specialized professional exper-tise.4

Methods

In this study supply was defined as quantita-tive consideration of the numbers and distributionof facilities and health care personnel relative tothe population served.5 To assess supply we stud-ied the factors listed in Table I.

In July 1985 we surveyed the medical directorsof all 10 level III NICUs in Ontario for annual datafor 1980-84 on numbers of neonatologists, pedia-tricians, neonatology trainees and pediatric resi-dents staffing their units, the percentage of timethat each staff member spent in direct patient care,education, research and administration, and thenumber of neonatology trainees and pediatric resi-dents staffing each shift on weekdays, weeknightsand weekends. The definition of a neonatologytrainee for the purposes of this study was apediatric resident specifically training in the care ofthe newborn.

We surveyed the directors of all five Ontariopostgraduate pediatric residency programs for an-nual data for the same period on the number ofneonatology trainee and pediatric residency posi-tions filled by,Canadians and by non-Canadiansand the number of graduates from the subspecialtyprograms in neonatology.

We surveyed all 80 physicians working in the10 level III NICUs at the time. Physicians includedneonatologists, neonatology trainees and second-year to fourth-year residents in the core pediatricprograms. Information collected from the physi-cians included number of years of experience in anNICU, size of daily patient assignments andamount of time spent in direct patient care, educa-tion, research and administration.

In this study, demand was defined as the typeand amount of health care services required.5 Sincethe type and amount of health care servicesprovided in an NICU vary with patient acuity, westudied the factors listed in Table II. Each of thesefactors permitted assessment of change in patientacuity over the study period. Patient acuity isdefined as the number of direct hours of actual"hands-on" patient care and is categorized asconvalescent, intermediate or intensive,6 increasingacuity being associated with more intensive care.

All 10 NICU medical directors and headnurses were asked to provide annual data for1980-84 about demand, including number of ad-missions to the NICU according to birth weight,length of stay, ventilator patient-days, patient acu-ity, rates of transfer out of the NICU and occupan-cy rates.

All the questionnaires were self-administered.To increase the response rate we mailed to thenonrespondents a second set of questionnaires; if

these were not returned the nonrespondents re-ceived a telephone reminder.

Adequacy of staffing in NICUs has previouslybeen determined by calculating the ratio of person-nel to patients.67 To determine the balance be-tween supply and demand we calculated theclinical workload for neonatologists by dividingthe official bed capacity for each NICU by thenumber of neonatologists staffing the unit.

Comparable data are presented from all cen-tres when available. When uniform data for all theyears surveyed were not available from otherunits, the data from the NICU in the McMasterDivision of Chedoke-McMaster Hospitals wereused to illustrate trends.

Results

One of the 10 NICUs surveyed was designat-ed as a level II NICU by its medical director andwas therefore excluded from the analyses. Theresponse rates for the remaining nine NICUs were89% (8/9) for medical directors, 100% (5/5) forprogram directors and 71% (57/80) for physicians.Data about demand were provided by the medical

Table I --- Factors affecting the supply of medicalpersonnel in level Ill neonatal intensive care units(NICUs) in Ontario

.LL~ I

Table It Factors affecting the demand on medicaipersonnel in NICUs

1322 CMAJ, VOL. 140, JUNE 1, 1989

.!.,--., l'! P;.

.. .. ....i 'I

directors and head nurses for 78% (7/9) of theNICUs.

Factors affecting the supply ofpersonnel

Fig. 1 summarizes the percentage of timespent by neonatologists, neonatology trainees andpediatric residents in direct patient care, education,research and administration in 1982-84 as report-ed by the NICU medical directors. Neonatologistsspent an average of 39% (19 to 39 hours) of theiraverage 64-hour workweek in direct patient care,and neonatology trainees spent an average of 55%(27 to 41 hours) of their time in this activity. Forboth these groups there was a wide range ofresponses, the time spent in patient care rangingfrom 15% to 80%. In contrast, pediatric residentsspent 70% to 90% (average 84%) of their time indirect patient care. Responses from the staff physi-cians confirmed these figures.

The ratio of neonatologists to patients in theeight NICUs in 1984 ranged from 1:6 to 1:12. Todetermine the adequacy of the number of neona-tology trainees and residents staffing the NICUs,we compared the ratio of these personnel topatients on weekdays, weeknights and weekends.In 1984 each neonatology trainee or pediatric

resident was responsible for an average of 11patients (extremes 6 and 20) on weekdays. Onweekday nights and weekends this increased to anaverage of 19 patients (extremes 8 and 30).

Positions filled by Canadian and non-Canadi-an neonatology trainees in the eight NICUs werecompared. Except in 1984, neonatology traineepositions filled by non-Canadians outnumberedpositions filled by Canadians, in ratios rangingfrom 2:1 to 6:1 (Table III). These figures do notrepresent the total number of trainees staffingOntario NICUs because some hospitals are able tofund additional positions through private (intemal)resources. Between 1980 and 1984 there wereapproximately 10 such positions in 4 hospitals,70% of which were filled by non-Canadians. Thenumber of non-Canadian graduates from theseprograms over the 5 years, 66, substantially ex-ceeds the number of Canadian graduates (10). Ofthe 66 non-Canadian graduates 16 (24%) remainedin Canada to practise neonatology on completionof their training, compared with 9 (90%) of theCanadian graduates.

Factors affecting the demand on personnel

The number of infants of extremely low birth

Neonatologists (n = 22)Hours worked weekly a 64

(range 50-100)

Education &research (35%)

Neonatology trainees (n a 23)Hours worked weekly * 66

(range 50-75)

Direct patientcare (39%)

Other (9%)

Administration(17%)

Pediatric residents (n m 25)Hours worked weekly m 61

(range 16-85)

Direct patientcare (84%)

Administration(1%) (

CMAJ, VOL. 140, JUNE 1, 1989 1323

Direct patientcare (55%)

Research(26%)

Other(1%)

Education &research(15%)

Fig. 1 - Percentage of time spent in various activities by neonatologists, neonatology trainees and pediatricresidents in level III neonatal intensive care units (NICUs) in Ontario in 1982-84, as reported by medicaldirectors.

weight (less than 1000 g) admitted to the McMas-ter NICU in 1984 was 30% higher than thenumber admitted in 1980. In the same unit thenumber of infants admitted weighing 1000 g ormore increased by only 2%. Between 1982 and1984 the number of infants weighing less than1000 g admitted to an NICU in'London, Ont.,increased by 58%, whereas the number of thoseweighing 1000 g or more decreased by 2%. Similartrends were observed in other Ontario NICUs, butcomplete data were unavailable for analysis.

Owing to their small size and more criticalhealth status, babies of extremely low birth weightremain in NICUs longer.8 In 1984 the averagelength of stay in the McMaster NICU for infantsweighing 1000 g or more was 11.7 days, comparedwith 40.7 days for infAnts weighing less than 1000g. The corresponding figures for an NICU inLondon in the same year were 12.6 and 53 days.

In five NICUs for which comparable data wereavailable, the total number of patient-days in-creased by 23.3%, from 28 289 in 1981 to 34 868in 1984. Increasing lengths of stay contributed tothe increasing number of patient-days between1981 and 1984.

'Low-birth-weight infants often require assist-ed ventilation, which necessitates intensive surveil-lance and care by clinicians. This correspondinglyraises the level of patient acuity. At an NICU inLondon the total number of ventilator patient-daysrose from 745 in 1981 to 2500 in 1984, an increaseof 235.6%. During the same period, in the largestlevel III NICJ 'in Ontario the total number ofventilator patient-days increased 105.1%, from3251 to 6669.

Fig. 2 shows the percentage increase between1980 and 1984 in the admission and occupancyrates, patient-days, patient acuity and transfers outof the NICU at McMaster. The rate of transfer ofpatients out of the NICU increased substantially inthe face of relatively stable admission and occu-pancy rates. This is the result of increasing patientacuity, which is reflected in the increased numberof patient-days; this suggests that the smallerinfants whose condition was more critical re-mained in the NICU longer.

At McMaster, where there have been noapparent changes in the birth rate or referralpattern since 1'977,9 there was a 10-fold increase

between 1977-80 and 1981-84 in the number ofinfants weighing 501 to 600 g at birth whosurvived.9

The length of stay affects occupancy rates,which climbed during some months to greater than100% at some of the NICUs. At McMaster theoccupancy rate exceeded 100% during 2 months in1982, 3 months in 1983 and 5 months in 1984.Occupancy rates greater than 100% far exceed theCanadian hospital standards for nurseries, 65% to70%.1o

Discussion

In 1980 the Committee on Fetus and Newbornof the American Academy of Pediatrics recom-mended that level III NICUs be staffed by at leastthree full-time neonatologists to provide patientcare while meeting educational, research, investi-gational and administrative needs."1 In 1985 thecommittee recommended that neonatologists su-pervising an adequate number of other health careproviders, such as additional physicians or nurse-clinicians, should each care for an average of sixpatients.7 On the basis of this recommendation,between 1980 and 1984 the total number ofneonatologists required to staff seven Ontario

250 -

U

0 200C

*, 150-0A.

100 -

Transfersout

'S/// Patient

/ - __-_-- - *- - - - - - - acuity

- , o' .... ,,,,,,,,, Patient-/o days

w oo, o ' ~~~~~~~~~Occupancy

Admrisionsto NICU

1980 1981 1982 1983 1984

Year

Fig. 2 - Percentage increase in factors affectingdemand on medical personnel between 1980 and W984at NICU in McMaster DivisiOn of Chedoke-McMasterHospitals. To permit compparison of five differentmeasurement units all data originate at the 100%point.

Table Ill - Number of neonatology trainee positions funded by the Ontario Ministry of Health filled by Canadians andnon-Canadians in Ontario in 1980-84

H-

1324 CMAJ, VOL. 140, JUNE 1, 1989

NICUs was 25. The average actual staff comple-ment was 18, a shortfall of 28% (Table IV).

Fig. 3 shows the supply of neonatologists perNICU from 1982 to 1984 relative to the product ofbed capacity and occupancy rate (factored capaci-ty). Although bed capacity is an officially statednumber for each unit, several units were forced toexceed bed capacity during this period to respondto the province's need for neonatal intensive care.The factored capacity, therefore, gives a moreaccurate representation of the situation. With cur-rent guidelines specifying an ideal neonatologist:patient ratio of 1:6, given an adequate number ofsupport staff,7'11 most of the NICUs would beconsidered to be understaffed even if the necessaryinfrastructure were present. In fact, the report ofthe Sub-Committee on Institutional ProgramGuidelines for Canada suggests that when theinfrastructure of personnel in NICUs is absent, theratio of one neonatal or perinatal specialist to sixpatients should be increased.6 Moreover, the rec-ommended ratio, which evolved from a report bySwyer,12 is now 19 years out of date, and newstandards are urgently needed given the rapidlychanging levels of acuity in Ontario NICUs.

0(A1._

0

4a(a0

z

6

4'

2

0

12 36 48Factored capacity

(bed capacity x occupancy rate in percentage)

Fig. 3 - Supply of neonatologists per NICU relativeto bed capacity and occupancy rate. Ideal ratio is thatrecommended by the American Academy of Pediat-rics.7* = 1982; A = 1983; Ei = 1984.

Although the amount of time that neonatolo-gists and neonatology trainees spent in directpatient care varied considerably across the nineNICUs, pediatric residents consistently spent 84%of a 61-hour workweek (51 hours) in this activity.This heavy clinical load is felt to compromise theeducational objectives of residents. The Royal Col-lege of Physicians and Surgeons of Canada nowemphasizes structured educational activities, inte-grated program activity, ambulatory care experi-ence and opportunities for scholarship and re-search in their objectives for specialty trainees.'3This emphasis challenges all residency programs tobroaden educational components for residentswhile ensuring that the clinical teaching units inwhich training occurs continue to provide optimalpatient care and meet all service needs.13

The number of patients assigned to eachneonatology trainee or pediatric resident in Ontar-io NICUs is excessive given the critical condition ofthese infants. In our study many of the traineesand residents were caring for up to 11 patients onweekdays and up to 19 on weeknights and week-ends. A large increase in the workload at nightmay not be justified, because critically ill neonatesdo not show the typical wakefulness-sleep pat-terns of patients in an adult or pediatric ward.Other than activities such as patient rounds andelective investigations, the three shifts in an NICUare very similar in terms of service demands suchas numbers of admissions and numbers of infantsneeding intensive surveillance.

Although enough Canadian physicians areapplying for pediatric residency positions, they aremuch less interested in becoming subspecialists inneonatology, as is evidenced by the paucity ofCanadians in neonatology trainee positions in ourstudy. Consequently, there is a heavy reliance onnon-Canadians to fill these positions. In the past,most of these physicians have chosen not toremain in Canada as neonatologists. Recent gov-ernment legislation and inhibitory professionalscreening requirements have greatly reduced thenumber of non-Canadian applicants to neonatolo-gy trainee positions while prohibiting even thosefew who are interested in remaining, and who areneeded to fill vacant positions, from doing so.

Table IV - Ideal and average actual staff complement in seven level Ill NICUs in Ontario in 1980-84

Mean no. ofpatient-daysper annumNICU no.

Idealcomplement7

j t 13 5882 10 1313 9 7964 8 6415 46966 4 6437 2 934Total 54 431

*Total number of neonatologists in 1980-84 divided by the number of years.tData available only for 1982-84.

6.2

Actualcomplement*

4.84.64.44.02.12.11.3

24.9 1

5.03.71.01.52.00.518.2

CMAJ, VOL. 140, JUNE 1, 1989 1325

G0

The nature of neonatal care has changed inrecent years. Whereas NICU beds were once filledwith infants ranging in health from critically ill toconvalescent, the convalescent infants are nowbeing transferred to other units, so that the NICUhas a higher proportion of infants of very low birthweight who are critically ill and who need inten-sive surveillance. This change in the nature of theNICU patient population has caused an increase inboth the workload and the stress level of clinicians.Concomitant with this development the Ontariogovernment has legislated two changes that affectthe medical staffing of NICUs. First, non-Canadianphysicians who come to Canada for specialtytraining are not allowed to remain in the countryafter completion of their training. This has asignificant effect in neonatology because many ofthe neonatology trainee positions are filled bynon-Canadians. Second, the government has or-dered a cutback of 35% in the funding of pediatricresidency positions, to occur over a 5-year period.14This cutback has already worsened the personnelshortage in Ontario NICUs. This disequilibriumwill become even more dramatic owing to therecent change in guidelines recommending thatbed requirements for NICUs per 1000 births beincreased to 1.75 from 1.00.15 This requirementwas calculated on the basis of survival rates andduration of hospital stay, the three recognizedlevels of care needed for the sick neonate beingtaken into account. NICUs will therefore havemore beds filled with critically ill infants but fewerphysicians to provide the intensive care required.

We have shown that there is a disequilibriumin the medical staffing of Ontario NICUs, withdemand exceeding supply. Strategies to addressthis medical staffing shortage must be considered.Although additional neonatologists are needed, themain requirement is for bedside caregivers. Asneonatologists spend only 39% of their time inactual caregiving, increasing their numbers to re-solve the service shortfall would be inefficient.Increasing the percentage of time neonatologistsspend in patient care would compromise theirleadership activities in education, research andadministration.11 Moreover, there is a very smallpool of Canadian neonatology trainees from whichto draw. Increasing the number of trainees is not afeasible alternative given that recruitment to dateof both Canadian and non-Canadian applicantshas been difficult.

What is needed is replacement of resident-dependent activity with resident-independent ser-vice. The existing shortfall may be met by otheralternatives, including "complement" and "substi-tute" personnel such as general pediatricians, gen-eral physicians, anesthetists, respiratory therapistsand expanded-role nurses or some optimal combi-nation of these professionals (Jonathan Lomas:unpublished data, 1987). The roles of health careworkers such as nutritionists, pharmacists andbiotechnologists in direct patient care should beexplored further. It is important that the alterna-

tives selected be evaluated as to availability, feasi-bility, acceptability and cost-effectiveness.

We thank all those who provided data for this study:NICU medical directors Drs. Wesley Boston, GrahamChance, Ann Comet, Timothy Frewen, Michael Hardie,Brock MacMurray, Andrew Shennan and Paul Swyer;NICU head nurses Marjorie Birchall, Elva Bote, MarieDore, Jocelyn Lawrence, Susan Leach, Ros O'Reilly,Janet Pinelli, Eleanor Rivoire, JoAnne Scoon and SandraWhittall; and the NICU neonatologists, neonatologytrainees and residents in pediatric programs. We alsothank the anonymous reviewers for their comments andLee Ecker for her secretarial support.

This study was supported by the Ontario Ministryof Health.

References

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1326 CMAJ, VOL. 140, JUNE 1, 1989