Báo cáo y học: Staffing level: a determinant of late-onset ventilator-associated pneumonia

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Báo cáo y học: "Staffing level: a determinant of late-onset ventilator-associated pneumonia" Available online http://ccforum.com/content/11/4/154CommentaryStaffing level: a determinant of late-onset ventilator-associatedpneumoniaJeannie P CimiottiUniversity of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania 19104-6096, USACorresponding author: Jeannie P Cimiotti, jcimiott@nursing.upenn.eduPublished: 8 August 2007 Critical Care 2007, 11:154 (doi:10.1186/cc6085)This article is online at http://ccforum.com/content/11/4/154© 2007 BioMed Central LtdSee related research by Hugonnet et al., http://ccforum.com/content/11/4/R80Abstract measures, such as the presence or absence of mouth care [5,6], which is a potential risk factor for VAP. In addition, I amA body of knowledge exists to suggest an association between surprised that the authors did not include hand hygiene as anurse staffing and adverse patient outcomes. Hugonnet and risk factor of interest, because there is a well established linkcolleagues add further evidence by linking nurse staffing to late-onset ventilator-associated pneumonia. Discussed are a number of between hand hygiene and health care associated infections,concerns surrounding the analytic component of this study, and one that the authors have worked with extensively [7,8].including the construction of variables and the statistical models.The authors’ estimation that hospitals maintaining a nurse-to- The authors painstakingly constructed a comprehensive riskpatient ratio above 2.2 could decrease the risk of health care adjustment model that includes, but is not limited, to theassociated infections is based on findings that are potentially Charlson comorbidity index [9], the Acute Physiology andbiased and unrealistic. Chronic Health Evaluation II score [10], and the Projet deHugonnet and colleagues [1] present an interesting article on Recherché en Nursing acuity score. I am concerned,nurse staffing and ventilator-associated pneumonia (VAP). however, that these measures overlap and, although notAlthough this study joins a number of other studies on nurse mentioned, I hope that the authors verified that there were nostaffing and adverse outcomes of hospitalized patients, I feel issues with collinearity. The Cox hazards model is ancompelled to address several important limitations of this appropriate choice when measuring time to VAP, but I have astudy. What I find disappointing is the fact that these authors few concerns surrounding the method of censoring anddescribe an observational study in which I expect they had an construction of the variables that are time dependent. I canopportunity to add something substantial to the body of understand the exposure period for the nurse staffingliterature on nurse staffing and adverse health care related variable, but I think it best to construct all other of the time-outcomes, but failed to do so. dependent variables as days from admission to censoring. As for censoring, I also do not agree with censoring 5 days post-There is sufficient evidence in the literature to suggest that extubation. The authors’ choice of censoring prohibits takingnurse staffing is significantly associated with health care into account the patients who might well have experiencedassociated infections [2-4], but we lack data on the process respiratory compromise and required re-intubation. Becauseof nursing care that may very well inform us as to why this the extubated patients were censored (removed from thestaffing association exists. The authors do state that some of analytic model) on day 5 after extubation, these patients arethe process of care measures were not consistently no longer included in the sample for analytic purposes, evenrecorded, but they do not state that all of t ...