Potential of Earlier Detection and Treatment of Disease-Related Malnutrition with Oral Nutrition Supplements to Release Acute Care Bed Capacity.

A recent systematic review and meta-analysis shows that appropriate use of oral nutrition supplements (ONS) in community patients is associated with a significant reduction in hospitalisations. Given higher use of acute care resource by malnourished versus normally nourished patients, this paper examines the potential to reduce bed utilisation by applying these results to Irish inpatient and malnutrition prevalence data. In 2013, adults admitted to hospital with medium or high malnutrition risk scores used an estimated 36% of adult acute inpatient bed days. Targeted use of ONS in community patients might reduce hospitalisation by 168,438 adult bed days per year, equivalent to 460 beds per day. This is particularly important, given high bed occupancy rates and twelve month daily averages of 254 patients on trolleys. Relevant stakeholders should consider strategies to ensure effective ONS use with a view to improving outcomes and reducing pressure on the acute care system.

Association Among ICU Congestion, ICU Admission Decision, and Patient Outcomes.

OBJECTIVES: To employ automated bed data to examine whether ICU occupancy influences ICU admission decisions and patient outcomes. DESIGN: Retrospective study using an instrumental variable to remove biases from unobserved differences in illness severity for patients admitted to ICU. SETTING: Fifteen hospitals in an integrated healthcare delivery system in California. PATIENTS: Seventy thousand one hundred thirty-three episodes involving patients admitted via emergency departments to a medical service over a 1-year period between 2008 and 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A third of patients admitted via emergency department to a medical service were admitted under high ICU congestion (more than 90% of beds occupied). High ICU congestion was associated with a 9% lower likelihood of ICU admission for patients defined as eligible for ICU admission. We further found strong associations between ICU admission and patient outcomes, with a 32% lower likelihood of hospital readmission if the first inpatient unit was an ICU. Similarly, hospital length of stay decreased by 33% and likelihood of transfer to ICU from other units-including ICU readmission if the first unit was an ICU-decreased by 73%. CONCLUSIONS: High ICU congestion is associated with a lower likelihood of ICU admission, which has important operational implications and can affect patient outcomes. By taking advantage of our ability to identify a subset of patients whose ICU admission decisions are affected by congestion, we found that, if congestion were not a barrier and more eligible patients were admitted to ICU, this hospital system could save approximately 7.5 hospital readmissions and 253.8 hospital days per year. These findings could help inform future capacity planning and staffing decisions.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro.

OBJECTIVE: To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health. METHODS: The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011. RESULTS: There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours. CONCLUSIONS: Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

Reducing the length of postnatal hospital stay: implications for cost and quality of care.

BACKGROUND: UK health services are under pressure to make cost savings while maintaining quality of care. Typically reducing the length of time patients stay in hospital and increasing bed occupancy are advocated to achieve service efficiency. Around 800,000 women give birth in the UK each year making maternity care a high volume, high cost service. Although average length of stay on the postnatal ward has fallen substantially over the years there is pressure to make still further reductions. This paper explores and discusses the possible cost savings of further reductions in length of stay, the consequences for postnatal services in the community, and the impact on quality of care. METHOD: We draw on a range of pre-existing data sources including, national level routinely collected data, workforce planning data and data from national surveys of women's experience. Simulation and a financial model were used to estimate excess demand, work intensity and bed occupancy to explore the quantitative, organisational consequences of reducing the length of stay. These data are discussed in relation to findings of national surveys to draw inferences about potential impacts on cost and quality of care. DISCURSIVE ANALYSIS: Reducing the length of time women spend in hospital after birth implies that staff and bed numbers can be reduced. However, the cost savings may be reduced if quality and access to services are maintained. Admission and discharge procedures are relatively fixed and involve high cost, trained staff time. Furthermore, it is important to retain a sufficient bed contingency capacity to ensure a reasonable level of service. If quality of care is maintained, staffing and bed capacity cannot be simply reduced proportionately: reducing average length of stay on a typical postnatal ward by six hours or 17% would reduce costs by just 8%. This might still be a significant saving over a high volume service however, earlier discharge results in more women and babies with significant care needs at home. Quality and safety of care would also require corresponding increases in community based postnatal care. Simply reducing staffing in proportion to the length of stay increases the workload for each staff member resulting in poorer quality of care and increased staff stress. CONCLUSIONS: Many policy debates, such as that about the length of postnatal hospital-stay, demand consideration of multiple dimensions. This paper demonstrates how diverse data sources and techniques can be integrated to provide a more holistic analysis. Our study suggests that while earlier discharge from the postnatal ward may achievable, it may not generate all of the anticipated cost savings. Some useful savings may be realised but if staff and bed capacity are simply reduced in proportion to the length of stay, care quality may be compromised.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro / Dificuldades de acesso e estimativas de leitos públicos para unidades de terapia intensiva no estado do Rio de Janeiro

ABSTRACT OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health. METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011. RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours. CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

RESUMO OBJETIVO Determinar o número necessário de leitos públicos de unidades de terapia intensiva para adultos no estado do Rio de Janeiro para atender à demanda existente, e comparar os resultados com a recomendação do Ministério da Saúde. MÉTODOS Seguiu-se modelo híbrido que agrega séries temporais e teoria de filas para prever a demanda e estimar o número de leitos necessários. Foram considerados quatro cenários de fluxo de pacientes, de acordo com as solicitações de vagas, proporção de desistências e tempo médio de permanência no leito de unidade de terapia intensiva. Os resultados foram confrontados com os parâmetros do Ministério da Saúde. Os dados foram obtidos da Central Estadual de Regulação, de 2010 a 2011. RESULTADOS Houve 33.101 solicitações médicas para 268 leitos de unidade de terapia intensiva regulados no Rio de Janeiro. Com tempo médio de permanência das unidades de terapia intensiva reguladas de 11,3 dias, haveria necessidade de 595 leitos ativos para garantir a estabilidade do sistema e 628 leitos para o tempo máximo na fila de seis horas. Deduzidas as atuais taxas de desistência por melhora clínica (25,8%), estes números caem para 441 e 471. Com tempo médio de permanência de 6,5 dias, o número necessário seria de 342 e 366 leitos, respectivamente; deduzidas as taxas de desistência, de 254 e 275. O Ministério da Saúde estabelece parâmetro de 118 a 353 leitos. Embora o número de leitos regulados esteja na faixa recomendada, necessita-se incremento de 122,0% de leitos para garantir a estabilidade do sistema e de 134,0% para um tempo máximo de espera de seis horas. CONCLUSÕES O dimensionamento adequado de leitos deve considerar os motivos de limitações de acesso oportuno e a gestão do fluxo de pacientes em um cenário que associa priorização das solicitações com menor tempo médio de permanência.

Measuring the use of examination room time in oncology clinics: a novel approach to assessing clinic efficiency and patient flow.

PURPOSE: The use of time in outpatient cancer clinics is a marker of quality and efficiency. Inefficiencies such as excessive patient wait times can have deleterious effects on clinic flow, functioning, and patient satisfaction. We propose a novel method of objectively measuring patient time in cancer clinic examination rooms and evaluating its impact on overall system efficiency. METHODS: We video-recorded patient visits (N = 55) taken from a larger study to determine patient occupancy and flow in and out of examination rooms in a busy urban clinic in a National Cancer Institute-designated comprehensive cancer center. Coders observed video recordings and assessed patient occupancy time, patient wait time, and physician-patient interaction time. Patient occupancy time was compared with scheduled occupancy time to determine discrepancy in occupancy time. Descriptive and correlational analyses were conducted. RESULTS: Mean patient occupancy time was 94.8 minutes (SD = 36.6), mean wait time was 34.9 minutes (SD = 28.8), and mean patient-physician interaction time was 29.0 minutes (SD = 13.5). Mean discrepancy in occupancy time was 40.3 minutes (range, 0.75 to 146.5 minutes). We found no correlation between scheduled occupancy time and patient occupancy time, patient-physician interaction time, and patient wait time, or between discrepancy in occupancy time and patient-physician interaction time. CONCLUSION: The method is useful for assessing clinic efficiency and patient flow. There was no relationship between scheduled and actual time patients spend in exam rooms. Such data can be used in the design of interventions that reduce patient wait times, increase efficient use of resources, and improve scheduling patterns.

Evaluating palliative care ward staffing using bed occupancy, patient dependency, staff activity, service quality and cost data.

BACKGROUND: Palliative care staffing has remained unchallenged for decades while service provision has changed markedly, bringing new workforce demands. There is little evidence to inform hospice workforce structures, which strive to deliver the highest-quality holistic care. AIM: The study had three main aims, to: (i) adapt the acuity-quality workforce planning method used extensively in the UK National Health Service (NHS) for use in hospices; (ii) compare hospice and NHS palliative care staffing establishments and their implications; and (iii) create ward staffing benchmarks and formulae for hospice managers. DESIGN: A method adapted from a widely used nursing workforce planning and development (WP&D) study was used to collect data in hospice and palliative care wards. SETTING: Twenty-three palliative care and hospice wards, geographically representing England, were studied. RESULTS: A dataset, which profiles and benchmarks hospice and NHS palliative care ward occupancy, patient dependency, staff activity, ward establishments, quality and costs in 23 palliative care and hospice wards has been created. The database reveals large differences between hospice and palliative care wards. For example, hospice wards are better staffed and more expensive to run but staff deliver higher-quality care (measured using an established service quality audit) despite facing heavier workloads. Consequently, staffing multipliers are created to help managers estimate workload-based ward staffing. CONCLUSIONS: This dataset provides evidence-based recommendations to inform palliative care nursing workforce modelling, including deciding future nursing workforce size and mix based on rising workloads. The new dataset is suitable for use in UK hospice wards and may be appropriate for future international use.

Diabetes inpatients: a case of lose, lose, lose. Is it time to use a 'diabetes-attributable hospitalization cost' to assess the impact of diabetes?

AIMS: The UK National Health Service in England pays for inpatients using a formula ('tariff'). The appropriateness of the tariff for people with diabetes is unknown. We have compared the tariff paid and costs for inpatients with/without diabetes and tested the concept of a 'diabetes-attributable hospitalization cost'. METHODS: This was a cross-sectional, retrospective 12-month audit in a single teaching hospital assessing mortality, bed days per annum and 'diabetes-attributable hospitalization cost' (i.e. the proportion of costs for all patients with diabetes in excess of that paid for comparable patients without diabetes). RESULTS: There were 64 829 inpatient admissions, with 4864 of those coded as having diabetes; 12.9% was estimated to be the number of patients having diabetes but not coded. People with diabetes occupied 13.9% of all bed days and were 18.1% (1.3-37.8%) more likely to die (age adjusted). The mean bed days per annum were greatest among those with (vs. without) diabetes (men 10.9 ± 17.0 vs. 6.3 ± 12.8; women 11.4 ± 19.4 vs. 5.9 ± 11.6; P < 0.001). The greatest excess admission rates were among those aged 25-64 years. The annual mean tariff was greater for those with diabetes (5380 ± 8740) than those without diabetes (3706 ± 6221) (P < 0.001). The overall cost was even higher among those with diabetes: 5835 ± 11 246 vs. 3567 ± 7238 (P < 0.001). The diabetes-attributable hospitalization cost was 46.5% (9 125 085). An HbA(1c) > 10.0% (> 86 mmol/mol) was associated with excess hospitalization. CONCLUSIONS: Those with diabetes cost more and are more likely to die when inpatients. The tariff paid for diabetes is high, but in this centre less than the actual costs. Approaches known to reduce hospitalization are urgently required.

Bed utilization in two differently organized community mental health services in Northern Norway: the VELO-project.

BACKGROUND: The literature on the dynamics between community- and hospital services concerning utilization of psychiatric beds is inconclusive. The Norwegian VELO-project provides an opportunity to study this in a natural experiment. Two service-systems are compared. The "central-bed system" have mainly outpatient- and day-hospital services locally, with psychiatric beds at a central mental hospital. The "local-bed system" have only one outpatient clinic, with beds at three local inpatient units. Also utilization of sheltered homes was studied. Hypotheses were predicted from Goldberg and Huxley's' stage theory and the Thornicroft and Tansella's' hydraulic model. MATERIALS AND METHODS: The case-registries of 2005 were linked across service levels by patients' 11-digit Social Security Number. From 1,865 single treatment episodes, 1,348 continuous courses by 1,253 individual patients were extracted. RESULTS: For overall utilization of psychiatric beds there was only a small difference, were the central-bed system utilized 10% less than the other. For utilization of emergency inpatient admissions and acute hospital beds, the rate was more than twice in the central-bed system compared to the other. For utilization of municipalities sheltered homes, the rate was three times higher in the local-bed system. DISCUSSION: There may be bedrock of need for psychiatric beds regardless of system-organization. Distance may in general be a minor issue for utilization of psychiatric beds, and may primarily interact with patient- or contextual characteristics associated with acute situations. Activity of day-hospital services rather than outpatient consultations may affect utilization of sheltered homes. The main theoretical models are conceptually useful, although more research is needed to specify mechanisms.

Use of complementary and alternative medicine (CAM) by Washington State hospices.

PURPOSE: To assess the use of complementary and alternative medicine in hospice care in the state of Washington. METHODS: Hospices offering inpatient and outpatient care in Washington State were surveyed by phone interview. RESULTS: Response rate was 100%. Results indicated that 86% of Washington State hospices offered complementary and alternative services to their patients, most frequently massage (87%), music therapy (74%), energy healing (65%), aromatherapy (45%), guided imagery (45%), compassionate touch (42%), acupuncture (32%), pet therapy (32%), meditation (29%), art therapy (22%), reflexology (19%), and hypnotherapy (16%). Most hospices relied on volunteers with or without small donations to offer such services. CONCLUSIONS: Complementary and alternative therapies are widely used by Washington State hospices but not covered under hospice benefits. Extensive use of these therapies seems to warrant the inclusion of complementary and alternative providers as part of hospice staff, and reimbursement schedules need to be integrated into hospice care.

[Tertiary obstetric care: the aims of the planning decree on perinatal care of 2001 have not yet been achieved]. / Derdelijns verloskundige zorg: doelstellingen van het 'planningsbesluit bijzondere perinatologische zorg' uit 2001 nog niet gehaald.

OBJECTIVE: To compare the actual situation in tertiary perinatal care in the Netherlands with the objectives laid down in the 2001 decree on perinatal care by the Dutch Ministry of Health, Welfare and Sport. DESIGN: Descriptive, retrospective. METHOD: Data on tertiary perinatal care, the transfer or refusal of women with very endangered pregnancies and the personnel of obstetric high care (OHC) units in 2006 were compared with the targets laid down in the planning decree on perinatal care and in a report by the Dutch Health Council from 2000. Parameters of tertiary perinatal care output were the number of admissions, and the number of beds in OHC units and neonatal intensive care units (NICU). RESULTS: In 2006, 128 of the 250 beds intended for OHC had been obtained. The degree of capacity utilisation was 94%, while the norm is 80%. 312 women were transferred due to lack of capacity of OHC units and NICU. The number of staff, specialised physicians as well as nurses, was considerably lower than the planned capacity. But training for obstetric perinatologists and OHC nurses was given. CONCLUSION: The targets for the number of beds for tertiary obstetric care and associated medical personnel have not been achieved as yet. As a consequence, the number of transfers is still too high. The funding of OHC units is not attuned to the complexity of tertiary perinatal care. Closer supervision of the execution of the planning decree and an adequate financing system are needed to achieve the objectives of the planning decree in the next 3 years.

[Hospital beds and mental health reform in Brazil]. / Leitos hospitalares e reforma psiquiátrica no Brasil.

The objective of this study was to estimate the number of psychiatric beds occupied per State in Brazil and the amount paid by the Unified National Health System (SUS) for hospitalizations, professional services, tests, and medicines in the country in 2004. The mean number of psychiatric beds occupied, estimated on the basis of total days of hospitalization during the year, and the amount paid by the SUS were obtained from the Hospital Admissions Authorizations (AIH). A total of 45 thousand psychiatric beds were occupied by the SUS in 2004. The SUS paid a total of BRL$487 million (some U$270 million) for hospitalization of patients with mental disorders in 2004. Private hospitals accounted for 78.8% of all psychiatric beds occupied by the SUS. Although the deactivation of 15 mil psychiatric beds could currently generate BRL$162 million (U$90 million) to be reallocated to non-hospital psychiatric services, planning and implementation of the Psychiatric Reform have been very limited. The precarious extra-hospital network has been used as a barrier to deactivation of psychiatric beds, although the latter generates the necessary resources for the former.

Incorporating efficiency in hospital-capacity planning in Germany.

Hospital occupancy is a key metric in hospital-capacity planning in Germany, even though this metric neglects important drivers of economic efficiency, for example treatment costs and case mix. We suggest an alternative metric, which incorporates economic efficiency explicitly, and illustrate how this metric can be used in the hospital-capacity planning cycle. The practical setting of this study is the hospital capacity planning process in the German federal state of Rheinland-Pfalz. The planning process involves all 92 acute-care hospitals of this federal state. The study is based on standard hospital data, including annual costs, number of cases--disaggregated by medical departments and ICD codes, respectively--length-of-stay, certified beds, and occupancy rates. Using the developed metric, we identified 18 of the 92 hospitals as inefficient and targets for over-proportional capacity cuts. On the upside, we identified 15 efficient hospitals. The developed model and analysis has affected the federal state's most recent medium term planning cycle.

A clinical pathway for treating pneumonia in the nursing home: part I: the nursing perspective.

OBJECTIVES: This paper examines nursing staff's perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia. DESIGN: A qualitative (case study) design was used. SETTING: Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home-acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home). PARTICIPANTS: A total of 7 focus groups and 1 one-on-one interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes. FINDINGS: Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail. CONCLUSIONS: The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents.

A clinical pathway for treating pneumonia in the nursing home: part II: the administrators' perspective and how it differs from nurses' views.

OBJECTIVES: This paper examines the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia from the perspective of nursing administrators and medical directors in Ontario, Canada. The discussion includes a comparison of the perspectives of the administrators and the nursing staff (reported in part I of this article). DESIGN: A qualitative case study design was used. SETTING: Data were collected from 6 nursing homes in Southern Ontario that were drawn from a larger randomized controlled trial of a clinical pathway to help identify, diagnose, and manage cases of nursing home-acquired pneumonia. PARTICIPANTS: Six interviews were conducted with nursing administrators and 2 with medical directors (1 per facility). Key themes were identified in the interview data using the template style of analysis described by Miller and Crabtree. FINDINGS: Administrators were in favor of using a clinical pathway for identifying and treating pneumonia in nursing home residents. Participants thought that during the study residents with pneumonia received better and more timely care, and that nurses' clinical skills, knowledge, and confidence had improved. In comparison with views expressed by nurses and medical directors in the same facilities, nursing administrators tended to report less clinical training and staff support were required to successfully implement the pathway. CONCLUSIONS: Even though nurses and administrators strongly support the use of a pneumonia clinical pathway in nursing homes, implementation plans should be tailored to individual facilities and be informed by the perspectives of both administrators and staff.

Inappropriate acute neurosurgical bed occupancy and short falls in rehabilitation: implications for the National Service Framework.

Patients undergoing neurosurgical intervention may require different types of organized rehabilitation. A prospective study was performed of the care needs of neurosurgical inpatients between the ages of 16 and 70 years who were in acute wards for more than 2 weeks. Only 58% of bed occupancy days were devoted to essential acute neurosurgical ward management. This figure was even lower for patients admitted with subarachnoid haemorrhage (36%) or traumatic brain injury (38%). Overall, 21% of bed days would have more appropriately spent in 'rapid access'/acute rehabilitation beds, 13% in 'active participation' rehabilitation beds and 5% in cognitive/behavioural rehabilitation units. Addressing this unmet need would increase the availability of acute neurosurgery beds, without needing to build and staff more neurosurgery wards.

Is midwife workload associated with quality of process of care (continuous electronic fetal monitoring [CEFM]) and neonatal outcome indicators? A prospective study in consultant-led labour wards in Scotland.

Evidence for staffing recommendations in labour wards is scant. This study aimed to test association between midwife workload with adjusted process of continuous electronic fetal monitoring (CEFM) and neonatal outcome indicators. This was a prospective workload study in 23 consultant-led labour wards in Scotland. There were 3489 livebirths during September 2000, and 1561 consecutively delivered women with CEFM case review during the mid-two weeks. Process measures were: adjusted rates of CEFM, appropriate CEFM, and time to medical response for a serious fetal heart trace abnormality. Neonatal outcome indicators were: Apgar score < 7 at 5 minutes, admission to neonatal unit (NNU) > 48 hours, and neonatal resuscitation. Complete information was available for 99% (2553/2576) of workload time points, 99% (1559) of CEFM process, and 3083 eligible neonates. There were no associations between occupancy or staffing ratios and adjusted CEFM process, Apgar < 7 at 5 minutes (0.98 [0.83, 1.15]) or admission to NNU for > 48 hours (0.97 [0.95, 1.00]). However, there was association between increasing staffing ratios and lower odds of adjusted neonatal resuscitation (excluding bag and mask only) (0.97 [0.94, 0.99]). The direction of effect of increasing workload suggests detriment to outcome indicators, although the size of effect may be small.