Pushing the Envelope in NICU: Are we ready?

Another year has passed and another World Prematurity Day is upon us.  I thought about what to write for this day that draws attention to premature infants worldwide and was hit with many ideas which no doubt will form the basis for many posts to come. There was one thought that struck me though as being so important to think about as we push forward, striving to improve survival across the globe for our smallest patients.  There is no doubt that you will have heard the expression “just because we can do something, should we?”  In 2015 I don’t think this applies more than at this very moment.

At a Tipping Point

You see we are at a tipping point as Malcolm Gladwell explained so brilliantly in his book by the same name.  Tipping-PointIn April of 2015 Rysavy et al published the results of survival and morbidity data for infants born in 24 US hospitals between the ages of 22 – 26 weeks.  The nearly 5000 infants included demonstrated two very important things.  Firstly, survival is possible at 22 and 23 weeks and there is a chance, albeit less than 50% that these infants will survive without moderate or severe disability.  Secondly, at these gestational ages 75% of hospitals included provided active resuscitation to these infants.  Given that this is the largest study out there and shows that survival is possible and we can expect to see some good outcomes it would seem logical to move forward with universal resuscitation of these infants would it not?

You Are Going To Practice on What?!

As the saying goes though, “Perfect Practice Makes Perfect”.  Not all hospitals have equal performance at these gestational ages which is demonstrated in the ranges of outcomes across hospitals as shown in the Rysavy paper.  To even suggest that we need to practice on premature babies will no doubt leave many of you feeling queasy but in essence that is what is truly needed to improve our outcomes further.  An infant born at 22 – 24 weeks is vastly different than one born at a later gestational age.  Their skin is extremely fragile and prone to breakage with resultant risk of infection.  Their lungs are in a stage of development that has yet to produce any real abundance of gas exchanging alveoli and their brains lacking the sulci and gyri that are to come many weeks later.  They are in need of meticulous “best practice” care and without that their outcomes are certainly to be influenced.  Depending on the centre though, you may see 5, 10, 15, 20 patients a year at these ages.  How can a team possibly gain enough experience in treating these children appropriately if they see 1 or 2 every two months?  Add to this that you may have 10 different Neonatologists so on average each of you may take care of one patient a year at birth.  This is a recipe prone to poor outcomes if you ask me.

The Evolution of the Small Baby Unit

The answer no doubt will lie in creating smaller teams; so called “Small Baby Units”.  Such units have small groups of health care providers dedicated to treating such infants thereby increasing the frequency of individuals exposure to these babies.  There is some recent evidence published in Pediatrics that supports this notion.  Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants.  In this study a period of two years before and four years after opening such a unit were compared across a number of measures. The findings were as follows “There was a reduction in chronic lung disease from 47.5% to 35.4% (P = .097). The rate of hospital-acquired infection decreased from 39.3% to 19.4% (P < .001). Infants being discharged with growth restriction (combined weight and head circumference <10th percentile) decreased from 62.3% to 37.3% (P = .001). Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 (P < .001) and radiographs decreased from 45 to 22 (P < .001).”   I hope you would agree that achievements such as these are worth the effort to create such an environment.  Future studies I believe will confirm these findings although having the gold standard RCT may be difficult to achieve as I suspect we will have lost equipoise.

This brings me to the final point though and that is whether we are ready as a health care system for the increase patient load that this change will bring about.  Based on an expected stay of 4 months for a baby born at this age and knowing the average number of such babies delivered per year, we would be looking at about 600 patient days per year added to each hospital’s occupancy in our two centres.  photo-meet-MacThis represents about a 5% increase in patient bed days per year.  Five percent may not seem like a large increase at first blush but when we like many hospitals have been trying to deal with staffing issues and many days in which we are at or near capacity, this is not an insignificant challenge.  It is a challenge though that we must face head on.  Resources must be found, and space provided to accommodate for these children.  We live in a world now where it is not solely up to us but to the family as well who must be integral to any such decision to either pursue or withdraw care.  News of such infants surviving has spread to the public and I have no doubt that many families will have heard stories of such survivors.  The next phase of care for these infants must address the shortcomings in care at the moment.

How do we educate families about what to expect in the long run?

How do we support these families when they make such difficult decisions either way?

How do we support our front line staff who may hold quite discrepant viewpoints about what is “right” yet expect them to function as one team moving clearly in a direction that supports the family?

How do we ensure that our focus on our smallest infants does not distract us from the attention needed by those born at later gestational ages?

I could go on but these are just some of the questions that I hope the next year begins to tackle.  We are in the midst of an evolutionary point in Neonatology and we owe it to ourselves and the families we care for to navigate this change as best we can.

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