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PubMed2001

A critical review of cost reduction in neonatal intensive care. I. The structure of costs.

Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.

Accounting↗
PubMed1979

Osteomyelitis in a neonatal intensive care unit.

Neonatal osteomyelitis presents with few clinical signs despite multiple sites of involvement. Four cases of osteomyelitis due to Staphylococcus aureus or Candida albicans were encountered in a neonatal intensive care unit. Three were unsuspected clinically and were detected as incidental radiologic findings. The fourth presented with soft-tissue abscesses. Long bone metaphyses were most frequently affected. Other sites included iliac bones, clavicles, and spine. On follow-up the bones healed, but one patient was left with hip deformity secondary to destruction of the cartilaginous femoral heads and another patient developed obstructive hydrocephalus due to Candida ventriculitis. Complete skeletal survey is indicated in any infant with osteomyelitis at one site to seek additional silent areas of involvement.

Abscess↗
PubMed2006

Mothers' experiences of having their newborn child in a neonatal intensive care unit.

BACKGROUND: From birth the child has an ability to respond to the environment, which influences the interaction between mother and child. If this attachment is interrupted, the child's emotional development is negatively influenced. When the child needs care in a neonatal intensive care unit (NICU) it is difficult to establish contacts between mother and child. Separation from the child is found to be the most difficult aspect for mothers when their newborn child is hospitalized in a NICU. AIM: The aim of this study was to describe mothers' experiences when their full-term newborn child was cared for in a NICU during the postpartum maternity care period. METHOD: A phenomenological hermeneutic interview study was performed. Ten mothers were interviewed once, 6 months to 6 years after the experience. RESULTS: The essence of the experience is understood as an alternation between two opposite concepts, exclusion and participation, with emphasis on exclusion. A feeling of exclusion dominates when the new mother feels a lack of interaction and a sense of not belonging to either the maternity care unit or the NICU. This has a negative effect on her maternal feelings. On the contrary, when a feeling of participation dominates, a continuous dialogue exists and the mother is cared for as a unique person with unique needs. This supports her maternal feelings in a positive direction. The implication of the result for nurses is that it is important to decrease mothers' experience of exclusion and to increase their feeling of participation when their child is cared for in a NICU. A return visit to the responsible nurse to go through the treatment and experiences should be offered to all parents whose child has been cared for in a NICU.

Adaptation, Psychological↗
PubMedDate not supplied

Methods in informatics: using data derived from a systematic review of health care texts to develop a concept map for use in the neonatal intensive care setting.

A qualitative systematic review of textbooks and clinical guidelines identified assessment criteria for initiation of nipple feeds in premature infants cared for in the neonatal intensive care unit (NICU) setting. Using a structured method for text source selection and data extraction, 43 health care texts were systematically reviewed yielding 153 separate statements related to assessing premature infants' feeding readiness. Following this procedure, a pile sort method was conducted wherein an expert neonatal nurse practitioner (NNP) grouped the statements according to similarity in meaning. Ten piles of terms emerged from this process. Each pile was "named," depicting discrete components used when assessing premature infants' readiness for nipple feeding. Using these public data and the private knowledge of the NNP informant, a concept map was constructed to illustrate a framework for decision support development and to examine the map's usefulness for structuring knowledge that will provide input to an intelligent decision support system.

Computational Biology↗
PubMed1993

Staff views on parental visiting of very low birthweight infants in neonatal intensive care units--results of a staff enquiry across eleven countries of the European Community. EC-Study Group on Parental Involvement in Neonatal Intensive Care.

As part of a larger European study of parental visiting and involvement in the care of very low birth weight infants in neonatal intensive care units, the results of a self-completed anonymous enquiry of 1008 medical/nursing staff of 35 units in 11 European countries are presented. The study demonstrates a general agreement with parental visiting and involvement, with sometimes striking differences in views of staff of different countries, but with little or no differences between medical and nursing staff. Staff with more than seven years experience in neonatal care have a less positive attitude towards parent's presence in the unit. The same holds true for staff of units that have a restricted policy toward parents' visiting, i.e. units which do not have a 24-hours visiting policy for parents.

Attitude of Health Personnel↗
PubMed1998

Declining severity adjusted mortality: evidence of improving neonatal intensive care.

OBJECTIVES: Declines in neonatal mortality have been attributed to neonatal intensive care. An alternative to the "better care" hypothesis is the "better babies" hypothesis; ie, very low birth weight infants are delivered less ill and therefore have better survival. DESIGN: We ascertained outcomes of all live births <1500 g in two prospective inception cohorts. We estimated mortality risk from birth weight and illness severity on admission and measured therapeutic intensity. We calculated logistic regression models to estimate the changing odds of mortality between cohorts. PATIENTS AND SETTING: Two cohorts in the same two hospitals, 5 years apart (1989-1990 and 1994-1995) (total n = 739). RESULTS: Neonatal intensive care unit mortality declined from 17.1% to 9.5%, and total mortality declined from 31.6% to 18.4%. Cohort 2 had lower risk (higher birth weight, gestational age, and Apgar scores and lower admission illness severity for newborns >/=750 g). Risk-adjusted mortality declined (odds ratio, 0.52; confidence interval, 0.29-0. 96). One third of the decline was attributable to "better babies" and two thirds to "better care." Use of surfactant, mechanical ventilation, and pressors became more aggressive, but decreases in monitoring, procedures, and transfusions resulted in little change in therapeutic intensity. CONCLUSIONS: Mortality decreased nearly 50% for infants <1500 g in 5 years. One third of this decline is attributable to improved condition on admission that reflects improving obstetric and delivery room care. Two thirds of the decline is attributable to more effective newborn intensive care, which was associated with greater aggressiveness of respiratory and cardiovascular treatments. Attribution of improved birth weight specific mortality solely to neonatal intensive care may underestimate the contribution of high-risk obstetric care in providing "better babies."

Hospital Mortality↗
PubMedDate not supplied

Another false alarm? apnea monitor activation in a Neonatal Intensive Care Unit graduate.

Neonatal emergencies have become more common as increasingly sophisticated Neonatal Intensive Care Units graduate lower birth-weight babies born at younger gestational ages. These patients present a number of challenges to emergency physicians. They are often discharged with apnea monitors, which generate a high number of false alarms. Neonatal Intensive Care Unit graduates, however, are predisposed to a number of conditions that can result in true episodes of apnea. We present such a case and will discuss the unusual underlying cause of apnea, the utility of apnea monitors, and the need for emergency physicians to be prepared to evaluate and treat these potentially complicated patients.

Apnea↗
PubMed2003

Do we practice evidence-based care in our neonatal intensive care units?

The RPA NICU has attempted to work as a team to provide consistent family centered care based on the best available evidence. This has been facilitated by a number of factors. The RPA NICU is in an academic institution with most staff involved in teaching and research and clinical care. All of the consultant neonatologists have research degrees, a factor associated with the use of evidence in practice. A key factor is the collaborative effort among consultant neonatologists with an agreement that consistent care is important. Staff buy-in is important for consistent approaches to care 24 hours a day at every bedside when there are rotating house staff and nurses. A team effort involving both physicians and nurses is particularly important in this regard. Difficulties do arise when there is insufficient evidence to inform practice in acute care settings. When treating seriously ill newborns, pressure from anxious staff and parents to "do something" is great. It is tempting to introduce new high-technology treatments, such as high-frequency oscillatory ventilation or extracorporeal membrane oxygenation, before their usefulness has been established. In these situations, a clear distinction is required between practice and research. Where possible, new treatments should be evaluated within a scientific framework so as to add new knowledge about the clinical intervention. It is difficult (although not necessarily impossible) to discontinue a practice that has been in routine use despite a lack of evidence. Management of hyperbilirubinemia in term and preterm infants is a good example. Replacing competition with collaboration and consensus among staff and agreeing to a broad framework for systematic evaluation, implementation, and evaluation of evidence in patient-centered care should allow the authors' center and others to improve patient outcomes in the short term and promote better clinical research to improve outcomes in the future.

Biomedical Research↗
PubMed1998

Developmentally supportive care in a neonatal intensive care unit: a research utilization project.

PURPOSE: To implement three aspects of developmental care: lower noise levels, decreased light levels, and flexed, midline positioning. DESIGN: Research utilization project. The developmental care interventions were implemented on a daily basis for two hours of "quiet time" during each eight-hour shift. SAMPLE: 49 infants with mean gestational ages of 35.1 +/- 3.2 weeks and mean weights of 2,107 +/- 464 gm. MAIN OUTCOME VARIABLE: Noise levels, light levels, and flexed midline positioning. RESULTS: Mean light levels and mean noise levels decreased during "quiet time" on all three shifts during the project. Optimal positioning was achieved 78 percent of the time during the project period observations.

Child Development↗
PubMed2005

17 alpha-hydroxyprogesterone caproate (17P) usage in a Medicaid managed care plan and reduction in neonatal intensive care unit days.

PURPOSE: To evaluate whether providing 17 alpha-hydroxyprogesterone caproate (17P) to high-risk pregnant women who have a history of preterm delivery in a Medicaid managed care population reduces the rate of neonatal intensive care unit (NICU) admissions, NICU length of stay, and associated costs. DESIGN: A 2004-2005 longitudinal review of birth outcomes in 24 pregnant women with a history of preterm delivery who were treated with 17P versus a control group. METHODOLOGY: Intervention included offering 17P as a benefit to pregnant women who had a history of preterm labor and delivery and who were deemed to be appropriate candidates for this treatment by their physicians. An educational program about 17P was developed that was aimed at physicians, their office staff, and plan members. A process of early identification of potential 17P candidates was also implemented. PRINCIPAL FINDINGS: NICU admission rates decreased to 14.3 percent in the control group and 8.3 percent in the 17P group. NICU length of stay decreased significantly from 231 days in the control group to 149 days in the 17P group. Overall costs for the control group were dollar 568,462 versus dollar 165,487 in the treatment group--a significant savings of dollar 402,975. CONCLUSION: Offering 17P as a benefit to pregnant women enrollees with a history of preterm delivery can decrease NICU days significantly for a Medicaid managed care plan.

17 alpha-Hydroxyprogesterone Caproate↗
PubMed1992

Rate of bronchopulmonary dysplasia as a function of neonatal intensive care practices.

Some differences among neonatal intensive care units (NICUs) in incidence of bronchopulmonary dysplasia may reflect variations in medical care practices. After adjusting for differences in the inherent risk of bronchopulmonary dysplasia among 223 infants of less than 1751 gm birth weight who were admitted to three Harvard-affiliated NICUs, we used multivariate analysis to explore the extent to which medical care practices during the first days of life varied with the rate of bronchopulmonary dysplasia. In our analyses, variables were grouped by three major hypotheses: oxygen toxicity, barotrauma, and fluid overload. The NICU designated 1 (the one with the highest rate of bronchopulmonary dysplasia) used much higher than expected colloidal volumes during the first 4 days of life; in contrast, in the NICU designated 3 (the one with the lowest rate of bronchopulmonary dysplasia), infants consistently received lower than expected amounts of colloidal solution. Signs of patent ductus arteriosus were also much more frequent than expected during this time at NICU 1; rates were much lower than predicted at NICU 2 and were near predicted values at NICU 3. Maximum inspired oxygen fraction during the first 4 days varied significantly in a direction inconsistent with the oxygen toxicity hypothesis. Maximum arterial oxygen tension was significantly less than expected at the hospital with the lowest rate of bronchopulmonary dysplasia (NICU 3). None of six medical care practices indicating potential for barotrauma varied with NICU expect for positive end-expiratory pressure, which varied in a direction suggesting a protective effect against bronchopulmonary dysplasia. These findings agree best with the hypothesis that differences in hydration during the first days of life account for some of the difference among NICUs in bronchopulmonary dysplasia occurrence.

Bronchopulmonary Dysplasia↗
PubMed2006

A model of nursing care microsystems for a large neonatal intensive care unit.

Nationally the number and size of neonatal intensive care units (NICUs) continues to grow. Today, NICUs with >40 beds, often referred to as "megaunits," are not uncommon. Staff in large units find it challenging to maintain teamwork, communication, and continuity of nursing care for patients. Families find large units overwhelming. In large NICUs, nurse leaders struggle to achieve a balance between parent satisfaction with care provided and nursing job satisfaction. This article describes the development of a new model of nursing practice, a nursing team microsystem. This innovative model has the unique effect of creating smaller units within the larger one, using highly skilled nursing teams, that are geographically grouped to provide care for infants and their families. The model supports teamwork, communication, continuity of care, and has shown a positive impact on both family and nurses' job satisfaction.

Continuity of Patient Care↗
PubMed1999

[Standards for neonatal intensive care nursing: unit directed management standards].

The neonate has the right to quality nursing care and the Neonatal Intensive nursing care practitioner is professionally-ethically and personally liable for quality nursing care. The process of quality improvement is a structured, planned and purposeful action were standards are set and the nursing care is evaluated after which remedial steps are taken to improve quality nursing care. In this study the focus is on the first step in the quality assurance cycle:the setting of standards. The purpose of the study is to describe and formulate standards for Neonatal Intensive nursing care which can be utilised as an accreditation instrument for institutional selfevaluation to improve quality nursing care. Standards for Neonatal Intensive nursing care were developed and validated by utilising a three-phase research method. In phase one subjects for standards were identified by a panel of experts. The identification was done by means of a critical debate, after which a preliminary conceptual framework was formulated. During the second phase a literature control was done to refine the conceptual framework. It consisted of a conceptual framework pertaining to unitmanagement (article 1) and an conceptual framework pertaining to high incidency, high risk interactions in the Neonatal Intensive Care Unit. The conceptual framework pertaining to the high incidency, high risk interactions in the Neonatal Intensive Care Unit consisted of: assessment of the neonate preparedness for neonatal resuscitation mechanical ventilation humidification during ventilation physiotherapy and suctioning of the ventilated neonate weaning during mechanical ventilation ecstubation During the third phase, the standards were validated by means of a consencus debate. An accreditation instrument was developed for institutional selfevaluation to improve quality nursing care in the Neonatal Intensive Care Unit. The standards that were formulated consisted of standards for unitmanagement (article 1) and standards directed at high incidency, high risk interactions in the Neonatal Intensive Care Unit which is published in the second article in this series.

Accreditation↗
PubMed2000

Prediction of outcome at school age in neonatal intensive care unit graduates using neonatal neurologic tools.

Prediction of outcome for neonatal intensive care unit graduates is clinically useful to counsel families effectively and target those who may benefit from early interventions. Evoked potentials have proven prognostic value of neurologic outcomes in early childhood; however, their long-term predictive validity remains to be determined. The objective of this prospective study was to determine the long-term predictive value of three neonatal neurologic assessments: brainstem auditory evoked potentials, somatosensory evoked potentials, and the Einstein Neonatal Neurobehavioral Assessment Scale. Seventy-eight high-risk newborns and 28 healthy controls were recruited and were assessed in the newborn period using these tests. At 8 to 9 years of age, 42 subjects and 13 controls were re-evaluated for developmental progress using a range of psychologic, sensorimotor, and neurologic measures. Findings indicated that the somatosensory evoked potential was most accurate at predicting outcome at school age, with high specificity (83-100%) across all domains tested and good sensitivity (80-100%) for intellectual performance and sensorimotor abilities. The brainstem auditory evoked potential was limited by false-negatives, whereas the neonatal neurobehavioral assessment yielded many false-positives. This study provides new evidence that associations between neonatal somatosensory evoked potentials and developmental sequelae continue to be significant at school age.

Brain Diseases↗