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Neonatal intensive care requires continuous close monitoring of several physiological parameters. The machinery involved is complex but has to be understood by medical staff with the minimum of training in its use. Failure of correct application and interpretation of results can be dangerous for the sick or preterm infant.
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Using the Norris and Grove (1986) questionnaire of perceived needs of families of critically ill patients, 11 registered nurses working in the neonatal intensive care unit and 19 registered nurses working in the intensive care unit of two mid-northern community hospitals provided their perceptions of family needs. Their responses were compared with responses of family members of patients in the intensive care unit (n = 25) and the (n = 24). Results suggest that regardless of unit, registered nurses' perceptions of family needs are congruent. Family members collectively and by unit ranked their needs consistently higher and in some areas differently than did the registered nurses.
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Although neonatal intensive care has been praised widely for individual successes, its effectiveness has not been established systematically or conclusively. The literature consists principally of reports from individual intensive care units with sample sizes too small for statistical validation or generalization. This study analyzes the results obtained by recalculating and pooling the isolated reports. In addition, the findings of the solitary clinical trial, some scattered epidemiologic data, and several analyses of regional birthweight-specific time series data are reviewed. Taken together, this constitutes a body of evidence that supports the conclusion that intensive neonatal medical care has played a significant role in bringing about the impressive reduction in infant mortality that has taken place in this country since 1965.
Neonatal intensive care units may choose to selectively withdraw support in some neonates with severe brain damage. We offer suggestions for criteria for such withdrawal, and a review of 20 cases in which such a decision-making process occurred in our neonatal intensive care unit.
Neonatal mortality has declined since the advent of intensive care. The incidence of cerebral palsy has likewise decreased in spite of increased survival of low birth weight infants.
The continued rise of health care costs, despite private and governmental control efforts, has sustained cost containment as a central issue for health care researchers and policy makers. In keeping with these concerns, the Florida Health Care Cost Containment Board conducted a study of neonatal intensive care units (NICUs) in Florida to ascertain the costs, charges, and net revenues associated with NICU services in individual hospitals, to document cost shifting and cross-subsidization as a means of financing NICU care for indigent populations, and to assess the fiscal impact of NICUs in state-sponsored vs non-state-sponsored Regional Perinatal Intensive Care Center hospitals providing NICU care. Hospitals in the state-sponsored program reported a loss of approximately $16.5 million in contrast to the non-state-sponsored hospitals, which reported a gain of $1 million. Payment being generated by private-pay patients amounted to almost 60% of total revenues but constituted less than one third of the costs in state-sponsored hospitals, indicating a high level of cost shifting. Government support of state-sponsored NICUs, while substantial, has been insufficient; increasing constraints on this funding source would likely worsen the deficit and increase the necessity of cost shifting.
The accuracy of a neonatal intensive care unit (NICU) staff in predicting the outcome and length of stay of infants admitted to the NICU, and the factors they felt were important in making these predictions, were evaluated. This prospective study used a questionnaire to survey 44 nurses, residents, and attending neonatologists working in the NICU about the predicted outcomes of 52 infants admitted to the NICU at the University of Nebraska Medical Center over a 1-month period. Factors previously identified by the staff as important indicators of infant outcome were assigned points of importance by the respondents, and specific values for these factors were recorded for each infant. The NICU staff indicated that gestational age was the most important indicator of infant outcome. The attending neonatologists placed more value on gestational age (analysis of variance [ANOVA] P less than .0001) than did the nurses or residents. Among the staff groups, there were significant differences in the weight or points assigned to a given factor for pulmonary function, renal function, number of resuscitations, and the "other" category (ANOVA P less than .05). The nurses ranked pulmonary function criteria lower than the residents did (P less than .04), but considered renal function more important than either the residents (P = .005) or the attending neonatologists considered it to be (P = .01). The number of resuscitations was ranked higher by the nursing staff than by other groups, whereas the attending neonatologists assigned less importance to the "other" category.(ABSTRACT TRUNCATED AT 250 WORDS)
Observed and birthweight-specific neonatal mortality rates have been used for assessing quality of neonatal care, but these are crude and affected by risk characteristics of the population served. Even when neonatal mortality rate is corrected for four risk factors, race, sex, birthweight, and multiple births, (California Data Research Facility, Santa Barbara, CA) it is possible that the corrected neonatal mortality rate is not comparable among institutions because of population differences not corrected for, eg, prenatal care. To analyze whether our high neonatal mortality rate is primarily dependent on population risk or quality of neonatal care, we used contemporaneous data collection by senior physicians and a microcomputer database system to construct indices of quality of care that are based on diagnoses graded according to disease severity. For the 1987/1988 academic year, we found: neonatal intensive care unit nosocomial infection rate, 20%; severe intraventricular hemorrhage per 100 very low birthweight infants (1500 g), 20%; bronchopulmonary dysplasia per 100 cases of severe respiratory distress syndrome, 27%; necrotizing enterocolitis per 100 neonatal intensive care unit discharges, 5%; air leak per 100 cases of severe respiratory distress syndrome, 21%; and neonatal mortality rate per very low birthweight delivery rate, 0.4. We propose that microcomputer, hospital-based analyses will improve comparisons of neonatal intensive care unit quality of care if appropriate indices can be sufficiently well-defined and shared.
This study deals with clinical results obtained at the neonatal intensive care unit of the Kinderklinik der Stadt Wien - Glanzing since its inception in 1974. An analysis of our newborn cases-admitted from 14 obstetric departments in Vienna and some obstetric departments in Lower Austria and Burgenland soon after birth-points to the fact that prematurity is still the most important risk factor in neonatal mortality. The results show that the prognosis of high-risk newborn infants depends very much on condition in the delivery room following primary resuscitation, the neonatal mortality increases with immaturity, hyaline membrane disease is the most important indication for artificial ventilation of premature infants, 30% of all patients requiring artificial ventilation are fullterm infants; 45% of them suffer from cerebral respiratory dysfunction, the mortality rate in mechanically-ventilated infants could not be significantly decreased over the past years. The consequences are discussed.
Neonatal intensive care unit survivors (N = 494) from 10 tertiary care centers were evaluated over the first 4 to 5 years of life to determine the relative contributions of birth weight and sociodemographic factors to mental development. Six sociodemographic factors were studied: sex, race, family income, and mother's marital status, age, and educational level; the last five factors also are known to be associated with premature birth. Mental development was measured with the Bayley Scales of Infant Development (12 to 24 months) and the Stanford Binet Intelligence Test (4 to 5 years). Each factor's influence was assessed by multivariate analysis. Birth weight had limited long-term implications; at 4 to 5 years, only infants with birth weights less than 1000 gm had significantly lower scores than those in other birth weight categories. Sociodemographic variables had a greater impact on mental development, with age-dependent differences found between nonwhite and white children and between children with mothers of low, medium, and high educational levels.
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This study reports the growth and development of 28 survivors who had a birth weight of less than or equal to 1,000 g and were cared for at a Regional Neonatal Intensive Care Unit. Only eight (30%) had neurologic abnormalities including spastic hemiparesis, retrolental fibroplasia, hydrocephalus, motor retardation, and some delay in language skills. The other survivors had normal physical examinations and developmental progress judged by a variety of screening examinations up to age four years, three months. The average caloric intake during the first week was 61 kg/da, although over half never reached that level until day 4. Nearly all the infants have had standard growth patterns thus far.
A comprehensive approach to the delivery of family-centered care in the neonatal intensive care unit (NICU) requires that parental perceptions of caregiving be addressed. The Parent Feedback Questionnaire is based on researched needs of NICU parents. Specific dimensions of needs (informational, emotional, parenting, and environmental) and overall satisfaction are identified and included in survey items. Ongoing feedback from parents is obtained and incorporated into a planned multidisciplinary continuous quality improvement program. Evaluation of data has resulted in planned interventions to reduce sources of stress and dissatisfaction for parents.
Eight years after neonatal intensive care, parents of 597 survivors indicated whether the initial illness and separation had had a long-term effect on their parent-child relationships. Forty percent felt there was an effect on the parent-child relationship, sixty percent did not. Neonatal, medical and social conditions, and the child's outcome (i.e., disabled or not) were variables analyzed to determine differences between the two groups of parents. Parents who felt an effect from the initial illness and separation had children who required supplemental oxygen significantly longer and were from significantly higher socioeconomic and education levels. Length of stay in neonatal intensive care and outcome were among the not significant variables.
Neonatal mortality due to congenital malformations or genetic disorders has not decreased despite a decrease in overall neonatal deaths with recent advances in medical technology. As a consequence, an increasing percentage of neonatal deaths is attributable to congenital malformations and genetic disorders. This study retrospectively reviewed neonatal deaths associated with congenital malformations over an 11-year period in the neonatal intensive care unit (NICU) at Kosair Children's Hospital, Louisville, Kentucky. Presently, congenital malformations are responsible for approximately 45% (range 32% to 61%) of deaths in the NICU with congenital heart disease, lethal genetic disorders, and pulmonary hypoplasia being the main contributors. Other major causes of neonatal death included extreme prematurity, respiratory disorders, necrotizing enterocolitis, sepsis, asphyxia, and primary pulmonary hypertension. It is important that clinicians are aware that improved survival is expected for most diseases because of technological advances, but that further significant reductions in neonatal mortality will depend on genetic counseling and prevention of congenital malformations.
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.