Creating Regional Neonatal ICUs to Better Protect Babies and Moms
By Dr. Brian Iriye
Seeing how many people with a Rolex watch in Southern Nevada is impressive. They are expensive timepieces, built to extreme tolerances, and passionately created for excellence and innovation by skilled engineers, watchmakers, and designers. At the same time, I often wonder how many I see are real. A quick perusal of the web allows me to buy a “Rolex” that looks very real. However, the components are not the same; they are not waterproof, the accuracy is decreased, and the sturdiness is questionable.
Similarly, there has been a proliferation of “specialized” services within Nevada with tags of “centers of excellence”. Within the field of pregnancy and neonatal care, there has been an explosion of every hospital“needing” a level 3 neonatal intensive care unit. These units are for the sickest of newborns, some weighing less than a pound and born 4 months too soon. The personnel working in these units (nurses, doctors, respiratory therapists, social workers, and administrative personnel)do a fantastic job with their resources. High-level care requires a highly trained and experienced team to get the best outcomes for these critically ill newborns. Currently, 8 of 9 hospitals that deliver babies in Clark County have or will soon have these level 3 NICUs. Hence, that requires trained personnel teams and equipment in 8areas instead of maybe the 4 teams the Southern Ne-vada region needs. This dilutes the experience of care at each center. It also waters down skilled leadership and personnel education making efforts more challenging to disseminate critical new medical information. Instead of high-volume experienced teams, there is a weakening of care, education, and experience.
Well, you may ask, how many NICUs are too many? What is the genuine “Rolex of NICU care”? Data seems to support hospitals that take care of a low volume of very low birth weight infants (those that weigh less than1500g or roughly 3 pounds 5 ounces) have worse outcomes. Delivering a very low birth weight baby at a hospital that takes care of less than 50 very low birthweight deliveries annually has an 11% increase in neonatal death. Another study, after adjusting for risk, showed that there also was a 16 to 55% higher risk of morbidity or abnormal outcome as well for hospital NICUs that did less than 50 low birthweight deliveries per year. Within all of Nevada in 2020, there were only 436 births at less than 1500g. Hence, most hospitals in southern Nevada are falling under the 50 very low birth weight babies per year where outcomes are compromised, according to major studies.
The spreading out of neonatal care also strains the care of moms. How so? Many pregnancies requiring early delivery are due to maternal medical problems such as severe blood pressure elevations or significant respiratory issues. The same dilution of medical care within NICUs also occurs in labor and delivery units. It strains the work of maternal-fetal medicine (high-risk pregnancy) physicians that must cover 8-9 Clark County hospitals, often with only 1 or 2 sick mothers at each. Nursing care is also diluted when the nursing workforce is strained from PTSD in a post-pandemic world. This is not a good recipe for success in a country with the highest maternal death rate in the developed world. Nevada is also 1 of 2 states in the country without a centralizing perinatal quality collaborative to improve maternal care within hospitals.
How have we landed here? The NICU is one of the top 3 most profitable places in a hospital and generates significant revenue, so incentives are to build them. NICUs are supposed to be need-based, but these criteria are based chiefly on delivery volume. However, evidence exists that NICU admission rates correlate with NICU available bed numbers. At the cost of greater than $5000/day, NICU care, if unneeded, is an expensive proposition. If care is delivered less than ideal to babies and possibly diminishing care of mothers with illnesses, this lack of a comprehensive community solution is a problem.
How can this be fixed? Financial incentives for more units and more beds exacerbate our problems. Instead, paying more for experienced care and less for inexperienced care would make sense at a hospital level. Hospital systems could assist by pushing for regionalized centers which would save system (over individual medical centers) money while improving outcomes. Politicians would help by instituting regulations enforcing a strict level of need to open and operate higher-level NICU services. Currently, our state has a “certificate of need” program, but it is easy to meet. States like Massachusetts with a strict certificate of need regulation for perinatal services have seen low NICU growth and yet still have the lowest infant mortality rate in the US. Payors should advocate for NICU admissions review of late preterm and early term infants which account for large majority of unnecessary NICU admissions. Physicians need to educate themselves on the outcomes of lower volume units and drive care to experience over expedience. Physician groups need to come together to provide true value-based care where the best outcomes are provided for efficient costs. Only then can we encourage care that operates like a fine-tuned Swisswatch instead of a replica.
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