Wednesday, May 30, 2007

Practice Makes Perfect

Larger, busier neonatal intensive care units have better outcomes than the very smallest ones.

Surprised? I wasn't. We have slow spells, but overall we're pretty busy for a community hospital. When we orient new nurses, we like to be busy. Not crazy, but busy enough for the orientees to get significant experience before they have to function without someone looking over their shoulder.

Even when they finish orientation, we try not to staff any particular shift with mostly new nurses. It's best to have at least a couple of experienced nurses around in case something unusual comes in the door. We can do that, because we have a large enough staff. Imagine a unit that only staffs 2-3 nurses on a shift. Not nearly so much flexibility there.

Even when we have only experienced nurses on a shift, we bounce ideas off each other. We ask for input from our co-workers and we share what we've learned from conferences and journal articles. It helps us all to be better nurses. It also means that when we send one nurse to a delivery, there is more than one other nurse in the NICU. You just can't be at 2 bedsides at the same time.

It doesn't surprise me that the death rate for very low birth weight preemies (VLBW) -- under 1500 grams or about 3 pounds -- nearly doubles in hospitals which admit fewer than 10 babies that size in a year. You just don't get enough experience to keep your skills and judgment honed when you are dealing with such small numbers of babies.

Mortality rates for very low birth weight babies is about 18% in level 3 NICUs that admit more than 100 of them every year. NICUs that see 50-100 do nearly as well, with a mortality rate of 20%. I'd like to see morbidity statistics compared, but that will be another study. Still, hundreds of babies are dying who might not in a larger NICU.

The worst statistics are for hospitals which admit 10 or fewer VLBW babies, the mortality rate is 31%. The most shocking thing to me is that size doesn't matter. Gender doesn't matter. Race doesn't matter. These smallest NICUs have a significantly higher mortality rate across the board. That surprised me, because in larger NICUs there are pronounced race and gender differences in survival and the larger, more mature preemies have a better chance.

This is a situation which could be improved by regionalizing neonatal care -- stepping back in time to an era when not every hospital with a birthing center had a neonatal ICU. At the very least, returning to an era when maternal transports were more common so that the very smallest newborns could be delivered in the regional hospital which saw the most of them. That won't be a popular suggestion for hospital administrators who might lose their NICUs, but maybe it's time. The babies ought to come first.

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