Tuesday, March 9, 2010

Primer on NICUs

Last week I posted on neonatal hypertension. This week I am reminded that not everyone appreciates the level of care some newborn infants require, nor that nurseries are rated for the level of care that they may provide.

The American Academy of Pediatrics describes 3 major levels of newborn nursery care, with 4 sublevels for those serving the sickest infants as outlined below:

Basic neonatal care (level I)

    Well-newborn nursery

    Evaluation and postnatal care of healthy newborns

    Neonatal resuscitation

    Stabilization of ill newborns until transfer to a facility at which specialty neonatal care is provided

Specialty neonatal care (level II)

    Special care nursery

    Care of preterm infants with birth weight at least 1500 g

    Resuscitation and stabilization of preterm and/or ill infants before transfer to a facility at which newborn intensive care is provided

Subspecialty neonatal intensive care (level III)

Level IIIA

        Hospital or state-mandated restriction on type and/or duration of mechanical ventilation

Level IIIB

        No restrictions on type or duration of mechanical ventilation

        No major surgery

Level IIIC

        Major surgery performed on site (eg, omphalocele repair, tracheoesophageal fistula or esophageal atresia repair, bowel resection, myelomeningocele repair, ventriculoperitoneal shunt)

        No surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass and /or ECMO for medical conditions

Level IIID

        Major surgery, surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass, and/or ECMO for medical conditions

I visited a shopping center yesterday that was plastered with posters about a new Women’s Hospital nearing completion in Omaha. According to these posters, this place will provide comprehensive service for mothers and infants, including the first level III NICU in west Omaha. On their website they describe the design and engineering that will make their facilities wonderful:

Unfortunately, the subtlety of “virtually all” critically ill neonates may be lost on a lot of laypeople. Many of them will see the following still on the landing page and assume that “everything” means, well, everything:Women's Hospital

I am one of two Pediatric Nephrologists in this region. We currently see patients, including sick newborns, at 3 hospitals in the Omaha area, all with level III NICUs (2 are IIID; the other is IIIC or D). I also have a lab and a bunch of other job responsibilities, so I am seeing patients about one-third of the time. Essentially, a single kidney specialist serves the state of Nebraska and other nearby areas (western Iowa and the Dakotas). Covering the hospitals we currently serve is difficult at best. Another level III NICU in Omaha (covered by our neonatologists) wants us to provide services, but we do not have the personnel to do it. They show similar ads for their NICU around town, and I shudder when I see the billboards.

Adding yet another NICU to our coverage is not in the cards right now. In other words, if your baby encounters problems with its kidneys, pediatric subspecialty care will not be available at this shiny new neonatal unit. I am sure it is a beautiful unit, with everything new parents could want. But not a nephrologist.

I cannot speak for all pediatric subspecialists in Omaha, but it is not clear which, if any, of them will be covering the new hospital.

Parents need to understand these issues (if they are not having an absolutely uncomplicated pregnancy) and discuss the best place to deliver with their perinatologist. Ask if the appropriate pediatric specialists will be available immediately, if needed, or if the baby will have to be transferred to get all the care it (probably) needs. Ask if you can talk to these specialists before planning your delivery. Some abnormalities may not require immediate care, allowing mom and dad more choices about where baby is born. Other conditions will limit options; transporting the baby in a uterus is generally easier than moving a critically ill newborn in an ambulance.

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