Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement

Neonatal Therapy Staffing in the United States and Relationships to Neonatal Intensive Care Unit Type and Location, Level of Acuity, and Population Factors

OBJECTIVES

This study aimed to (1) estimate the total pool of neonatal therapists (occupational therapists, physical therapists, and speech-language pathologists who work in the neonatal intensive care unit [NICU]) and the average number represented in each U.S. based NICU, and (2) investigate the relationships between the number and type of neonatal therapy team members to NICU/hospital, population, and therapy factors.

STUDY DESIGN

This study used several methods of data collection (surveys, phone calls, and web site searches) that were combined to establish a comprehensive list of factors across each NICU in the United States.

RESULTS

We estimate that there are 2,333 full-time equivalent (FTE) positions designated to neonatal therapy coverage, with 4,232 neonatal therapists covering those FTEs. Among 564 NICUs with available neonatal therapy staffing data, 432 (76%) had a dedicated therapy team, 103 (18%) had pro re nata (as the circumstances arise; PRN) therapy coverage only, and 35 (6%) had no neonatal therapy team. Having a dedicated therapy team was more likely in level-IV (n = 112; 97%) and -III (n = 269; 83%) NICUs compared with level-II NICUs (n = 51; 42%; p < 0.001). Having a dedicated therapy team was related to having more NICU beds (p < 0.001), being part of a free-standing children's hospital or children's hospital within a hospital (p < 0.001), and being part of an academic medical center or community hospital (p < 0.001). Having a dedicated therapy team was more common in the Southeast, Midwest, Southwest, and West (p = 0.001) but was not related to the proportion of the community living in poverty or belonging to racial/ethnic minorities (p > 0.05). There was an average of 17 beds per neonatal therapy FTE, a good marker of therapy coverage based on NICU size. Three-hundred U.S. based NICUs (22%) had at least one Certified Neonatal Therapist (CNT) in early 2020, with CNT presence being more likely in higher acuity NICUs (59% of level-IV NICUs had at least one CNT).

CONCLUSION

Understanding the composition of neonatal therapy teams at different hospitals across the U.S. can drive change to expand neonatal therapy services aimed at optimizing outcomes of high-risk infants and families.

KEY POINTS

· We estimated that there are 4,232 neonatal therapists working in NICUs in the United States.. · Dedicated therapy teams for the NICU are more common in large, high acuity NICUs.. · An average of 17 beds per neonatal therapy FTE was observed.. · In 2020, 22% of NICUs had CNTs, and CNTs were more common in large and high acuity NICUs.. · Benchmarking neonatal therapy staffing can aid in expanding NICU therapy services where needed..

The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk

BACKGROUND

The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need.

OBJECTIVE

The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk.

RESEARCH DESIGN

A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression.

SUBJECTS

All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644).

MEASURES

Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment.

RESULTS

Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth.

CONCLUSION

The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.

NICUs in the US: levels of acuity, number of beds, and relationships to population factors

OBJECTIVE

To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs.

STUDY DESIGN

Cohort study of US NICUs.

RESULTS

There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level (p < 0.0001). Higher acuity level and number of NICU beds related to being in a children's hospital (p < 0.0001;p < 0.0001), part of an academic center (p = 0.006;p = 0.001), and in a state with Certificate of Need legislation (p = 0.023;p = 0.046). Higher acuity level related to higher population density (p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region.

CONCLUSIONS

This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.

Association of Rural and Frontier Residence with Very Preterm and Very Low Birth Weight Delivery in Nonlevel III NICUs

OBJECTIVE

Delivery of very preterm and very low birth weight neonates (VPT/VLBW) in a nonlevel III neonatal intensive care unit (NICU) increases risk of morbidity and mortality. Study objectives included the following: (1) Determine incidence of VPT/VLBW delivery (<32 weeks gestational age and/or birth weight <1,500 g), in nonlevel III units in Colorado; (2) Evaluate the independent association between residence and nonlevel III unit delivery; (3) Determine the incidence of and factors associated with postnatal transfer.

STUDY DESIGN

This retrospective cohort study used 2007 to 2016 Colorado birth certificate data. Demographic and clinical characteristics by VPT/VLBW delivery in level III NICUs versus nonlevel III units were compared using Chi-square analyses. Multivariable logistic regression was used to estimate the independent association between residence and VPT/VLBW delivery.

RESULTS

Among patients, 897 of 10,015 (8.96%) VPT/VLBW births occurred in nonlevel III units. Compared with infants born to pregnant persons in urban counties, infants born to those residing in rural (adjusted odds ratio [AOR] = 1.58, 95% confidence interval [CI]: 1.33, 1.88) or frontier (AOR = 3.19, 95% CI: 2.14, 4.75) counties were more likely to deliver in nonlevel III units and to experience postnatal transfer within 24 hours (rural AOR = 2.24, 95% CI: 1.60, 3.15; frontier AOR = 3.91, 95% CI: 1.76, 8.67). Compared with non-Hispanic Whites, Hispanics were more likely to deliver VPT/VLBW infants in nonlevel III units (AOR = 1.36, 95% CI: 1.15, 1.61).

CONCLUSION

A significant number of VPT/VLBW neonates were born in nonlevel III units with associated disparities by race/ethnicity and nonurban residence.

KEY POINTS

· Preterm delivery in a nonlevel III NICU increases risk of neonatal morbidity and mortality.. · A significant number of preterm deliveries in Colorado occur in hospitals with nonlevel III NICUs.. · Disparities in preterm delivery by race/ethnicity and nonurban residence exist..

Accuracy and Completeness of Intermediate-Level Nursery Descriptions on Hospital Websites

IMPORTANCE

Birth at hospitals with an appropriate level of neonatal intensive care units is associated with better neonatal outcomes. The primary sources for information about hospital neonatal unit levels for prospective parents, referring physicians, and the public are hospital websites, but the accuracy of neonatal unit capacity is unclear.

OBJECTIVE

To determine if hospital websites accurately report the capabilities of intermediate (ie, level II) units, which are intended for care of newborns with low to moderate illness levels or the stabilization of newborns prior to transfer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared descriptions of level II unit capabilities on hospital web pages in 10 large states with their respective state-level designation. Analyzed units were located in the 10 states with the highest number of live births in 2019 (excluding states with no level II regulations) and had active websites as of May 2021.

MAIN OUTCOMES AND MEASURES

Hospital websites were assessed for whether there was any mention of the unit, the description of the unit was provided, the unit was identified as a level III or both levels II and III, the terms "neonatal intensive care unit" or "NICU" were used without indicating limits in care available or newborn acuity, or the unit was claimed to provide the most advanced level of care.

RESULTS

A total 28 states had no regulation of nursery unit levels; in the 10 large, regulated states, web descriptions of level II units were incomplete for 39.2% of hospitals (95% CI, 33.3%-45.3%) and inaccurate for 24.6% (95% CI, 19.6%-30.2%). Within incomplete descriptions, 2.6% (95% CI, 1.1%-5.3%) of hospitals did not mention an advanced care unit and 22.0% (95% CI, 17.2%-27.5%) identified a level II unit without providing further description. Within inaccurate descriptions, 25.4% (95% CI, 20.3%-31.0%) of hospitals described the unit as a "neonatal intensive care unit" or "NICU" without any qualification and 9.3% (95% CI, 6.3%-13.5%) claimed that the unit provided the most advanced neonatal care or care to the sickest newborns; 3.0% of hospitals (95% CI, 1.3%-6.0%) stated that their unit was level III and 1.5% (95% CI, 0.4%-3.8%) as level II and III. Across states there was substantial variation in rates of incompleteness and inaccuracy.

CONCLUSIONS AND RELEVANCE

Incomplete and inaccurate hospital web descriptions of intermediate newborn care units are common. These deficits can mislead parents, clinicians, and the public about the appropriateness of a hospital for sick newborns, which raises important ethical questions.

Seven years later: state neonatal risk-appropriate care policy consistency with the 2012 American Academy of Pediatrics Policy

OBJECTIVE

To assess consistency of state neonatal risk-appropriate care policies with the 2012 AAP policy seven years post-publication.

STUDY DESIGN

Systematic, web-based review of all publicly available 2019 state neonatal levels of care policies. Information on infant risk (gestational age, birth weight), technology and equipment capabilities, and availability of specialty staffing used to define neonatal levels of care was extracted for review.

RESULT

Half of states (50%) had a neonatal risk-appropriate care policy. Of those states, 88% had language consistent with AAP-defined Level I criteria, 80% with Level II, 56% with Level III, and 55% with Level IV. Comparing policies (2014-2019), consistency increased in state policies among all levels of care with the greatest increase among level IV criteria.

CONCLUSION

States improved consistency of policy language by each level of care, though half of states still lack policy to provide minimum standards of care to the most vulnerable infants.

The center-effect on outcomes for infants born at less than 25 weeks

Marked variation exists in the care of infants born at <25 weeks' gestation. The center or location where a fetus or infant is cared for influences outcomes at very early gestational ages. Understanding this "center-effect," including characteristics associated with centers that have high survival of births at <25 weeks' gestation, may inform future studies and guide care practices to improve outcomes. This review focuses on the impact that the location or center of birth has on survival and other important outcomes for infants born at <25 weeks' gestation. We review potential sources of variation in care practices and other factors that might explain the "center-effect."

Trends in neonatal intensive care unit admissions by race/ethnicity in the United States, 2008-2018

To examine temporal trends of NICU admissions in the U.S. by race/ethnicity, we conducted a retrospective cohort analysis using natality files provided by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention. A total of 38,011,843 births in 2008–2018 were included. Crude and risk-adjusted NICU admission rates, overall and stratified by birth weight group, were compared between white, black, and Hispanic infants. Crude NICU admission rates increased from 6.62% (95% CI 6.59–6.65) to 9.07% (95% CI 9.04–9.10) between 2008 and 2018. The largest percentage increase was observed among Hispanic infants (51.4%) compared to white (29.1%) and black (32.4%) infants. Overall risk-adjusted rates differed little by race/ethnicity, but birth weight-stratified analysis revealed that racial/ethnic differences diminished in the very low birth weight (< 1500 g) and moderately low birth weight (1500–2499 g) groups. Overall NICU admission rates increased by 37% from 2008 to 2018, and the increasing trends were observed among all racial and ethnic groups. Diminished racial/ethnic differences in NICU admission rates in very low birth weight infants may reflect improved access to timely appropriate NICU care among high-risk infants through increasing health care coverage coupled with growing NICU supply.

Neonatal Mortality After Interhospital Transfer of Pregnant Women for Imminent Very Preterm Birth in Illinois

IMPORTANCE

Reducing neonatal mortality is a national health care priority. Understanding the association between neonatal mortality and antenatal transfer of pregnant women to a level III perinatal hospital for delivery of infants who are very preterm (VPT) may help identify opportunities for improvement.

OBJECTIVE

To assess whether antenatal transfer to a level III hospital is associated with neonatal mortality in infants who are VPT.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study included infants who were born VPT to Illinois residents in Illinois perinatal-network hospitals between January 1, 2015, and December 31, 2016, and followed up for 28 days after birth. Data analysis was conducted from June 2017 to September 2018.

EXPOSURES

Delivery of an infant who was VPT at a (1) level III hospital after maternal presentation at that hospital (reference group), (2) a level III hospital after antenatal (in utero) transfer from another hospital, or (3) a non-level III hospital.

MAIN OUTCOMES AND MEASURES

Neonatal mortality.

RESULTS

The study included 4817 infants who were VPT (gestational age, 22-31 completed weeks) and were born to Illinois residents in 2015 and 2016. Of those, 3302 infants (68.5%) were born at a level III hospital after maternal presentation at that hospital, 677 (14.1%) were born at a level III hospital after antenatal transfer, and 838 (17.4%) were born at a non-level III hospital. Neonatal mortality for all infants who were VPT included in this study was 573 of 4817 infants (11.9%). The neonatal mortality was 10.7% for the reference group (362 of 3302 infants), 9.8% for the antenatal transfer group (66 of 677 infants), and 17.3% for the non-level III birth group (145 of 838 infants). When adjusted for significant social and medical characteristics, infants born VPT at a level III hospital after antenatal transfer from another facility had a similar risk of neonatal mortality as infants born at a level III hospital (odds ratio, 0.79 [95% CI, 0.56-1.13]) after maternal presentation at the same hospital. Infants born at a non-level III hospital had an increased risk of neonatal mortality compared with infants born at a level III hospital after maternal presentation to the same hospital (odds ratio, 1.52 [95% CI, 1.14-2.02]).

CONCLUSIONS AND RELEVANCE

The risk of neonatal mortality was similar for infants who were VPT, whether women initially presented at a level III hospital or were transferred to a level III hospital before delivery. This suggests that the increased risk of mortality associated with delivery at a non-level III hospital may be mitigated by optimizing opportunities for early maternal transfer to a level III hospital.

Designation of neonatal levels of care: a review of state regulatory and monitoring policies

OBJECTIVE

Summarize policies on levels of neonatal care designation among 50 states and District of Columbia (DC).

STUDY DESIGN

Systematic review of publicly available, web-based information on levels of neonatal care designation policies for each state/DC. Information on designating authorities, designation oversight, licensure requirement, and ongoing monitoring for designated levels of care abstracted from 2019 published rules, statutes, and regulations.

RESULT

Thirty-one (61%) of 50 states/DC had designated authority policies for neonatal levels of care. Fourteen (27%) incorporated oversight of neonatal levels of care into the licensure process. Among jurisdictions with designated authority, 25 (81%) used a state agency and 15 (48%) had direct oversight. Twenty-two (71%) of 31 states with a designating authority required ongoing monitoring, 14 (64%) used both hospital reporting and site visits for monitoring with only ten requiring site visits.

CONCLUSIONS

Limited direct oversight influences regulation of regionalized systems, potentially impacting facility service monitoring and consequent management of vulnerable infants.

Outcomes of outborn extremely preterm neonates admitted to a NICU with respiratory distress

OBJECTIVE

To compare the risk of mortality and morbidity between outborn and propensity score-matched inborn extremely preterm neonates.

SETTING

Multiple neonatal intensive care units (NICU) across the USA.

PATIENTS

Singleton neonates born at 22-29 weeks' gestation with no major anomalies who were admitted to a NICU and discharged between 2000 and 2014. Outborn neonates were restricted to those who transferred into a NICU on the day of birth.

METHODS

The association between inborn-outborn status and the time-to-event outcomes of in-hospital mortality and necrotising enterocolitis (NEC) were assessed using Cox proportional hazards regression. Logistic regression was used to assess the remaining secondary outcomes: retinopathy of prematurity requiring treatment (tROP), chronic lung disease (CLD), periventricular leucomalacia (PVL) and severe intraventricular haemorrhage (IVH). Since outborn status was not random, we used 1:1 propensity score matching to reduce the imbalance in illness severity.

RESULTS

There were 59 942 neonates (7991 outborn) included in the study. Outborn neonates had poorer survival than inborns and higher rates of NEC, severe IVH, tROP and PVL. Inborn-outborn disparities in mortality were reduced over the study period. When analysing the matched cohort (6524 matched pairs), outborns were less likely to die in-hospital compared with inborns (HR 0.84, 95% CI 0.77 to 0.91). However, outborns experienced higher rates of NEC (HR 1.14, 95% CI 1.04 to 1.25), severe IVH (OR 1.52, 95% CI 1.38 to 1.68), tROP (OR 1.45, 95% CI 1.25 to 1.69) and CLD (OR 1.12, 95% CI 1.01 to 1.24).

CONCLUSION

Additional research is needed to understand the contributors to increased morbidity for outborn extremely preterm neonates and identify interventions that mitigate this risk.

Levels of Maternal Care in the United States: An Assessment of Publicly Available State Guidelines

Background: Recent increases in maternal mortality and severe maternal morbidity highlight the need to improve systems for safe maternity care. We sought to identify whether publicly available state perinatal guidelines incorporate levels of maternal care (LoMC) criteria. Materials and Methods: We searched websites for 50 U.S. states and Washington, D.C. for LoMC guidelines. The Health Resources and Services Administration's Title V Program directors confirmed/updated search results through January 2018. Data abstracted included: (1) definitions of levels; (2) provider types; (3) facility capabilities and services; and (4) programmatic responsibilities as promoted in the 2015 Society for Maternal/Fetal Medicine and American College of Obstetricians and Gynecologists consensus document on LoMC. Results: LoMC guidelines were identified for 17 states; 12 defined four levels and five defined three levels of care. In Level I, 14/17 states specified obstetric provider availability for every birth and five specified an available surgeon to perform emergency cesareans. Fourteen states specified the availability of blood bank and laboratory services at all times. In the highest level (III or IV), 16/17 state guidelines specified a maternal/fetal medicine specialist; all but two specified anesthesia providers or services. Ten states referenced availability of an onsite intensive care unit in their highest level. All 17 state guidelines specified maternal transport and referral systems. Conclusions: Only one-third of states have publicly available perinatal guidelines incorporating LoMC criteria. Definitions, criteria, and nomenclature varied. Lack of LoMC guidelines with standardized criteria limits monitoring and evaluation of regionalized systems of maternal care.

Breast milk expression for premature infant in the neonatal intensive care unit: A review of mothers' perceptions

OBJECTIVE

To identify the existing literature on mothers' perception towards the impact of expressing breast milk for their premature infant in the neonatal intensive care unit.

METHOD

Guided by the PRISMA Statement review checklist, a systematic review of the Scopus and Web of Science database has identified 10 related studies. The articles were assessed and analyzed after evaluated using The Joanna Briggs Institute Critical Appraisal tools (JBI). Thematic analysis was obtained after using Nvivo software as a tool for data analysis by author.

RESULT

Further review of these articles resulted in three main themes-maternal changes during expressing breast milk, pumping challenges and impact of motivation factors to initiating lactation.

CONCLUSION

Expressing breast milk should be recognized as an important way to restructure motherhood with a preterm infant in NICU. However, maintaining expressed breast milk during preterm infants' treatment period in NICU may increase stress and difficulties for some mothers. Some recommendations are emphasized in relation to the need for more qualitative studies in this issue, which is to have a specific and standard systematic review method for guide research synthesis in context of climate change adaptation.

Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants

IMPORTANCE

Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.

OBJECTIVE

To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018.

MAIN OUTCOMES AND MEASURES

The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.

RESULTS

Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.

CONCLUSIONS AND RELEVANCE

Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.