Wednesday, June 20, 2018

When Profit Trumps Our Most Vulnerable: The push to deliver preemies in community hospitals

Neonatal Intensive Care Units are truly a miracle of modern medicine. As recently as the 1960s, infants born six weeks early stood little chance of survival. But thanks to advances in neonatal medicine, babies born fully eight weeks before term now have a 99 percent survival rate—although, to be sure, preemies remain at much higher risk of developing a wide array of health risks throughout their whole lives.

Recently, more hospitals have been investing in the kind of expensive equipment needed to care for premature newborns. In Kitsap County, for example, the CHI Franciscan Harrison Hospital has expanded its services for premature babies, which, on the face of it, sounds like a good thing.

But the counterintuitive truth is that the increasing availability of such technology may actually do more harm than good. Pre-term infants are so vulnerable—to infections, breathing problems, bleeding on the brain, to name just a few complications—that you need more than just the latest high-tech supplies. You also need expert know-how, honed through constant practice: You need a team of specialized doctors, known as neonatologists, and neonatal nurses who handle preemies all day, every day.

And not every hospital has that.

In the mid-1970s, the March of Dimes proposed the idea of regionalized networks as part of a bid to make sure every area had at least one specialized neonatal unit, or NICU. Under the plan, highly specialized facilities, what are referred to as Level 3 or 4, would have a neonatology physician available 24 hours a day. Nurseries with lower-level designations, Level 1 or 2 facilities, would handle healthier infants and, therefore, not require in-hospital neonatologist coverage. 

The idea was that when a pregnant woman went into labor early, she would be transferred to the nearest Level 3 or 4 facility—provided her condition allowed for relocation. Only when transport was deemed impossible would the delivery occur at a lower-level hospital, with the newborn being stabilized and later transferred to a high-level unit.

Research supports this measured approach. Studies have consistently shown it’s far safer to move the mothers to a higher-level facility while the baby is still in the womb than to attempt transfer after birth, when the jostling of an ambulance ride or medevac can cause life-threatening complications, like bleeding in the brain, which can trigger permanent disabilities.

But now, with smaller, community hospitals buying more neonatal equipment, there’s increasing pressure to monetize the investment. That means taking the calculated risk of not transferring women in pre-term labor and allowing delivery at a location that neither has the specialized staff nor sufficient expertise to provide the kind of care premature infants require.

Taking this chance allows the community hospital to be paid for delivery and for providing the infant short-term stabilization care. However, this business-driven logic turns a willful blind eye to the toll that disruptive transfers can have on these vulnerable infants, putting them at unnecessary risk of complications. 

Statistically, the evidence is clear these fragile newborns fare best at the units that have more experienced staff and see the highest volume of patients.  Leap Frog collects data on the volume of high-risk infants cared for at hospitals in the region. Swedish First Hill, a Level 4 unit , managed 190 high-risk infants last year; the University of Washington, which is also Level 4, treated 137; while the CHI Franciscan Health Level 3 NICU, based at St. Joe’s Hospital, oversaw the care for 31 amongst its hospital system. These numbers are telling.

In my experience as a pediatrician in Kitsap County, I’ve had to readmit every single one of my pre-term patients who were born at the CHI Franciscan Harrison this year. In stark contrast, I haven’t had to readmit any of my patients who were delivered at Swedish or the UW.

This is not a risk that hospitals should take in the interest of their bottom line. The stakes are far too high. And if community hospitals are “selling” pregnant women on the convenience of giving birth close to home while glossing over the dangers of delivering high-risk, pre-term babies at a lower-level facility, then community physicians, like me, are obliged to speak out.

Every child deserves the best possible start in life, and the statistics show that specialist neonatologists practicing at high-volume NICUs are in the best position to provide it. Just because smaller community hospitals that have invested in state-of-the-art equipment can, technically, deliver preemies, doesn’t mean they should.



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