Thursday, February 01, 2007

Performance

There is some debate about whether large NICU's are better than small NICU's. There have been studies that show that large NICU's in general have better mortalilty rates than smaller ones. The studies aren't perfect, but it's probably true.

I have worked in both large and small NICU's and have enjoyed them both. I have been fortunate enough to work in units with good outcomes, where the babies have good survival rates and low rates of intracranial hemorrhage. In a large NICU you can be very busy and see all kinds of weird things. I suspect that the large NICU's have better outcomes because they are always in practice; some of the care becomes almost automatic. In a small NICU, though, it can be surprising how much interesting stuff you see. In my experience, I had a little more time to talk with the parents there, and the atmosphere was a little homier.

There are those who would say that health care payors, such as insurance companies, should require their babies to go to bigger NICU's, given the studies showing better outcomes in them. There was a time I would have agreed with that, but I no longer do. Could I be influenced by the fact that I have worked in a smaller NICU? Of course!

But here's the thing: The studies looking at outcomes of large versus small NICU's were using size of the NICU as a proxy, a substitute for the actual quality of outcomes at a given place, because the outcomes were not easily available. That is no longer necessary, because nearly every NICU now belongs to some collaboration of NICU's that keeps track of outcomes and lets you know how your unit is doing in comparison to others. (One of the largest of these is the Vermont Oxford Network, in which our NICU participates.) So it is no longer necessary to assume that a unit has better or worse outcomes because of its size. Instead, you can fairly easily compare the actual outcomes.

Although large NICU's might in general do better than smaller ones, there will be some large NICU's that do worse than smaller ones. It would be a shame to close those smaller ones and send the babies to larger units with worse outcomes, so let's stop this nonsense about assigning babies only to large NICU's and instead send babies to NICU's with the best outcomes, regardless of size. (You could make a case that small, good NICU's should combine and possibly become even better, but a discussion of regionalization of NICU's - or rather the lack of it - would give me a headache.)

Pay for performance. Supposedly it's coming. Let's do it right.

P.S. Due to some Blogger malfunction, you and I have not been able to get into my comments section for about the last day. I was able to see my comments, though, by going through my "edit posts" page. Thanks to all for the kind comments, well wishes, and suggestions.

10 Comments:

Blogger kate said...

Do you know if there is a way for the general public (i.e. patients) to access data on the outcomes of different NICU's? I was actually trying to figure out this information the first time i came upon your blog, but i have not been able to get anywhere with that. I suspect that either it is not public or that i am searching for the wrong thing -- all i get is job listings!

1:45 PM  
Blogger dreammom90 said...

As an FYI, even though the comment section wasn't working, anyone can "view" the comments by clicking on the time stamp of your post instead of the comments. When you do that, the entire post and all of the comments for that post come up.

I don't know about NICU's but I can tell you that with regards to Dear Son, I find that the larger academic medical centers typically have more experienced physicians, and I suspect better outcomes. I had a simple rule that I used for Dear Son, which told me if I was i the right place or not. The rule was this: my Dear Son can not be the "worst" patient in the physician's practice or the "worst" patient the physician sees that day, or we are not in the right place. By "worst" I mean in terms of his medical issues.

I suspect the larger NICU's have seen more "worst case scenarios" and thus would have better outcomes. The down side of the larger places, at least for me, is that there are sometimes a higher risk of a medical error, since the volume of patients is so high-typically these are medication type errors or non-physician errors. The issues I have there are also more "service" related.

In smaller places, I tend to see more inexperience in terms of the ability to care/treat special needs patients, even in pediatric facilities. The service part is high though-they attend to your every need, the nurse/patient ratios are much lower and the food is generally better. They also typically have less experience doing medical tests for children in wheelchairs-they often have great difficulty in doing a simple seated chest x-ray. They also appear more nervous to me. I've had some serious errors at local hospitals-like the failure to secure the airway before administering seizure meds and having the airway fail and a Code Blue was called. Fifty people watched as they tried to resusitate Dear Son. That was fun. Or with the MRSA pneumonia, the failure to transfer, despite the fact he was in septic shock and had Acute Respiratory Distress Syndrome. Oh, and both places were local pediatric hospitals. I can tell countless stories of errors at the smaller places, most involve failure to make appropriate referrals or failure to identify when Dear Son was in dire straights.

If I had a infant today, that had issues, I wouldn't hesitate to get the best and largest NICU available since I think the outcomes would be better. You couldn't pay me to bring him elsewhere. I am sure there are smaller places that have good outcomes too but I wouldn't try it with my baby.

2:16 PM  
Anonymous Chris and Vic (CAK) said...

I believe there is yet another factor, the "history" of the NICU, and how long it has been around. And in particular, how much history the nurses have in the unit. I would choose a unit where a certain high percentage of the nurses have been there longer than 5 years. Those nurses can "recognize" things early on and give "early warning" to docs.
In my NICU, a pretty good percentage have been there for 15 years or more . . . and they have the early-warning thing down pat; as well as having perspective. They have seen a lot. They're pretty much unflappable--calm in a crisis, or at a difficult delivery. (Parents may see them as cool or off-handed, but really, that is who I'd want at my delivery, one of those cool nurses.) They just don't flinch!

I also think that in this line of buisness, attentiveness to detail is a must---even how clean, neat, orderly the bedside is kept. To me, it tells a lot.

I have worked at several NICUs and my grandchild was born and admitted to a 4th NICU in my area. The following impressions do not correlate with size--they correlate with acuity.

The inner-city hospital has seen everything. There were MRSA epidemics; there were several syphyllis epidemics over the years; we've seen some really rare things, like the infant born with cancer. The acuity is generally high among teen moms who use drugs/don't get prenatal care, have STDs and bacterial vaginosis. (However, the C-section rate is 10%, the lowest in our area.) With no prenatal care, no due date, no prenatal tests available, the docs and nurses get pretty sharp about instantaneouly guessing gestational age, just by the physical exam. Lab work is FAST, because we need to know Hepatitis status in order to give a Hep vac within 12 hours of delivery, etc. We are tuned in to high acuity and high risk.

The other NICU is amaller, has less history and experience among staff. Nurses may have worked in other NICUs, but they have not worked with these colleagues, and teamwork may play a large role in the fluency of services. Patients in this other NICU seem lower in acuity (but there is a much higher C-section rate, above 20%), having had prenatal care, private insurance, stable, married, etc.
But it is at that NICU that I have seen epidemics of Methadone-exposed babies, who have had very difficult course, and who have stayed in the NICU for several months, trying to wean them from their Morphine and phenobarbital, which is what gets them off of Methadone. These are term or near-term infants . . .

The same neonatology group rotates through both facilities, in fact, through all the NICUs in the area. So even though the docs are a constant, there is a definite difference, having to do with the demographics of the area, and with the staff (this NICU is less than 5 years old).

I think if you tour your facility ahead of time, if you have twins or triplets on the way, you should ask for the medical director of the unit, and ask if this unit is in the VON (Vermont Oxford Network) and ask for data. If the NICU is not keeping stats for VON, then they should be keeping stats for themselves, in some systematic manner, as Neonatal Doc states.

Your punch-line, Neonatal Doc, is about pay-for-performance (P4P, isn't it?), and I think it is edifying that you say "Let's do it right" instead of kicking against that goad. That statement is loaded. You should explain what pay for performance means, how it works, for your readership.

There was a P4P pilot a while back, and my large healthcare org participated---because Medicaid is reimbursed at $0.13-$0.14 on the dollar in my state (in the lowest 10% of all the states), and the hospital, particularly the inner-city hospital, with the biggest NICU, needed to try to get better reimbursement. We ended up doing well with the stats that we kept, and "qualified" for P4P monies. In the middle of that pilot, we got involved in the 10,000 lives thing, as well. The inner-city hospital, the poor step-sister of a hospital within this large system of 24 hospitals and many other services, did quite well. Not just in the NICU--but in other areas, as well. I am able to pull up the comparison charts on the computer. I think even if I wasn't an employee in this system, I would have been able to find them. During my master's program, I was able to compare every hospital in the state---I forget the website's name. If I find it I will send it at a later time.
Chris and Vic (CAK)

3:11 PM  
Anonymous Julie said...

Hey, doc, I'd love to hear your thoughts on the Canadian sextuplets when you have some time.

3:22 PM  
Blogger Bardiac said...

I have no experience with NICUs, but I live where any "real" medical problem means you get sent to another state (the academic centerS there are closer than in this state). So I think just having care in really big academic centers means those of us in less urban areas can't get timely care, or have to travel a long ways.

On the most mundane level, the frustration you mention sometimes about parents not seeming to care because they don't come in often would seem to apply for people who have to work and travel even a couple hours to get to whatever main hospital there is. (I know someone who basically had to move to a different city when her husband had cancer, and it was especially hard for her to be totally without even a basic social network; the extra rent didn't make things easier, either.)

Were I a parent who might need an NICU for my kid, I'd appreciate a smaller one if it could be nearer so that I would actually be able to see my kid every day and not have to travel to a different state. I'd like to have even one possibility; I can't imagine having several choices as Dreammom90 seems to have.

3:40 PM  
Anonymous Helen Harrison said...

When I was searching for a NICU during our second pregnancy (which thank heaven we never needed), I began by consulting the experts -- local, long-time NICU nurses.

I also had candid conversations with the OB and pediatrician.

Putting all the info together, my husband and I made contingency plans to deliver in a nearby city at a hospital slightly further from our house than first time around.


We made our wishes known in writing (a sort of advance prenatal directive), and we made sure to interview possible NICU docs to be sure we had a shared philosophy.

Here are some questions I would also ask:

What is the hospital's BPD rate at each gestational age? How many average days on the ventilator?
(ventilator days and BPD are major contributors to brain/lung damage).

I would also like to know about sepsis rates, particularly rates of nosocomial (hospital-based) infenctions -- these are also big contributors to poor outcome.

I would ask: What is this unit's attitude toward developmental care (a big plus if it takes such care seriously), Kangaroo Care, breastfeeding?

And what about conintuity of care? In speaking with my NICU nurse friends, I have really begun to appreciate the need for a single small group of nurses to provide care for a single baby. So many important details and observations are lost during shift changes, so the fewer the better.

I would not personally place so much emphasis on the mortality rates. Rather I would ask about the *morbidity* rates (long-term handicap and health problems of survivors). A higher than average mortality rate may simply mean more serious decision-making is going on -- and few hospitals are willing to go the record about how often this occurs.

Getting reliable morbidity rates (long-term, which is what really counts) is also problematic because few units collect or advertise this information. The best parents can do now is to look at indirect markers such as BPD, infection rates,ventilator strategies and developmental care.

5:42 PM  
Anonymous Karen said...

Neonatal Doc, how large does a NICU have to be to be considered "large" (i.e. how many beds?)

8:28 PM  
Anonymous Anonymous said...

I had my 26 weeker in a small NICU (15 beds maximum, normal capacity is probably 6 to 8 infants). As a result of mistake they made (leaving a UAC in for 27 days even when it was not working), my son suffered from acute renal failure due to a blood clot in his aorta. He has one kidney now -- suffering from renal stenosis in it -- therefore will need surgery to fix it soon. He takes 7 meds for high blood pressure. Also, this "smaller" NICU is still of the belief that these little preemies can't feel pain. Some small NICUs should be shut down irregardless of the fact that some families would have to travel further distances to see their babies.

11:25 AM  
Anonymous Lori said...

I think this varies so widely...I think there are both good and bad small NICUs and good and bad big ones. I am not sure if the NICU where we had our 28 week son would qualify as small, but it had 27 beds. The neos "rotated" through. Some belonged only to that "small" hospital while some were from a large university NICU. I think it was a good blend. The thing that made our small NICU unique was the developmental care focus. Even though it is a level 3, it has private rooms. Each baby has its own space. No other babies alarming around our son, no unnecessary noise from other families, dimmer lights, and most of all....privacy for nice, quiet kangaroo care. Of course I have no way to prove this, but I firmly believe our son benefited from this "calmer" set-up.

11:18 PM  
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2:04 AM  

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