The Effect of Low to Moderate Patient Volume on Very Low-Birth-Weight Outcomes in a Level III-B Neonatal Intensive Care Unit

ABSTRACT

We studied the effect of a low- to moderate-volume, level III-B neonatal intensive care unit (NICU) on very low-birth-weight (VLBW) outcomes. We performed a retrospective analysis of the King Abdulaziz Hospital (KAH) NICU electronic database. Short-term outcomes of all inborn VLBW infants (501 to 1500 g) in the well-equipped, well-staffed KAH NICU (2003 to 2008) were benchmarked with data (1997 to 2002) from the National Institute of Children Health and Human Development and Neonatal Research Network (NICHD-NRN). Survival without major neonatal morbidity was defined as survival without bronchopulmonary dysplasia (BPD), grade III to IV intraventricular hemorrhage (IVH), and Bell's stage II to III necrotizing enterocolitis (NEC). The survival rates of VLBW infants at the KAH NICU (n = 250) and the NICHD-NRN (n = 18,153) were similar (84 versus 85%). A significantly higher rate of survival without major neonatal morbidity (80 versus 70%, p = 0.002) and lower rate of BPD (14 versus 22%, p = 0.005) were observed in KAH. The rates of grade III to IV IVH, Bell's stage II to III NEC, and late-onset sepsis were comparable in both cohorts. Our low- to moderate-volume, well-equipped, well-staffed, level III-B NICU achieved outcomes similar to the NICHD-NRN. Further study is warranted to ascertain how a lower-volume NICU achieved similar outcomes, as this could then be applied to quality improvement efforts.

KEYWORDS

Survival rate - survival without major neonatal morbidity - low patient volume - moderate patient volume - intraventricular hemorrhage - periventricular leukomalacia - bronchopulmonary dysplasia - necrotizing enterocolitis - late-onset sepsis

REFERENCES

• 1 Wikipedia. Al-Ahsa Governorate. Available at: http://en.wikipedia.org/wiki/Al-Ahsa_Governorate Accessed February 8, 2010
• 2 Stark A R. American Academy of Pediatrics Committee on Fetus and Newborn . Levels of neonatal care.  Pediatrics. 2004;  114 1341-1347 Erratum in: Pediatrics 2005;115:1118
• 3 Holmstrom S T, Phibbs C S. Regionalization and mortality in neonatal intensive care.  Pediatr Clin North Am. 2009;  56 617-630
• 4 Jochum F, Schmidt B, Schunk K et al.. Quality of care of VLBW neonates: relationship between unit volume and outcome is different between metropolitan and rural regions.  Acta Paediatr. 2008;  97 1470-1474
• 5 Tucker J. UK Neonatal Staffing Study Group . Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation.  Lancet. 2002;  359 99-107
• 6 Horbar J D, Badger G J, Lewit E M, Rogowski J, Shiono P H. Vermont Oxford Network . Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants.  Pediatrics. 1997;  99 149-156
• 7 Phibbs C S, Bronstein J M, Buxton E, Phibbs R H. The effects of patient volume and level of care at the hospital of birth on neonatal mortality.  JAMA. 1996;  276 1054-1059
• 8 Phibbs C S, Baker L C, Caughey A B, Danielsen B, Schmitt S K, Phibbs R H. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.  N Engl J Med. 2007;  356 2165-2175
• 9 Bartels D B, Wypij D, Wenzlaff P, Dammann O, Poets C F. Hospital volume and neonatal mortality among very low birth weight infants.  Pediatrics. 2006;  117 2206-2214
• 10 Rogowski J A, Horbar J D, Staiger D O, Kenny M, Carpenter J, Geppert J. Indirect vs direct hospital quality indicators for very low-birth-weight infants.  JAMA. 2004;  291 202-209
• 11 Synnes A R, Macnab Y C, Qiu Z Canadian Neonatal Network et al. Neonatal intensive care unit characteristics affect the incidence of severe intraventricular hemorrhage.  Med Care. 2006;  44 754-759
• 12 Fanaroff A A, Stoll B J, Wright L L et al.. Trends in neonatal morbidity and mortality for very low birthweight infants.  Am J Obstet Gynecol. 2007;  196 147-e1–e8
• 13 Wadhawan R, Oh W, Perritt R et al.. Association between early postnatal weight loss and death or BPD in small and appropriate for gestational age extremely low-birth-weight infants.  J Perinatol. 2007;  27 359-364
• 14 Lemons J A, Bauer C R, Oh W NICHD Neonatal Research Network et al. Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996.  Pediatrics. 2001;  107 E1
• 15 Alexander G R, Himes J H, Kaufman R B, Mor J, Kogan M. A United States national reference for fetal growth.  Obstet Gynecol. 1996;  87 163-168
• 16 Warner B, Musial M J, Chenier T, Donovan E. The effect of birth hospital type on the outcome of very low birth weight infants.  Pediatrics. 2004;  113 (1 Pt 1) 35-41
• 17 Mayfield J A, Rosenblatt R A, Baldwin L M, Chu J, Logerfo J P. The relation of obstetrical volume and nursery level to perinatal mortality.  Am J Public Health. 1990;  80 819-823
• 18 Menard M K, Liu Q, Holgren E A, Sappenfield W M. Neonatal mortality for very low birth weight deliveries in South Carolina by level of hospital perinatal service.  Am J Obstet Gynecol. 1998;  179 374-381
• 19 Lee H C, Subeh M, Gould J B. Low Apgar score and mortality in extremely preterm neonates born in the United States.  Acta Paediatr. 2010;  Jul 7 [Epub ahead of print]
• 20 Rüdiger M, Küster H, Herting E et al.. Variations of Apgar score of very low birth weight infants in different neonatal intensive care units.  Acta Paediatr. 2009;  98 1433-1436
• 21 Chedid F, Shanteer S, Haddad H et al.. Short-term outcome of very low birth weight infants in a developing country: comparison with the Vermont Oxford Network.  J Trop Pediatr. 2009;  55 15-19
• 22 Alshimmiri M M, Al-Saleh E A, Alsaeid K, Hammoud M S, Al-Harmi J A. Birthweight percentiles by gestational age in Kuwait.  Arch Gynecol Obstet. 2004;  269 111-116
• 23 Van Marter L J. Epidemiology of bronchopulmonary dysplasia.  Semin Fetal Neonatal Med. 2009;  14 358-366
• 24 Mu S C, Lin C H, Chen Y L et al.. Impact on neonatal outcome and anthropometric growth in very low birth weight infants with histological chorioamnionitis.  J Formos Med Assoc. 2008;  107 304-310
• 25 Been J V, Zimmermann L J. Histological chorioamnionitis and respiratory outcome in preterm infants.  Arch Dis Child Fetal Neonatal Ed. 2009;  94 F218-F225
• 26 Tin W, Wiswell T E. Drug therapies in bronchopulmonary dysplasia: debunking the myths.  Semin Fetal Neonatal Med. 2009;  14 383-390
• 27 Resch B, Vollaard E, Maurer U, Haas J, Rosegger H, Müller W. Risk factors and determinants of neurodevelopmental outcome in cystic periventricular leucomalacia.  Eur J Pediatr. 2000;  159 663-670
• 28 Martens S E, Rijken M, Stoelhorst G M Leiden Follow-Up Project on Prematurity, The Netherlands et al. Is hypotension a major risk factor for neurological morbidity at term age in very preterm infants?.  Early Hum Dev. 2003;  75 79-89