Download PDF
Am J Perinatol 2024; 41(06): 747-755
DOI: 10.1055/a-1772-4637
Original Article

Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants

Anthony Debay
1   Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
,
Prakesh Shah
2   Departement of Pediatrics, Toronto University, Toronto, Ontario, Canada
,
Abhay Lodha
3   Departement of Pediatrics, University of Calgary, Calgary, Alberta, Canada
,
Sandesh Shivananda
4   Departement of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
,
Stephanie Redpath
5   Departement of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
,
Mary Seshia
6   Departement of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
,
Jon Dorling
7   Departement of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
,
Anie Lapointe
8   Departement of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
,
Rody Canning
9   Departement of Pediatrics, Moncton Hospital, Moncton, Alberta, Canada
,
Lannae Strueby
10   Departement of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
,
Marc Beltempo
1   Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
,
on behalf of the Canadian Neonatal Network Investigators › Author Affiliations Funding M.B. holds an Early Career Investigator Grant from the CIHR Institute of Human Development, Child and Youth Health (IHDCYH), a Research Grant Funding from the FRSQ Clinical Research Scholar Career Award Junior 1, and an Early Career Investigator Grant from the Montreal Children's Hospital Foundation. J.D. holds grants from the Canadian Institutes of Health Research (CIHR), Research Nova Scotia, the National Institutes of Health Research, and the IWK Health Centre. This study was supported by a grant from the CIHR funding the Canadian Preterm Birth Network, Government of Canada (grant no.: PBN 150642).
› Further Information
    Permissions and Reprints

Abstract

Objective This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA).

Study design Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders.

Results Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12–10.6 and aOR = 3.33, 95% CI: 1.44–7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants).

Conclusion 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out.

Key Points

  • Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage

  • The type of 24h in-house coverage was not associated with mortality and/or major morbidity.

  • High-volume centers more often have 24h in-house neonatal fellow coverage

Keywords

prematurity - coverage - neonatal intensive care unit - resuscitation - delivery room - cardiopulmonary resuscitation - neonatologist

Note

This study was partly presented at the Canadian Pediatric Socciteoes – June 11th 2021 Annual Conference (Oral Presentation) and Pediatric Academic Societies – May 2nd 2021 (Poster Presentation).


Supplementary Material



Publication History

Received: 11 January 2022

Accepted: 14 February 2022

Accepted Manuscript online:
15 February 2022

Article published online:
18 April 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA 2010; 304 (09) 992-1000
    CrossrefPubMedGoogle Scholar
  • 2 Stoll BJ, Hansen NI, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012. JAMA 2015; 314 (10) 1039-1051
    CrossrefPubMedGoogle Scholar
  • 3 Lee SK, Beltempo M, McMillan DD. et al; Evidence-based Practice for Improving Quality Investigators. Outcomes and care practices for preterm infants born at less than 33 weeks' gestation: a quality-improvement study. CMAJ 2020; 192 (04) E81-E91
    CrossrefPubMedGoogle Scholar
  • 4 McCormick MC, Shapiro S, Starfield BH. The regionalization of perinatal services. Summary of the evaluation of a national demonstration program. JAMA 1985; 253 (06) 799-804
    CrossrefPubMedGoogle Scholar
  • 5 Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996; 276 (13) 1054-1059
    CrossrefPubMedGoogle Scholar
  • 6 Pearson G, Shann F, Barry P. et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet 1997; 349 (9060): 1213-1217
    CrossrefPubMedGoogle Scholar
  • 7 Pollack MM, Alexander SR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities. Crit Care Med 1991; 19 (02) 150-159
    CrossrefPubMedGoogle Scholar
  • 8 Gemke RJ, Bonsel GJ. Pediatric Intensive Care Assessment of Outcome (PICASSO) Study Group. Comparative assessment of pediatric intensive care: a national multicenter study. Crit Care Med 1995; 23 (02) 238-245
    CrossrefPubMedGoogle Scholar
  • 9 Hanson III CW, Deutschman CS, Anderson III HL. et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med 1999; 27 (02) 270-274
    CrossrefPubMedGoogle Scholar
  • 10 Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002; 288 (17) 2151-2162
    CrossrefPubMedGoogle Scholar
  • 11 Vincent J-L. Need for intensivists in intensive-care units. Lancet 2000; 356 (9231): 695-696
    CrossrefPubMedGoogle Scholar
  • 12 Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012; 366 (22) 2093-2101
    CrossrefPubMedGoogle Scholar
  • 13 Lyu Y, Shah PS, Ye XY. et al; Canadian Neonatal Network. Association between admission temperature and mortality and major morbidity in preterm infants born at fewer than 33 weeks' gestation. JAMA Pediatr 2015; 169 (04) e150277
    CrossrefPubMedGoogle Scholar
  • 14 Croop SEW, Thoyre SM, Aliaga S, McCaffrey MJ, Peter-Wohl S. The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit. J Perinatol 2020; 40 (03) 530-539
    CrossrefPubMedGoogle Scholar
  • 15 Arabi Y. Pro/Con debate: should 24/7 in-house intensivist coverage be implemented?. Crit Care 2008; 12 (03) 216
    CrossrefPubMedGoogle Scholar
  • 16 Wilcox ME, Chong CA, Niven DJ. et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med 2013; 41 (10) 2253-2274
    CrossrefPubMedGoogle Scholar
  • 17 Banerjee R, Naessens JM, Seferian EG. et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med 2011; 39 (06) 1257-1262
    CrossrefPubMedGoogle Scholar
  • 18 Rizzolo A, Shah PS, Bertelle V. et al; Canadian Neonatal Network (CNN) and Canadian Preterm Birth Network (CPTBN) Investigators. Association of timing of birth with mortality among preterm infants born in Canada. J Perinatol 2021; 41 (11) 2597-2606
    CrossrefPubMedGoogle Scholar
  • 19 Jensen EA, Lorch SA. Association between off-peak hour birth and neonatal morbidity and mortality among very low birth weight infants. J Pediatr 2017; 186: 41-48.e4 , e4
    CrossrefPubMedGoogle Scholar
  • 20 Kerlin MP, Small DS, Cooney E. et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013; 368 (23) 2201-2209
    CrossrefPubMedGoogle Scholar
  • 21 Lee SK, Lee DSC, Andrews WL, Baboolal R, Pendray M, Stewart S. Canadian Neonatal Network. Higher mortality rates among inborn infants admitted to neonatal intensive care units at night. J Pediatr 2003; 143 (05) 592-597
    CrossrefPubMedGoogle Scholar
  • 22 Lodha A, Brown N, Soraisham A, Amin H, Tang S, Singhal N. Twenty-four-hour in-house neonatologist coverage and long-term neurodevelopmental outcomes of preterm infants. Paediatr Child Health 2017; 22 (05) 249-254
    CrossrefPubMedGoogle Scholar
  • 23 Kerlin MP, Adhikari NK, Rose L. et al; ATS Ad Hoc Committee on ICU Organization. An official American Thoracic Society systematic review: the effect of nighttime intensivist staffing on mortality and length of stay among intensive care unit patients. Am J Respir Crit Care Med 2017; 195 (03) 383-393
    CrossrefPubMedGoogle Scholar
  • 24 Shahroor M, Lehtonen L, Lee SK. et al; on behalf of the International Network for Evaluation of Outcomes (iNeo) of neonates. Unit-level variations in healthcare professionals' availability for preterm neonates< 29 weeks' gestation: an international survey. Neonatology 2019; 116 (04) 347-355
    CrossrefPubMedGoogle Scholar
  • 25 Canadian Neonatal Network. Abstractor's Manual v2.1.2. 2014 http://www.canadianneonatalnetwork.org/
    PubMedGoogle Scholar
  • 26 Kramer MS, Platt RW, Wen SW. et al; Fetal/Infant Health Study Group of the Canadian Perinatal Surveillance System. A new and improved population-based Canadian reference for birth weight for gestational age. Pediatrics 2001; 108 (02) E35
    CrossrefPubMedGoogle Scholar
  • 27 Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001; 138 (01) 92-100
    CrossrefPubMedGoogle Scholar
  • 28 Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics 1988; 82 (04) 527-532
    CrossrefPubMedGoogle Scholar
  • 29 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
    CrossrefPubMedGoogle Scholar
  • 30 An international classification of retinopathy of prematurity. Pediatrics 1984; 74 (01) 127-133
    CrossrefPubMedGoogle Scholar
  • 31 Willinger U, Lenzinger E, Hornik K. et al; European fluvoxamine in alcoholism study group. Anxiety as a predictor of relapse in detoxified alcohol-dependent patients. Alcohol Alcohol 2002; 37 (06) 609-612
    CrossrefPubMedGoogle Scholar
  • 32 Bell MJ, Ternberg JL, Feigin RD. et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978; 187 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 33 Hanley JA, Negassa A, Edwardes MD, Forrester JE. Statistical analysis of correlated data using generalized estimating equations: an orientation. Am J Epidemiol 2003; 157 (04) 364-375
    CrossrefPubMedGoogle Scholar
  • 34 Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990; 1 (01) 43-46
    CrossrefPubMedGoogle Scholar
  • 35 Bensouda B, Boucher J, Mandel R, Lachapelle J, Ali N. 24/7 in house attending staff coverage improves neonatal short-term outcomes: a retrospective study. Resuscitation 2018; 122: 25-28
    CrossrefPubMedGoogle Scholar