Boosting micropreemie outcomes
Hospital-based care for extremely low-birth-weight (ELBW) infants has evolved significantly, resulting in improved outcomes for these patients at discharge. This article reveals how one children’s hospital initiated a program to push even further process-improvement initiatives of evidence-based care to reduce high-risk morbidities in these tiniest of newborns.
Hospital discharge for extremely low-birth-weight (ELBW) infants, defined as those born at 28 weeks or earlier and weighing less than 1000 g at birth, often means significant ongoing health challenges for these babies and their families. A program called the small baby unit (SBU), which focuses on their care, uses a multidisciplinary team approach that has been shown to improve the outcomes of these tiny patients in a number of measurable ways.1
With the goal of improving outcomes for ELBW infants, the staff at Children’s Hospital of Orange County (CHOC), Orange, California, established the separate SBU in the hospital’s neonatal intensive care unit (NICU). The hospital’s core SBU multidisciplinary team is charged with participating in ongoing educational and process improvement initiatives aimed at standardizing evidence-based care for ELBW babies on the unit.
Researchers and team members studied the evolution of care on the unit by reporting on data from 2 years prior to and 4 years after opening the SBU. They found important milestones in several areas that indicated their approach was working to improve outcomes, including:
· Percentage of babies leaving the unit with chronic lung disease fell from 47.5% at 2 years prior to the unit opening to 35.4% at 4 years after the unit opened;
· Rate of hospital-acquired infection decreased from 39.3% to 19.4%;
· Infants discharged with growth restriction, which is a combined weight and head circumference less than the 10th percentile, decreased from 62.3% to 37.3%; and
· Babies received fewer laboratory tests and radiographs, signaling reduced resource utilization, with the mean number of lab tests per patient decreasing from 224 to 82 and the mean number of radiographs decreasing from 45 to 22.
Although the researchers concluded that having a distinct unit for these babies run by a consistent multidisciplinary SBU team using quality improvement methods improved outcomes for ELBW infants, they noted that ongoing team engagement and development are required to sustain these better outcomes.1
About ELBW babies
Premature birth remains a significant cause of infant and child morbidity and mortality, according to investigators of a recent 2015 study.2 The researchers found that the premature birth rate, after increasing steadily in the 1990s and early 2000s, decreased annually for the last 7 years to a rate of about 11.39%. Further, in developed countries, human viability (ie, gestational age at which survival chance is 50%) is now approximately 23 to 24 weeks.2
These ELBW infants are at higher risk than babies of normal weight for several neonatal complications.
In another recent study from 2015, researchers looked at a prospective registry of 34,636 infants (22–28 weeks’ gestation; birth weight, 401 g–1500 g) born at 26 Neonatal Research Network centers between 1993 and 2012.3 Their results in reviewing these 20-year trends indicated that for infants who survived more than 12 hours, major morbidities included severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and severe retinopathy of prematurity.3
The list of potential neonatal complications for severely underweight newborns is even longer. Among these are hypothermia, hypoglycemia, perinatal asphyxia, respiratory problems, fluid and electrolyte imbalances, hyperbilirubinemia, anemia, impaired nutrition, infection, neurologic problems, ophthalmologic complications, hearing deficits, and sudden infant death syndrome.4
The good news is that early outcomes for ELBW infants seem to be improving in the United States. The review of 20-year trends seen in the ELBW infant population born at US academic centers resulted in the conclusion that there had been changes in maternal and infant care practices as well as small reductions in some morbidities, with the exception of an increased incidence of bronchopulmonary dysplasia. For infants born at 23 and 24 weeks’ gestation, the increase in survival was found to be the most marked, from 27% to 33% and from 63% to 65%, respectively. In addition, for those infants at 25 to 28 weeks’ gestation, survival without major morbidity increased approximately 2% per year.3