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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.
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
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
The study’s lead author and ELBW program coordinator at CHOC, Mindy Morris, DNP, NNP-BC, CNS, explains that the concept for the hospital’s SBU started in 2008. It was inspired by a study demonstrating a reduction in one of the high-risk morbidities for which these babies are at risk, severe retinopathy of prematurity, by applying a unified approach to care.5
“We thought that sounded like a great idea, but to extend that care throughout the length of stay. Because although the first few days of life are certainly high risk for these babies, they are in our NICU for 3 to 4 months on average. There’s a lot of risk in that timeframe,” Morris comments.
Researchers had reported on that precarious time in mid-2015, noting that even for extremely premature infants who experience a fairly uncomplicated course in an intensive care nursery, they still have a discharge date close to the estimated date of confinement prenatally.2 Their findings show that extremely premature infants (<28 weeks’ gestation) and ELBW infants (<1000 g) continue to be at high risk for disability and death (30%-50% mortality), despite the work of child health experts and numerous technological advances over the last 20 to 30 years. For those infants who survive, the risk of morbidity remains at least 20% to 50%.2
The team in CHOC’s SBU is an interdisciplinary mix of healthcare professionals who typically have backgrounds in caring for low-birth-weight babies. They’re committed to being part of this core group of providers, each of whom brings his or her own individual experience, but now are acquiring expertise working together on a day-to-day basis, explains Morris.
“It is common sense. The more you do something, the better you are at it. So, why not have a special team that cares for these babies because, theoretically, we should become better at delivering care, doing it day to day to day,” she says.
The interdisciplinary team includes a lead physician, neonatal nurse practitioner, nursing staff, respiratory care practitioners, developmental care specialists (in physical therapy, occupational therapy, and speech pathology), dieticians, pharmacists, lactation support, and social services.
Having a dedicated team means more than gathering qualified clinicians. It requires a focus on continuous education and having a staff that is willing to work as a unit. For example, initial training for the SBU requires interdisciplinary team members to complete about 8 hours of independent study before attending an 8-hour didactic course and hands-on skills workshop, in which they complete modules in areas such as neurologic care and fluids/electrolytes/nutrition.1 According to the study by CHOC, key components of program development include continuous education and team communication.1
Morris notes that one aspect that stands out about the evolution of the SBU staff is that it went from being a multidisciplinary, or multiprofessional, group to a more interdisciplinary team.
“Although every professional has their expertise, it really sort of blurs the lines a little bit because they become skilled at other professional jobs as well,” Morris says.
Other team requirements are that each member participates in ongoing team training and team building. Everyone attends quarterly update meetings throughout the year. This gives dayshift and nightshift staff a chance to share their experiences and ideas.
“We go over our data and talk about how we’re doing and where we have other opportunities. It also gives them the chance to interact with the other team members to move this teambuilding forward and to keep us delivering care in a consistent, standardized manner, which is how we designed things,” Morris explains.
CHOC’s SBU is separate from the hospital’s main NICU. The reason, according to Morris, is that one of the primary goals of the SBU is to adhere to evidence-based practices specifically for the care of ELBW patients.
The unit’s guidelines of care are specific to the ELBW babies. These are structured as 3 phases of care: Guideline 1, birth through 10 days of life; Guideline 2, days of life 11 to 30; and Guideline 3, 1 month to discharge.1
Another reason for having a separate unit for ELBW infants is that although they need darkness and quiet to help approximate the womb environment early on, new evidence suggests that well-timed exposure to noise and activity are also important. Thus, CHOC has both individual patient rooms and 4-bed pods in the mix of options.
As the study further points out, the darker and quieter environment of the smaller unit helps foster developmentally supportive care. Finally, because this separate unit brings this special population together, there is an opportunity for parents undergoing similar experiences to form strong bonds with other families.1
The SBU team is committed to sharing best practices, especially about reducing chronic lung disease, infections, number of infants discharged with growth restriction, and laboratory tests and radiographs. All these efforts result in a better outcome for their ELBW patients.
Reducing chronic lung disease. The CHOC study authors attribute the reduction in chronic lung disease to the team’s commitment to use less-invasive respiratory support. This initially meant early extubation to continuous positive airway pressure (CPAP). Subsequently, it included nonintubation in the delivery room and consistent use of CPAP.1
Most of the evidence in the current literature points to minimizing time on invasive ventilation as much as possible, according to Morris. In a study published in early 2009, researchers found a significant reduction in the incidence of chronic lung disease in infants with birth weights of <1500 g, from 46.5% in 2002 to 20.5% in 2005. This marked improvement was the result of implementing a quality improvement process that included avoidance of intubation, adoption of new pulse oximeter limits, and early use of nasal CPAP therapy. No significant short-term complications occurred, and these results persisted.6
Although it might be nonintuitive for a bedside nurse to extubate a baby when it’s so small, the team approach at CHOC helps to support and indoctrinate bedside and all staff so they realize it can be done, asserts Morris. “Again, I think the core of our success is having these consistent healthcare providers,” she says.
Reducing chronic lung disease at discharge is important. For example, babies who have chronic lung disease have a much higher rate for readmission to the hospital.7
“They’re much more susceptible to respiratory viruses. By having babies with a lower rate of chronic lung disease, their lungs are more mature, healthier, and more fully developed, so they’re not as at risk in the general population,” Morris explains.
Reducing infections and number of infants discharged with growth restriction. Studies in the NICU literature suggest most units are incorporating all the same best practice guidelines for central line care that have specifically reduced infections across NICUs.
“There was nothing specific that we changed in this unit to target a reduction in infection that we didn’t change in our entire NICU, with the exception of a more detailed focus on our nutrition processes. We are fairly aggressive in early feeding,” Morris comments.
The sooner these babies tolerate full feedings, the earlier they come off intravenous (IV) nutrition and their central lines are removed. These central lines pose a significant infection risk.
“This is a known risk factor for any patient. Central lines increase the risk of infection. It is a risk factor that has been targeted by every NICU in the country, and most have significantly decreased their infection rates by improving central line care [bundles],” according to Morris.8
“Again, that’s the consistency of having a team at the bedside who is comfortable feeding these babies and knows the signs to look for with intolerance,” Morris explains further.
The team’s commitment to improving nutritional outcomes also helped to reduce the number of infants discharged with growth restriction. Babies discharged with growth restriction are at higher risk than those without growth restriction for poor neurodevelopment.9
Among the practices that are helping the SBU to achieve improved nutritional outcomes has been what Morris calls weekly pharmacy-nutrition rounds.
“That’s where our pharmacist, a dietician, lactation consultants, and someone from our developmental team discuss nutrition and medication management for these babies,” Morris says. “It helps our medication stewardship by having the pharmacist there to remind us of medications that maybe should be discontinued or dose adjusted. Certainly, improved nutritional delivery occurs with the dietician and the pharmacist changing IV nutrition to maximize it and later adjusting enteral nutrition.”
Reducing laboratory tests and radiographs. Often, the running motto in CHOC’s SBU is “Less is more.”
“Sometimes, practitioners have a habit of ordering labs because we want to see the number. It’s not necessary that we see the number, but we want to see it,” Morris says. “The more you know your patient population, the more comfortable you are skipping a day here or there. That adds up to fewer labs for these babies. Certainly, reducing labs causes less pain and stress, which impacts their neurodevelopment throughout their stay. It also leads to less blood being taken, which means these babies get fewer blood transfusions.”10,11
Blood transfusions in this ELBW infant population come with a high risk of necrotizing enterocolitis and other complications.
“The risk has been stated as an association, not necessarily causation, but the risk has a lot of NICUs around the country changing their transfusion practices,” Morris explains.
This means they are holding feedings surrounding blood transfusion for fear of increased risk of necrotizing enterocolitis. “Decreasing the number of unnecessary lab tests and therefore decreasing blood transfusions will decrease the risk,” she says.
Survival rates for ELBW babies are improving. According to another recent study in 2015, the improvement is fueled by physician-driven, multidisciplinary, individualized, and multifactorial quality improvement efforts, which can positively impact the care of extremely preterm infants in the community NICU setting.12
What is changing in the small baby unit at CHOC and in other NICUs that focus on evidence-based practice for this population are the outcomes for these babies at discharge, according to Morris. That’s important, because it means fewer babies have had infections during hospital stays in the NICU. Fewer are being discharged with chronic lung disease and serious growth concerns. Such results could lead to fewer hospital readmissions and better neurodevelopmental outcomes, as well as less need for outside resources when ELBW babies go home.
“So, really by improving their outcomes at discharge, hopefully that leads to having improved outcomes as toddlers and preschoolers and school-aged children,” Morris says. “Unfortunately, we don’t have our data collected for our patients who are now 5 years old, but that is information that we are continuing to collect.”
What’s still missing is the longer-term collaboration with community pediatricians, according to Morris. The challenge to developing those relationships with community pediatricians is that the babies are taken to so many different pediatricians, in different communities, after discharge.
“We look for more of an opportunity to figure out a way to collaborate with pediatricians after these babies go home. We welcome the opportunity to figure out how to collaborate while the baby is in house, to have an ongoing communication, and then certainly at discharge,” Morris adds.
1. Morris M, Cleary JP, Soliman A. Small baby unit improves quality and outcomes in extremely low birth weight infants. Pediatrics. 2015;136(4):e1007-e1015.
2. Glass HC, Costarino AT, Stayer SA, et al. Outcomes for extremely premature infants. Anesth Analg. 2015;120(6):1337-1351.
3. 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.
4. UCSF Children’s Hospital at UCSF Medical Center. Very Low and Extremely Low Birthweight Infants. Intensive Care Nursery House Staff Manual. Regents of the University of California; 2004. Available at: https://www.ucsfbenioffchildrens.org/pdf/manuals/20_VLBW_ELBW.pdf. Accessed February 18, 2016.
5. Chow LC, Wright KW, Sola A; CSMC Oxygen Administration Study Group. Can changes in clinical practice decrease the incidence of severe retinopathy of prematurity in very low birth weight infants? Pediatrics. 2003;111(2):339-345.
6. Birenbaum HJ, Dentry A, Cirelli J, et al. Reduction in the incidence of chronic lung disease in very low birth weight infants: results of a quality improvement process in a tertiary level neonatal intensive care unit. Pediatrics. 2009;123(1):44-50.
7. Greenough A. Long-term respiratory consequences of premature birth at less than 32 weeks of gestation. Early Hum Dev. 2013;89(suppl 2):S25-S27.
8. Shalabi M, Adel M, Yoon E, et al; Canadian Neonatal Network. Risk of infection using peripherally inserted central and umbilical catheters in preterm neonates. Pediatrics. 2015;136(6):1073-1079.
9. Ehrenkranz RA, Dusick AM, Vohr BR, et al. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics. 2006;117(4):1253-1261.
10. Attarian S, Tran LC, Moore A, Stanton G, Meyer E, Moore RP. The neurodevelopmental impact of neonatal morphine administration. Brain Sci. 2014;4(2):321-334.
11. Grunau RE. Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides Med J. 2013;4(4):e0025.
12. Owens JD, Soltau T, McCaughn D, et al. Multi-hospital community NICU quality improvement improves survival of ELBW infants. J Miss State Med Assoc. 2015;56(8):237-242.
Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.