NICU study: Best practices are not always followed

Dramatic variations in more than 13,000 cases

A new nationwide review of more than 13,000 premature and other medically complex newborns reveals a dramatic variation of care in the neonatal intensive care unit (NICU), with treatment often deviating from medical literature and leading to less than optimal outcomes for newborns and their families.

The study was sponsored by Paidos Health Management Services Inc., a Deerfield, IL-based specialist in comprehensive NICU population management. Paidos, a ParadigmHealth company, employs neonatal nurse care managers to prospectively collect and populate the Paidos database, called PROACT. "By benchmarking practices and using thoughtfully developed clinical guidelines founded in a review of the current literature and provider experience, Paidos believes the practice variation can be reduced and neonatal outcomes significantly improved," says Alan R. Spitzer, MD, chairman of the Paidos scientific advisory board.

Key findings of the study include:

  • The medical literature recommends infants with suspected sepsis be treated with antibiotics for two to three days unless tests show a positive result, yet more than one-third of the infants studied were treated for periods of time outside of this recommendation (in some cases as many as seven days), even though test results were negative.
  • Previously, physicians were reluctant to discharge infants until they reached a certain weight or gestational age. Now physicians are more likely to discharge premature infants after they have reached certain important milestones.
  • There is a need for additional clinical studies on the use of certain commonly used treatments, such as inhaled nitric oxide (iNO) and metoclopramide for low birth weight babies. These drugs are often prescribed, yet few formal studies support their use, and iNO is not approved by the Food and Drug Administration for premature infants.

Findings such as these take on added significance considering the extent of the NICU industry, says Greg Lippe, president and CEO of Paidos. "This is a $10 billion to $15 billion industry; most insurers say that one in four admissions are NICU-related, or 350,000 to 450,000 admissions a year," he observes. Paidos’ initial client base has been insurance companies. "Our staff serve and interact with the physicians and nurses at the hospitals, and they have the ability to collect information on up to 300 variables on infants, to make sure optimal outcomes are achieved," Lippe says.

The data gathering is a team effort, he emphasizes. "We view our staff as nursing executives who are able to deliver excellent data and share information," he notes. "The data gathering has a collaborative flavor, because there’s a constant interest in what the data say. Plus, our database includes all NICU admissions — not just the very small kids."

Lippe emphasizes that developing a good relationship with nurses across the country is critical to the collection of data and to benchmarking. "The nurses who manage and run the units allow the access to the data," he explains.

Behind the review

Why did Paidos decide to do this particular study? "It goes back to our historical commitment to achieving the highest quality outcomes for infants," says Lippe.

"At this point, we’ve been involved in NICU admissions in about 800 hospitals in the U.S., and we now manage about 35,000 cases or more, so studying this on an interim basis is a good way to improve outcomes on all infants. Plus, sharing information is part and parcel of what we do."

The Neonatal Practice Benchmarks study reportedly is the first of its kind to provide a comprehensive overview of current neonatology practice in the United States. The report benchmarks more than 300 clinical variables on all categories of infants admitted to 504 of the nation’s more than 800 NICUs.

The report was overseen by Spitzer, who is chief of neonatology at the State University of New York at Stony Brook, and Michael Kornhauser, MD, Paidos’ senior medical director.

Spitzer had this to say about the study’s findings: "Although there is an increasing emphasis in the neonatal literature on evidence-based medicine,’ many daily decisions are minimally supported by the literature on current practice. As a result, many neonatal decisions are made based on the local training of the physician, his or her practice experiences, the local norms of practice, and what little science is available."

The resulting variation in practice, he notes, can lead to differing, and at times, less than the most favorable outcomes for newborns and their families, as well as unnecessarily prolonged hospital stays.

One area of care that requires further improvement, based on the study’s findings, is the treatment of infants with possible infection. Treating infants with antibiotics for periods of time outside of the recommendation of the medical literature, the report notes, may prove detrimental and costly, leading to the emergence of resistant bacteria that may be difficult to treat, and possibly placing other infants at higher risk.

"Clinicians and hospitals may not always know or have access to information regarding the current standard practices in neonatology," Kornhauser says. "Individual practitioners would be well served to compare their own practices to data in this report, and if significantly different from these benchmark data, to reevaluate their practices and protocols for care of their NICU infants."

One the positive side, the benchmarking data indicated promising developments regarding changing criteria for hospital discharge, especially for low birth weight infants. Previously, physicians were reluctant to discharge infants until they reached a certain weight or gestational age. Now physicians are more likely to discharge premature infants after they have reached certain important milestones, including the ability to feed and maintain a stable body temperature in an open crib, rather than age/weight-based criteria.

In addition, the report also reviewed other areas of NICU care, including feeding practices, respiratory management, and complications in the NICU.

Lippe sees significant potential benefits in sharing knowledge such as this. "We believe that, hopefully, there are some data in here that are real important," he notes.

"One that struck me personally was how infections are treated. We think we can offer some value to people, perhaps causing them to examine their current benchmarks in this and other areas," he adds. Have they established policies on certain issues raised by the study? Our experience is, there is still a lot work to be done on policy development and benchmarking; we hope this is a good first step for small NICUs and nurseries that have not had their own numbers that indicated the need to do so."

The study has been mailed to NICUs across the country, Lippe says.

Need More Information? 

For more information, contact:

• Michael Kornhauser, MD, Senior Medical Director, Paidos Health Management Services, Deerfield, IL. Telephone: (800) 396-0706, ext. 311. Web site: www.paidosonline.com.