Which Nurseries Currently Care for Ventilated Neonates in Illinois and Wisconsin? Implications for the Next Generation of Perinatal Regionalization

ABSTRACT

We were interested in the extent to which advances in the availability of neonatalogy expertise have provided a centrifugal impetus to perinatal care. Specifically, we wondered where infants who were sick enough to require mechanical ventilation were currently being managed. We surveyed 116 of 140 hospitals in Illinois and Wisconsin that offered obstetric/newborn services in 1998-1999. The 23 Level I nurseries were consistently small, and offered virtually no ``advanced'' neonatal intensive care unit (NICU) technology. The 16 Level III NICUs were consistently large, offered advanced technology and personnel, and received sick infants from many hospitals in their regional network. The 77 Level II nurseries (two thirds of all hospitals with newborn services) were less consistently characterized. In general, Level II nurseries were a ``spoke'' (not a hub), and did not offer extracorporeal-membrane oxygenation (ECMO), nitric oxide (NO), or cardiovascular (CV) surgery. However, 19 (25%) of 77 Level II centers self-designated as ``Level II+''. These were significantly more likely to offer ventilators, percutaneous central venous catheters (PCVCs), total parenteral nutrition (TPN), and surgery. Fifty-three percent (18/34) of all nurseries offering mechanical ventilation self-designated as a Level II or II+, as opposed to Level III. Facile inferences about the appropriate role of Level II centers derived from decades-old data are probably unsupportable. It is time to acknowledge the distinction between the Level II nursery of the past and the newly evolving Level II+ NICUs.

KEYWORDS

Perinatal regionalization - mechanical ventilation - neonatal intensive care - standards of medical care

REFERENCES

• 1 Boyle M H, Torrance G W, Sinclair J C, Horwood S P. Economic evaluation of neonatal intensive care of very low birthweight infants.  New Engl J Med . 1983;  308 1330-1336
• 2 Butterfield L J. Regionalization for respiratory care.  Pediatr Clin North Am . 1973;  20 499-505
• 3 Butterfield L J. The nursery network: an option to deregionalization.  J Perinatol . 1987;  7 1
• 4 Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy: Recommendations for the Regional Development of Maternal and Perinatal Health Services and Beyond White Plains, NY: The National Foundation-March of Dimes 1976
• 5 Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy: The 90s and Beyond White Plains, NY: March of Dimes Birth Defects Foundation 1993
• 6 Gagnon D E, Allison-Cooke S, Schwartz R M. Perinatal care: the threat of deregionalization.  Pediatr Ann . 1988;  17 447-452
• 7 Goldenberg R L, Hanson S, Wayne J B, Koski J. Vital statistics data as a measurement of perinatal regionalization in Alabama, 1970 to 1980.  South Med J . 1985;  78 657-660
• 8 Guidelines for Perinatal Care. 3rd ed. Elk Grove Village, IL and Washington, DC: American Academy of Pediatrics and American College of Obstetrics and Gynecologists 1993
• 9 Kanto W P. Regionalization revisited.  Am J Dis Child . 1987;  141 403-404
• 10 Kollee L A, Verloove-Vanhoric P P, Verwey R A, Brand R, Ruys J H. Maternal and neonatal transport: results of a national collaborative survey of preterm and very low birthweight infants in the Netherlands.  Obstet Gynecol . 1988;  72 729-732
• 11 Little G A, Merenstein G B. Toward improving the outcome of pregnancy, 1993; perinatal regionalization revisited.  Pediatrics . 1992;  92 611-612
• 12 Mammel M C, Josten L, Fuller B, Coleman J M, Boros S J, Fehr P F. Delivery in a tertiary care perinatal center reduces neonatal intensive care costs.  Minn Med . 1986;  69 504-506
• 13 Menard M K, Liu Q, Holgren E A, Sappenfield W M. Neonatal mortality for very low birthweight deliveries in South Carolina by level of hospital perinatal service.  Am J Obstet Gynecol . 1998;  179 374-381
• 14 Paneth N, Kiely J L, Wallenstein S, Marcus M, Pakter J, Susser M. Newborn intensive care and neonatal mortality in low birth weight infants: a population study.  New Eng J Med . 1982;  307 149-155
• 15 Phibbs C, Bronstein J, 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
• 16 Powell S L, Holt V L, Hickok D E, Easterling T, Connell F A. Recent changes in delivery site of low-birth-weight infants in Washington: impact on birthweight-specific mortality.  Am J Obstet Gynecol . 1995;  173 1585-1592
• 17 Schwartz R M, Luby A M, Scanlon J W, Kellogg R J. Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g.  New Engl J Med . 1994;  330 1476-1480
• 18 Sinclair J C, Torance J C, Boyle M H. Evaluation of neonatal intensive care programs.  New Engl J Med . 1981;  305 489-494
• 19 Walker D-JB, Vohr B, Oh W. Economic analysis of regionalized neonatal care for very low-birthweight infants in the state of Rhode Island.  Pediatrics . 1985;  76 69-74
• 20 Williams R L. Evaluating the effectiveness of perinatal regionalization in California during the 1970s.  J Cal Perinatal Assoc . 1982;  2 65-71
• 21 Meadow W, Kim M, Mendez D. A direct comparison of optional versus obligatory transfer of infants who require mechanical ventilation born at level II hospitals.  Neonatal Intensive Care . 2001;  3 28-36