New, small NICUs – convenient, or risky?

April 4, 2016
Imposing hospital facade

The big hospital downtown, Swedish Medical Center at First Hill in Seattle. This wing, one of several in the big complex, was where our son was treated in the NICU.

Five months in the NICU made the daily drive to Swedish Medical Center in Seattle quite tiresome. And then we met some Alaskans in the waiting room, who told us stories about being hustled on to air ambulances when pre-term labor was discovered, about husbands who had never seen their child because they had to stay with the other children, and about getting tired of living at the Ronald McDonald House.

I said, “There really ought to be a NICU in Juneau like the one here so you can be closer to home!”

A year after our family got home from the hospital, I went to a talk given by a neonatologist about how preemie care developed, and discovered that the issue of building smaller NICUs at community hospitals is complicated and controversial.

It takes a Level III NICU to deal with a micropreemie such as our son, born at 22 weeks and 6 days of gestation. Having seen the wonders a Level III NICU can do, I would think more of them ought to be better. A smaller facility ought to have advantages, too, because a baby would get more personal attention from doctors. Parents would not feel lost in a huge institution.

It turns out the opposite is true. Bigger, busier NICUs have higher survival rates. A study published in The New England Journal of Medicine in 2007 looked at survival rates in NICUs in California from 1991 to 2000, and found that very-low-birthweight infants (under 1,500 grams) were more likely to survive if they were treated in NICUs that deal with 100 or more VLBW infants per year. They concluded that 21 percent of preemie deaths were preventable if the babies’ care could be shifted to the larger hospitals.

In the 1960s and 1970s, new medical technologies such as ventilators and CPAP became available for preemies, but not every hospital had them, or had doctors trained in their use. Hospitals formed referral networks to get women in pre-term labor transferred to a regional perinatal center before giving birth.

Hospital administrators went along with this idea because it did not look like preemie care was going to make much money, so giving up low-revenue patients was not a problem, according to pediatricians John Lantos and William Meadow in their 2006 book, Neonatal Bioethics: The Moral Challenges of Medical Innovation.

As neonatal medicine advanced, hospitals discovered that preemie care was profitable. Hospitals could put 8 or 10 intensive-care patients in to a room that could hold only two adults. This was a substantial productivity increase – a rare thing for hospitals as their productivity is limited by the number of beds they can fit in a space. NICUs made money, and many hospitals wanted to open them.

Hospitals also have a motive to retain babies for their NICUs because Labor and Delivery is typically a money-losing department for hospitals, but the fees the hospital receives for a NICU stay can help recover some of that loss. To illustrate this relationship, Lantos and Williams included financial information from the University of Chicago Hospital in their book:

The NICU, which accounted for 4 percent of the patients in the hospital, generated 10 percent of the hospital’s revenue. By contrast, adult medical/surgical patients comprised 54 percent of admissions and 53 percent of revenue, adult cardiology patients comprised 10 percent of admissions and 11 percent of revenue, obstetrics had 15 percent of admissions and only 6 percent of revenue.

Hospitals advertise heavily to women expecting babies because women make most of the medical decisions for families. A positive experience with a birth is believed to bring family members back in later years. NICUs are part of this advertising, not because people want to go there, but because a NICU makes the hospital look modern and advanced.

The trend of smaller hospitals opening small NICUs is known as de-regionalization, and whenever it shows up in medical-journal articles, it is generally described negatively because small NICUs have a hard time keeping neonatologists and other specialists on call 24 hours a day, often sharing neonatologists between facilities and stretching resources thin.

Lantos and Williams predict in their book that the trend of de-regionalization is going to continue because of the financial incentives for hospitals, but they offer some hope that the disparity in survival outcomes for very-low-birthweight infants will get better in small facilities. As medical technology becomes more user friendly, and the use of surfactant becomes better understood by more doctors in the small hospitals, the outcomes should improve, they say.

Parents generally don’t think about this difference in care between types of hospital. Before Gabriel was born, I did not even know what the acronym “NICU” stood for. While we were in the NICU at the big hospital, we saw a large number of specialists come through on the rotation to take care of Gabriel, which at first annoyed us, and later made us glad there were so many pairs of eyes watching our son. Several suburban hospitals have opened new NICUs around Seattle to compete for babies like Gabriel since he was born. If child No. 2 comes along, it might be tempting to go to one of the nearer hospitals with a shiny new NICU, but if the future child is a preemie, would the care there be as good?