Regionalization for Respiratory Care

Symposium on Respiratory Disorders in the Newborn

Regionalization for Respiratory Care

L. Joseph Butterfield, M.D.*

The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew and act anew. We must disenthrall ourselves. ABRAHAM LINCOLN DECEMBER 1862

Throughout the health scene today, there is a frenzy of activity in the attempt to distribute the products of basic research and clinical experience to the far-flung consumers of health care. As a result the development of a regional approach to the delivery of special care for mothers and newborn infants has gained considerable momentum in the past decade. The leading causes of death under 1 year include (1) diseases of early infancy, which include birth asphyxia, hyaline membrane disease, and prematurity; (2) congenital anomalies; and (3) influenza and pneumonia. These disorders account for 80 per cent of infant deaths and contribute excessively to later neurologic and sensory handicaps among survivors. Improvement in the rate of salvage of newborn infants and betterment of later performance depends on optimal care at birth and in the first months of life. Since respiratory disorders, including neonatal asphyxia, respiratory distress syndrome, pneumothorax, and pneumonia, are more easily identified and managed than in the past, it is appropriate to assign respiratory care high priority. There are approximately 5000 hospitals in the United States with maternity services. The size and the characteristics of these institutions vary considerably. In 1968, a national study of maternity care and obstetric practices was conducted by the Committee on Maternal Care of the American College of Obstetricians and Gynecologists. 1 Thirty-five per cent of the hospitals responding to the questionnaire reported fewer than 250 births per year; and 6 per cent of all births occurred in these hospitals. Eight per cent of the hospitals reported 2000 or more live births annually, which accounted for 32 per cent of all live births in the United States. Studies of this nature point to the continuation of the delivery of critical services to the mother and her newborn infant in small community ':'Associate Clinical Professor of Pediatrics, University of Colorado School of Medicine; Director, The Newborn Center, The Children's Hospital, Denver, Colorado

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hospitals. Often there is no choice, since sparse population and isolated communities must be supported by the best maternity care available, and that may have to be in a service which has less than an ideal case volume. When current obstetric principles are applied in the early recognition of high risk mothers, it should be possible to sort out those mothers who might better be delivered in a regional obstetric service which is more properly staffed and equipped to serve the mother or her newborn at excessive risk. The organization of each community or region into a more efficient and effective maternity and newborn care system has, therefore, become a national issue. The details of prenatal prediction of respiratory distress, the management of the asphyxiated newborn in the delivery room, and the recognition and care of the newborn with respiratory distress syndrome are covered elsewhere. s, 16 A number of actions by a variety of groups and agencies bear eloquent testimony to the movement toward regionalization of maternal and newborn care. In the summer of 1971 the House of Delegates of the American Medical Association 2 adopted a landmark policy regarding the regional approach to perinatal care, with the following recommendations: The AMA urges that in every community (or if more appropriate geographical region) attention be directed to the development and operation of such centralized special care facilities. Goals in these programs should include: . 1. Programs to identify the high-risk pregnancy in sufficient time to allow for delivery at those hospitals which are staffed, equipped, and organized for optimal perinatal care. 2. Programs for the early recognition of high-risk infants not identified during the prenatal period, which provide for the prompt transfer of a distressed infant to a more appropriately equipped facility when indicated. Arrangements for transport should be an integral part of the planning for community centered programs. The AMA recognizes that the implementation of centralized community or regionalized perinatal programs is a responsibility of physicians, government, and the public, and encourages: 1. Training programs for medical and allied personnel necessary to staff regional facilities. 2. Allocation of facilities and equipment within communities and the development of guidelines, consistent with state law, for the operation of regional facilities. 3. Continuing research into the etiologic factors responsible for the high-risk infant and improved methods of medical management. 4. Continuing evaluation of the results of the regionalized programs.' In Canada, a joint committee on the regional approach to reproductive care of the Society of Obstetricians and Gynaecologists of Canada and the Canadian Pediatric Society adopted a set of terms of reference that included the following reference to regionalization: "Therefore the joint committee intends ... to develop recommendations for delivery of optimal reproductive care on a regional basis, in order to improve prospects for survival and subsequent health for the mother and her child."15 Swyer has provided a useful guide to planning for neonatal care on a regional basis with early consideration of vital statistics, geographic and obstetric unit relationships, means of transportation, communication between obstetric units and regional newborn centers, bed requirements and staffing needs. 17

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The Great Plains Organization for Perinatal Health was organized in 1970. Medical, nursing and allied health professionals from North and South Dakota, Minnesota, Wisconsin, Iowa and Nebraska joined together with the objectives of upgrading all health personnel in the care of sick newborn infants, establishing regional newborn and perinatal centers, and providing education and consultation to smaller hospitals within the six states served by the organization. Through regular meetings and workshops a regional effort was launched which cut across the traditional state boundaries. 7 In Nebraska, guidelines were developed for the care of both well and sick newborn infants. Hospital visits were made by nurse-physician teams to teach methods of early identification and stabilization of highrisk newborns. Transfer techniques were discussed at a local level and improved methods of data collection were developed. 19 Similar activity in Wisconsin, Minnesota, North Dakota, and Iowa emphasized a coordination of existing professionals and health facilities. Maximal care facilities were identified in centers throughout the 6 states. Emphasis was placed on early identification of high-risk newborn infants and improvement of care at the local hospitals, as well as early selection and transfer of certain sick newborn infants to maximal care facilities. Within the region, 14 perinatal centers are operational and 5 more are under development. The Intermountain Regional Newborn Intensive Care Unit in Salt Lake City, Utah, serves a 6 state area that includes Utah, Idaho, Wyoming, Nevada, Montana and northern Arizona. According to a recent report 62 per cent of the newborn infants treated at the center have respiratory distress. The director of the center estimates that there are 80,000 live births per year in the service region. Because of the distances involved, air transport systems are commonly used to reduce transit time between hospitals. Helicopter and fixed-wing aircraft are used with a physician and a nurse in attendance during the entire mission. Battery operated transporters provide monitoring capability for heart rate, respirations, and temperature, as well as respiratory support when necessary. Transport team nurses receive special intensive care procedural training (intubation, umbilical artery catheterization, etc.) since such procedures may be employed en route. Two-way radio contact between the transport team and the center maximizes in transit communication and coordination of the support facilities at the center upon arrival. 9 • 11 Since 1947 sick newborn infants have been referred to the University of Colorado Medical Center from the Rocky Mountain and Great Plains states. Originally a premature infant center, this regional center has shifted to a full-service newborn center. In cooperation with The Newborn Center at The Children's Hospital, Denver, through the Perinatal Division of the University of Colorado Medical Center, common regional health goals are pursued with a common faculty and house staff, joined by an amalgam of effort by community, state, and regional agencies. Improving the quality of life through better maternal and newborn care is the simple driving force. 4 Total admissions to the two newborn centers for the 12 month period ending June 1972 totaled 1266, an average of 105 per month and 3.5 per day.

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Colorado has developed 12 planning regions with reasonable geosocial-political boundaries. These regions are used to display newborn referrals to the newborn centers in a way that reflects transport activity by region. The actual number of referrals varied from 700 from Region III (Metropolitan Denver, with 20,720 live births per year) to 1 from Region X (Western Slope Colorado, with 610 live births per year). U sing live births as a denominator, it can be shown that the transport rate (total transported newborn infants per 1000 live births per year) varies from 35 in Region III to 1 in another metropolitan area. Although there is not a direct correlation by region with neonatal death rate, the larger contrast between metropolitan Denver and the rest of Colorado (17,000 live births) reveals a higher transport rate in metropolitan Denver (35) and a lower neonatal mortality rate (12.6 per 1000) compared to nonmetropolitan Denver (6 and IB.l per 1000, respectively). This trend of neonatal outcome being favored by high utilization of newborn centers has previously been reported in Canada 18 and New Jersey.6 In the western states, the need for regionalization of all newborn services is emphasized by an examination of the Denver trade region on a county by county basis. Of 171 counties fanning out from Denver into the states of Colorado, New Mexico, Wyoming, Nebraska, Kansas and South Dakota, only three (Denver, Jefferson, and Bernalillo) report 1 or more hospitals with 2000 or more live births (by occurrence) and 93 counties reported less than 500 births per year. Clearly the hospital providing service to the occasional newborn is unable to justify more than the minimal acceptable standard of care. Definitions of the levels of care and guidelines for minimal staffing, equipment, space and organization are needed. In the past year an ad hoc committee on perinatal health, representing the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American Medical Association, in cooperation with the National Foundation/March of Dimes, is working on such guidelines. Task forces on facilities and services, personnel, and finances are exploring the best use of manpower, facilities and funds with the objective of developing guidelines for practices and programs to improve the health of the mother, fetus, and newborn infant. The Georgia Regional Medical Program has developed a plan for a statewide system of high-risk newborn care. 3 Hospital categories proposed are (1) primary, serving asymptomatic, full-term newborns; (2) secondary, providing care for the growing premature, the convalescing newborn, the moderately ill newborn, and the normal full-term newborn; and (3) tertiary, serving the full range of care from special intensive care for newborns from a wide area through normal full-term newborn care. The qualifications of personnel, the needs of each category of hospital in terms of facilities, utilities, equipment, laboratory capability, special diagnostic and support services are increasingly complex and costly as the level of care is increased. 3

THE ROLE OF THE STATE HEALTH DEPARTMENT State health departments have stimulated and supported the development of regional maternal and newborn services in a variety of ways.

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The Arizona State Division of Maternal and Child Health Premature Advisory Committee was appointed in 1964 to plan for special newborn care. Special care centers were established in two large metropolitan hospitals in Phoenix under the direction of H. B. P. Meyer, M.D. In 1967 a demonstration project was begun to transport sick newborn infants from Arizona hospitals to the two centers. Ambuiances with appropriate equipment and fixed-wing aircraft were used to move the sick newborns from the hospital of birth. The impact of the system was evaluated by an examination of neonatal mortality rates, distances transported, and variation from predicted morbidity and mortality. Meyer presented this experience at the Society for Pediatric Research in 1971. He stated that significant decreases in neonatal mortality occurred following the development of the newborn intensive care centers and the statewide transport system. Babies with respiratory distress syndrome who were transported to a center had significantly lower mortality rates (32 per cent) than did their counterparts who remained at the hospital of birth (59 per cent). Travel distance had no apparent effect on outcome, using 60 miles as the dividing line between near and far transport. Meyer concluded that the project had demonstrated a reduction in neonatal mortality through a systematic approach to delivery of intensive neonatal care with a sophisticated transport plan and trained professionals bridging the gap between the distant community hospital and the newborn intensive care center. lO Regionalization of maternity and newborn services in Massachusetts has been stimulated by new regulations for newborn services in hospitalS. 12 These regulations reflect the urgency in the early recognition of newborn problems, and appropriate disposition of the baby in either the hospital of birth or a transfer nursery. "Special Care Infant" has been defined by the Massachusetts Department of Public Health to include 8 categories of infants, with conditions such as (1) low birth weight, less than 2,000 grams and/or less than 32 weeks gestation; (2) significant congenital anomalies; (3) respiratory distress, cyanosis, infection or sepsis, early jaundice, etc. New regulations require that special care nurseries shall be provided in "all hospitals having an average daily census of 4 or more low birth weight infants or more than 2000 deliveries per year ... " and that "all hospitals with ... less than 2000 deliveries per year shall submit, for approval by The Department, written plans and descriptions of facilities, equipment, and staff for the care of low birth weight infants, high risk infants, and infants in need of special care, either in the hospital of birth or by transfer of these infants to a hospital with appropriate staff and equipment."2o The smaller maternity services in Massachusetts must now declare a plan for prompt transfer of certain categories of sick infants. During the convalescent or "growing" phase it is possible for the same infant to be transferred back to the hospital of birth. The California State Department of Public Health's Bureau of Crippled Children Services has affected the care of the newborn with respiratory distress syndrome by the issuance of standards for infant intensive care units. Hyaline membrane disease and respiratory distress syndrome are considered conditions or diseases of the newborn that are eligible for care. Care of such infants is only reimbursable when such care is pro-

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vided in units approved by the Bureau of Crippled Children Services. It is specifically stated in the standards that "approval may not be granted if there is no need for additional infant intensive care beds in the community. This will be determined in cooperation with Comprehensive Health Planning and the Bureau of Maternal and Child Health. 5

A REGIONAL NEWBORN CENTER IN A COMMUNITY HOSPITAL A regional newborn center, as defined by Ellis, is "a specialized unit, serving a specific geographic region, appropriately designed, staffed, and equipped to care for those newborns who are at highest risk to the neurological, cardiorespiratory, gastrointestinal, renal and developmental sequelae of the extrauterine environment." Ellis lists the criteria for transfer of infants to a regional newborn center as follows: 1. 2. 3. 4. 5.

weight less than 1500 grams; gestation less than 34 weeks; infant of a diabetic mother; neonatal seizures; known isoimmunization prior to 36 weeks gestation and LIS ratio less than

2:1;

6. suspected neonatal sepsis and/or meningitis; 7. persistent cyanosis without respiratory distress (RDS); 8. congenital anomalies requiring observation for neonatal surgery; 9. respiratory distress and metabolic acidosis persisting after 4 hours of age.

Since 1968 up to 552 newborn infants have been admitted to the Regional Newborn Center at Monmouth Medical Center each year, with an increasing number being transported (202 in 1971). Using standard statistical analysis the "user" hospitals were compared with the "nonuser" hospitals in the two suburban New Jersey counties served by the Regional Newborn Center. Neonatal mortality rates were compared in the following categories: (1) Group I: newborns weighing 501 to 1500 gm.; (2) Group II: newborns weighing 1501 to 2500 gm.; (3) Low birth weight: newborns weighing 501 to 2500 gm.; (4) Total newborns: all newborns weighing more than 500 grams. Ellis concluded that: (1) newborns weighing less than 2000 gm. comprise 65 to 75 per cent of the neonatal deaths; (2) a significant reduction of neonatal mortality among 501 to 1500 gram newborns occurs where more than 40 per cent of such infants are referred; and (3) a Regional Newborn Center can significantly lower neonatal mortality when 2 per cent or more of all newborns are referred. The above presentation was made in the form of a scientific exhibit at the Annual Meeting of the Medical Society of New Jersey on May 6 to 8, 1972. The collection and collation of data and the cost analyses generated from the program at Monmouth Medical Center are valuable demonstrations. Doctor Clark Vincent, Director of the Behavioral Sciences Center at Bowman Gray School of Medicine, recently described the 35 to 55 yearold parent as belonging to the "caught generation" - "caught in between the demands of youth and the expectations of the elderly."2o In every region of the country there are hospitals in the "caught" category

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-caught in between the concern about the cost of change by the medical staff, the administration, and the board of directors on the one hand, and the rising expectations of young, better-educated parents who have accepted the philosophy of fewer children but expect a higher quality of life for each. Medical staffs, boards of directors and administrators who are bound by conscience and concern for community well-being are likely to accept the regional approach to sick newborn and eventually all perinatal care. As evidence accumulates to show that there are more and higher quality survivors of neonatal intensive care,13 there will be a parallel increase in cost figures to show that there is also a long-range cost effectiveness in regional intensive care centers. Faced with these two primary facts, logical decisions about consolidation of health services and coordination of regional health facilities will be easier to make at all levels of responsibility.

REFERENCES 1. American College of Obstetricians and Gynecologists: The National Study of Maternity Care: Survey of Obstetric Practice and Associated Services in Hospitals in the United States. Chicago, Illinois, 1971. 2. American Medical Association, House of Delegates: Report J. Atlantic City, New Jersey, 1971. 3. Blackmon, L. R., and Brown, A. K.: Recommended standards for hospital nursery services. In press. 4. Butterfield, L. J.: Regional newborn care. American Medical Association, Proceedings of the Quality of Life, 1972. 5. California State Department of Public Health, Bureau of Crippled Children, 1972. 6. Ellis, W.: The regional newborn center: the effect on neonatal mortality of referring hospitals. Scientific exhibit, Annual Meeting, Medical Society of New Jersey, May 6, 1972. 7. Graven, S.: Personal communication. 8. Gregory, G. A.: Respiratory care of newborn infants. PEDIAT. CLIN. N. AMER., 19:311, 1972. 9. Jung, A. L., and Smith, K.: Newborn intensive care in the inter-mountain west. Rocky Mountain Med. J., 68:16, 1971. 10. Meyer, H. B. P.: Personal communications. 11. Neonatal ICU reaches out via airlift. Hosp. Pract., 7: 115 (Dec.) 1972. 12. New regulations for newborn services. Editorial. New Eng. J. Med., 286: 1363, 1972. 13. Rawlings, G., Stewart, A., Reynolds, S. O. R., et a!.: Changing prognosis for infants of very low birth weight. Lancet, 1 :516, 1971. 14. Regulations governing newborn services in hospitals. Commonwealth of Massachusetts, Department of Public Health, 1970. 15. Report of the Joint Committee on the Regional Approach to Reproductive Care of the Society of Obstetricians and Gynaecologists of Canada and the Canadian Pediatric Society, 1971. 16. Segal, S.: Manual for the Transport of High-Risk Infants. Canadian Pediatric Society, 1972. 17. Swyer, P.: The regional organization of special care for the neonate. PEDIAT. CLIN. N. AMER., 17:761, 1970. 18. Usher, R. H.: The role of the neonatologist. PEDIAT. CLIN. N. AMER., 17:199, 1970. 19. van Leeuwen, G.: Newborn medicine consultation in Nebraska. Nebraska Med. J., May 1972, p. 187. 20. Vincent, C. K: An open letter to the "caught" generation. Family Coordinator, April 1972, p. 150 Children's Hospital 1056 East 19th Avenue Denver, Colorado 80218