Reducing length of stay in hospital for very low birthweight infants by involving mothers in a stepdown unit: an experience from Karachi (Pa
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《英国医生杂志》
1 Aga Khan University, Karachi 74800, Pakistan
Correspondence to: Z A Bhutta zulfiqar.bhutta@aku.edu
Abstract
Survival and outcome of infants with a very low birth weight (weighing less than 1500 g at birth) have improved tremendously in recent years, and in most developed countries, survival rates are 80-90% for infants weighing 750-1500 g.1 2 In contrast, data on very low birthweight infants from the developing world are scarce, and available information is largely restricted to reports from infants admitted to hospital.3-5 Clinical care of very low birthweight infants in developing countries can be difficult and labour intensive, and with limited resources for intensive care, alternative strategies such as Kangaroo Mother Care have been employed for the care of very low birthweight infants.6 7
Context
By 1993-4, because of the large number of high risk infants born in the Aga Khan Center and external referrals, a major bottleneck to outside admissions was the length of time that such very low birthweight infants stayed in hospital, which averaged 18-21 days.8 After stabilisation and graduation from intensive care, most such infants were kept in the transitional care area of the neonatal intensive care unit until they were ready for discharge. Although parents were allowed free access, no facilities were available for "rooming in," and all routine care was provided by the unit's nurses and paramedical staff. The overall cost of intensive care in the neonatal intensive care unit at the centre (average $90-100/day in 1993-4) was lower than in developed countries,9 but prolonged hospital stay was a source of considerable economic burden on families and possible third parties that pay such as corporate groups and local health insurance companies.
Strategies for change
In addition to the existing system of data collection on morbidities and outcomes (survival to discharge and at 12 months of age), we chose length of stay in hospital, cost of care, frequency of readmission to the neonatal intensive care unit from the stepdown unit as well as readmission to hospital in the four weeks after discharge as key measures of improvement.
We analysed the clinical course, morbidity patterns, and outcomes of the entire very low birthweight cohort born at the centre for the time periods before and after the stepdown unit was created (1987-1994 and 1995-2001). We used univariate methods (SPSS for Windows, version 10) to compare the two time periods for length of stay in hospital, mortality patterns, and outcomes associated with very low birth weight. To categorise the condition at admission and severity of illness objectively, we assigned the clinical risk index for babies (CRIB) score to all very low birthweight infants.10 We also evaluated the survival of infants in a prespecified, stepwise, logistic regression model including the variables birth weight, sex, birth asphyxia, admission CRIB score, and the time period (before and after the stepdown unit).
Effects of change
Our experience shows that it is possible to motivate and involve mothers in the care of very low birthweight infants in hospital, with early discharge home. Our data also show that the creation of a stepdown unit with maternal involvement in the care of very low birthweight infants was associated with a shorter stay in hospital and fewer nosocomial infections in the neonatal intensive care unit.
Limitations
Notwithstanding the above, several limitations must be recognised in reviewing these data. This was not a randomised controlled trial of the impact of a stepdown unit on outcomes of very low birth weight, as the facility was largely created because of pressing clinical needs and admission bottlenecks. We cannot entirely exclude the possibility of a systematic selection bias. However, we found no indication of a selection bias as our analysis includes information on the clinical course and outcome to discharge for 509/517 very low birthweight infants born in hospital, as well as follow up data during infancy on 79% of the survivors. Although some newborn infants exhibited evidence of growth restriction, 97% of the very low birthweight infants were preterm. Our data on overall rates of live births of infants with a very low birth weight and prematurity in the birth cohort are comparable to those reported from other centres in India11 and Brazil,12 although they are higher than those reported from the West.13 The prevalence of respiratory distress syndrome in these infants was also similar to that reported from the large Vermont-Oxford Trials Network Database Project from a comparable time period.14
Another issue concerns a possible secular trend in improvement of the quality of neonatal care over this time period. Although this may be possible, no major change occurred in staffing ratios and treatment protocols over this time period except for the introduction of surfactant therapy for respiratory distress syndrome in 1990. The proportion of high risk preterm births increased in the period after the stepdown unit opened, and the respective CRIB scores indicated increasing severity of illness and instability at admission. Other surrogate markers of severity of illness and complications remained the same over the time periods reviewed, except for comparatively lower rates of birth asphyxia. The latter did not, however, emerge as a significant factor in the logistic regression model.
A major coincidental finding after the creation of the stepdown unit was the dramatic reduction of rates of overall nosocomial infections among infants admitted to the neonatal intensive care unit, which was possibly related to reduced congestion and relatively reduced handling of infants by multiple care providers. Similar findings have also been reported by Callaghan et al—namely, a higher risk of mortality in very low birthweight infants with increasing ratios of staff to infants.15 Although the mothers were counselled specifically on the importance of asepsis, we have no objective data on rates of handwashing practices over this period. Among the cohort itself, rates of culture proved neonatal sepsis and necrotising enterocolitis for the two time periods were comparable.
Implications and next steps
Preterm births are recognised as an important cause of neonatal mortality in developing countries.16 17 Although improved survival among such high risk infants by provision of neonatal intensive care has been reported,18 19 such care facilities are also often under high pressure for admissions. Others have provided data on using mothers to look after infants with a low birth weight20 as well as on the potential benefit of home care and community nursing for larger infants,21 22 but these reports include few very low birthweight infants at high risk.
Our data provide encouraging information that mothers can be motivated and trained to look after very low birthweight infants in a specialised unit before discharge from hospital and to look after such infants weighing between 1000-1500 g at home in a satisfactory manner, with reasonably intact outcomes. Although we did not undertake formal neurodevelopmental assessment, the overall rate of adverse outcomes at 12 months among surviving babies with a very low birth weight is low and comparable to data from Malaysia,23 Spain,24 and South Africa.25 We believe that our experience in Karachi and the concept of involving mothers in the care of some very low birthweight infants, especially those with a birth weight of 1000-1500 g, can be replicated in other settings in Pakistan and developing countries of comparable constraints on resources and staffing. In view of the rising costs of neonatal intensive care,26 these findings may also be of relevance to developed countries.
We thank the scores of residents and nurses, and the families who were responsible for the care and follow up of these infants. In addition, several research officers and data managers have been responsible for maintenance of the database over the years, notably Saleem Islam, Kiran Chaudhry, Kamran Yusuf, Rashid Gadet, and Rashida Shaikhali.
Contributors: ZAB conceived the idea of this intervention and was the director of neonatal services at the Aga Khan University Medical Center from 1989 to 2003. He supervised the data collection, analysis, wrote the manuscript, and is the guarantor. IK and SS contributed to the clinical care of infants in the study and the manuscript review process. FR helped with data collection and analysis and staff nurse HA oversaw the staff training in the stepdown unit and contributed to the manuscript review.
Competing interests: None declared.
Ethical approval: Since the creation of the stepdown unit was not a formal "research" initiative, a specific clearance from the ethics review committee at Aga Khan University was not sought. A prospective system for data collection on all high risk admissions to the neonatal care unit was already in place since 1987, and the protocol for the analysis of outcomes of babies with a very low birth weight was approved by the Departmental Research committee. All parents provided written consent for the anonymised use of clinical information for research and audit purposes at admission.
References
Kaiser JR, Tilford JM, Simpson PM, Salhab WA, Rosenfeld CR. Hospital survival of very-low-birth-weight neonates from 1977 to 2000. J Perinatol 2004;24: 343-50.
Fanaroff AA, Hack M, Walsh MC. The NICHD neonatal research network: changes in practice and outcomes during the first 15 years. Semin Perinatol 2003;27: 281-7.
Boo NY, Ong LC, Lye MS, Chandran V, Teoh SL, Zamratol S, et al. Comparison of morbidities in very low birthweight and normal birthweight infants during the first year of life in a developing country. J Paediatr Child Health 1996;32: 439-44.
Grupo Colaborativo Neocosur. Very-low-birth-weight infant outcomes in 11 South American NICUs. J Perinatol 2002;22: 2-7.
Ali M M, Kawser C A, Talukder M Q-K. Very low birth weight infants (1500 g or less). I. Outcome of neonatal admission. Bangladesh J Child Health 1988;12: 90-6.
Lincetto O, Vos ET, Graca A, Macome C, Tallarico M, Fernandez A. Impact of season and discharge weight on complications and growth of Kangaroo Mother Care treated low birthweight infants in Mozambique. Acta Paediatr 1998;87: 433-9.
Kambarami RA, Chidede O, Kowo DT. Kangaroo care for well low birth weight infants at Harare Central Hospital Maternity Unit--Zimbabwe. Cent Afr J Med 1999;45: 56-9.
Bhutta ZA, Yusuf K, Khan IA. Is management of neonatal respiratory distress syndrome feasible in developing countries? Experience from Karachi, Pakistan. Pediatr Pulmonol 1999;27: 305-11.
Rogowski J. Using economic information in a quality improvement collaborative. Pediatrics 2003;111: e411-8.
The International Neonatal Network. The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units. Lancet 1993;342: 193-8.
Ravikumara M, Bhat BV. Early neonatal mortality in an intramural birth cohort at a tertiary care hospital. Indian J Pediatr 1996;63: 785-9.
Gray RH, Ferraz EM, Amorim MS, de Melo LF. Levels and determinants of early neonatal mortality in Natal, northeastern Brazil: results of a surveillance and case-control study. Int J Epidemiol 1991;20: 467-73.
Darlow BA, Cust AE, Donoghue DA, on behalf of the Australian and New Zealand Neonatal Network (ANZNN). Improved outcomes for very low birthweight infants: evidence from New Zealand national population based data. Arch Dis Child Fetal Neonatal Ed 2003;88: F23-F28.
Investigators of the Vermont-Oxford Trials Network Database Project. The Vermont-Oxford trials network: very low birth-weight outcomes for 1990. Pediatrics 1993;91: 540-5.
Callaghan LA, Cartwright DW, O'Rourke P, Davies MW. Infant to staff ratios and risk of mortality in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2003;88: F94-F97.
Yasmin S, Osrin D, Paul E, Costello A. Neonatal mortality of low-birth-weight infants in Bangladesh. Bull WHO 2001;79: 608-14.
Kulmala T, Vaahtera M, Ndekha M, Koivisto AM, Cullinan T, Salin ML, et al. The importance of preterm births for peri- and neonatal mortality in rural Malawi. Paediatr Perinat Epidemiol 2000;14: 219-26.
Boo NY. Outcome of very low birthweight neonates in a developing country: experience from a large Malaysian maternity hospital. Singapore Med J 1992;33: 33-7.
Atasay B, Gunlemez A, Unal S, Arsan S. Outcomes of very low birth weight infants in a newborn tertiary center in Turkey, 1997-2000. Turk J Pediatr 2003;45: 283-9.
Arif MA, Arif K. Low birthweight babies in the Third World: maternal nursing versus professional nursing care. J Trop Pediatr 1999;45: 278-80.
Mbweza E. Bridging the gap between hospital and home for premature infants in Malawi. Int Nurs Rev 1996;43: 53-7.
Tafari N, Sterky G. "Early" discharge of low birth-weight infants in a developing country. J Trop Pediatr Environ Child Health 1974;20: 73-6.
Arce Casas A, Iriondo Sanz M, Krauel Vidal J, Jimenez Gonzalez R, Campistol Plana J, Poo Arguelles P, et al. Neurological follow-up of very low birth weight newborns at the age of two years (1998-1999). Ann Pediatr (Barc) 2003;59: 454-61.
Ho JJ, Amar HS, Mohan AJ, Hon TH. Neurodevelopmental outcome of very low birth weight babies admitted to a Malaysian nursery. J Paediatr Child Health 1999;35: 175-80.
Cooper P, Sandler D L. Outcome of very low birth weight infants at 12 to 18 months of age in Soweto, South Africa. Pediatrics 1997;99: 537-44.
Merritt TA, Pillers D, Prows SL. Early NICU discharge of very low birth weight infants: a critical review and analysis. Semin Neonatol 2003;8: 95-115.(Zulfiqar A Bhutta, profes)
Correspondence to: Z A Bhutta zulfiqar.bhutta@aku.edu
Abstract
Survival and outcome of infants with a very low birth weight (weighing less than 1500 g at birth) have improved tremendously in recent years, and in most developed countries, survival rates are 80-90% for infants weighing 750-1500 g.1 2 In contrast, data on very low birthweight infants from the developing world are scarce, and available information is largely restricted to reports from infants admitted to hospital.3-5 Clinical care of very low birthweight infants in developing countries can be difficult and labour intensive, and with limited resources for intensive care, alternative strategies such as Kangaroo Mother Care have been employed for the care of very low birthweight infants.6 7
Context
By 1993-4, because of the large number of high risk infants born in the Aga Khan Center and external referrals, a major bottleneck to outside admissions was the length of time that such very low birthweight infants stayed in hospital, which averaged 18-21 days.8 After stabilisation and graduation from intensive care, most such infants were kept in the transitional care area of the neonatal intensive care unit until they were ready for discharge. Although parents were allowed free access, no facilities were available for "rooming in," and all routine care was provided by the unit's nurses and paramedical staff. The overall cost of intensive care in the neonatal intensive care unit at the centre (average $90-100/day in 1993-4) was lower than in developed countries,9 but prolonged hospital stay was a source of considerable economic burden on families and possible third parties that pay such as corporate groups and local health insurance companies.
Strategies for change
In addition to the existing system of data collection on morbidities and outcomes (survival to discharge and at 12 months of age), we chose length of stay in hospital, cost of care, frequency of readmission to the neonatal intensive care unit from the stepdown unit as well as readmission to hospital in the four weeks after discharge as key measures of improvement.
We analysed the clinical course, morbidity patterns, and outcomes of the entire very low birthweight cohort born at the centre for the time periods before and after the stepdown unit was created (1987-1994 and 1995-2001). We used univariate methods (SPSS for Windows, version 10) to compare the two time periods for length of stay in hospital, mortality patterns, and outcomes associated with very low birth weight. To categorise the condition at admission and severity of illness objectively, we assigned the clinical risk index for babies (CRIB) score to all very low birthweight infants.10 We also evaluated the survival of infants in a prespecified, stepwise, logistic regression model including the variables birth weight, sex, birth asphyxia, admission CRIB score, and the time period (before and after the stepdown unit).
Effects of change
Our experience shows that it is possible to motivate and involve mothers in the care of very low birthweight infants in hospital, with early discharge home. Our data also show that the creation of a stepdown unit with maternal involvement in the care of very low birthweight infants was associated with a shorter stay in hospital and fewer nosocomial infections in the neonatal intensive care unit.
Limitations
Notwithstanding the above, several limitations must be recognised in reviewing these data. This was not a randomised controlled trial of the impact of a stepdown unit on outcomes of very low birth weight, as the facility was largely created because of pressing clinical needs and admission bottlenecks. We cannot entirely exclude the possibility of a systematic selection bias. However, we found no indication of a selection bias as our analysis includes information on the clinical course and outcome to discharge for 509/517 very low birthweight infants born in hospital, as well as follow up data during infancy on 79% of the survivors. Although some newborn infants exhibited evidence of growth restriction, 97% of the very low birthweight infants were preterm. Our data on overall rates of live births of infants with a very low birth weight and prematurity in the birth cohort are comparable to those reported from other centres in India11 and Brazil,12 although they are higher than those reported from the West.13 The prevalence of respiratory distress syndrome in these infants was also similar to that reported from the large Vermont-Oxford Trials Network Database Project from a comparable time period.14
Another issue concerns a possible secular trend in improvement of the quality of neonatal care over this time period. Although this may be possible, no major change occurred in staffing ratios and treatment protocols over this time period except for the introduction of surfactant therapy for respiratory distress syndrome in 1990. The proportion of high risk preterm births increased in the period after the stepdown unit opened, and the respective CRIB scores indicated increasing severity of illness and instability at admission. Other surrogate markers of severity of illness and complications remained the same over the time periods reviewed, except for comparatively lower rates of birth asphyxia. The latter did not, however, emerge as a significant factor in the logistic regression model.
A major coincidental finding after the creation of the stepdown unit was the dramatic reduction of rates of overall nosocomial infections among infants admitted to the neonatal intensive care unit, which was possibly related to reduced congestion and relatively reduced handling of infants by multiple care providers. Similar findings have also been reported by Callaghan et al—namely, a higher risk of mortality in very low birthweight infants with increasing ratios of staff to infants.15 Although the mothers were counselled specifically on the importance of asepsis, we have no objective data on rates of handwashing practices over this period. Among the cohort itself, rates of culture proved neonatal sepsis and necrotising enterocolitis for the two time periods were comparable.
Implications and next steps
Preterm births are recognised as an important cause of neonatal mortality in developing countries.16 17 Although improved survival among such high risk infants by provision of neonatal intensive care has been reported,18 19 such care facilities are also often under high pressure for admissions. Others have provided data on using mothers to look after infants with a low birth weight20 as well as on the potential benefit of home care and community nursing for larger infants,21 22 but these reports include few very low birthweight infants at high risk.
Our data provide encouraging information that mothers can be motivated and trained to look after very low birthweight infants in a specialised unit before discharge from hospital and to look after such infants weighing between 1000-1500 g at home in a satisfactory manner, with reasonably intact outcomes. Although we did not undertake formal neurodevelopmental assessment, the overall rate of adverse outcomes at 12 months among surviving babies with a very low birth weight is low and comparable to data from Malaysia,23 Spain,24 and South Africa.25 We believe that our experience in Karachi and the concept of involving mothers in the care of some very low birthweight infants, especially those with a birth weight of 1000-1500 g, can be replicated in other settings in Pakistan and developing countries of comparable constraints on resources and staffing. In view of the rising costs of neonatal intensive care,26 these findings may also be of relevance to developed countries.
We thank the scores of residents and nurses, and the families who were responsible for the care and follow up of these infants. In addition, several research officers and data managers have been responsible for maintenance of the database over the years, notably Saleem Islam, Kiran Chaudhry, Kamran Yusuf, Rashid Gadet, and Rashida Shaikhali.
Contributors: ZAB conceived the idea of this intervention and was the director of neonatal services at the Aga Khan University Medical Center from 1989 to 2003. He supervised the data collection, analysis, wrote the manuscript, and is the guarantor. IK and SS contributed to the clinical care of infants in the study and the manuscript review process. FR helped with data collection and analysis and staff nurse HA oversaw the staff training in the stepdown unit and contributed to the manuscript review.
Competing interests: None declared.
Ethical approval: Since the creation of the stepdown unit was not a formal "research" initiative, a specific clearance from the ethics review committee at Aga Khan University was not sought. A prospective system for data collection on all high risk admissions to the neonatal care unit was already in place since 1987, and the protocol for the analysis of outcomes of babies with a very low birth weight was approved by the Departmental Research committee. All parents provided written consent for the anonymised use of clinical information for research and audit purposes at admission.
References
Kaiser JR, Tilford JM, Simpson PM, Salhab WA, Rosenfeld CR. Hospital survival of very-low-birth-weight neonates from 1977 to 2000. J Perinatol 2004;24: 343-50.
Fanaroff AA, Hack M, Walsh MC. The NICHD neonatal research network: changes in practice and outcomes during the first 15 years. Semin Perinatol 2003;27: 281-7.
Boo NY, Ong LC, Lye MS, Chandran V, Teoh SL, Zamratol S, et al. Comparison of morbidities in very low birthweight and normal birthweight infants during the first year of life in a developing country. J Paediatr Child Health 1996;32: 439-44.
Grupo Colaborativo Neocosur. Very-low-birth-weight infant outcomes in 11 South American NICUs. J Perinatol 2002;22: 2-7.
Ali M M, Kawser C A, Talukder M Q-K. Very low birth weight infants (1500 g or less). I. Outcome of neonatal admission. Bangladesh J Child Health 1988;12: 90-6.
Lincetto O, Vos ET, Graca A, Macome C, Tallarico M, Fernandez A. Impact of season and discharge weight on complications and growth of Kangaroo Mother Care treated low birthweight infants in Mozambique. Acta Paediatr 1998;87: 433-9.
Kambarami RA, Chidede O, Kowo DT. Kangaroo care for well low birth weight infants at Harare Central Hospital Maternity Unit--Zimbabwe. Cent Afr J Med 1999;45: 56-9.
Bhutta ZA, Yusuf K, Khan IA. Is management of neonatal respiratory distress syndrome feasible in developing countries? Experience from Karachi, Pakistan. Pediatr Pulmonol 1999;27: 305-11.
Rogowski J. Using economic information in a quality improvement collaborative. Pediatrics 2003;111: e411-8.
The International Neonatal Network. The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units. Lancet 1993;342: 193-8.
Ravikumara M, Bhat BV. Early neonatal mortality in an intramural birth cohort at a tertiary care hospital. Indian J Pediatr 1996;63: 785-9.
Gray RH, Ferraz EM, Amorim MS, de Melo LF. Levels and determinants of early neonatal mortality in Natal, northeastern Brazil: results of a surveillance and case-control study. Int J Epidemiol 1991;20: 467-73.
Darlow BA, Cust AE, Donoghue DA, on behalf of the Australian and New Zealand Neonatal Network (ANZNN). Improved outcomes for very low birthweight infants: evidence from New Zealand national population based data. Arch Dis Child Fetal Neonatal Ed 2003;88: F23-F28.
Investigators of the Vermont-Oxford Trials Network Database Project. The Vermont-Oxford trials network: very low birth-weight outcomes for 1990. Pediatrics 1993;91: 540-5.
Callaghan LA, Cartwright DW, O'Rourke P, Davies MW. Infant to staff ratios and risk of mortality in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2003;88: F94-F97.
Yasmin S, Osrin D, Paul E, Costello A. Neonatal mortality of low-birth-weight infants in Bangladesh. Bull WHO 2001;79: 608-14.
Kulmala T, Vaahtera M, Ndekha M, Koivisto AM, Cullinan T, Salin ML, et al. The importance of preterm births for peri- and neonatal mortality in rural Malawi. Paediatr Perinat Epidemiol 2000;14: 219-26.
Boo NY. Outcome of very low birthweight neonates in a developing country: experience from a large Malaysian maternity hospital. Singapore Med J 1992;33: 33-7.
Atasay B, Gunlemez A, Unal S, Arsan S. Outcomes of very low birth weight infants in a newborn tertiary center in Turkey, 1997-2000. Turk J Pediatr 2003;45: 283-9.
Arif MA, Arif K. Low birthweight babies in the Third World: maternal nursing versus professional nursing care. J Trop Pediatr 1999;45: 278-80.
Mbweza E. Bridging the gap between hospital and home for premature infants in Malawi. Int Nurs Rev 1996;43: 53-7.
Tafari N, Sterky G. "Early" discharge of low birth-weight infants in a developing country. J Trop Pediatr Environ Child Health 1974;20: 73-6.
Arce Casas A, Iriondo Sanz M, Krauel Vidal J, Jimenez Gonzalez R, Campistol Plana J, Poo Arguelles P, et al. Neurological follow-up of very low birth weight newborns at the age of two years (1998-1999). Ann Pediatr (Barc) 2003;59: 454-61.
Ho JJ, Amar HS, Mohan AJ, Hon TH. Neurodevelopmental outcome of very low birth weight babies admitted to a Malaysian nursery. J Paediatr Child Health 1999;35: 175-80.
Cooper P, Sandler D L. Outcome of very low birth weight infants at 12 to 18 months of age in Soweto, South Africa. Pediatrics 1997;99: 537-44.
Merritt TA, Pillers D, Prows SL. Early NICU discharge of very low birth weight infants: a critical review and analysis. Semin Neonatol 2003;8: 95-115.(Zulfiqar A Bhutta, profes)