November is Prematurity Awareness Month and this past Saturday was World Prematurity Day. I have two reasons to be personally involved in this cause.
First, I will serve as an honorary co-chair for the March of Dimes March for Babies 5k walk in Boise on April 27. As I have learned more about the March of Dimes and this event, I have become more passionate about providing support for affected families and more research, education, and awareness for everyone.
My second reason is the three grandchildren that I have on the way! My oldest daughter is due to deliver on the day of the walk! My youngest daughter is pregnant with twins due in February. Twins aren’t expected to go to full term and therefore, the risk for prematurity is significantly increased. Unless my oldest daughter is in labor, I plan to be at the walk with my twin grandsons, and I hope that you will contribute to this cause and join us. Read on for more information, and I'll have more as we get closer to the walk.
In Idaho, one in every eight births is a premature birth compared with a national average of one in 10 births. That is why our state has been given a B grade. It's a big improvement; not that many years ago, Idaho rated a D. New grades are due out this month, and we're all aiming for an A!
At St. Luke’s, we share a common goal with the March of Dimes: to increase the number of healthy people living in healthy communities having healthy babies. Idaho’s goal is to reduce premature births by 8 percent by 2014. St. Luke’s goal is to improve the health of all the people we serve, and we are implementing accountable care to accomplish just that.
I’ve asked Dr. Scott Snyder, a neonatologist and our medical director of neonatology for St. Luke’s Children’s Hospital, to share what he and his team are doing and what they are seeing when it comes to prematurity. I want to share with you the results we are seeing as we move toward the Triple Aim of better health, better care, and lower costs, which is creating increased value of our health services for all the communities we are privileged to serve.
First, the good news: Prematurity has slightly declined among the largest population of neonates, the late pre-term population of those born at 34 to 37 weeks’ gestation. We know this based on national figures and our own Neonatal Intensive Care Unit numbers. Admissions for us have declined. And the prematurity rate nationally has fallen for the fifth straight year in a row, to its lowest level in a decade.
And because prematurity can, and often does, bring with it vision problems, hearing loss, chronic respiratory infections and other conditions, learning and behavioral disabilities, and problems with bone growth and general development, victories with prematurity have huge multiplier benefits over time and across generations.
There are several reasons for the decrease, among them the dip in birthrates that we see in economically stressed times. So, for example, many would-be parents will choose to delay in vitro fertilization in a time of economic uncertainty. IVF can be expensive, and often results in multiple births; when multiple births are involved, the rate of prematurity increases. So when the economy is down, IVF is down, and the number of premature deliveries also goes down. This is a cyclical pattern, and in fact, we’re seeing IVF procedures pick up and will anticipate a parallel increase in NICU admissions as the result of a percentage of these pregnancies.
But positive health measures also seem to be an influence in what we’re experiencing. Some of this has to do with the application of evidence-based medicine more prevalently.
Here are some great examples. For St. Luke’s, they have everything to do with our Triple Aim goals, in particular better health and better care, and our 2013 goals to create an exceptional patient experience and to create exceptional outcomes through TEAMwork.
We are seeing the results of increased collaboration with our obstetrical colleagues, who several years ago implemented evidenced-based guidelines to limit elective inductions at less than 39 weeks’ gestation unless clear indications for early delivery are present. Even small increases of time in the womb improve the health of the newborn, and in some instances, mean all the difference between admission to the NICU or a trip home with mom.
Increasing use of progesterone therapy to prolong pregnancy following preterm labor also may be lowering the rate of preterm delivery. Even in cases where the infant still delivers prematurely, prolonging the pregnancy, even briefly, often allows the mother to receive steroid injections which rapidly prepare the baby for life outside the womb. These medications are very effective at decreasing complications impacting the lungs and brain, and shorten time in the hospital.
We’ve also stepped up our vigilance when it comes to neonatal jaundice. Neonatal jaundice, or neonatal hyperbilirubinemia, is common in newborns and is the most common reason for an infant’s readmission to the hospital in that baby’s first 30 days. Untreated, it’s a condition that can cause severe neurologic impairment, and we want to catch it early.
We have become much more diligent in closely assessing newborns with respect to jaundice before discharge to try to minimize the possibility of readmission. Our Newborn Subcommittee of the Department of Pediatrics started focusing on this more than a year ago, and we’re seeing success in catching jaundice earlier and reducing readmissions as the result of this effort. Again, an example of better care with an eye to the patient experience, and an example of how we’ve applied the ideas of timely, effective, accountable, and measurable – the TEAM in TEAMwork – to benefit our patients.
Current areas of focus for us have to do with standardizing care when it comes to extubation. Using evidence-based medicine, we’ve developed an early extubation clinical pathway and order set, held a retreat to educate staff members, and trained to our standardized approach so that we can wean our little patients off of ventilators as quickly as is safely possible. This strengthens their respiratory systems and lungs, and makes for healthier babies and the adults they become.
Chronic lung disease also drops when this happens, as does ventilator-associated pneumonia, which we have virtually eliminated. And we have seen a dramatic decrease in ventilator days in the NICU as the result of this initiative, and a drop in the number of total days in the NICU by two to three days. When you consider that a day in the NICU can cost $3,000, cutting ventilator time when it’s safe and right to do so is a huge win for everyone, from our tiny patient to everyone involved in the costs associated with these procedures.
Looking ahead, we are as alarmed as Dr. Pate is about the obesity crisis. Maternal obesity is an increasing concern, in large part because of its correlation with type 2 diabetes. A pregnant woman’s high blood sugar can lead to a dramatic drop in her infant’s blood sugar when he or she is born. And poor control of diabetes can result in impacts to nearly all of an infant’s organ systems, including heart, lungs, limbs, and brain. Growing evidence also suggests that there may be adult-onset diseases that are essentially “preprogrammed” in the fetal period, and maternal diabetes is believed to be a major factor.
We have seen an increase in the number of infants of diabetic mothers in the past several years, and the challenges have been so significant that we have developed a new order set to wean these neonates off fluids in a standardized manner, to ensure the shortest length of stay that still provides safe care and prevents dramatic drops in blood sugar.
Nonetheless, these infants still spend several days in the NICU, and low blood sugar is rapidly becoming one of the most common reasons for admission to the NICU. These babies tend to feed poorly, are less healthy, and may be more susceptible to costly and chronic health problems throughout their lives.
Another thing we are keeping an eye on is the number of NICU patients we see born to mothers on methadone and other drugs. This is an emerging challenge, in part because methadone can be of significant benefit in decreasing some of the problems associated with substance abuse.
We have noted dramatic increases in the doses of methadone prescribed to mothers, which can mean NICU stays of upwards of weeks or even months as the infants are gently weaned off of these medications to avoid withdrawal. We are beginning to collaborate with substance abuse specialists, share knowledge and education around methadone use, and develop approaches to coordinate both maternal and infant care.
Where do we go from here? It’s my goal for St. Luke’s to be recognized as the region’s Maternal-Child Center of Excellence, through which we can further our collaboration, maximize our physician leadership and application of team-based care, and take great strides toward our Triple Aim and our patient experience and TEAMwork goals.
Health care reform is challenging, no doubt about it. But at the same time, from my vantage point, the opportunity for collaboration, information-sharing, and process improvement that the times demand makes this a very interesting point in history to be a physician. I’m glad to be part of the solutions St. Luke’s is coming up with, and I look forward to continuing our prematurity progress.
Thank you, Dr. Snyder. I am so proud of all the many neonatologists, pediatricians, pediatric specialists, maternal fetal medicine specialists, obstetricians, neonatal nurses (the highest quality, most caring, most innovative neonatal nurses in the country!), nurse practitioners, respiratory therapists, social workers, chaplains, and everyone else who contributes to the fantastic care of our tiniest patients and their families and who work tirelessly to ensure that we have the best outcomes possible.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.