Wednesday, June 17, 2009

The trouble with NICUs

I have been chewing this one over for more than a month because the idea is so distasteful. But alas, I feel compelled to write about it because a friend's baby, born a little bit early but weighing more than 5 pounds, was in the NICU for no great reason and she had to go home without him.

So here it is: At a recent maternity care conference, a couple people had the courage to speak out regarding the "elephant in the room," ie. neonatal intensive care units as the new cash cows for hospitals. These specialized units are popping up even well outside the realm of the urban teaching hospital. And more babies are being sent there. If more babies need NICUs than ever before, that is alarming and we need to ask ourselves why (too many c-sections, perhaps?. If more babies don't need them but the hospitals do, that is horrible, and probably unethical.

For skeptics who may ask, "What is the harm in providing extra services for borderline cases," such as my friend's baby?

Atul Gawande's piece in a recent New Yorker explains it far better than I could.


Reality Rounds said...

I would be curious to know what the gestational age and diagnosis for admission was for your friends baby. Weight is not a major qualifier for why an infant needs NICU care. You are right that NICU's can be cash cows for hospitals. But, the money is not from patients like your friend's baby. It is for the long-term preemie's who require a lot of interventions that can be billed for and for surgical infants. There is no justification for separating a well baby from it's mother. We used to have a home health nurse visit those boderline high risk infants, but the state stopped reimbursement, so that program went away. I would like to see some evidence that NICU's are admitting infant's that should not be there.

pinky said...

Tina, I had an interesting chat with one of my favorite Nicu Docs a couple of months ago.

One of my babys. Meaning I was the nurse in the room watching the monitor. Watching the Mom. Taking the vital signs. Etc etc...Well all was fine. This lady was low risk and she had a vag delivery but the baby eventually went to nicu for respiratory problems. I blamed myself, I thought what did I miss, what did I miss?

Well after a long talk with the Doc, he agreed I didn't miss anything. Years ago when we had kids grunting or even turn blue once, we would give oxygen, deep suction and then put them on a warmer to keep a good eye on them. We would n't even call the Doc at home. Unless the baby kept doing it.

It was expected because the first 24 hours babys are sometimes juicy. but nowadays the hospital is so big that we cannot watch these babies in the normal nursey and we cannot keep the baby in the room in case they do it again. So we work them up. We get a chest X-ray and guess what it shows. Fluid. No shit huh? These kids are just slow to transition but they need more watching. If we had more staff they could probably stay in the normal nursey but we don't. However, these kids won't need oxygen and they won't need an iV and they are usuallly sent back to normal nursery the next day. Nicu beds are in demand. We don't need to drum up business. But I agree that we do get over excited these days when in years past we did not.

Amy Romano said...

Back in April, I blogged about a recent French study that shows that giving birth in a hospital with a NICU is a risk factor for having your baby sent there. Here's the link:

As yous said, when hospitals decide to build a NICU, it's a money-driven decision. Rather than a public health perspective ("Does this community need a NICU? Are there ways we could prevent some babies from ending up there? How can we create a system that provides ready access to those in need but doesn't squander resources on babies who could thrive with some low-tech care?"), it's all about the bottom line. And once it's built and staffed, you of course have to get those babies in there so you can bill the care.

I just attended a home birth of a baby born 5+lbs with evidence of IUGR (very calcified placenta.) If this baby had been born in the hospital, she would have been sent to the NICU for observation, and I strongly suspect she would have then developed complications, feeding problems, or both because she was separated from her mother. We did closer monitoring after the birth but the baby stayed continuously skin-to-skin for the first several hours and frequent skin-to-skin contact after that. She's thriving now, and never got anything but breastmilk! And all for a tiny miniscule fraction of the cost that a several day NICU stay would have cost. (Extra cost = extra home visits for weight checks and a little lactation support, claims that will most likely be denied by the insurance company and simply absorbed by our struggling home birth practice.)

It's maddening!

Adirondack Autumn said...

I've known about this for a while and I think it's a shame, a hospital that isn't tertiary probably shouldn't have a NICU or, if they do one of the criteria should be "would we otherwise be shipping this kid to big city?" because my community hospital regularly handles some antibiotics and most phototherapy as well as back transfers. I know of many babies born in community hospitals that sport NICUs and wind up in them where they wouldn't have been shipped from our hospital.

Sure there's a few times where we watch a baby who doesn't straighten out and fly right and does wind up getting shipped out. For every one of those I can think of 4-5 more who do straighten out her and would see NICU time if we had one.

Interestingly I recently took the STABLE course and our presenters had a dim view of non tertiary NICUS saying that these often miss things that get caught by tertiary NICUs. Maybe applications for new NICUs should be more carefully reviewed if they are not going to be regularly receiving babies from community hospitals...

Intertwined said...

This is interesting because I, too, have recently heard several cases of babies sent to NICU where it just a really strange call. In all the cases, staff cited "being extra careful" to the parents and, of course, the parents agreed. However, the danger to the breastfeeding relationship is high when separating a mother/baby pair for 24 or more hours. Baby will certainly receive some sort of artificial nutrition in that time and Mom will be introduced to the dreaded pump. It's a shame if those babies could be attended to at Mom's bedside. Costs are kept down, Mother/Baby are kept together, and the less invasive the procedures to baby in the first hours of life the better!

Kayce Pearson said...

This is a really interesting idea. My daughter had to be in a NICU for a week because of an unnecessary procedure leading to a cesarean before she was even term.

I believe the cesarean rate is a big factor in NICU babies, but I also agree with pinky. They can't be watched all the time except at a NICU. They get constant care, whether they truly need it or not.

juno said...

It seems to me that as time goes by, more and more babies born to +GBS moms are going to NICU for sepsis workup or just grunting.

When I started OB 12 yrs ago, we weren't even testing moms. Today, moms are tested & treated if necessary. However, I don't see much change in numbers of babies being worked up for sepsis.

Are the drugs not working? Resistant bacteria? Some other cause of problems not related to GBS?

Jenn said...

A friend of mine gave birth via "emergency" cesarean section at 28 weeks for "suspected" membrane rupture.

Her baby spent months in the NICU, and now at 2 years old, he still needs therapy several days a week, and likely will have issues for life.

Meanwhile I had a client a couple of years ago who had complete rupture of membranes (not "suspected") at 32 weeks, and her OB managed her case to prevent birth due to the possible issues of prematurity, and she didn't end up giving birth until 35 weeks, to a perfectly healthy baby who needed no special care.

I don't know much about the Dr who made the decision to do the cesarean (classical since she was so early in the pregnancy), but I do know something about my client's Dr--he had a premature baby himself, and lived with it. I think that greatly influenced his decision to try to prevent the birth.

My friend's Dr. told her "10 years ago your son would not have lived." I wanted to scream when she told me that and tell her "no, 10 years ago your Dr would not have done that cesarean so soon because there would have been no hope of your child living--so he would have had more time to develop in utero, and likely would have been healthier now."

Yes, I do believe there is a down side to the growing technology for preterm babies.

Laura (aka Waldenmommy) said...

Here's another thought for you- sometimes, some mothers do it to themselves. Some drs are willing to take a baby at 35-37 weeks GA because the mother is "done being pg." And, yes, even those "late term preemies" end up in the NICU with lung problems. I had a late term preemie (he came on his own, though!) and he spent 9 days in the NICU. I spoke with his neonatologist about it and this idea (taking babies for no good reason other than mom being "done" wanting her dr to deliver, etc) really steamed her up. There are problems with these kids- I'll tell anyone who askes about the feeding problems and delays we experienced.