Predictors of mortality and length of stay for neonates admitted to children's hospital neonatal intensive care units

Abstract

Objective: Current scoring systems, which adjust prediction for severity of illness, do not account for higher observed mortality in neonatal intensive care units (NICUs) of children's hospitals than that of perinatal centers. We hypothesized that three potential predictors, (a) admission from another NICU, (b) presence of congenital anomalies and (c) need for surgery, would modify expected mortality and/or length of stay for infants admitted to NICUs in children's hospitals.Study Design: We reviewed consecutive admissions to two NICUs in children's hospitals in Canada. We performed regression analyses to evaluate these potential predictors and severity-of-illness indices for the outcomes of mortality and length of stay.Result: Of 625 neonatal admissions, transfer from another NICU, congenital anomalies requiring admission and surgery were identified in 371 (59%). Using logistic regression, mortality was predicted based on admission from another NICU (odds ratio (OR) 1.92; 95% confidence interval (CI) 1.04, 3.57), congenital anomalies (OR 7.28; 95% CI 3.69, 14.36) and a validated severity-of-illness score, the Score for Neonatal Acute Physiology Perinatal Extension Version II (SNAPPE-II; OR 1.07; 95% CI 1.05, 1.09 per point). By contrast, surgical intervention was predictive of survival (OR 0.35; 95% CI 0.18, 0.67). Length of stay X21 days was predicted by SNAPPE-II (OR 1.02; 95% CI 1.01, 1.03 per point), congenital anomalies (OR 2.47; 95% CI 1.60, 3.79) and surgery (OR 2.73; 95% CI 1.77, 4.21).Conclusion: Fair performance comparisons of NICUs with different casemixes, such as children's hospital and perinatal NICUs, in addition to severity-of-illness indices, should account for admissions from another NICU, congenital anomalies and surgery.

Letter to the Editor

“…The minimally invasive approach in handling surgical conditions in children, evolved in the last decade, has more recently been applied to the treatment of intussusception. Other authors have also looked at laparoscopy for childhood intussusception after doubtful or failed enema reduction or with recurrent cases [2][3][4]. We are pleased to report a prospective, active surveillance study on intussusception, which has started in the United Kingdom and Republic of Ireland.…”

“…Although it has proven robust across populations [4], to our knowledge, it has not been used in a serial manner nor has it been incorporated into a decisionmaking algorithm. Although the serial application of the scoring system may provide information regarding the clinical evolution of the patient, Richardson et al [3] describe the SNAPPE-II score as "an admission score" and explicitly advise against using it as a basis for decision making.…”

Levels of Neonatal Care

“…In some cases, regional coordination may be provided adequately by the collaboration of a children's hospital with a subspecialty perinatal facility that is in close geographic proximity. 61 …”

Transforming risk factors into an unbiased mortality model

“…Patients at children's hospital NICUs may differ in many ways from those at other NICUs, and some of those differences might explain the unadjusted association between NICU type and mortality. Severity of illness does not explain the unadjusted association between NICU type and mortality, so in this issue Berry et al 1 explore additional risk factors.…”