The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

Abstract

ObjectiveTo examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.DesignA retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.Setting165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.Participants20 554 infants born at <33 weeks completed gestation (17 995 born at 27–32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009–31 December 2011.InterventionTertiary designation or high-volume neonatal care at the hospital of birth.OutcomesNeonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.ResultsInfants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.ConclusionsHigh-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

“…This study employed an instrumental variable method, which has been widely applied in other healthcare evaluations 25. However, we are only aware of two previous studies incorporating this method in perinatal settings, including one study using NNRD data previously conducted by the authors 26 27. Our findings can be compared with three previously conducted studies that found a reduction in risk-adjusted mortality with higher nurse-to-patient ratios in neonatal healthcare 14 18 19.…”

Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes

“…Such an approach would require significant alterations in the delivery of neonatal care as currently many level 3 NICUs do not have on-site neonatal surgical expertise. However, existing data support the concept of centralisation such as this with a recognised relationship between birth and subsequent care in a level 3 NICU23 or high-volume NICU24 and improved outcomes for preterm infants. Finally the high requirement for further surgical intervention could be used as an argument for infants who have had a laparotomy remaining in a unit with neonatal surgical (general, cardiothoracic and ophthalmology) expertise until discharge.…”

Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants

“…Reduced mortality and improved outcomes for preterm infants at institutions with higher patient volumes and levels of care has been shown. 13,14 The concept that a consistent team caring for the ELBW population would improve care was supported by reports of improved safety, process, and outcomes with team-based training, and provided the foundation of our care-delivery model. 10,15 The improved outcomes in the SBU likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population.…”