Prevalence and Predictors of Back-Transport Closer to Maternal Residence After Acute Neonatal Care in a Regional NICU

Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation

BACKGROUND

Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants.

METHODS

Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory.

RESULTS

Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services.

CONCLUSIONS

Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.

The Role of Distance from Home to Hospital on Parental Experience in the NICU: A Qualitative Study

Prolonged admission to the neonatal intensive care unit presents challenges for families, especially those displaced far from home. Understanding specific barriers to parental engagement in the NICU is key to addressing these challenges with hospital-based interventions. The objective of this qualitative study was to explore the impact of distance from home to hospital on the engagement of parents of very preterm infants (VPT) in the neonatal intensive care unit (NICU). We used a grounded theory approach and conducted 13 qualitative interviews with parents of VPT who were admitted ≥14 days and resided ≥50 miles away using a semi-structured interview guide informed by the socio-ecological framework. We used constant comparative method with double coders for theme emergence. Our results highlight a multitude of facilitators and barriers to engagement. Facilitators included: (1) individual-delivery preparedness and social support; (2) environmental-medical team relationships; and (3) societal-access to perinatal care. Barriers included: (1) individual-transfer stressors, medical needs, mental health, and dependents; (2) environmental-NICU space, communication, and lack of technology; and (3) societal-lack of paid leave. NICU parents with geographic separation from home experienced a multitude of barriers to engagement, many of which could be addressed by hospital-based interventions.

Pulmonary Support of Infants with Tracheotomies in a Regional Neonatal Intensive Care Unit

OBJECTIVE

 We evaluate patient characteristics, hospital course, and outcome by type discharge pulmonary support; mechanical ventilation (MV) or with tracheotomy masks (TM).

STUDY DESIGN

 We reviewed records of infants admitted to the neonatal intensive care unit (NICU) that underwent tracheotomy within their first year of life between 2006 and 2017. We evaluated patient characteristics, referral pattern, destination of discharge, and outcome by type of pulmonary support at discharge (MV vs. TM).

RESULTS

 Of the 168 patients, 63 (38%) were inborn, 91 (54%) transferred to our NICU, and 5 (3%) were readmitted after being home. Median gestational age at birth was 34 weeks. Twenty-three (14%) infants were transferred to hospitals closer to their homes (13 with MV and 10 with TM), and 125 (74%) were discharged home (75 on MV and 50 on TM). Twenty patients (12%) died in the regional center (RC). Among those discharged home from our RC, infants on MV were of lower birth weight and younger gestational age, had tracheostomies later in life, had longer duration between tracheostomy to discharge to home, and had longer total duration of hospitalization at the RC. In addition, infants in the MV group were more frequently dependent on MV at time of placement of tracheostomies, less frequently had congenital airway anomalies and more frequently having possibly acquired airway anomalies and more frequently having major congenital anomalies, more frequently treated with diuretics, inhaled medications and medications for pulmonary hypertension, and more frequently had gastrostomies for feeding compared with the TM group.

CONCLUSION

 Patients with tracheostomies in the NICU and discharged from RC on MV or TM vary by patient characteristic, timing of tracheostomy placement, timing of discharge from RC, type of upper airway anomalies, duration of stay in the hospital, and complexity of medical condition at discharge.

KEY POINTS

· Infants on home mechanical ventilation have long hospital stay and complex conditions at discharge.. · We describe factors associated with the type of pulmonary support for infants with tracheostomies.. · Treatment strategy may influence type of discharge pulmonary support in infants with tracheostomies..

Transfer Patterns of Very Low Birth Weight Infants for Convalescent Care

OBJECTIVES

To examine the prevalence, characteristics, clinical course, and length of stay (LOS) among 4 groups of infants who were transferred for convalescence and subsequently discharged from the hospital; failed transfer for convalescence and were (a) either readmitted, or (b) transferred again; and were not transferred for convalescence.

METHODS

Among very low birth weight infants hospitalized at US Vermont Oxford Network centers between 2006 and 2020, we examined the distribution of characteristics, delivery room and NICU usage measures, outcomes, and LOS among the 4 groups of infants.

RESULTS

Among 641 712 infants, a total of 28 985 (4.5%) infants were transferred for convalescent care; of 28 186 infants, 182 (0.65%) died before hospital discharge and 2551 (9.1%) failed the transfer (1771 [6.3%] were readmitted and 780 [2.8%] were transferred again). There were major regional and NICU variations in the practice of the transfer for convalescence; New England (18.8%) had the highest whereas East South Central (2.2%) had the lowest percentage of transfer for convalescence. Infants who transferred for convalescence and were discharged from the hospital had a similar LOS and similar distribution of NICU usage measures and outcomes to infants who were not transferred for convalescence. Infants who failed the transfer for convalescence had a longer LOS than infants who were transferred for convalescence and then discharged from the hospital.

CONCLUSIONS

The rates of transfer for convalescence and transfer for convalescence failure were low. Future studies should weigh the risks and benefits of transfer for convalescence, which might differ on the basis of geography.

The Association of Social Factors and Time Spent in the NICU for Mothers of Very Preterm Infants

OBJECTIVES

Evaluate the association between maternal social factors and maternal time spent in the NICU for very preterm infants admitted to 4 level III and IV NICUs.

METHODS

In this prospective observational cohort study, we enrolled mother-infant dyads whose infants were born <32 weeks' gestation. Enrollment occurred after 2 weeks of NICU exposure, when maternal social factors and demographic information was collected. Maternal time spent in the NICU was abstracted from the electronic medical record and was dichotomized into 0 to 6 days and ≥6 days per week. Demographic differences between the 2 groups were compared by using χ2 tests. Logistic regression was used to assess the independent association between maternal social factors and the average number of days per week spent in the NICU.

RESULTS

A total of 169 mother-infant dyads were analyzed. Maternal social factors associated with more time spent in the NICU included an annual household income of >$100 000, compared with those with an annual household income of <$50 000 (adjusted odds ratio [aOR]: 5.68; 95% confidence interval [CI] 1.77-18.19), a travel time <30 minutes to the NICU (compared with those who traveled >60 minutes [aOR: 7.85; 95% CI 2.81-21.96]), and the lack of other children in the household, compared with women with other children (aOR: 3.15; 95% CI 1.39-7.11).

CONCLUSIONS

Maternal time spent in the NICU during a prolonged birth hospitalization of a very preterm infant differed by socioeconomic status, travel time, and presence of other dependents. Strategies to better identify and reduce these disparities to optimize engagement and, subsequently, improve infant health outcomes is needed.

Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal (in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly 70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality, racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used to improve the care provided to women, their fetuses, and infants.

Back Transfer of Infants with Tracheostomies: A Regional Center Experience

We describe our center's experience with the back transfer of infants following tracheostomies. We conducted a retrospective cohort study of infants transferred to pediatric critical care units of our regional center with conditions originating in the neonatal period who underwent tracheostomy during the hospitalization within their first year of life between 2006 and 2017. Recovering patients are discharged home or transferred back to the referring hospitals. We evaluated patient characteristics, destination of discharge and type of pulmonary support at discharge, and mechanical ventilation (MV) or tracheotomy masks (TM). Of the 139 included patients, 72% were transferred to the neonatal intensive care unit, 21% to the pediatric cardiothoracic unit, and 7% to the pediatric intensive care unit. Their median gestational age was 35 weeks. They were admitted at a median 22 days of life and lived at a median distance of 56 miles from our center. Furthermore, 34 infants (24%) were back transferred closer to their homes (23 with MV and 11 with TM), and 84 (60%) were discharged home (53 on MV and 31 on TM). Twenty-one patients (15%) died in the hospital (before discharge or transfer). Back transferred patients on MV had a significantly shorter duration between tracheostomy and transfer compared with those discharged home from our center: MV (median = 22 vs. 103 days, p < 0.0001) and TM (median = 13 vs. 35 days, p < 0.0001). Back transfer of infants with tracheostomies closer to their homes was associated with a significantly shorter hospitalization and more efficient use of the subspecialized resources at the RC.

Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care

BACKGROUND

Family-centered care (FCC) in neonatal intensive care units (NICUs) was initiated in 1992 to promote a respectful response to individual family needs and support parental participation in care and decision-making for their infants. Although benefits of FCC have been reported, changes in the maternal experience in the NICU are unknown.

PURPOSE

The purpose of this study was to compare mothers' experiences in NICUs where FCC is the standard of care and to compare these with the experiences of mothers 2 decades ago.

METHODS

In this qualitative descriptive design, mothers of infants born under 32 weeks postconceptional age were asked to describe their experiences with their infant's birth and hospitalization. Open-ended probing questions clarified maternal responses. Saturation was reached after 14 interviews. Iterative coding and thematic grouping was used for analysis.

RESULTS

Common themes that emerged were: (1) visiting; (2) general caregiving; (3) holding; (4) feeding; and (5) maternal ideas for improvement. Findings indicated important improvements in privacy, mother-nurse relationship, ease of visiting, and maternal knowledge and participation in infant caregiving.

IMPLICATIONS FOR PRACTICE

Mothers suggested improvements such as additional comforts in private rooms, areas in the NICU where they can meet other mothers, and early information on back-transport. Better recognition and response for mothers without adequate social support would provide much needed emotional assistance.

IMPLICATIONS FOR RESEARCH

Future research addressing benefits of webcams, wireless monitors, back-transport, maternity leave, and accommodations for extended visiting for siblings would address other needs mentioned by mothers.

Mothering in the NICU: A qualitative exploration of maternal engagement

Research suggests maternal engagement in the neonatal intensive care unit (NICU) may positively impact maternal and infant health outcomes. However, the U.S. has lower rates of maternal engagement in the NICU compared to other developed countries. This qualitative study reflects a transdisciplinary research partnership between social work, nursing, and neonatology. Qualitative inquiry explores maternal experiences in the NICU from the perspectives of mothers of preterm infants hospitalized in 2 U.S. NICUs. Results support an ecological systems framework to understanding barriers and facilitators to maternal engagement in the NICU and the utilization of a trauma-informed health care approach in NICU settings.