Outcomes of a Quality Improvement Initiative to Prevent Unnecessary Packed Red Blood Cell Transfusions Among Extremely Low Birth-Weight Neonates.

BACKGROUND: Extremely low birth-weight (ELBW) infants frequently receive packed red blood cell (PRBC) transfusions. Recent studies have shown that more restrictive PRBC transfusion guidelines limit donor exposure and reduce transfusion-related costs without any increase in adverse clinical outcomes. PURPOSE: We developed and implemented an evidence-based PRBC transfusion guideline for ELBW infants treated in our unit and then measured provider adherence to this guideline. METHODS/SEARCH STRATEGY: We performed a retrospective review of all PRBC transfusions given to ELBW infants in 2012 (preguideline) and the first half of 2014 (postguideline). We identified the indication for each transfusion by reviewing physiological/laboratory data and the daily clinical note. We then determine whether each transfusion met criteria according to our new evidence-based guideline. FINDINGS/RESULTS: When extrapolating the newly developed protocol to 2012 data, less than 15% of transfusions among ELBW infants would have met the current evidence-based standard. Conversely, during the first 6 months of 2014, 61% of transfusions were administered in adherence to the guideline (P < 001). Using current cost estimates, this represents a projected cost savings of $31,000 in that 6-month period. IMPLICATIONS FOR PRACTICE: A multidisciplinary approach to improving PRBC transfusion practices results in potentially safer, more cost-effective care for ELBW infants. IMPLICATIONS FOR RESEARCH: Given the frequency, potential harms, and costs associated with PRBC transfusions in ELBW infants, it seems both feasible and important to pursue prospective clinical trials comparing permissive and restrictive approaches to transfusion in this vulnerable population.

Variation in Neonatal Inpatient Charges at the State and Local Level.

In an analysis of all Ohio newborn infants discharged home alive between 2007 and 2012, the authors identified that significant variation in hospital charges (among Medicare Severity Diagnostic Related Group categorizations), previously identified nationally, persists at the state and local levels among term and preterm infants (p <.0001). Additionally, the authors identified variation in length of stay among infants with extreme immaturity or respiratory distress syndrome (p <.0001). Charge data remain the best available proxy for closely guarded hospital cost figures; increased pricing transparency would further support comparison of hospital newborn care costs.

Collaboration, not competition: cost analysis of neonatal nurse practitioner plus neonatologist versus neonatologist-only care models.

BACKGROUND: Although advanced practice in neonatal nursing is accepted and supported by the American Academy of Pediatrics and National Association of Neonatal Nurse Practitioners, less than one-half of all states allow independent prescriptive authority by advanced practice nurse practitioners. PURPOSE: The purpose of this study was to compare costs of a collaborative practice model that includes neonatal nurse practitioner (NNP) plus neonatologist (Neo) versus a neonatologist only (Neo-Only) practice in Washington state. Published Internet median salary figures from 3 sources were averaged to produce mean ± SD provider salaries, and costs for each care model were calculated in this descriptive, comparative study. FINDINGS/RESULTS: Median NNP versus Neo salaries were $99,773 ± $5206 versus $228,871 ± $9654, respectively (P < .0001). The NNP + Neo (5 NNP/3 Neo full-time equivalents [FTEs]) cost $1,185,475 versus Neo-Only (8 Neo FTEs) cost $1,830,960. The NNP + Neo practice model with 8 FTEs suggests a cost savings, with assumed equivalent reimbursement, of $645,485/year. IMPLICATIONS FOR PRACTICE: These results may provide the impetus for more states to adopt broader scope of practice licensure for NNPs. IMPLICATIONS FOR RESEARCH: These data may provide rationale for analysis of actual costs and outcomes of collaborative practice.

Incremental Hospital Costs Associated With Comorbidities of Prematurity.

PURPOSE: Preterm birth (PTB), defined as birth at a gestational age (GA) of less than 37 weeks, is associated with increased hospital costs. Lower GA at birth is negatively correlated with the presence of neonatal comorbidities, further increasing costs. This study evaluated incremental costs associated with comorbidities of PTB following spontaneous labor at 24-36 weeks. DESIGN: Birth records from January 2001 to December 2010 at the Medical University of South Carolina were screened to identify infants born at GA 23-37 weeks after uncomplicated singleton pregnancies and surviving to discharge. METHODOLOGY: Comorbidities of interest and incremental costs were analyzed with a partial least squares (PLS) regression model adjusted for comorbidities and GA. Incremental comorbidity-associated costs, as well as total costs, were estimated for infants of GA 24-36 weeks. RESULTS: A total of 4,292 delivery visit records were analyzed. Use of the PLS regression model eliminated issues of multicollinearity and allowed derivation of stable cost estimates. Incremental costs of comorbidities at a mean GA of 34 weeks ranged from $4,529 to $23,121, and exceeded $9,000 in 6 cases. Incremental costs rangedfrom a high of $41,161 for a GA 24-week infant with a comorbidity of retinopathy of prematurity requiring surgery (ROP4) to $3,683 for a GA 36-week infant with a comorbidity of convulsions. Incremental comorbidity costs are additive, so the costs for infants with multiple comorbidities could easily exceed the high of $41,161 seen with ROP4. CONCLUSIONS: The PLS regression model allowed derivation of stable cost estimates from multivariate and highly collinear data and can be used in future cost analyses. Using this data set, predicted costs of all comorbidities, as well as total costs, negatively correlated with GA at birth.

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet, Bangladesh.

OBJECTIVE: To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh. METHODS: In a cluster-randomized controlled trial, two strategies for neonatal care--known as home care and community care--were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy--compared with that of the pre-existing levels of maternal and neonatal care--was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis. FINDINGS: The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833-7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72-265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844-7628) and US$ 104.62 (95% CI: 65.15-266.60), respectively. The home-care package was cost-effective--with 95% certainty--if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective. CONCLUSION: The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.

Extending total parenteral nutrition hang time in the neonatal intensive care unit: is it safe and cost effective?

AIM: To investigate the effects of prolonging hang time of total parenteral nutrition (TPN) fluid on central line-associated blood stream infection (CLABSI), TPN-related cost and nursing workload. METHODS: A before-after observational study comparing the practice of hanging TPN bags for 48 h (6 February 2009-5 February 2010) versus 24 h (6 February 2008-5 February 2009) in a tertiary neonatal intensive care unit was conducted. The main outcome measures were CLABSI, TPN-related expenses and nursing workload. RESULTS: One hundred thirty-six infants received 24-h TPN bags and 124 received 48-h TPN bags. Median (inter-quartile range) gestation (37 weeks (33,39) vs. 36 weeks (33,39)), mean (±standard deviation) admission weight of 2442 g (±101) versus 2476 g (±104) and TPN duration (9.7 days (±12.7) vs. 9.9 days (±13.4)) were similar (P > 0.05) between the 24- and 48-h TPN groups. There was no increase in CLABSI with longer hang time (0.8 vs. 0.4 per 1000 line days in the 24-h vs. 48-h group; P < 0.05). Annual cost saving using 48-h TPN was AUD 97,603.00. By using 48-h TPN, 68.3% of nurses indicated that their workload decreased and 80.5% indicated that time spent changing TPN reduced. CONCLUSION: Extending TPN hang time from 24 to 48 h did not alter CLABSI rate and was associated with a reduced TPN-related cost and perceived nursing workload. Larger randomised controlled trials are needed to more clearly delineate these effects.

The costs and potential savings of telemedicine for acute care neonatal consultation: preliminary findings.

Telemedicine was used as a substitute for the telephone (usual care) for some acute care consultations from nurseries at four peripheral hospitals in Queensland. Over a 12-month study period, there were 19 cases of neonatal teleconsultation. Five (26%) cases of avoided infant transport were confirmed by independent assessment, four of which were avoided helicopter retrievals. We conducted two analyses. In the first, the actual costs of providing telemedicine at the study sites were compared with the actual savings associated with confirmed avoided infant transport and nursery costs. There was a net saving to the health system of 54,400 Australian Dollars (AUD) associated with the use of telemedicine over the 12-month period. In the second analysis, we estimated the potential savings that might have been achieved if telemedicine had been used for all retrieval consultations from the study sites. The total projected costs were AUD 64,969 while the projected savings were AUD 271,042, i.e. a projected net saving to the health system of AUD 206,073 through the use of telemedicine. A sensitivity analysis suggested that the threshold proportion of retrievals needed to generate telemedicine-related savings under the study conditions was 5%. The findings suggest that from the health-service perspective, the use of telemedicine for acute care neonatal consultation has substantial economic benefits.

The role of the neonatal nurse practitioner in the community hospital level I nursery.

Neonatal nurse practitioners (NNPs) have played a significant role in providing medical coverage to many of the country's Level III neonatal intensive care units (NICUs). Extensive education and experience are required for a nurse practitioner (NP) to become competent in caring for these critically ill newborns. The NNP can take this competence and experience and expand her role out into the community Level I nurseries. Clinical care of the infants and close communication with parents, pediatricians, and the area tertiary center provide a community service with the goal of keeping parents and babies together in the community hospital without compromising the health of the baby. The NNP service, with 24-hour nursery and delivery coverage, supports an ongoing obstetric service to the community hospital. The NNP's experience enables her to provide a neonatal service that encompasses a multitude of advanced practice nursing roles.

NNP education in neonatal end-of-life care: a needs assessment.

PURPOSE: To determine from practicing neonatal nurse practitioners (NNPs) their perceived end-of-life (EOL) care learning needs. DESIGN AND METHOD: A needs assessment-based evaluation methodology was used to answer the research questions. A neonatal EOL needs assessment survey was developed, pilot tested, and then mailed to 260 NNPs across the United States. RESULTS: NNPs in clinical practice regarded their education on EOL for neonates and their families as inadequate. Twenty-three percent ranked "delivery room decisions to resuscitate infants considered at edge of viability" as the item for which they most wanted more training. The other top-ranked EOL items included balance between giving parents false hopes and removing all hopes, and communicating and giving bad news to families. CLINICAL IMPLICATIONS: Based on these findings, specific neonatal EOL education and communication skill workshops are warranted for graduate nursing core and advance practice continuing education courses. Additionally, there needs to be a mechanism to provide EOL content and support for the NNP already in clinical practice; it is suggested that learning about EOL issues can be integrated into existing (continuing nursing education CNE) educational activities. Further research is needed on what issues, tools, and methods in CNE programs make a difference in the experience of NNPs.

Financial costs for parents with a baby in a neonatal nursery.

AIM: To determine the additional financial cost to families of babies admitted to the nurseries of The Royal Women's Hospital, Melbourne, Australia. METHODS: Prospective case series of consecutive babies admitted to the Special and Intensive Care Nurseries at The Royal Women's Hospital, Melbourne, Australia. Data were collected from diaries completed by parents who recorded expenses related to having their baby in hospital. Fifty nine families of babies born <34 weeks' gestation who were hospitalised for at least 2 weeks. RESULTS: The median expenditure per family per week was Australian (A) $243 and the median length of stay in the nurseries was 7 weeks. The major costs were related to food and transport. Expenses related to the expression/storage of breast milk and accommodation were also considerable consuming 11% and 14%, respectively of the weekly amount spent. Of the 23 families who reported lost or reduced income, the median amount lost per week per family was A$324. CONCLUSION: The financial burden on families with babies admitted to a tertiary neonatal unit is substantial. The median cost per week was approximately one quarter of the average gross weekly income and included lost income as well as additional expenses. It is important that institutions and health-care systems recognise the magnitude of this additional burden on vulnerable families.

The perinatal patient safety nurse: a new role to promote safe care for mothers and babies.

Medical malpractice premiums and costs of obstetric claims, settlements, and jury awards are at an all-time high. This article describes one professional liability company's initiative to promote safer perinatal care and decrease costs of claims, including the development of the perinatal patient safety nurse role. The primary responsibility of the perinatal patient safety nurse is to promote safe care for mothers and babies by keeping patient safety as a focus of all unit operations and clinical practices.

Economics of home vs. hospital breastfeeding support for newborns.

AIM: This paper presents the findings of research comparing the incremental costs associated with the provision of home-based vs. hospital-based support for breastfeeding by nurse lactation consultants for term and near-term neonates during the first week of life. BACKGROUND: A consequence of both consumer demands and increasing health resource constraints is that alternative care delivery models for safe, efficacious and cost-effective breastfeeding programmes have steadily evolved. To date, the economic impact of the setting (home or hospital) where lactation support is delivered has received little research attention. METHODS: Mother-infant dyads were stratified by gestational age as term (>37 weeks gestational age; n = 101) or near term (35-37 weeks gestational age; n = 37) and randomized to standard hospital care and postpartum follow-up (standard care), or to standard hospital care plus home support from certified nurse lactation consultants (experimental). Data collection occurred at study entry, hospital discharge and at a seventh day postpartum follow-up session. Costs to the family (out-of-pocket and time costs) and to the healthcare system (during hospitalization and after hospital discharge) were measured. Total societal costs were defined as the sum of both family and healthcare system costs. RESULTS: Compared with standard hospital-based care, home support by nurse lactation consultants showed no statistically significant differences in either time costs to the family or total societal costs. Term infants who received home support had statistically significantly greater postdischarge system costs (P < 0.0001), with a trend towards lower out-of-pocket expenses to their families (P = 0.12). There were no statistically significant differences between the two groups in overall combined family and healthcare system costs. CONCLUSIONS: These results suggest that the cost of home lactation support programmes were comparable with the costs of hospital-based standard care. Breastfeeding support at home by lactation consultants should be considered as an option as it was no more costly than support from lactation consultants in the hospital setting. The findings for near-term infants need to be interpreted with caution, given the small sample size.

Strengthening social support for the low-income mother: five critical questions and a guide for intervention.

The visit to the nurse can become a vehicle for low-income mothers to develop one of the most critical health resources available to them: social support. Economic limitations require low-income mothers to create social support structures that are functional but may not match notions of ideal social support. Extensive experience of two advanced practice psychiatric mental health nurse-clinicians revealed that low-income mothers' social support was characterized by concern for basic necessities, precarious situations, self-replicating patterns, entrepreneurial requirements, and demonstrations of strengths. Five key questions during the encounter between nurse and mother can assist the nurse in planning interventions that fit these mothers' needs and benefit their health and that of their children.