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Cost Effective Care in NICU

Experts

Dr Anu Thukral, Dr Anuradha S

Dr Asim Mallick, Dr B Sudha, Dr Y Damera

Moderator

Dr Rhishikesh Thakre

Prof. Asim Kumar Mallick

Professor, Department of Pediatrics and In-charge, Neonatal Intensive Care unit (NICU),Nil Ratan Sircar Medical College & Hospital ,

Kolkata-14

MBBS, DCH, MD Pediatrics (Gold Medalist)

Neonatal Hyper Bilirubinemia (Invention of Transcutaneous

Bilirubinometer), Quality Improvement

Dr Anu Thukral

CURENT POSITIONAsst Prof Pediatrics (AIIMS, New Delhi)

QUALIFICATIONSMD DM DNB MNAMS

RESEARCH AND AREA OF INTERESTEducation- simulation base

E learning, Follow up of high risk infants

Dr. ANURADHA SANADHYA

Associate professor and SNCU incharge, RNT

Medical College, Udaipur

MD Pediatrics

Preventive Neonatology and Perinatology

Dr. Sudha.B

Consultant Neonatologist

NICE Hospital,Hyderabad

MD(PGIMER), DNB PEDIATRICS , FELLOWSHIP IN

NEONATOLOGY

Areas of Interest: Therapeutic Hypothermia and PPHN

Dr DAMERA YADAIAH

CURENT POSITIONNodal Officer (SNCU, Nalgonda, T.S)

QUALIFICATIONSMBBS, DCH

RESEARCH AND AREA OF INTERESTRational Antibiotics usage,

Implementation of Kangaroo Mother Care and Early Initiation of Breast Feeding

Current PositionDirector, Neo Clinic & Hospital,Aurangabad. MS.

Research and Area of InterestResuscitation, Teaching

Dr Rhishikesh ThakreDM, MD, DNB, DCH, FCPS, FIAP

Cost of NICU

• Two NICU populations : Preterm / Term

• Expensive = Illness intensity x Duration

• AIM= Low cost + Safety + Quality

Getting to a Good Start !

“ We know the price of everything but value of nothing ”

Antenatal Steroids (AS)

• Benefits?

• Cost?

• Costs of hospitalization in preterm infants: impact of antenatal steroid therapyJ Pediatr (Rio J). 2016;92(1):24---31

• The survivors with gestational age <30 weeks showed a decrease in the total cost of 38% (p = 0.008) and a 49% reduction of NICU length of stay (p = 0.011).

• Cost-effectiveness of Antenatal Corticosteroid Therapy vs No

Therapy in Women at Risk of Late Preterm Delivery

JAMA Pediatr. 2019 May 01; 173(5): 462–468.

“ Missed Opportunities ”

Don’t Miss in Delivery Room (DY)

• Why document temperature on exit?

• Best strategy for thermal well being?

For every degree below 36.5C risk of mortality increases by at least 28%

‘Right’ to Admission (SB)

To admit to NICU or not? Yes/No

34- 36 weeks, well

1.8-2 kg, well

IUGR term, asymptomatic

Sepsis work up for asymptomatic babies

Prenatal (Eg. hydronephrosis, ventricular dilatation, echogenic foci)

VIP Baby

Triage/Consider Intermediate Care / With mother

‘Grunting’ with Care

Rationalize Oxygen (AM)

• Blender Vs No blender?

• Alarm limits?

• Minimize oxygen requirement?

https://www.everypreemie.org/donoharmbriefs

Parmar J & Team, SCNU, Dhar, Neocon 2017

Money saved657000/- INR.

CPAP or MV (AS)

• Benefits of CPAP?

• Threshold for starting CPAP?

• How to make CPAP work in unit?

• CPAP failure predictors – Role for MV

Surfactant (AS)

• FiO2 Threshold for SRT?

• InSURE Vs MV?

• How to reduce wastage?

Efficacy and safety of surfactant replacement therapy for preterm neonates with respiratory distress syndrome in low- and middle-income countries: a systematic review.

Journal of Perinatology (2016) 36, S35–S47

BMJ 2016;354:bmj.i2976

Use of evidence based practices to improve survival without severe morbidity for very preterm infants:

results from the EPICE population based cohort

Maximize monitoring (DY)

• Sole as window to well being

• Monitoring the ‘monitors’

- How to make the most of the monitors

- Alarm fatigue

Birth of a preterm is a “ NUTRITIONAL” emergency

“MOM” (AM)

• First feed ?

• MOM (ml/kg/day) value?

• Value of time to full feed?

• Value of regaining birth weight?

• How to maximize MOM

How to minimize Formula feeds? (AT)

• Unit Strategies?

• Role of donor human milk?

• Role of banked human milk?

• Role of animal milk?

To feed or not to feed? (AS/AT)

• Should all stable VLBW infants be started on IVF?

• Slow vs Fast tube feeding?

• Role of standardized feeding protocol?

Economic Benefits and Costs of Human Milk Feedings: A Strategy to Reduce the Risk of Prematurity-Related Morbidities in Very-Low- Birth-Weight Infants

Adv. Nutr. 5: 207–212, 2014;

Journal of Perinatology 2013;1-6.

Antibiotics “SUTRA” (SB/DY)

• For all VLBW?

• Short Vs Standard duration

• EXIT criterion

• Best strategies

Minimize Infections (AM/AS)

• High risk places?

• Cloth vs Disposable diapers?

• IV Care Bundle?

• CLABSI Bundle?

• VAP Bundle?

• Routine microbial surveillance ?

Testing a Test (SB/DY)

• Routine sepsis screen?

• Routine labs for sick newborn?

• Daily XRC for ventilated baby?

• Routine TORCH serology for IUGR?

• Routine MRI for VLBW at discharge?

Unproven Strategies (AS/SB)

• Prophylactic role ?

- IVIG

- Indomethacin

- CPAP

- Antibiotics

- Phototherapy

- Phenobarb

• GM-CSF

• Transfusion

Reduce Duration of Stay (AT/AS)

• Step Down

• KMC Ward

• Oil massage

• Discharge efficiency

• Home care

Early Discharge (DY/AM)

• Criterion

Empowering Parents (SB/AT)

• Involve in Care?

• Shared Decision making?

Empowering Nurses (AM/DY)

• Staffing pattern

• Training, education

• Communication

Does Quality improve Cost? (AM/AT)

• What? How?

• Examples

Hidden Costs

• Family cost

• Personal cost

• Societal cost

• Long term burden

Low Cost Care

Clinical Competency

Family Integrated

Quality Improvement

Empower Nurses

Key Messages

• More intensive is “less invasive”

• Minimal handling & minimal interventions

• Early, More , Exclusive “MOM”

• Use checklists/Bundles for Care

• Involve mother in care

• Empower nurses