LESS IS BETTER
In 1974 the Neonatal Intensive Care Unit (NICU) at Women & Infants had one baby who weighed less than or equal to 1,000 grams, which is considered extremely low birth weight (ELBW). Now they have about 100 babies a year born in that weight category.
“We have 1,300 admissions a year [in our NICU],” says James F. Padbury, William and Mary Oh - William and Elsa Zopfi Professor of Pediatrics for Perinatal Research and pediatrician-in-chief at Women & Infants. Patients are drawn from Women & Infants’ 10,000 annual deliveries, as well as community hospitals throughout Rhode Island, Connecticut, and eastern Massachusetts. Located in the smallest state, the NICU ranges from the third to fifth largest in the country depending on the census.
Padbury says that while neonatology is a young discipline (first credentialed in 1971), major breakthroughs in treatment have made survival possible for smaller and younger infants. Now, 23-weekers have about a 45 percent chance of survival, 24-week babies like the Collins twins have a 60 percent chance, and 25-week babies – still the second trimester of pregnancy – have an 80 percent shot. The Women & Infants’ NICU has numbers better than these national averages. Padbury says in prior studies among the members of the Neonatal Intensive Care Unit Network, a consortium of university NICUs, Women & Infants (along with the University of Miami) has the best survival rate, the lowest chronic lung disease rate, and the lowest rate of cerebral palsy.
“How?” the network wanted to know. They chartered a benchmarking study and sent doctors, nurses, respiratory therapists, and other NICU professionals to all 16 participating centers looking for outcomes. But they couldn’t find a singular reason why Women & Infants’ outcomes were better.
“The difference between good and great is details,” Padbury says. “They came around looking for some hole in one. They’re not going to find it. It’s details. Less is better.”
“Less is better” is the mantra of what has come to be known nationally as the “Providence style.” Padbury says while everyone uses antenatal steroids to boost lung growth as much as possible before delivery and surfactant afterward to improve ventilation in neonates, each NICU develops its own formula for ventilation and other care. In Providence, they tread lightly.
Take, for example, a baby who has to be on a ventilator. “We think if you ventilate that child just the right way, with just the right nursing, you can get the child to calm down and breathe comfortably on the ventilator without using narcotics or other analgesics,” Padbury explains. One study found that they use one-fortieth the amount of narcotics as other nurseries studied. “We believe in (blood) transfusion as needed but just as much as is needed, no more. We do fewer blood samples and less transfusion support. We still have the shortest length of stay, and the best survival.”
Less is not better, of course, when it comes to nutrition. Padbury says they also have better postnatal growth than other centers, and he attributes that to the nutritionists who round with them and “count every calorie” to provide optimal nutrition for each infant. The inclusion of nutritionists on the team is now the standard of care.
Built in 1986 and designed for 41 children, the original NICU comprised five open bays with isolettes and warming tables lining the walls. Babies and their attendant equipment filled every inch of space, with barely enough room for a rocking chair for each mother. Over the past two decades, growth in demand has outpaced available space, Padbury says. “Our average census last year was 67, average last month was 76.”
After two years of construction and $76.8 million, Women & Infants opened a brand new wing on September 12 that boasts a two-story NICU capable of caring for 80 preemies at a time. Padbury calls it the “NICU of the future.”
Jim Padbury is principal investigator on Women & Infants' $11 million COBRE grant.