The neonatologist as primary care physician.
Although trained first as pediatricians, neonatologists are not typically viewed as primary care physicians. However, given their particular training and expertise, patient population, and interaction with families as the newborn's first physician in many settings, neonatologists may rightly be viewed as the most appropriate primary care physician for newborns with medical or surgical problems. We review the fundamental underpinnings of primary care medicine with particular attention to how the neonatologist functions in such capacities. Neonatologist can contribute greatly to ensuring continuity of care for the sick newborn, the comprehensive nature of that care, and the coordination of care. Neonatologists' interactions with elements of the community to which the newborn will be discharged are an asset, as is their ability to work as part of a team. Given recent changes in practice management, the availability of neonatologists in the United States, and the desire for full-service mother and infant care capabilities in community hospitals, the primary care role of neonatologists bears recognition and support in today's changing healthcare marketplace. (+info
Non-ophthalmologist screening for retinopathy of prematurity.
AIM: To determine if a non-ophthalmologist can accurately screen for retinopathy of prematurity (ROP) by evaluating the posterior pole blood vessels of the retina. ROP is a common ocular disorder of premature infants and may require multiple screening examinations by an ophthalmologist to allow for timely intervention. Since there is a strong correlation between posterior pole vascular abnormalities and vision threatening ROP, screening examinations performed by non-ophthalmologist may yield useful clinical information in high risk infants. METHODS: Infants born at the Medical University of South Carolina who met screening criteria (n = 142) were examined by a single non-ophthalmologist using a direct ophthalmoscope to evaluate the posterior pole blood vessels for abnormalities of the venules and/or arterioles. To determine the accuracy of the non-ophthalmologist's clinical observations, infants were also examined by an ophthalmologist, using an indirect ophthalmoscope, who graded the posterior pole vessels as normal, dilated venules, or dilated and tortuous venules and arterioles (including "plus disease"). RESULTS: There was significant correlation (p <0.001) between the non-ophthalmologist's and ophthalmologist's diagnoses of posterior pole vascular abnormalities. 47 infants had normal posterior pole blood vessels by the non-ophthalmologist examination. Of these, 31 (66%) were considered to have normal vessels and 16 (34%) to have dilated venules by the ophthalmologist. The non-ophthalmologist correctly identified abnormal posterior pole vessels in all 21 infants diagnosed with abnormal arterioles and venules by the ophthalmologist. No infants with clinically important ROP ("prethreshold" or worse) would have failed detection by this screening method. CONCLUSION: Using a direct ophthalmoscope, a non-ophthalmologist can screen premature infants at risk for ROP by evaluating the posterior pole blood vessels of the retina. While not necessarily recommended for routine clinical practice, this technique may nevertheless be of value to those situations where ophthalmological consultation is unavailable or difficult to obtain. (+info
Variation in the use of alternative levels of hospital care for newborns in a managed care organization.
OBJECTIVE(S): To assess the extent to which variation in the use of neonatal intensive care resources in a managed care organization is a consequence of variation in neonatal health risks and/or variation in the organization and delivery of medical care to newborns. STUDY DESIGN: Data were collected on a cohort of all births from four sites in Kaiser Permanente by retrospective medical chart abstraction of the birth admission. Likelihood of admission into a neonatal intensive care unit (NICU) is estimated by logistic regression. Durations of NICU stays and of hospital stay following birth are estimated by Cox proportional hazards regression. RESULTS: The likelihood of admission into NICU and the duration of both NICU care and hospital stay are proportional to the degree of illness and complexity of diagnosis. Adjusting for variation in health risks across sites, however, does not fully account for observed variation in NICU admission rates or for length of hospital stay. One site has a distinct pattern of high rates of NICU admissions; another site has a distinct pattern of low rates of NICU admission but long durations of hospital stay for full-term newborns following NICU admission as well as for all newborns managed in normal care nurseries. CONCLUSIONS: Substantial variations exist among sites in the risk-adjusted likelihood of NICU admission and in durations of NICU stay and hospital stay. Hospital and NICU affiliation (Kaiser Permanente versus contract) or affiliation of the neonatologists (Kaiser Permanente versus contract) could not explain the variation in use of alternative levels of hospital care. The best explanation for these variations in neonatal resource use appears to be the extent to which neonatology and pediatric practices differ in their policies with respect to the management of newborns of minimal to moderate illness. (+info
Graphical user interface for a neonatal parenteral nutrition decision support system.
We developed and implemented a decision support system for prescribing parenteral nutrition (PN) solutions for infants in our neonatal intensive care unit. We employed a graphical user interface to provide clinical guidelines and aid the understanding of the interaction among the various ingredients that make up a PN solution. In particular, by displaying the interaction between the PN total solution volume, protein, calcium and phosphorus, we have eliminated PN orders that previously would have resulted in calcium-phosphorus precipitation errors. (+info
The uneven landscape of newborn intensive care services: variation in the neonatology workforce.
CONTEXT: In the past 30 years, the number of neonatologists has increased while total births have remained nearly constant. It is not known how equitably this expanded workforce is distributed. OBJECTIVE: To determine the geographic distribution of neonatologists in the United States. DATA SOURCES: 1996 American Medical Association physician masterfiles; 1999 survey of all U.S. neonatal intensive care units; 1995 American Hospital Association hospital survey; and 1995 U.S. vital records. MEASURES: The number of neonatologists and neonatal mid-level providers per live birth within 246 market-based regions. RESULTS: The neonatology workforce varied substantially across neonatal intensive care regions. The number of neonatologists per 10,000 live births ranged from 1.2 to 25.6 with an interquintile range of 3.5 to 8.5. The weakly positive correlation between neonatologists and neonatal mid-level providers per live birth is not consistent with substitution of neonatal mid-level providers for neonatologists (Spearman rank-correlation coefficient, 0.17; P < 0.01). There was no difference in the percentage of neonatal fellows in the lowest and highest workforce quintile (14% vs. 16%) or in the percentage of neonatologists engaged predominantly in research, teaching, or administration (14% in lowest and highest quintiles). CONCLUSIONS: The regional supply of neonatologists varies dramatically and cannot be explained by the substitution of neonatal mid-level providers or by the presence of academic medical centers. Further research is warranted to understand whether neonatal intensive care resources are located in accordance with risk and whether more resources improve newborn outcomes. (+info
Sir Leonard Parsons of Birmingham (1879-1950) and antenatal paediatrics.
Born and educated in the Midlands, Sir Leonard Parsons made major contributions to the field of paediatrics in that area and played a leading role in the regional organisation of this specialty throughout the United Kingdom in the later years of his life. He was a founder member and later President of the British Paediatric Association, and later became Vice-President of the International Pediatric Congress and the President of the paediatric section of the Royal Society of Medicine. (+info
Parents' perceptions of research with newborns.
OBJECTIVE: To examine beliefs and attitudes of parents about research with babies. STUDY DESIGN: Survey of 72 parents of newborn babies in the neonatal intensive care unit (NICU), and 159 parents of normal newborns using instrument designed for the study. The instrument included questions with graded responses and five research scenarios with varied risks and benefits. Statistical analysis included chi(2) analysis and Fisher's exact test. RESULTS: Parents showed generally favorable attitudes toward research with babies. There were few differences between the two groups of parents, but there was a trend toward more trust in doctors by "NICU parents." Couples with newborns in NICU were significantly more likely to enroll their newborn in a study involving moderate risk and possible major direct benefit. Almost a third of the sample in both groups was willing to enroll their newborn in a study with moderate risk and no direct benefit. CONCLUSION: Parents believe research is necessary and want to be asked for consent, but many feel they have limited knowledge and would depend on their physician's advice. The fact, that some might enroll their newborn in a study involving a risky procedure that would not benefit the newborn, supports the notion of vulnerability and emphasizes the fact that physicians must be alert to the possibility of coercion and undue influence. (+info
Creation of a neonatal end-of-life palliative care protocol.
OBJECTIVE: To create a protocol delineating the needs of patients, families, and staff necessary to provide a pain-free, dignified, family-, and staff-supported death for newborns who cannot benefit from intensive, life-extending, technological support. STUDY DESIGN: Using Internet e-mail, a Delphi study with sequential questionnaires soliciting participant response, investigator analysis, and follow-up responses from participants was conducted to build a consensus document. Institutional review was granted and respondents gave consent. Recruitment was conducted at medical, ethics, nursing, and multidisciplinary organization meetings. Synthesis of 16 palliative care/end-of-life protocols developed by regional, institutional, and parent organizations was included. Participants from 93 locations in the US and 4 abroad gave feedback to 13 questions derived from clinical experience and the literature. The data underwent four rounds of analysis with 95% retention of the 101 participants over an 18-month period. RESULTS/CONCLUSION: Specific consensus-based recommendations are presented with a description of palliative care; categories of candidates; planning and education needed to begin palliative care services; relationships between community and tertiary centers; components of optimally supported neonatal death; family care, including cultural, spiritual, and practical needs; ventilator withdrawal, including pain and symptom management; recommendations when death does not occur after cessation of life-extending interventions; family follow-up care; and necessary ongoing staff support. (+info