R.I. hospital's new NICU allows for infant care delivery innovations

PROVIDENCE, R.I.—Welcome to the future of neonatal healthcare. Women & Infants Hospital of Rhode Island opened a new neonatal intensive care unit (NICU) in 2009 to facilitate the delivery of family-centered healthcare and the increasingly coordinated efforts of its staff. As a core component of the Transition Home Plus Program, an initiative aimed at improving outcomes for prematurely born infants, the state-of-the-art NICU is a hotbed for healthcare innovation.

The atmosphere in the 80-bed, two-story unit is unlike most others experienced in hospital settings. With private rooms, multiple spaces reserved for patients’ families and large team rooms for employees, the hallways are calm and parents privately tend to their newborns behind closed doors with the help of NICU clinical staff. Compare this scene to a photograph of the old NICU at Women & Infants where beds were placed about six feet apart, various cables snaked haphazardly across the floor and monitors cluttered the walls. Looking at the image, infants’ cries, parents’ strained voices and incessant monitor alarms are nearly audible.

That photograph leans against the wall in a conference room where students from Brown University Alpert Medical School, also in Providence, are educated. Its presence is intended to remind medical students and young physicians that conditions weren’t always like this at Women & Infants and still aren’t at the majority of NICUs across the U.S., according to James F. Padbury, MD, the pediatrician-in-chief of Women & Infants and a professor at Brown. “They think this is what an NICU looks like,” he said, gesturing toward the surrounding walls.

Coordinated, family-centered care
Betty R. Vohr, MD, director and 38-year veteran of the Women & Infants’ neonatal follow-up clinic, led a 2006 pilot program that provided coordinated care to 50 prematurely born infants during and following their stays in the NICU. The Transition Home Plus Program received financial support from the March of Dimes, a Providence, R.I.-based nonprofit, during its inaugural year and from CVS Caremark, a Woonsocket, R.I.-based retail pharmacy chain, in subsequent years.

Now, the Transition Home Plus Program coffers are bolstered by the Centers for Medicare & Medicaid Services (CMS). Women & Infants received a $3.2 million grant from the CMS Innovation Center earlier this year to expand its coordinated care initiative. It was one of only 26 applicants to receive a grant out of more than 3,000 that applied during the first round of funding to a program established by the Patient Protection and Affordable Care Act to encourage innovative efforts to reduce healthcare costs and improve quality.

The Transition Home Plus Program provides prematurely born infants with a medical home model of care, or “enhanced transitional care coming from one environment to the home environment,” according to Vohr. The purpose is to support families caring for high-risk infants and to alleviate the effects of adverse social and environmental conditions by ensuring they have the resources necessary to care for their child. These families can expect home visits and phone calls from Women & Infants’ neonatal follow-up clinic staff who actively communicate with NICU employees and infants’ primary care providers (PCPs).

“The intention is not to displace,” Padbury said, referring to the PCP’s role. “The intention is to coordinate.”

A look at the numbers shows why the Transition Home Plus Program was approved for a CMS Innovation Center grant. The 18-month rehospitalization rate among all preterm infants at Women & Infants dropped from 30 percent in 2007 to 22 percent in 2008, and from 34 percent in 2007 to 23 percent in 2008 among preterm infants with public insurance, according to Vohr.

The program has only been open to families with extreme preterm infants, but the CMS funds will allow families with moderate and late preterm infants to benefit from the medical home model as well, according to Vohr. The Transition Home Plus Program will be able to grow from approximately 100 patients per year to approximately 800 patients per year, or all preterm babies born at the Women & Infants’ NICU or at Rhode Island’s only other NICU—Warwick, R.I.-based Kent County Hospital. The funds also will allow for the training and hiring of additional program staff.

Health IT drives care 
As NICU staff pushing workstations on wheels dispersed from a morning meeting, Padbury borrowed a nurse’s mobile communication and monitoring device to demonstrate its various functions. It beeps and he clears the alert. “It’s up,” he said, shooting the nurse a thumbs up to indicate a patient’s blood pressure reading had returned positive results.  

The new Women & Infants NICU expanded the unit’s space from 9,000 square feet to more than 55,000 square feet and decentralized the provider team, a move to account for hallways one-half mile long and to enhance the feel of a more family-centered environment. At the beginning of their shifts, each clinical staff member is assigned a mobile device that displays patient information and goes over color-coded charts that show who their colleagues’ patients are, where they will be working and their contact number.  

Lab results and patient alerts are delivered to these mobile devices via a server in the hospital’s basement that reads data streams from patient monitors and interprets them according to clinical decision support developed in-house. If a clinical staff member does not respond to a patient alert within 10 seconds, it is sent to another staff member working in the same patient “neighborhood,” the term Women & Infants uses to describe patient bays. If the second staff member does not respond within 10 seconds, the alert is then sent to the entire clinical team. “Technology is crucial to operating in the decentralized mode,” Padbury said.

“EHRs have aided in the efficiency and accuracy of documentation,” added Padbury, who foresees a future where EHRs will enable his staff to conduct informatics research and test hypotheses. Everything in the NICU is documented, whether it’s a team member’s response to a patient alarm or an order placed electronically. “While there is pushback from a lot of places, we like EHRs.”

Everything in the NICU is standardized, from clinical team rooms to patient rooms to patient neighborhoods. A high-definition imaging station in the team room on the second floor is identical to the one in the matching team room on the first floor. Whether NICU employees need to find clean sheets or the appropriate electrical outlet, they know where to look because they are in the same location in every patient room. “These rooms are plug and play,” Padbury said.

Situational awareness is necessary to manage complex systems, Padbury believes. That’s why he and his staff always run simulations before implementing a particular practice. For instance, clinical staff members designed the headwalls in patient rooms by using sticky notes in a mock room to determine where the 32 electrical, eight oxygen, eight air and four vacuum outlets should be located. Construction workers also explored every nook and cranny in the unit with the mobile communication and monitoring devices to ensure there were no dead zones.

Making healthcare better
“The key to winning is teamwork and collaboration,” said Padbury, who noted that the NICU team includes supervising physicians, resident physicians, nutritionists, case managers and a pharmacist. “It’s popular to talk this way, but that’s the way we run and the way these programs run.”

Increased collaboration and a multidisciplinary approach to healthcare is expected to make the industry better, and Women & Infants is showing how it’s done. Patient outcomes, at least as illustrated by rehospitalization rates, have improved. Women & Infants staff and CMS also expect the Transition Home Plus Program to reduce costs by up to $1.5 million per year, according to Vohr.

Discussions among healthcare professionals about improving healthcare while lowering its costs incorporate many of the buzzwords that Padbury likes to use and rely on generalizations that seem to address broad societal concerns with healthcare more than individual patient concerns. However, for physicians like Padbury, the motivation to improve the overall state of healthcare is derived from a personal desire to deliver improved patient-centered care to individuals.

“The value of sending a child home to their family cannot be measured,” he said. “It’s an extraordinary privilege.”