Thinking More About Less: A Healthcare System for Lower-Acuity Infants

Although the neonatal intensive care unit (NICU) is best known to care for small, sick infants, the majority of NICU care is for lower-acuity, less premature infants.1 In this issue of Pediatrics, Schulman et al report that lower-acuity inborn NICU admissions (“LAINA,” or infants >1500 g and 32 weeks’ gestational age [GA] or beyond without markers of acuity) comprise 59% of all admissions and are most common in community units. The authors of this study describe how common LAINA diagnoses (suspected infection, hyperbilirubinemia, and feeding difficulty) may be treatable in lower-acuity settings.2 More research is needed to understand how to optimize outcomes for less acute infants in less acute settings.First, LAINAs are not a monolith. They consist of 2 distinct populations: (1) moderate and late preterm infants between 1500 and 2000 g and between 32 and 35 weeks’ GA requiring specialized nursing care to supporting emerging feeding and developmental skills, and (2) term infants with diagnoses potentially treatable in the newborn nursery, including hyperbilirubinemia and observation for early-onset sepsis. Solutions for optimizing care for each population may differ dramatically.More population-level data on both subpopulations are needed to understand how to optimize outcomes. The Vermont Oxford Network all-admissions database includes more than 400 000 lower-acuity infants but is not a national, population-level data set, limiting its generalizability.3–5 Internationally, databases such as the Australian Generation Victoria special care registry are emerging to fill this gap, but they only assess the region from which they collect data.6 US clinicians, health systems, and networks should collect lower-acuity patient population data along with unit organization and staffing data in a coordinated national effort to best understand how to structure care to optimize LAINA outcomes.Research focused on NICU organization may improve care for preterm LAINAs who require lower-acuity specialized NICU care. Schulman et al introduces the concept of a “neonatal comprehensive care unit” to acknowledge that the NICU provides care for several different types of low- and high-acuity infants. But how and where to deliver these different care models remains open for debate. Prior work demonstrates that strain (increased care demand relative to resources) may negatively affect lower-acuity infants.7 For example, there is an elevated risk of sepsis when the census of infants of fewer than 32 weeks’ gestation is greater8 and when there is more missed nursing care during periods of acuity.9 One proposed mitigation strategy is creating a separate “lower acuity neonatal unit,” or intermediate care nursery. This facilitates care of lower-acuity patients in a dedicated unit where they can receive condition-specific attention, such as specialized nursing care. Units for higher-acuity infants, such as the small baby unit, are already being implemented to improve high-acuity patient outcomes.10 Given the heterogeneity in intermediate care nursery services, future work should focus on how to best use these nurseries.11 In smaller units where care specialization may be more challenging given patient volumes, investing resources in staff development to ensure expertise in all patient populations may be an alternate strategy.Identifying the optimal staffing for term LAINAs is critical to increase the frequency of their care in the nursery. The variability in nursery staffing (pediatric hospitalists, family physicians, neonatologists) may limit the diagnoses cared for in this setting.12 Indeed, there is national variability in which diagnoses are cared for in the nursery, with certain “discretionary” admissions,12,13 such as observation for early-onset sepsis,14 transitioning from the NICU to the nursery in recent years. Additionally, the rise in newborn rooming in with the birth parent has led to nurse:birth parent-infant dyads ratios of 1:3 or 1:4. These nursing ratios, as well as the need for diverse nursing skills, may prevent term LAINA infant care in the nursery. Focusing on what resources, training, and staffing are needed in the nursery, particularly in community units where LAINAs are more prevalent, to make care for lower-acuity newborns feasible and cost-effective in the nursery is a critical next step.Finally, revised reimbursement models are needed to ensure such care delivery structures are financially viable. Newborn care is more heavily government funded and thus more poorly reimbursed compared with adult services.15 Hospitals may fund less profitable service lines through more profitable ones, a process known as cross-subsidization.16 Given the costly nature of high-acuity infant care, lower-acuity infant care may be relatively more profitable and thus more desirable for a NICU’s financial viability. Hospitals may be incentivized to keep lower-acuity patients in higher-acuity settings with higher reimbursement. Alternate payment models focused on optimizing outcomes for this lower-acuity patient population should be considered.Ultimately, the prevalence of LAINAs highlighted by Schulman et al calls not only for the collection of coordinated outcomes data for both preterm and term LAINAs but also for the close study of the organizing, staffing, and financing of this care. Although term LAINA care may be optimized through alternate staffing strategies in the newborn nursery, preterm LAINA care requires considering the need for an intermediate care nursery. Given the investment required for each of these strategies, careful consideration of aligning financial incentives is critical to make improving LAINA care a possibility.