Levels of Neonatal Care

A new American Academy of Pediatrics (AAP) policy has been issued regarding levels of neonatal care.  This is a very confused topic since states may create levels of care as well or may not define levels of care.

While the AAP levels of care have long been designated by Level I, II and III, states sometimes designate levels by intermediate, community and regional or others.  Therefore, when comparing levels of care amongst hospitals, particularly when evaluating outcomes, it is difficult to know if like facilities are being compared.  For this reason, the AAP has revised their levels of care and encouraged states to adopt a standard definition of levels for outcome comparison.

So what has changed?  The 2004 policy statement identified several levels of care.  They were Level I, which referred to a newborn nursery caring for basically healthy infants.  These nurseries should also have the capability to stabilize ill newborns until they can be transferred to a higher level of care, as needed.  This level is unchanged in the new 2012 guidelines.  The 2004 guidelines had a subdivision of levels II and III into IIA and IIB, IIIA, IIIB, IIIC and IIID.  These are simplified to Level II, Level III and Level IV.

So, why is it important to identify levels of neonatal care?  Several studies have demonstrated improved outcomes in hospitals that care for more very low birth weight (VLBW) infants (less than 1500 gms or 32 weeks).  When outcomes are compared on a national level, definitions must be congruent.  In addition, when care providers need to make referrals to other institutions, it is important to know by the level of care designation what services they provide.  A study out of Australia showed many infants were transferred to a regional center and transferred again due to over crowding.  This led to a higher mortality rate than those who were cared for in the hospital of birth.  A single transport may increase mortality but multiple transports should absolutely be avoided.  For instance, if a baby is transferred to a Level III hospital and then discovered to have a congenital cardiac defect requiring immediate intervention, he/she may need to be transferred again to a higher level unit i.e. Level IV.  Maternal transfers are preferred, when possible and decrease the neonatal morbidity and mortality.

One study, conducted in California where care has become deregionalized,  found a drop in the percentage of VLBW babies born at higher level neonatal units and predicted that if those infants had been delivered in Level IIIC and IIID centers, 21% of the VLBW deaths would have been prevented.¹  A similar finding was published by Ohlinger et al from Germany where mortality rates were higher in relation to lower annual birth volume and NICU volume.²

For more information on the levels of neonatal care, go to http://pediatrics.org/cgi/doi/10.1542/peds.2012-1999

References:

1. Phibbs, Baker, Caughey, Danielsen, Schmitt, Phibbs.  Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.  New England Journal of Medicine.  2007; 356(21):2165-2175.

2. Ohlinger, Kantak, Lavin et al. Evaluation and development of potentially better practices for perinatal and neonatal communication and collaboration.  Pediatrics.  2006; 118(suppl 2):S147-S152.