From Connecticut Children s Neonatology Division NEWS November 2012 Inside this Issue... From the Director s Desk... 2 Wheels in motion on neonatal transport... 2 Spotlight on research... 3 Donor milk program nourishes... 4 Delivery time makes a difference... 5 ECMO technology saves lives... 5 Growing surgery program a plus... 6 Donor support strengthens NICUs... 6 Welcome to Neonatology News Welcome to the inaugural issue of Neonatology News, a semiannual publication of Connecticut Children s Medical Center Foundation, prepared especially for friends of the hospital s Neonatal Intensive Care Units (NICUs). Read on to learn more about the programs, technologies and research that benefit Connecticut Children s tiniest patient population. NICU Integration Celebrates First-Year Successes It s been one year since the Neonatal Intensive Care Units (NICUs) at Connecticut Children s Medical Center and the John Dempsey Hospital at the University of Connecticut Health Center joined forces. According to Victor Herson, MD, director of Connecticut Children s Neonatology Division, it s been a good year, yielding positive results for the units, for families and the region. The integration has resulted in better coordination and triage of infants between the two units, Dr. Herson said. It has also allowed families throughout the region to bring their infants to the appropriate site based on care needs, not financial considerations. Enhanced Services Since September 2011, the Division of Neonatology at Connecticut Children s has managed the neonatal care of babies as young as 23 weeks gestation at both the 40- bed Farmington facility renamed Connecticut Children s NICU at UConn Health Center and at the 32-bed Hartford facility. Since then, enhancements have included: Implementation of family-centered rounds, which encourage parent participation at the baby s bedside; NICU, continued on page 4 Neonatology Program Ranks Among the Best For the third consecutive year, Connecticut Children s has been named to the U.S. News & World Report s Best Children s Hospitals rankings, with the Neonatology Program earning its first such distinction and the Diabetes & Endocrinology Program earning its second. To determine the 2012-2013 rankings, U.S. News surveyed 178 pediatric centers and reviewed hard data in 10 specialties, such as availability of key resources and ability to prevent complications and infections. In Neonatology, Connecticut Children s was among 51 top-ranked programs. Survey data that looked at nurse staffing in neonatal intensive care units, ability to prevent bloodstream infections, and patient volume were among the factors comprising 75 percent of the score, based mostly on data from a U.S. News survey of children s hospitals. The other 25 percent reflected how many of 450 pediatric neonatologists surveyed in 2010, 2011 and 2012 recommended the hospital. For full rankings and methodology, visit www.usnews.com/childrenshospitals.
FROM THE DIRECTOR S DESK Welcome to the inaugural edition of Neonatology News. We re pleased to have this opportunity to update you on what s been happening in our NICU programs and to let you know of exciting new initiatives currently in the planning stages. We are in the middle of a period of unprecedented growth and development of Connecticut Children s Division of Neonatology, so this is an opportune time for this first issue. September 1st marked the one-year anniversary of the NICU integration, whereby the NICU beds at UConn Health Center became part of Connecticut Children s. This NICU integration formed a 72-bed, two-site neonatal program, making it the largest NICU in the state and the second largest in New England. There are many successes of this project to be celebrated. As discussed in our frontpage story as the highest level NICU in the region we need to be able to offer the most intensive services Updates and New Initiatives in Our NICUs By Victor Herson, M.D., Director, Division of Neonatology available that critically ill newborns require. Two new recently added programs enable us to do just that. First, thanks to the extraordinary leadership of Gale and Kip Dwyer and the generous support of many donors we now have ECMO (Extra- Corporeal Membrane Oxygenation) available to newborns with respiratory failure unresponsive to all other treatments (see story on page 5). This means that critically ill and unstable infants no longer have to be transported elsewhere to receive this lifesaving intervention. Second, a new comprehensive pediatric cardiovascular surgical program has just been launched so that newborns with critical congenital heart disease can also be cared for locally (see page 6 to learn more). This coming year we will begin another new venture: a full-service neonatal transport program bringing our staff to hospitals in our region to assist in stabilizing critically ill newborns and transporting them safely to one of our NICUs to receive specialty care (see story elsewhere on this page). Learning new and better ways to help newborns is an important part of our mission. We invite you to read more about some of the exciting research highlighted in this issue in the areas of oxygen therapy, reducing prematurity and donor breast milk. These and other factors led to the U.S. News and World Report including our NICU in their top national rankings for the first time. We are very grateful for that recognition and the support from our friends and donors who have helped us achieve this honor. Wheels in Motion... Neonatal Transport Plans 2013 Start The wheels are in motion on a Pediatric Transport Program at Connecticut Children s that will soon provide hospital-to-hospital transportation for children and neonates with life-threatening emergencies. Victor Herson, MD, director of the Division of Neonatology, anticipates that the Neonatal Transport service will begin early next year. We expect to go live with the Neonatal Transport portion of the overall Transport Program in early calendar 2013, Dr. Herson said. The staff has been hired; next steps are staff training and the purchase of state-of-the-art transport equipment. The Transport Program, which will be in service 24 hours a day, seven days a week, will serve approximately 450 children and neonates, and more than 40 community hospitals each year. A REGIONAL HUB As the hub of a regional network of 19 area neonatal intensive care units, the Transport Program will ensure that babies born in other hospitals who require Level III neonatal intensive care can be transferred to Connecticut Children s NICUs in Hartford and Farmington with ease. Mobile intensive care units fitted with mechanical ventilators, infusion pumps and physiological monitors that emulate the hospital s NICU will allow for uninterrupted care during transport. Watch for more information about this program in an upcoming issue of Neonatology News. 2.
SPOTLIGHT ON RESEARCH: New Study Eyes Factors Affecting Oxygen Levels Oxygen With Love (OWL) signs posted in Connecticut Children s Neonatal Intensive Care Units (NICUs) serve as a gentle reminder that the search for optimal oxygen saturation levels in preterm newborns continues. The OWL signs were put in place in 2009 as part of an initiative to reduce retinopathy of prematurity, a disease of the retina in premature newborns. Today, a new study at Connecticut Children s is looking at factors or clinical practices that optimize oxygen saturation levels in premature babies. Oxygen saturation and the search for the best target range has long been a hot topic in the literature, said neonatologist and researcher David Sink, MD. But this is the first time we re looking at how specific clinical practices affect the achievement of optimal saturation levels. This research is timely because many NICUs are adjusting their saturation target range in response to new data. We are looking at factors that will help NICUs achieve whatever range they choose as optimal. TARGETING OPTIMAL RANGE According to Dr. Sink, the problem with oxygen saturation levels is that no one knows what the optimal range is. If you go to 10 different NICUs, there will be 10 different target ranges, he said. We don t know the exact optimal range for these babies. It may vary over time for individual infants. At Connecticut Children s, the target range is between 85 and 93 percent. Staying within that range requires constant monitoring and intervention when levels become too high or too low. The research I do is to see how we can best manage our oxygen therapy in premature newborns, Dr. Sink said. We know that too much oxygen can be harmful, just as too little can be harmful. If it s too low, it will decrease retinopathy but increase mortality; if it s too high, it will do the opposite. THE SEARCH FOR VARIABLES We now have a multicenter study underway among different NICUs, said The OWL program reminds staff of the importance of monitoring oxygen saturation levels in the NICU. Dr. David Sink (pictured here) and colleagues are now looking at clinical practices such as these types of bedside reminders to find commonalities between NICUs in achieving optimal oxygen saturation levels for premature babies. Dr. Sink, who is the principal investigator of the new AVIOx2 Study short for Achieved Versus Intended Oxygen Saturations. He is joined by colleagues James Hagadorn, MD the lead investigator of the original AVIOx Study, which examined achieved versus intended pulse oximeter saturation in infants born less than 28 weeks gestation and by neonatologist Jenn Trzaski, MD, and Sandra Bellini, APRN. In the new study, Dr. Sink and colleagues are testing different variables and clinical practices, such as nurse staffing, respiratory support and oximeter alarm setting compliance, to look for possible common denominators between NICUs, their practices and optimal oxygen saturation levels. What are the clinical practices that optimize a baby s time in the NICU? We re testing a lot of different variables to come up with generalizable factors, Dr. Sink said. We want to see if what we ve found is generalizable to other NICUs. OPTIMIZING OUTCOMES A lot of NICUs are interested in quality and from a quality improvement standpoint, this study should help NICUs optimize oxygen management and clinical outcomes, such as retinopathy, chronic lung disease and mortality, Dr. Sink noted. Currently, Connecticut Children s and four other centers are participating in the study. Dr. Sink said he hopes to enroll between five and 10 centers and recruit as many as 100 babies. He plans to have the data collected by next summer. It s a nice study design, Dr. Sink said. It provides a nice snapshot across multiple NICUs of factors affecting optimal oxygen saturation levels. Donor support helps fund many research projects at Connecticut Children s, including NICU research. To learn how you can help, contact Connecticut Children s Foundation at 860.837.5700. 3.
Donor Milk Program Nourishes NICU Newborns More than 200 babies cared for in Connecticut Children s Neonatal Intensive Care Units (NICUs) have benefited from the Center s Donor Milk Program since the program s inception in the Hartford unit two years ago. The program uses breast milk from donor moms supplied by certified donor banks to nourish premature and other at-risk babies who might not otherwise receive the benefits of human milk. The literature shows that we should be providing a human milk diet for these babies, said Kathleen Marinelli, MD, a neonatologist at Connecticut Children s and an International Board Certified Lactation Consultant and Presidentelect of the United States Breastfeeding Committee. We are the first unit in the state to institute a Donor Milk Program and the first in New England. A Case for Donor Milk Human milk is the best food for babies, both full- and pre-term, because it contains an ideal mixture of protein, carbohydrate and fat, as well as the vitamins and minerals babies need to develop and thrive. In premature babies, especially, human milk has been proven to greatly decrease a serious condition called necrotizing enterocolitis (NEC), in which the intestines become infected and can begin to die. It s a very devastating disease, Dr. Marinelli said. Breast milk contains protective factors that encourage good intestinal development and can reduce the amount of harmful bacteria in the intestines, thereby reducing the incidence of NEC and other infections. It is also more easily digested, helping these babies to reach full feeds earlier and get off intravenous feedings sooner. As mothers of pre-term babies may have difficulty getting their milk to come in after an early delivery, donor milk becomes an important option. It is only given when mother s own milk is not available, Dr. Marinelli noted. We always use mother s own milk first. Human Milk Banking We started using donor milk at Connecticut Children s for the first time 15 years ago, Dr. Marinelli said. It wasn t a program at the time, but it was dispensed on a case-by-case basis. As the need for donor milk increased, a more formal program was implemented at Connecticut Children s on Aug. 1, 2010. We looked at all of the literature and a team of us in the NICU conducted a cost-analysis to see what it would cost to obtain donor milk, Dr. Marinelli explained. Donor milk costs approximately $4 to $4.50 an ounce. Connecticut Children s NICU teamed up with HMBNA the Human Milk Banking Association of North America which provides guidelines for how donor banks function. All donor mothers undergo a very rigorous screening process and are not paid for their donations, Dr. Marinelli said. Most donor mothers are in their 20s or 30s and their babies must be under a year of age. That s when breast milk has the most appropriate nutrients for the premature babies in it, she explained. As a final step, the donor milk is pasteurized. Neonatologist Kathleen Marinelli, M.D., displays bottles of pasteurized donor milk from one of the NICU freezers. Donor Milk at Connecticut Children s According to Dr. Marinelli, donor milk is delivered every week from the Ohio s Mother s Milk Bank. It comes overnight on dry ice and is kept in freezers, she said. It s administered as a standard of care to babies who fit any of the following criteria: 32 weeks gestation or less; 1,800 grams (about 4 pounds or less); and Mom doesn t have enough or any of her own milk. Premature babies only receive the donor milk while in the NICU, Dr. Marinelli said. Our protocol is 10 weeks or until discharge, whichever comes first. Since the program s implementation, a number of clinical studies have been conducted on Connecticut Children s population of donor milk babies. The results have been presented at national and international meetings and will soon be published in the scientific literature. Photo Credit: Michael McCarter NICU Integration Celebrates First-Year Successes, continued from page 1. 4. A comprehensive policy review incorporating best practices from both sites; New patient safety initiatives, including a new occurrence reporting system; and A new infant security system. According to Marla Booker, RN, director of Neonatal Nursing, the enhanced services have benefited families not only by increasing their comfort levels with security but by providing them with access to new pediatric resources. Among the new services offered in Farmington are a recently established breast pump depot and a Donor Milk program, which was introduced in the Hartford unit in August 2010, she said. A Special Kids Support Center, which offers supportive services for families of children with special healthcare needs, and a Safe Kids program, which offers safety tips for children, are among other services offered at both sites. Advancing Care Collaborative efforts to educate staff and establish practices for new equipment and technology have also been positive outcomes of the integration, according to Booker. The integration has increased collaboration and communication across sites to best utilize the strengths and best practices of each unit, she said. As the highest level NICU in our region, we need to be able to offer the most intensive services available that critically ill newborns and children require, Dr. Herson said. To learn more about Connecticut Children s NICU services, visit www.connecticutchildrens.org.
Delivery Time Makes a Difference Your baby needs time to develop and grow. That s why delivering your baby prior to the 39th week of gestation for convenience s sake is not in the best interest of your child, experts say. Connecticut Children s Division of Neonatology supports that stance as part of the March of Dimes 39 Weeks initiative to encourage mothers to wait until labor begins if their pregnancy is healthy, instead of opting for an early elective induction or cesarean section. Consumers don t understand the risk of early deliveries said Marilyn Sanders, MD, an attending neonatologist and principal investigator and director of the 39-weeks initiative at Connecticut Children s. Part of the problem relates to a consumer interest in convenience. It s when families decide, Wouldn t it be great if Joey were born on Grandpa s birthday? RISKS OF EARLY ELECTIVE DELIVERY The March of Dimes project, now entering its third year at Connecticut Children s, casts a light on the risks of early elective delivery. Data started coming out that not all term babies are created equally, Dr. Sanders said. Babies born too early tend to have more health problems, not only at birth, but later in life. According to the March of Dimes, nearly half a million babies are born too soon in the United States each year. Those who survive face an increased risk of health problems from breathing problems to vision and hearing loss, learning disabilities and more. It s best to deliver at 39 or 40 weeks, Dr. Sanders said. The best way to prevent early deliveries is for doctors and hospitals to educate pregnant women on the risks to the baby and to have policies reinforce that message. HOSPITAL POLICIES HELP What the March of Dimes found in earlier work is that you have to have hospital policies that put roadblocks in place that do not allow non-medically indicated inductions of labor or cesarean sections, Dr. Sanders explained. Other than medical necessity, the exception to the 39-week rule is elective delivery of twins at 38 weeks. In Connecticut, six hospitals, including Connecticut Children s, are collaborating on the project. Connecticut Children s is not a birthing hospital, but Connecticut Children s has taken a leadership role in this, Dr. Sanders said, explaining that the next stage of the project will involve data collection. We have the NICUs we see the results of early delivery, she said. For more information about the 39 Weeks project, visit the March of Dimes website at www.marchofdimes.com/ pregnancy/pregnancy_39weeks.html ECMO Technology Saves Lives Extracorporeal membrane oxygenation or ECMO for short has already proven to be a life-saver in Connecticut Children s Neonatal Intensive Care Unit. This advanced technology, which does the work of the heart or lungs of a critically ill child, has been used twice since its implementation this year on patients from the Hartford NICU. According to Victor Herson, MD, director of the Division of Neonatology, both patients were newborns with medical complications resulting in pulmonary hypertension, a condition causing blood to circulate in the body without first going to the lungs to be oxygenated. Without oxygen, vital organs, such as the liver, kidney and brain, can become stressed, putting the infant at risk. ECMO helps maintain the blood flow and oxygenation to these vital organs. When these infants failed to respond to maximum medical therapy, they were transferred to the PICU for their ECMO treatment. Both babies did very well and were ultimately discharged home. Without ECMO availability, both of these infants would have needed to undergo a prolonged and risky transport to New Haven or Boston, Dr. Herson said. This state-of-the-art technology was made possible, in part, by donor generosity. ECMO, a life-saving technology now available at Connecticut Children s (pictured at left), does the work of the heart or lungs in critically ill children. When newborns in the Hartford NICU need ECMO treatment, they are moved to the Pediatric Intensive Care Unit (PICU). Photo Credit: Michael McCarter 5.
Connecticut Children s Medical Center 282 Washington Street Hartford, CT 06106 NONPROFIT U.S. POSTAGE PAID HARTFORD, CT PERMIT NO. 3745 CARDIOVASCULAR SURGERY PROGRAM GROWING Good News for Newborns with Heart Defects A full-service cardiovascular surgical program being implemented at Connecticut Children s is good news for the hospital s littlest patients. According to Victor Herson, MD, director of Connecticut Children s Neonatology Division, the growing program includes a senior cardiovascular surgeon, who is now on board, and recruitment of a second surgeon to ensure 24-hour-a-day coverage, seven days a week, for premature and at-risk newborns in need of cardiovascular surgery. This will enable neonates with serious congenital heart defects to have their surgery performed locally rather than be transferred to Boston, said Dr. Herson. We expect the program to handle the surgeries on virtually all problems encountered. NEWSLETTER CONTRIBUTORS: Sharon Napolitano, Senior Editor Victor Herson, MD, Division Director Ed Jalinskas, Creative Services NICUs Strengthened by Donor Support Connecticut Children s Medical Center is a unique and special place, and our Neonatal Intensive Care Units (NICUs) are no exception. Each year, about 900 premature or high-risk newborns are admitted to our NICUs, which offer intensive medical, surgical and nursing care as well as a range of diagnostic and therapeutic capabilities. At Connecticut Children s we are committed to excellence, and much of what defines that commitment is made possible by the support of our generous donors. Donations have helped us purchase state-of-the-art equipment to provide our newborns with advanced respiratory support and nutritional therapies. Donor dollars have also helped us open or refurbish overnight rooms and lounges for the comfort and ease of our families. While Connecticut Children s delivers cutting-edge treatments today, we are also developing the next generation of cures through research. Today s investments in research will make tomorrow s care even more exceptional for our tiniest patients. How can you help? Please consider making a tax-deductible donation to Connecticut Children s NICU services by contacting Connecticut Children s Medical Center Foundation at (860) 837-5700. (Please indicate the NICU as the recipient of your donation.) Your act of generosity will help us provide our children with the best care possible today and every day. To learn more about the many programs and services supported by Connecticut Children s Foundation, visit www.connecticutchildrensfoundation.org. Neonatology News is a semi-annual publication of Connecticut Children s Foundation, highlighting the programs and services of Connecticut Children s NICUs. To be added to or removed from our mailing list, please contact the editor at SNapolitano02@connecticutchildrens.org. 12-432