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Cost Effective Care in NICU
Experts
Dr Anu Thukral, Dr Anuradha S
Dr Asim Mallick, Dr B Sudha, Dr Y Damera
Moderator
Dr Rhishikesh Thakre
Prof. Asim Kumar Mallick
Professor, Department of Pediatrics and In-charge, Neonatal Intensive Care unit (NICU),Nil Ratan Sircar Medical College & Hospital ,
Kolkata-14
MBBS, DCH, MD Pediatrics (Gold Medalist)
Neonatal Hyper Bilirubinemia (Invention of Transcutaneous
Bilirubinometer), Quality Improvement
Dr Anu Thukral
CURENT POSITIONAsst Prof Pediatrics (AIIMS, New Delhi)
QUALIFICATIONSMD DM DNB MNAMS
RESEARCH AND AREA OF INTERESTEducation- simulation base
E learning, Follow up of high risk infants
Dr. ANURADHA SANADHYA
Associate professor and SNCU incharge, RNT
Medical College, Udaipur
MD Pediatrics
Preventive Neonatology and Perinatology
Dr. Sudha.B
Consultant Neonatologist
NICE Hospital,Hyderabad
MD(PGIMER), DNB PEDIATRICS , FELLOWSHIP IN
NEONATOLOGY
Areas of Interest: Therapeutic Hypothermia and PPHN
Dr DAMERA YADAIAH
CURENT POSITIONNodal Officer (SNCU, Nalgonda, T.S)
QUALIFICATIONSMBBS, DCH
RESEARCH AND AREA OF INTERESTRational Antibiotics usage,
Implementation of Kangaroo Mother Care and Early Initiation of Breast Feeding
Current PositionDirector, Neo Clinic & Hospital,Aurangabad. MS.
Research and Area of InterestResuscitation, Teaching
Dr Rhishikesh ThakreDM, MD, DNB, DCH, FCPS, FIAP
Cost of NICU
• Two NICU populations : Preterm / Term
• Expensive = Illness intensity x Duration
• AIM= Low cost + Safety + Quality
Getting to a Good Start !
“ We know the price of everything but value of nothing ”
Antenatal Steroids (AS)
• Benefits?
• Cost?
• Costs of hospitalization in preterm infants: impact of antenatal steroid therapyJ Pediatr (Rio J). 2016;92(1):24---31
• The survivors with gestational age <30 weeks showed a decrease in the total cost of 38% (p = 0.008) and a 49% reduction of NICU length of stay (p = 0.011).
• Cost-effectiveness of Antenatal Corticosteroid Therapy vs No
Therapy in Women at Risk of Late Preterm Delivery
JAMA Pediatr. 2019 May 01; 173(5): 462–468.
“ Missed Opportunities ”
Don’t Miss in Delivery Room (DY)
• Why document temperature on exit?
• Best strategy for thermal well being?
For every degree below 36.5C risk of mortality increases by at least 28%
‘Right’ to Admission (SB)
To admit to NICU or not? Yes/No
34- 36 weeks, well
1.8-2 kg, well
IUGR term, asymptomatic
Sepsis work up for asymptomatic babies
Prenatal (Eg. hydronephrosis, ventricular dilatation, echogenic foci)
VIP Baby
Triage/Consider Intermediate Care / With mother
‘Grunting’ with Care
Rationalize Oxygen (AM)
• Blender Vs No blender?
• Alarm limits?
• Minimize oxygen requirement?
https://www.everypreemie.org/donoharmbriefs
Parmar J & Team, SCNU, Dhar, Neocon 2017
Money saved657000/- INR.
CPAP or MV (AS)
• Benefits of CPAP?
• Threshold for starting CPAP?
• How to make CPAP work in unit?
• CPAP failure predictors – Role for MV
Surfactant (AS)
• FiO2 Threshold for SRT?
• InSURE Vs MV?
• How to reduce wastage?
Efficacy and safety of surfactant replacement therapy for preterm neonates with respiratory distress syndrome in low- and middle-income countries: a systematic review.
Journal of Perinatology (2016) 36, S35–S47
BMJ 2016;354:bmj.i2976
Use of evidence based practices to improve survival without severe morbidity for very preterm infants:
results from the EPICE population based cohort
Maximize monitoring (DY)
• Sole as window to well being
• Monitoring the ‘monitors’
- How to make the most of the monitors
- Alarm fatigue
Birth of a preterm is a “ NUTRITIONAL” emergency
“MOM” (AM)
• First feed ?
• MOM (ml/kg/day) value?
• Value of time to full feed?
• Value of regaining birth weight?
• How to maximize MOM
How to minimize Formula feeds? (AT)
• Unit Strategies?
• Role of donor human milk?
• Role of banked human milk?
• Role of animal milk?
To feed or not to feed? (AS/AT)
• Should all stable VLBW infants be started on IVF?
• Slow vs Fast tube feeding?
• Role of standardized feeding protocol?
Economic Benefits and Costs of Human Milk Feedings: A Strategy to Reduce the Risk of Prematurity-Related Morbidities in Very-Low- Birth-Weight Infants
Adv. Nutr. 5: 207–212, 2014;
Journal of Perinatology 2013;1-6.
Antibiotics “SUTRA” (SB/DY)
• For all VLBW?
• Short Vs Standard duration
• EXIT criterion
• Best strategies
Minimize Infections (AM/AS)
• High risk places?
• Cloth vs Disposable diapers?
• IV Care Bundle?
• CLABSI Bundle?
• VAP Bundle?
• Routine microbial surveillance ?
Testing a Test (SB/DY)
• Routine sepsis screen?
• Routine labs for sick newborn?
• Daily XRC for ventilated baby?
• Routine TORCH serology for IUGR?
• Routine MRI for VLBW at discharge?
Unproven Strategies (AS/SB)
• Prophylactic role ?
- IVIG
- Indomethacin
- CPAP
- Antibiotics
- Phototherapy
- Phenobarb
• GM-CSF
• Transfusion
Reduce Duration of Stay (AT/AS)
• Step Down
• KMC Ward
• Oil massage
• Discharge efficiency
• Home care
Early Discharge (DY/AM)
• Criterion
Empowering Parents (SB/AT)
• Involve in Care?
• Shared Decision making?
Empowering Nurses (AM/DY)
• Staffing pattern
• Training, education
• Communication
Does Quality improve Cost? (AM/AT)
• What? How?
• Examples
Hidden Costs
• Family cost
• Personal cost
• Societal cost
• Long term burden
Low Cost Care
Clinical Competency
Family Integrated
Quality Improvement
Empower Nurses
Key Messages
• More intensive is “less invasive”
• Minimal handling & minimal interventions
• Early, More , Exclusive “MOM”
• Use checklists/Bundles for Care
• Involve mother in care
• Empower nurses