Arkansas nurses concerned about NICU rules 

Could require risky transport of infants.

New level-of-care designations for Arkansas neonatal intensive care units being created by a state Health Department advisory committee are worrying nurses, according to a spokesman for the nurses' union.

Paige Yates of Little Rock, a registered nurse who is head of United Health Care Local 22, said the level designations could mean that only the University of Arkansas for Medical Sciences or Baptist Health would be designated to handle certain high-risk deliveries, requiring other hospitals to arrange risky transport of women in distress or their babies.

Only three states do not have designated levels of neonatal intensive care; Arkansas is one of them.

A petition drive begun by a NICU nurse in Northwest Arkansas who administrators say works part-time at in the Willow Creek Women's Hospital in Johnson, part of the Northwest Health System, alerted nurses around the state to the work of the committee and asks that concerned people contact lawmakers and Dr. Paul K. Halverson, director of the Health Department. The petition, authored by Christine Picarelli, says that Willow Creek has had a "fully functioning level III NICU for over 11 years," and has beds for 24 sick or premature infants. "What the committee is proposing will take away this service for our NWA expectant families by limiting the number of preterm babies that can be delivered here. By transferring these babies to Little Rock, the families will have to travel long distances, be without their homes and family support, incur extra living expenses, and sacrifice time bonding with their infants due to the inconvenient 3 hour drive. The immediate transfer of these infants seems also unethical due to their extreme fragility in the first few days after birth, increasing the risk for mortality and severe morbidity."

Willow Creek said Picarelli started the petition drive on her own, without consulting the hospital.

Dr. Nate Smith, deputy director for public health programs at the Health Department, said NICUs may describe themselves as offering a level of care based on definitions from states that do define the levels. "Making sure that a baby is cared for at the right level can make a tremendous difference in whether and how well that baby survives," Smith said. "Not all NICUs are created equal."

Halverson convened the 21-member advisory group last spring to recommend whether Arkansas should adopt the classification system. Represented on the committee are doctors appointed by state agencies; Arkansas chapters of the American Academy of Pediatrics, the Arkansas Academy of Family Physicians and the American College of Obstetricians and Gynecologists; Arkansas Children's Hospital; the Arkansas Hospital Association; families who have used NICUs; the ANGELS program (Antenatal and Neonatal Guidelines, Education and Learning System at UAMS), the Arkansas Foundation for Medical Care and the Arkansas Medical Society.

The new rules would encourage women with high-risk pregnancies to deliver at hospitals with high-level NICUs. The committee is in the final stages of defining levels, Smith said. Unlike the trauma system levels, where Level 1 is the highest level, Level 4 is the highest; only Arkansas Children's Hospital, with its ability to provide ECMO blood circulation and surgical specialists, meets that criteria. ACH is not a delivery hospital, and there is consensus among committee members on the definition of Level 4, as well as levels 1 and 2, Smith said. At issue is what makes a Level 3 NICU.

"That's where there's lot of debate," Smith said. To allow hospitals that have been taking care of sick babies to continue that care, the committee has discussed dividing level 3 into two levels. The highest, level 3b, would be able to take care of babies weighing under 1,000 grams.

"The idea is mothers, if it looks like they're going to deliver a baby that small, then most appropriate thing ... would be that they would go where they could deliver at a 3b," Smith said.

"If the mother delivers at a facility where there is a high-level NICU, the baby does better than if she delivers and the baby is transported."

But Yates, a labor and delivery nurse at St. Vincent for 15 years, said women can go from having a normal pregnancy one minute to a high-risk one the next, and if they come to St. Vincent Infirmary in premature labor the new definitions would require the hospital to transport her or her baby to UAMS in a delicate condition.

"Say ... a patient walks in our door at 28 weeks [pregnant]" and delivers, Yates said. "We'd have to transport the 28-week baby," putting the infant at risk of a brain bleed. Alternatively, if a woman in Northwest Arkansas knows she is high-risk, she would have to deliver in Little Rock, far away from family.

The committee is working with definitions provided by the American Academy of Pediatrics. Another determinant in levels would be mortality rates, and Yates said that would present a problem for St. Vincent because, as a Catholic hospital, it admits pregnant women who are going into labor too early on the barest chance the baby could survive. "We're going to put you in a bed and watch you," Yates said. "When that patient delivers at 20 weeks, those numbers count against St. Vincent," Yates said.

According to Health Department data, Arkansas's infant mortality rate is consistently higher than the national average. In 2009, 39,665 babies were born to Arkansas mothers; 290 of those died before their first birthday. Only .7 percent of all babies delivered were delivered before 28 weeks, but those infants accounted for 36 percent of infant deaths. If 80 percent of all newborns less than 28 weeks were delivered in a level 3 NICU, 15 to 25 babies could be prevented from dying.

Yates said she understands that St. Vincent would be a level 2 under the level definitions, because it does not have a perinatologist, a specialist in high-risk pregnancies, on staff 24 hours.

Smith said hospitals could choose to staff their NICUs to meet criteria.

Other complicating factors: If the levels are voluntary, the Health Department would not have to seek legislation to put them in place. That might, however, affect reimbursement if Medicaid applied the criteria, refusing pay for lower levels of care for very sick babies. But if the state were to legislate the levels of care, as it does the trauma system, that would require inspections, which in turn would require funding.

Smith said Picarelli's petition brings up a "legitimate concern about wanting to have a high-level NICU as close to home as possible." He said the committee is working to address that concern. But the committee also has as a priority "that all babies born in Arkansas have access to the best care that's going to give them the best chance at life." The rules could affect hospital finances as well, if they are required to send patients away. But, Yates said, "that is not what this is about at all. It's a quality of patient care issue for babies and mamas." She said even if St. Vincent had to downsize its NICU, "every one of those nurses will find a job at St. Vincent."

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