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Should 24 hour Neonatologist In-House Coverage Be The Rule ?

AllThingsNeonatal

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human_infant_in_incubator.jpg?w=648

I have often said that if this came to pass as a mandatory requirement that I would make an announcement shortly thereafter that I was moving on to another career.  I think people thought I was kidding but I can put in writing for all to see that I am serious!  The subject has been discussed for some time as I can recall such talks with colleagues both in my current position and in other centres. The gist of the argument for staying in-house is that continuity is improved over that period and efficiency gained by avoiding handovers twice a day .  How many times have you heard at signover that extubation will be considered for the following morning or to keep the status quo for another issue such as feeding until the next day.  No doubt this is influenced by a new set of eyes being in the unit and a change in approach to being one of “putting out fires” overnight.  The question then is whether having one Neonatologist there for 24 hours leads to better consistency and with it better outcomes.   With respect to PICUs the AAP has previously recommended that 24 hour in-house coverage by an intensivist be the standard so should Neonatology follow suit?

A Tale of Two Periods

My friends in Calgary, Alberta underwent a change in practice in 2001 in which they transitioned from having an in-house model of Neonatologist coverage for 24 hours a day to one similar to our own centres where the Neonatologist after handover late afternoon could take call from home.  An article hot off the presses entitled Twenty-Four hour in-house neonatologist coverage and long-term neurodevelopmental outcomes of preterm infants seeks to help answer this question.  The team undertook a retrospective analysis of 387 infants born at < 28 weeks gestational age during the periods of 1998-2000 (24 hour period, N=179 infants) vs 2002 – 2004 (day coverage, N= 208 infants) with the goal of looking at the big picture being follow-up for developmental outcome at 3 years.  This is an important outcome as one can look at lots of short term outcomes (which they also did) but in the end what matters most is whether the infants survive and if they do are they any different in the long term.

As with any such study it is important to look at whether the infants in the two periods are comparable in terms of risk factors for adverse outcome.  Some differences do exist that are worth noting.

Increased risk factors in the 24 hour group

  1. Chorioamnionitis
  2. Maternal smoking
  3. Smaller birthweight (875 vs 922 g)
  4. Confirmed sepsis (23% vs 14%)
  5. Postnatal steroids (45% vs 8%) – but duration of ventilation longer in the day coverage group likely due to less postnatal steroids ( 31 vs 21 days)

All of these factors would predict a worse outcome for these infants but in the end for the primary outcome of neurodevelopmental impairment there was no difference.  Even after controlling for postnatal steroids, birth weight, sex and 5 minute apgar score there was still no difference.

What might this mean?

Looking at this with a glass is half full view one might say that with all of the factors above predicting worse outcome for infants, the fact that the groups are not different in outcome may mean that the 24 hour model does indeed confer a benefit.  Maybe having a Neonatologist around the clock means that care is made that much better to offset the effect of these other risk factors?  On the other hand another explanation could also be that the reason there is no difference is that the sample just isn’t big enough to show a difference.  In other words the size of the study might be underpowered to find a difference in developmental outcome.

One of the conclusions in this study is that the presence of a Neonatologist around the clock may have led to earlier extubation and account for the nearly 10 day difference in duration of ventilation.  While I would love to believe that for personal reasons I don’t think we can ignore the fact that in the earlier epoch almost 50% of the babies received postnatal steroids compared to 8% in the later period.  Postnatal steroids work and they do so by helping us get babies off ventilators.  It is hard to ignore that point although I woudl like to take credit for such an achievement.

For now it would appear that I don’t feel compelled to stay overnight in the hospital unless it is necessary due to patient condition necessitating me having my eye on the patient.  I am not sure where our field will go in the future but for now I don’t see the evidence being there for a change in practice.  With that I will retire to my bedroom while I am on call and get some rest (I hope).



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