Hospitals are tasked with a mission that can seem impossible: balance safe & effective healthcare with an ever-increasing focus on ROI and value-based care. Healthcare professionals are passionate about serving their local community by any means necessary, yet they must be diligent in assessing the cost to provide such care. No other hospital department highlights this challenge more than in the Neonatal Intensive Care Unit, or “NICU.”
A NICU is a special care nursery that is uniquely equipped with the technology and staff that specialize in the treatment of sick or premature infants. Neonatologists are distinguished from other newborn providers by extensive neonatal training and certification, which allows for the care of more complicated babies. They are often responsible for making the decision whether or not to keep a premature baby at their birthing hospital or if the baby’s complications require a higher level of care than the birthing hospital can provide.
In most cases, the need to transfer a sick infant to a higher level of care is based on state regulations related to birth weight, gestational age, and/or the neonatologist’s assessment of the complexity of the medical care needed. However, certain neonatal transports can be avoided appropriately at the discretion of the neonatologist. The first concern of a neonatologist is the care of their fragile neonatal patients, and if possible, keeping mothers and babies together. At times, a transport may seem like the best option, however, there can be hidden risks and costs for the infant, family, and the hospital.
Below are 4 potential risks and costs to consider, as a neonatologist, when faced with the difficult decision of whether or not to transport.
1. The transport itself can be risky.
The purpose of a transport is to improve the likelihood of a positive outcome for the neonate. However, the transport itself can be a risky ride for these fragile infants. The majority of neonatal transports are executed flawlessly and without incident, but occasionally something can go wrong during the transport. A study from the International Medical Society found that equipment failure, incomplete transport teams, accidents, and other variables can negatively impact the health of a fragile newborn. The best and safest place for a neonate is in the well-equipped, adequately staffed nursery in which they were born. This is especially true when they are at a hospital that is staffed with 24/7 in-house neonatologists, which ideally should be the staffing model at Level II and Level III NICUs.
2. There are emotional and financial costs for the family.
When an infant is born premature, or a full-term delivery takes a turn for the worse, a patient’s family can become understandably stressed. When their tiny fighter needs to be transported to a distant hospital for a higher level of care, the emotional and financial impact is significant. One study from the Journal of Pediatrics and Child Health found that the average commuting NICU family spends $243 per week for food, travel, etc., most of which goes without reimbursement. Many families also lose hundreds of dollars per week in income due to missed work days. For these reasons, the cost to the family must be respectfully considered when deciding to transport a fragile baby.
3. Hospital and physician relationships can suffer.
As neonatologists, it is pivotal that our values, clinical practices, and goals are aligned with those of the hospitals in which we serve. Hospitals that are passionate about women’s & children’s services invest substantially in their programs with the goal of providing premiere medical care and a superb patient experience at their own hospital. Hospitals that choose in-house neonatology often do so to decrease neonatal transfers. If a baby is unnecessarily transported out of the hospital, the baby, the family, and the hospital all potentially lose.
4. There are legal risks.
The Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that the transfer of patients with an emergency medical condition is appropriate if the patient makes a written request or if the facility does not have the capability or capacity to provide necessary treatment to stabilize the emergency medical condition. A qualified medical provider may sign the certification that benefits of transfer outweigh the risk. If you get it wrong, violations of the EMTALA statute may result in fines for hospitals and individual physicians, as well as termination of Medicare provider agreements or civil suits.
When a transport is being considered, as physicians, it is crucial that all costs are considered for the baby, the family, the hospital, and physicians themselves. If the decision is made to transport, it’s imperative to provide clear and thorough documentation in the discharge/transfer summary to ensure a safe and healthy hand off to the receiving hospital.