Dear Mommy and Daddy, I Wish to Go Home at the Right Date, Not Too Early But Not Too Late…*

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Editorial

Pediatric Critical Care Medicine www.pccmjournal.org 1175

R

ecent advances in neonatal care have markedly increased

survival among very preterm infants, that is, those born before 32 weeks gestational age (GA) (1). This positive trend has been observed particularly in the lowest GAs, where the limit of viability for extremely immature babies has been extended down to 23 or even 22 weeks GA in some settings (2, 3). However, such improvement has been linked to higher risk of complications and long-term sequelae in survivors. Fur-thermore, an increased number of very premature infants may require prolonged length of hospital stay, increasing workload of the healthcare service and associated costs. As an example, a singleton baby born at 24 weeks of gestation may spend a median of 123 days in the hospital before discharge, versus a median length of stay (LOS) of 34 days in a 31-week infant (4).

As the number of very preterm infants requiring long-term neonatal care keeps increasing, it is essential to improve our ability to accurately estimate LOS in neonatal care. By doing so, we could help clinicians in their counseling of parents, support healthcare policy-makers in allocating resources and establish-ing benchmarkestablish-ing for optimizestablish-ing local practices (4).

However, estimating LOS for infants born very preterm is a complicated task, as many confounding factors may intervene during the neonatal course, partially explaining the large varia-tion in LOS observed across different neonatal ICUs (NICUs) (5, 6). Furthermore, research about the optimal LOS for very preterm infants is still limited, and there is a lack of consensus on discharge criteria and care practices for these tiny babies.

In this issue of Pediatric Critical Care Medicine, Maier et al (7) present a large observational study comparing the duration in length of hospital stay (LOS) of very preterm infants surviv-ing to discharge. The study by Maier et al (7) was performed in 10 European regions supposed to have similar standard of liv-ing and healthcare systems. In addition, they evaluated if LOS did change over time in the same centers, trying to identify factors and variables associated with observed differences.

Data were obtained from two previous multicenter studies performed in 2003 (Models of Organizing Access to Inten-sive Care for Very Preterm Births study) and in 2011/2012

(Effective Perinatal Intensive Care in Europe study), respec-tively (8, 9). More than 8,000 medical records of very pre-term infants (from 22 + 0 to 31 + 6 wk GA) were analyzed in the two time periods, providing interesting information about patterns of LOS in different GAs, as well as on some maternal and infants characteristics with a strong indepen-dent impact on LOS (7).

As expected, among several other factors, low GA, small for GA, no antenatal steroids, multiparity and severe comorbidi-ties, such as bronchopulmonary dysplasia (BPD), were most associated with prolonged LOS.

Of note, the authors reported marked differences in LOS between single NICUs, even within the same region and after adjusting for maternal and infants characteristics. In fact, more than 2-week difference in duration of LOS was observed between some centers. Analogous patterns were present in both time periods. Similarly, by a sensitivity analysis, large regional differences in LOS were also observed in a lower risk popula-tion, that is, without severe neonatal morbidities or severe con-genital anomalies and with higher GA (from 29 to 31 + 6 wk).

In general, such disparities could be partially explained by different local and regional practices, variable case-mix, post-discharge organization of care or use of home oxygen, among others. However, further research is still needed to better clarify if other important factors may play a role in such variability.

Surprisingly, mean LOS until discharge was nearly identical in the two periods, at first glance indicating that little progress in duration of LOS has been obtained in nearly a decade (2003 vs 2011/2012) (7).

Actually, case-mix changed over time, with an increase of higher risk patients at very low GAs in the second epoch. Thus, higher survival of more extremely preterm babies could have implied longer duration of stay in the NICU and in hospital, somehow buffering the effect of shorter LOS of infants with higher GAs (7).

Nonetheless, recent advances suggest that there may be still room for improvement, aiming to reduce LOS in this fragile population.

Indeed, even reducing of just few days a prolonged hospital-ization can decrease healthcare costs, as well as gratify families eager to take their baby at home.

How can we do better? Can we optimize the duration of LOS for these patients, thus avoiding unnecessary hospital days while minimizing the risk of readmissions and adverse events after discharge?

Recent studies reported that prolonged cumulative mechan-ical ventilation was associated with higher risk of BPD and lon-ger LOS, while earlier attempts to extubate could reduce the occurrence rate of BPD as well as the duration of LOS in very preterm infants (10, 11).

*See also p. 1153.

Key Words: bronchopulmonary dysplasia; gestational age; length of hospital stay; mechanical ventilation; very preterm infant

Dr. Biban received funding from Masimo and Chiesi.

DOI: 10.1097/PCC.0000000000001755 Paolo Biban, MD

Division of Pediatric Critical and Emergency Care Neonatal and Pediatric Intensive Care Unit Verona University Hospital

Verona, Italy

Dear Mommy and Daddy, I Wish to Go Home at the

Right Date, Not Too Early But Not Too Late…*

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Editorials

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In a large cohort of more than 5,000 very low birth weight (VLBW) infants, from 69 NICUs participating in the Korean national registry, Choi et al (10) observed that a longer cumula-tive duration of mechanical ventilation was associated with higher mortality, increased odd of BPD and longer length of hospitaliza-tion. Conversely, in 224 infants born before 27 weeks of GA, Rob-bins et al (11) found that earlier first extubation attempts were associated with less need for supplemental oxygen, less moderate-to-severe BPD and shorter LOS. Of note, in case reintubation was needed this was not associated with adverse outcomes. These data reinforce the notion that the duration of invasive mechani-cal ventilation should be kept at a minimum in VLBW infants, while extubation should not be delayed due to fear of failure, as outcomes appear to be favorable even if reintubation is required.

Late-onset sepsis is another important factor which may complicate the neonatal course in very preterm infants. In some studies, late-onset sepsis was associated with a marked increase of LOS in survivors (12). Interestingly, a recent study reported the effect of heart rate characteristics (HRCs) moni-toring on LOS among VLBW infants (13). HRC monimoni-toring decreased LOS among a subgroup of survivors with proved infection, as assessed by a reduced postmenstrual age (PMA) at discharge (3.2 d less) (13). The authors analyzed the dataset of a previous RCT, where HRC monitoring was associated with a 40% decrease in mortality after infection compared with the control group (14). Thus, in the population of VLBW infants with positive culture, HRC monitoring in the NICUs may not only reduce mortality but may also reduce costs of hospitaliza-tion by decreasing LOS (13). Further studies will have to con-firm these promising observations.

Finally, another approach aimed to optimize LOS has been recently proposed by Lee et al (15), who adopted a collabora-tive quality improvement project to reduce NICU LOS in very preterm infants (from 27 + 0 to 31 + 6 wk GA). By standard-izing feeding approaches, discharge planning, definition and management of apnea, bradycardia and desaturation events, the authors obtained a 3-day reduction of PMA at discharge (primary outcome). In addition, early discharge (i.e., eli-gible infants discharged before 36 + 5 wk PMA) significantly increased from 31.6% to 41.9% (15).

In summary, a more accurate estimation of length of hos-pital stay in neonatal care is essential. This is particularly true in extremely preterm infants, who may require several months of special care before been discharged home. Detailed informa-tion on LOS may aid clinicians in counseling of parents and healthcare resources to be properly allocated. At the same time, further research is still needed to identify the best practices for

optimizing LOS in this fragile population. Of course, the aim should be to reduce LOS safely, implementing standardized approaches which may virtually eliminate untoward conse-quences such as readmissions or, even worse, life-threatening events at home.

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