Fewer tests, treatments for
 NICU babies reduces infections, cuts costs

About a decade ago, it wasn’t uncommon for the babies in the neonatal intensive-care unit at Intermountain Healthcare’s Dixie Regional Medical Center to receive as many as 78 tests or treatments during their stay. 

Each intervention can cause the fragile baby pain and increase the likelihood of infection, ultimately lengthening hospital stays and overall costs. Research shows that preterm babies are three times more likely to get a healthcare-associated infection than full-term babies in part because invasive monitoring and procedures are tough on their weak immune systems. Babies in the NICU typically receive many blood draws and have central lines inserted.

Disturbed by this disruption, Dr. Erick Ridout, a neonatologist at Dixie’s NICU, and the unit’s nurse manager, Jeannette Cutner, changed practices.

They began in 2008 by tracking all the interventions done every 12 hours for each baby in the 40-bed unit and sharing it with clinical staff. The goal was to justify every test and procedure. 

Ridout said there’s a culture in the NICU—and universally in medicine—to administer lab tests because “we check these every Monday and it’s Monday.” 

It’s estimated that about $200 billion is spent every year on healthcare services in the U.S. that provide little value. 

Ridout and Cutner spoke to staff about re-evaluating that mindset to focus on the babies and what their vitals show they need. “The baby doesn’t know it’s Monday,” Ridout said.

Another thing that helped change the staff mindset was the implementation of morning huddles, Cutner said. The entire clinical team and parents meet every morning to go over the baby’s last 12 hours and determine future treatment. The number of interventions done up to that point are also highlighted, which Dixie calls “pokes.” Physicians speak last at the huddles, which was done intentionally, Cutner said. 

“If they (the physicians) speak first, everyone becomes quiet even though they might have had a different approach,” she said. “This way everyone has a voice, including the parents.” 

The unit has 52 staff members, including nurses, nurse practitioners, respiratory therapists, dietitians and neonatologists. 

Before the morning huddles were started, neonatologists led decisionmaking and other clinical staff weren’t asked for their thoughts. Now, the physician only writes an order for another test or treatment if there is consensus among everyone at the meeting. 

The nurses love the work environment because they feel heard, Cutner said. Turnover in the NICU is at 1%—the lowest across all of Intermountain. 

The approach has also led to other new practices. For instance, blood from newborn babies is now taken from the umbilical cord instead of from the baby to reduce pokes. 

The changes in practice over the last 10 years have led to drops in infection rates and cost savings for Dixie Regional. The average length of stay for preterm babies in the NICU has decreased by 21% from 72 days to 57 days. Additionally, the average number of blood draws during stays fell from about 75 to fewer than 40 and only one baby has experienced a central line-associated bloodstream infection in 11 years. Ridout said the system has saved at least $2.8 million from the changes. 

Given the growing number of NICU admissions nationally, the practice could lead to big cost reductions across the industry. A 2015 study by Dartmouth researchers found that NICU admissions had grown by 23% in just five years, with most of those babies born preterm.

In an effort to further stem costs and improve quality, Dixie Regional is looking to use artificial intelligence to identify even more unnecessary treatment in the NICU because the team has “eliminated most of the low-hanging fruit,” Ridout said. A dashboard on the electronic health record tracks all treatments and tests for every patient. Predictive analytics from AI will be able to assess more potentially unnecessary treatments.

Intermountain plans to integrate this less-intrusive approach to NICU practices across the 23-hospital system. Right now three hospitals are taking “baby steps” to implement it, Ridout said.