Commentary: Neonatal cardiac care units: The next step in specialization and regionalization

Abstract

Central MessageColumbia University established a novel dedicated neonatal cardiac care unit in 2006. Improved outcomes for premature infants with CHD portend this model as the next step in regionalization of care.See Article page XXX. Columbia University established a novel dedicated neonatal cardiac care unit in 2006. Improved outcomes for premature infants with CHD portend this model as the next step in regionalization of care. See Article page XXX. The congenital heart center program from Columbia University in New York has reported the outcomes of a novel dedicated neonatal cardiac care unit.2Goldshtrom N. Vasquez A. Chaves D.V. Bateman D. Kalfa D. Levasseur S. et al.Outcomes after neonatal cardiac surgery: the impact of a dedicated neonatal cardiac program.J Thorac Cardiovasc Surg. June 28, 2022; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar This is one of the first units of its kind in the United States. The review covers a 10-year period from 2006 through 2017. During that time, the center had a distinct cardiac neonatal intensive care unit (ICU), which was a 17-bed subunit physically and functionally distinct in team structure and practices. This unit was separate from the pediatric cardiac ICU and the general neonatal ICU. The unit included a core group of dually trained cardiac neonatologists, neonatal cardiac nurses, and allied health providers with expertise in newborns. This was an acuity-adaptable unit with all phases of care from admission to discharge in the same location. The outcomes from this unit were excellent, particularly in the infants born very preterm. This novel concept is another example of regionalization improving the care of children (specifically neonates born preterm) with congenital heart disease.3Backer C.L. Pasquali S.K. Dearani J.A. Improving national outcomes in congenital heart surgery: the time has come for regionalization of care.Circulation. 2020; 141: 943-945Crossref PubMed Scopus (20) Google Scholar The new model of care addresses the known high mortality in infants born premature with congenital heart disease.4Costello J.M. Pasquali S.K. Jacobs J.P. He X. Hill K.D. Cooper D.S. et al.Gestational age at birth and outcomes after neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery database.Circulation. 2014; 129: 2511-2517Crossref PubMed Scopus (110) Google Scholar The reduction in mortality corresponds to the findings of the European Congenital Heart Surgeons Association regarding center volume of neonatal cardiac surgery versus mortality (Figure 1).1Kansy A. Zu Eulenburg C. Sarris G. Jacobs J.P. Fragata J. Tobota Z. et al.Higher programmatic volume in neonatal heart surgery is associated with lower early mortality.Ann Thorac Surg. 2018; 105: 1436-1440Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar In that multi-institutional study, there was a clear inflection point for improvement in survival at 60 neonatal cardiac operations per year, with a continually declining mortality to 120 cases per year, at which point the survival curve flattens. In this series from Columbia University, there were approximately 120 neonatal operations per year. This reflects an overall cardiac surgical volume of more than 600 congenital cardiac cases per year. This volume of cases is necessary to have the critical mass of resources needed for a dedicated neonatal cardiac care unit. Reviewing the Society of Thoracic Surgeons data, there are only 8 to 12 centers in the United States that have this volume of cases to support a dedicated neonatal cardiac unit. The analysis within the manuscript is that a center performing more than 120 neonatal cardiac surgeries annually would be able to staff a 12-bed dedicated neonatal cardiac ICU with approximately 250 annual admissions and an average hospital length-of-stay of 21 days. This collaborative dedicated care model will maximize therapeutic benefit for neonates while minimizing the time and cost of care, but requires regionalization of patients to achieve the necessary volume of patients. The development of dedicated neonatal cardiac ICUs is the next step in specialization of care for children with congenital heart disease and a natural evolution of regionalization of care for the benefit of these critically ill newborns. Outcomes after neonatal cardiac surgery: The impact of a dedicated neonatal cardiac programThe Journal of Thoracic and Cardiovascular SurgeryPreviewPrematurity is a risk factor for in-hospital mortality after cardiac surgery. The structure of intensive care unit models designed to deliver optimal care to neonates including those born preterm with critical congenital heart disease is unknown. The objective of this study was to evaluate in-hospital outcomes after cardiac surgery across gestational ages in an institution with a dedicated neonatal cardiac program. Full-Text PDF