Spinoff, NICU levels - does the definition need changing?

EricJRN, MSN, RN · Apr 1, 2006

I've often wondered whether the NICU level terminology is based on recommendations from an actual agency or not. I've heard some people refer to their NICU's as Level IV already.

I work for a combined Level II/III and we do surgery in the unit (esp GI, PDA ligations and eyes), HFOV, and some nitric (a few a year) -- but no ECMO or complex CV surgery. I think we consider all of our vent kids to be Level III babies, but it's just semantics I guess, since both levels are found on the same unit.

A pregnant friend of mine (who is not a nurse) was asking me about the capabilities of our area hospitals the other day. As I was explaining, it really opened my eyes to how many variations exists between facilities, both in terms of what we call ourselves and what we offer.

Mimi2RN, ASN, RN · Apr 1, 2006

Ok, for the record, these are the definitions I'm working with:

Level II (specialty): a hospital special care nursery organized with the personnel and equipment to provide care to infants born at more than 32 weeks' gestation and weighing more than 1500 g who have physiologic immaturity such as apnea of prematurity, inability to maintain body temperature, or inability to take oral feedings; who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis; or who are convalescing from intensive care. Level II care is subdivided into 2 categories that are differentiated by those that do not (level IIA) or do (level IIB) have the capability to provide mechanical ventilation for brief durations (less than 24 hours) or continuous positive airway pressure.
Level III (subspecialty): a hospital NICU organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. Level III is subdivided into 3 levels differentiated by the capability to provide advanced medical and surgical care.
Besides the fact that these definitions can be confusing, do you feel there needs to be a new classification system of NICUs?
In my city, we have 2 Lvl III and 7 lvl II NICUs. Of those two lvl IIIs, only 1 does surgery and ECMO. We have a population over 1million, and sending every baby to the Children's hospital is just not feasible. We struggle as it is to fit every baby in and we currently have 47 beds in our acute unit.
All of the lvl IIs will keep babies that are on vents. Sometimes long term vents. I know we got a baby finally who was a 24 weeker who spent over a week at one of the II+ hospitals. Don't get me started on that because I wonder how much that might contribute to the BPD around and other things.
Should though the system be revised into simpler terms? I is a newborn nursery, II keeps those transitioning babies, III keeps the vents, IV maybe HFOV/nitric, V Surgery and ECMO?
Thoughts? Ideas on different classifications? Is our city the only one with II+ NICUs?

We are a level II, but keep babies from about 27-28 weeks, and over a kilo. Some are on vents or CPAP (we loved Vapotherm.....). We send them out for major problems, including anything that might need surgery. We take in transports from other facilities, that don't need the Level III care. In fact the Level III transport team brings them to us, as they need their beds for sicker babies. Some of our babies are on vents for quite a while, we have used HVOF occasionally.

We don't quite fit with your definition. Our primary Level III doesn't do ECMO, but I believe just about everything else.

As a Level II, we won't keep anything like a 24 weeker, and we are much happier when the baby gets to take a ride to a different hospital while still inside mom! :)

LilPeanut, MSN, RN, NP · Apr 1, 2006

There is standardization with trauma centers, right?

your NICU sounds a lot like our II+s here.

And I agree, it's amazing the variation that there is out there in what the NICUs actually do.

dawngloves, BSN, RN · Apr 1, 2006

It really isn't cut and dry with the level III and IV classification.Like Eric, we do PDA ligations and ROP surgery. We also have HFOV and nitric.

Our Children's will take the ECMO and say CDH,HLH, Gastero kids but they hardly see micros because it is so risky to transport them.They would rather have some circling the drain term kid over a honeymooning 25 weeker.

llg, PhD, RN · Apr 1, 2006

For the record, the state of Virginia now officially has Level 4 centers, with the Level 4's about to do either ECMO or nitrous oxide. There are probably a few other criteria on the list, too.

I've been in the field since 1977 and have seen many changes over the years. The designations will always be evolving as new treatments are developed and hospitals jockey for position with marketing their perinatal services to the public.

The original levels were established by concensus of the "major players" (e.g. neonatologists) through discussions in the major professional organizations such as the National Perinatal Association and the neonatology section of the American Association (Academy?) of Pediatrics. (It's early in the morning here and my brain isn't fully awake yet, sorry.)

I think what is most important is for each hospital and each professional to act responsibly and ethically in "keeping" only those patients for which it can provide good service. Bad things happen when hospitals try to keep babies who need a level of service that exceeds that hospital's abilities.

llg

LilPeanut, MSN, RN, NP · Apr 1, 2006

On that same thought, I've wondered many times about whether our hospital should consider accepting transport of imminent micropreemie moms prior to birth. We're the best equipped to deal with them, but we do no deliveries (children's hospital) but I wonder if outcomes could be improved with that. Just a random thought

dawngloves, BSN, RN · Apr 2, 2006

On that same thought, I've wondered many times about whether our hospital should consider accepting transport of imminent micropreemie moms prior to birth. We're the best equipped to deal with them, but we do no deliveries (children's hospital) but I wonder if outcomes could be improved with that. Just a random thought

I've heard rumors of our Children's having an L&D floor for high risk moms. But so far it's just that. Seems to me the outcomes would be much better if they did deliver there.

iceNICUnurse · Apr 3, 2006

This is so complicated where you all are.

Where I work we are level everything. We just take every sick newborn no matter what. We only send out complicated cardiac surgery kids but all the others we keep.

LilPeanut, MSN, RN, NP · Apr 4, 2006

ice: I think a lot of it is the geography of the states. You have people who are potentially 2-3 hours from a major city, and while they have a small country hospital nearby, that hospital doesn't have the staff and/or equipment to handle a severely ill baby, they just don't get enough of them. But if at all possible, we want to try and keep the baby as close to mom/dad as we can. Overall it's like any medical issue, would you rather go to a dr. that only sees 1-2 preemies a month, vs. the large tertiary centers that have large, always full NICUs? The nurses and drs. are more comfortable with the babies, they have all the equipment and they're more skilled at what is going on with the kids.

fergus51 · Apr 4, 2006

I've always seen this as a bit of a pi$$ing contest to be honest. Level 1 meant healthy nursery, level 2 meant a little sick and level 3 meant really sick when and where I started in the NICU a few years ago. Level 4 meant heaven. Now, we have all these strange definitions and I don't really see what it serves. Few hospitals are going to fit into the descriptions exactly. I don't have any problem with a level 2+ taking vents if they can manage them well or any problems with a 3 that does surgery and not ecmo or vice versa. It seems very arbitrary to say a level 2 will do this ONLY and a level 3 will do the rest. If we do that, a lot of level 2s will just reclassify themselves to level 3s so they can keep taking vents or whatever. I just never understood why classifications like this matter to nurses.

fergus51 · Apr 4, 2006

On that same thought, I've wondered many times about whether our hospital should consider accepting transport of imminent micropreemie moms prior to birth. We're the best equipped to deal with them, but we do no deliveries (children's hospital) but I wonder if outcomes could be improved with that. Just a random thought

I used to work on the other end. Starting up a high risk L&D unit in a new hospital is no easy task, not to mention the fact that it can be very risky to transport a woman in labor with a micropremie (an ambulance delivery is not fun!!! Been there, done that.). Plus, the NICU nurses who work children's hospitals need time to get used to deliveries too. Our NICU had occasionally set things up so the mom would deliver at the children's hospital knowing the baby had a condition that the children's hospital needed to deal with, but our labor and delivery and nicu nurses had to do the delivery before passing off the baby to the children's hospital nicu nurses. It worked for us in those odd cases.