Hospital Referral Guidelines

Michigan Health and Safety Coalition Hospital Referral Guideline for Infants with Congenital Anomalies*

• NICUs caring for infants with congenital anomalies (see Appendix A for a list of codes) should possess the following structural characteristics:

1. a board-certified or board-eligible neonatologist should direct the NICU;
2. 24-hour in-house coverage should be provided by either a physician qualified in the intensive care of newborn infants or by an appropriately trained physician extender;
3. physician backup to the physician extender should be available within 30 minutes;
4. diagnostic modalities such as radiology, ultrasound, MRI imaging, including skilled interpretation appropriate for the specific anomaly are readily available; and
5. for the specific anomaly under treatment, appropriate medical, surgical, and pediatric subspecialists are available through established consultation and referral networks by which coordination of consultations, referrals, and potential transfers between NICUs will occur.

• Collect risk-adjusted morbidity and mortality data for all Michigan NICUs via the Vermont Oxford Network or develop a data procurement mechanism from Michigan sources by May 2002.

• Work with the Society of Michigan Neonatologists and other organizations to identify and convene Michigan physician and nurse practitioner neonatal and perinatology experts to:

1. establish and periodically review hospital-specific standards and guidelines for selected NICU quality of care indicators such as mortality, complications, access to specialty care and other services, NICU admission criteria, and NICU nurse staffing levels;
2. update the proposed guideline according to NICU quality of care indicators and consider whether the guideline should be more rigorously defined (e.g. low birthweight as 750-1000 grams rather than 1500 grams);
3. review and analyze risk-adjusted morbidity and mortality data (e.g., neonatal survival statistics by weight and gestational age);
4. evaluate hospital-specific performance relative to agreed upon standards and guidelines; and
5. disseminate hospital-specific performance information with physicians, hospitals, and the Michigan Health and Safety Coalition.

• Hospitals with Neonatal Intensive Care Units (NICUs) should admit at least 70 low birthweight infants (<1500 grams) on an annual basis.

• Hospitals should require that their medical staff implement appropriateness criteria and use the criteria to conduct clinical case review of all NICU admissions.

* This is meant to be a guideline and not a standard of care; this guideline represents the best of an evidence-based review at this time; the guideline is based on the principles of CQI and is not intended to be used in a punitive manner; this guideline needs to be taken as a whole, and not have selected parts be used without considering the entire content of the guideline.