Innovative use of Neonatal Nurse Practitioners in Rural Hawaii

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1 Innovative use of Neonatal Nurse Practitioners in Rural Hawaii Petri Pate Pieron, MSN, MPH, APRN Rx, CPNP, NNP Presentation was supported by NIH 1 R25 RR Clinical Research Education and Career Development (CRECD) in Minority Institutions Hawaii and University of Puerto Rico, Medical Sciences Campus, School of Medicine and School of Health Professions, Department of Graduates Programs

2 Objectives Overview neonates (newborns) who need special care and basic levels of care. Overview of increased need for neonatal providers coupled with rural OB/Gyn and pediatric provider shortages What are neonatal nurse practitioners (NNPs( NNPs)? Innovative service model being developed in rural, neighbor island community in Hawaii as a model for other rural areas Photo Courtesy of: neonatology.mc.duke.edu

3 Routine versus newborn special care Photo Courtesy of: health.uab.edu/ Photo Courtesy of:mtsinai.on.ca/nicu/

4 Levels of Newborn Care 1 Level I - routine healthy - term newborns born to healthy mothers Provider traditionally cares for both mother and infant at time of birth (OBGyn( OBGyn, family practice provider) Level 2 some level of risk to infant meconium in amniotic fluid, vacuum/forceps/c-section section assisted delivery, late preterm (>34( completed weeks), maternal illnesses (infection, HTN, DM, substance abuse, etc) Specific provider required to care for infant once born (traditionally a pediatrician) (no mechanical ventilation, vasopressor support, etc) but still in need of continuous cardiorespiratory monitoring, thermal support, etc ( telemetry( telemetry ). Level 3 neonatal / newborn intensive care unit (NICU) all other preterm infants and term infants who shortly after birth are symptomatic For large centers two providers for infant once born - neonatologist (MD, DO oversees plan of care) and neonatal nurse practitioner, pediatric c resident or more recently NICU hospitalist (provides care).

5 Who Needs Special Care? Photo Courtesy of: mtsinai.on.ca/nicu/ Premature < 37 weeks completed gestation Currently babies are able to survive born as early as 23 wks completed gestation and weighing as little as 450gms (1lb). Stressed/Sick newborns Labor & delivery complications (meconium( fluid, vacuum & forceps asssited births, Cesarean sections) Infants born with infections, retained fluid in the lungs, congenital defects (among other causes). Infants born to sick / at-risk mothers Chronic or new maternal illness (anemia, diabetes, high blood pressure) obesity, drug users, teenagers single mothers / below the poverty level (among other high risk indicators).

6 Increased need for neonatal providers Increasing preterm birth rates Higher maternal risk profiles over time Higher pre-existing existing morbidities Higher numbers >35yrs giving birth Persistent racial/ethnic, socioeconomic status, & access to care disparities in rural Hawaii create higher risks for newborns Percent of life births Percent Per Preterm Birth Rates Hawaii County Honolulu County 2002 Hawaii's versus National Maternal Rates of Anemia and Diabetes Preterm Birth Rates Compared HI 92 HI 02 PR 93 PR 03 USA 93 USA 03 0 Hawaii Anemia US Anemia Hawaii Diabetes US Diabetes

7 Dwindling rural OBGyn and pediatric providers in Hawaii 11 Comparison of Physicians per Capita 11 4 Per 1,000 people Nation Hawaii State Hawaii & Maui Dropped by 9% Hawaii % of OB/GYNs plan to quit - 29% plan to stop delivering babies in next 5 years. On neighbor islands 67% OB/GYNs plan to quit by Access to community-based pediatric subspecialty care on neighbor islands and in rural Oahu is a problem.

8 Hawaii is challenged (?Puerto Rico) as no ground transport to regional center (level 2 & 3) from most level 1 centers yet must deliver higher risk late preterm infants. Regionalized perinatal care model evolved to make newer and better services available to all patients regardless of their locale... Patients still need the best care as close to their homes as possible. 7 Original intent of the model was to improve access to quality and appropriate level of care. 7

9 Increase in late preterm births 2 obstetricians are seldom aggressive in prolonging pregnancies at 35 to 36 weeks gestation 4 & estimated distribution of gestational ages wks 28-31wks 32-36wks 80 Nearly 2/3 of national increase in preterm birth can be attributed to week age group week infants have a 6 fold increased risk of death in the first week of life and increased risk of death in first year of life 6

10 What are Neonatal Nurse Practitioners? Advanced Practice Registered Nurses with post-graduate preparation (master s s degree) who: Diagnose and treat in collaboration with neonatologists and other pediatric physicians. Function independently and interdependently. Select and perform clinically indicated advanced diagnostic and therapeutic invasive procedures. Often function as case managers and can provide primary care in the first two years of life. Provide continuity of care, and efficient, cost-effective quality care. 8

11 NNPs at a developing level 2 rural birthing center in Hawaii Provide competent, cost-effective medical management in-house for critically ill neonates and toddlers up to two years of age. Lead infant & toddler resuscitation and transport teams (high risk delivery attendance, nursery, emergency room, during transport requiring a provider). Provide care for back-transported infants and toddlers (from NICU and PICU / level 3 centers). Be utilized in follow-up clinics, specialty clinics (developmental, newborn screening, hearing, etc), case management, home care consultants of medically fragile and vulnerable infants and toddlers. Lead education endeavors (first responders, nurses, advanced practice nurses, physician assistants, physicians, and many other allied health care team members). Lead clinical research endeavors

12 Process and challenges Grass roots process brought on by crisis secondary to neonatal provider shortage and grounded transport planes pending investigation of two recent fatal crashes. Certificate of Need application to the State of Hawaii to designate / license for a 3 rd neonatal level 2 unit in State. Getting Hawaii Island community consensus on where the level 2 should be located. Getting ancillary departments and nursing to buy into forever doing more with no added resources. Resources and time needed for training.

13 Use of NNPs to address some health disparities in rural areas Hawaii is similar to many rural communities in the US that lack adequate providers, facilities and services to meet the needs of growing communities that house ever more infants and children needing specialized services. Photo Courtesy of:

14 Other Acknowledgements Mary E. Lynch, RN, MS, MPH, PNP Clinical Professor & Director of Advanced Practice Pediatric and Neonatal Nursing. Dept. of Family Health Care Nursing, University of California at San Francisco (UCSF) Numerous publications & presentations Lynch, ME (1995) Expanding the care giving environment for advanced practice neonatal nurses. Journal of Perinatal and Neonatal Nursing, 9(3), Sneha Sood, MD, Neonatologist Assistant Professor, John A. Burns School of Medicine, University y of Hawaii 2005 Recipient of University of Hawaii at Hilo Distinguished Alumni Award Senior Lectureer in neonatology at Middlemore Hospital and National Women's Hospital, University of Aukland,, NZ Numerous publications & presentations on effects of surfactants for acute respiratory distress syndrome and use of CPAP for their management

15 Questions? Land area: 6,423 sq mi ( 16,637 sq km) Population (2005 est.): 1,275,194 growth rate:1% birth rate: 14.5/1000; infant mortality rate: 6.95/1000 life expectancy 77-79: ; density per sq mi: 190 Land area: 3,459 sq mi (8,959 sq km) Population (2007 est.): 3,944,259 growth rate: 0.4% birth rate: 12.8/1000; infant mortality rate: 7.8/1000 life expectancy: 78.5; density per sq mi: 1,140

16 Muchas Gracias Photo Courtesy of: neonatology.mc.duke.edu

17 References 1. American Academy of Pediatrics and American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care. 5th ed Martin, J.A., et al., Births: final data for Natl Vital Stat Rep, (2): p Raju, T.N., The problem of late-preterm (near-term) births: a workshop summary. Pediatr Res, (6): p Ananth, C.V., AM, Maternal-fetal conditions necessitating a medical intervention resulting in preterm birth. Americal Journal of Obstetrics and Gynecology, : p Fuchs, K. and R. Wapner, Elective cesarean section and induction and their impact on late preterm births. Clin Perinatol, (4): p ; abstract viii. 6. Tomashek, K.M., Differences in Mortality Between Late-Preterm and Term Singleton Infants in the United States, Pediatrics, (5). 7. Hein, Herman. (2004). Regionalized Perinatal Care in North America. Seminars in Neonatology. 8. National Association of Neonatal Nurse Practitioners, 1996 & March of Dimes Perinatal Data Center. Accessed 11/28/ Lumley, J., The epidemiology of preterm birth. Baillieres Clin Obstet Gynaecol, (3): p Family Health Services Division Department of Health State of Hawaii, Maternal and Child Health Needs Assessment.. July 2005.

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