Bay area hospitals make room for babies born just a little bit too early

The smallest and most fragile patients in the Tampa Bay area are driving a multimillion-dollar hospital building boom. ¶ Next month, Tampa General Hospital's neonatal intensive care unit begins its move into a waterfront suite the size of a football field. All Children's Hospital dedicated an entire floor in its year-old building in downtown St. Petersburg to these babies. St. Joseph's Children's Hospital in Tampa is building an expansion that will raise the bar even higher on parent-friendly touches.

In the new units, slick amenities share center stage with medical improvements. All Children's private rooms boasted a comfy chair for parents; now Tampa General is adding a chair that reclines flat for sleeping. And St. Joseph's this summer will debut a fold-out double bed.

The hospitals meet their costs and even can make money on neonatal care, whether the babies are covered by private or public insurance. And the service helps to burnish their reputations for pediatric care. But doctors say it's a boom they wish wasn't needed.

"Business is too good," said Dr. Lewis P. Rubin, chief of neonatology at Tampa General Hospital and the University of South Florida. "Despite hopes that prematurity would be less common than it is currently, in fact, it's been increasing."

In 1994, 3,269 bay-area babies arrived prematurely. In 2008, that number had shot to 4,618, outstripping the overall growth in birth rate.

A variety of medical practices and health trends ranging from fertility treatment and maternal drug abuse to imprecisely calculated due dates and surgical schedules — are contributing to the number of babies arriving prematurely. And most of the increase isn't the tiniest babies. Rather, it's infants arriving just early enough — even by a few weeks — to require intensive medical intervention.

This growth in so-called late prematurity has the March of Dimes so concerned, it's working with hospitals in several states, including Florida, to reverse it.

Even if such measures succeed, hospital officials say they'll still have enough high-risk babies to need the beds in these expansions, which all together are costing roughly $100 million.

• • •

The three hospitals, the region's largest centers for neonatal care, say their old facilities were crowded and noisy, not the soothing environments now considered best for babies and parents.

Monitors beep loudly inside St. Joseph's neonatal intensive care unit, echoing beyond the nursing station overlooking a half-dozen open rooms, each packed with six or seven cribs. Space here is so tight that parents aren't allowed in before 11 a.m.

"We were busting at the seams," hospital administrator Michael Aubin said of the unit, designed about 25 years ago and expanding to 64 beds. "It desperately needed to be replaced."

On a recent weekend, "you couldn't sit there for two minutes without every buzzer in the place going off. It was just very stressful," said mother Debbie Heisler of Tampa. "The babies feel that stress, and the parents feel that stress."

Her daughter, Reagan Isabelle, is expected to remain in intensive care until Thanksgiving. Doctors delivered her two months early after Heisler developed preeclampsia, a dangerous condition for both mother and child. Reagan arrived weighing 1 pound, 15 ounces.

Even in the cramped conditions, Heisler is pleased with the care at St. Joseph's. But she says it would be hard for a parent — especially one who knows her baby will likely need a NICU stay — to resist picking one with more amenities.

Hospitals say some improvements are medically important, too — private rooms, for example, offer privacy, but also help to control the spread of infections.

Both Tampa General's and St. Joseph's new units feature lights that dim and rubber floors that absorb sound. Tampa General has a new monitoring system that sends an alarm directly to a nurse, rather than sounding a bell everyone can hear in its expansive, 82-bed unit. St. Joseph's plans in-room TVs for parents, but they'll have to use headphones.

The improvements reflect the latest thinking that fragile babies thrive better in womb-like quiet, a theory that sounds good but that researchers still are assessing to see how much difference it makes.

"This is right on the cusp between evidence-based and faith-based," said Rubin at Tampa General, which through its USF affiliation is studying how environment affects babies' stress levels.

• • •

Collectively, 72 additional neonatal beds are rising at All Children's, Tampa General and St. Joseph's — the equivalent of adding a large, new NICU.

Why do so many more babies need intensive care?

It's not because medicine is saving babies at ever younger ages. The survival threshold has held steady for about a decade.

"The quality has improved but there's an envelope there, there's a line somewhere around 23 weeks (gestational age) that hasn't gone down," said Dr. Roberto Sosa, head of neonatology at All Children's 97-bed NICU.

Overall, the bay area's premature births are up by 41 percent since 1994. But by next year, when the St. Joseph's project opens, NICU beds in the area will have increased by 62 percent.

Hospitals can't just expand at will; they must follow a state-regulated process to demonstrate the need for new services. Experts offer different explanations for the rising demand for neonatal care.

What they agree on is that most of the growth in prematurity comes in the late preterm category, not the smallest babies.

"Our growth is really all in the large, late preterm, which is the 34- to 37-week gestation kid," said Dr. John Curran, a USF pediatrics professor and neonatologist who is working with state health officials and the March of Dimes on the problem.

Critical lung and brain development occurs in the final weeks of pregnancy, so even slightly premature newborns can need high-tech help — even if only briefly, doctors say.

"These are kids who do not stay nearly as long as the very premature babies, but there are a lot more of them," said Rubin at Tampa General.

What else is going on? Some say fertility treatments, such as in vitro fertilization, have contributed to an increase in twins and triplets, who often arrive early.

The obesity epidemic means more pregnant women face high blood pressure and diabetes, which can create complications that mean an early delivery.

But medical practices also are playing a role, experts say. Rather than waiting for a woman to go into labor, sometimes elective C-sections are performed. Or when a due date has come and gone, some doctors will chemically induce labor.

The trouble is that calculating due dates is an inexact science, and relying on a calendar can lead to delivering a baby too soon.

"It's very common to think you are delivering a baby that's one week before due date with a C-section, and it could be three or four weeks early," said Dr. Mary Newport, medical director of the neonatal intensive care unit at Spring Hill Regional Hospital. "They end up coming in the NICU with premature lungs. Some of them can be quite sick."

Dr. Cathy Lynch, interim chair of obstetrics and gynecology at USF, says another factor is maternal expectation.

"It seems today the common thought is, 'Well, if I don't have my baby a week before my due date, my doctor is going to help me get it out,'" said Lynch.

But often medical necessity — and caution — lead to prematurity, she said.

"When you compound that she's got this risk factor and that risk factor — and she's overweight, and she was IVF — then suddenly the recommendation might be to deliver her early," she said. "There might be a risk of complication by letting her go to term."

The profession is trying to deal with the issue. For instance, doctors at USF in the past year have implemented a new standard, recommended by Tampa General, that physicians can't schedule deliveries prior to 39 weeks without approval by a monitoring obstetrician.

But even if efforts to reduce later prematurity succeed, hospital leaders say they will not have built too many NICU beds. Some babies are transported in from outside the area for advanced care, said All Children's Sosa. Along with preemies, they also treat babies with congenital health issues, often requiring surgery.

And hospitals, especially Spring Hill Regional, say they are seeing more newborns in drug withdrawal after their mothers became addicted to powerful, narcotic painkillers.

• • •

The NICU building boom at the three hospitals each is costing between $30 million and $40 million, although it's hard to price precisely because St. Joseph's and All Children's incorporated the units into larger construction projects.

The economics of running them are similarly complicated, hinging on how long a sick baby stays in intensive care and whether the child is covered by private or public insurance. But hospital officials say it can be a lucrative practice.

"Historically, it's contributed to a margin," said Bill Horton, senior vice president of strategic business services at All Children's. "But with the economy and with our larger draw of the sicker babies — and therefore higher cost associated with caring for those — it really depends upon the time period that you look at."

And the expansions may not be over. Spring Hill Regional is discussing plans to double the size of its 10-bed neonatal unit.

Experts say the trouble with building so much capacity for more newborns is that hospitals tend to fill these beds, sometimes with infants that don't really need to be there. Many babies with mild maladies, or who are just slightly early, may be better off closer to the mother's bedside, said Dr. David Goodman, a professor of pediatrics and health policy at the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire.

Goodman, an expert in neo­natal intensive care use, noted that the millions spent on upgrades do nothing to address the underlying causes of prematurity.

"In this country, rather than putting a fence on the top of the cliff," he said, "we put an ambulance on the bottom and provide the very best care when a baby falls off the cliff."

And the need for special care often continues as these babies grow up. Many neonates have lingering problems that bring them back repeatedly.

Neonatal intensive care units are "the front door for lots of the subspecialty services," said Aubin, the administrator for St. Joseph's Children's Hospital. Many kids with health issues "that end up being our chronic children — that we follow for years and years — start out as neonates."

Times researcher Shirl Kennedy contributed to this report. Letitia Stein can be reached at lstein@sptimes.com or (813) 226-3322. For more health news, visit www.tampabay.com/health.

Number of NICU beds in bay area

County1994Current/

expansion*
Hillsborough94183
Pinellas97117
Pasco00
Hernando0 10
Total191310

* Total number of state-approved beds, including those currently under construction

Source: Florida Agency for Health Care Administration

Tampa Bay

preterm births

Babies born very

preterm, less than 32 weeks gestation

1994: 586 babies

(2.15 percent of births)

2008: 780 babies (2.33 percent)

Preterm, 32 through

36 weeks gestation

1994: 2,683 babies (9.85

percent of births)

2008: 3,838 (11.48 percent)

Source: Florida Department of Health records for Hillsborough, Pinellas, Pasco and Hernando counties

Bay area hospitals make room for babies born just a little bit too early 10/22/10 [Last modified: Saturday, October 23, 2010 8:19pm]

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