Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 2076-2083 (doi:10.1542/peds.2006-1540)
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ARTICLE

Improved Outcomes of Extremely Premature Outborn Infants: Effects of Strategic Changes in Perinatal and Retrieval Services

Kei Lui, MBBS, FRACP, MDa,b, Mohamed E. Abdel-Latif, MBBS, MRCPCH, MPH, MScEpia,b, Catherine L. Allgood, MBBS, MRCPCHa,c, Barbara Bajuk, MPHd, Julee Oei, MBBS, FRACPa,b, Andrew Berry, MBBS, FRACPc, David Henderson-Smart, MBBS, FRACP, PhDe New South Wales and Australian Capital Territory Neonatal Intensive Care Unit Study Group

a Department of Newborn Care, Royal Hospital for Women, Randwick, Australia
b School of Women's and Children's Health, University of New South Wales, Sydney, Australia
c New South Wales Newborn and Pediatric Emergency Transport Service, Westmead, Australia
d Neonatal Intensive Care Units' Data Collection
e New South Wales Pregnancy and Newborn Services Network, New South Wales Center for Perinatal Health Services Research, University of Sydney, Sydney, Australia

OBJECTIVE. The goal was to evaluate the impact of statewide coordinated changes in perinatal support and retrieval services on the outcomes of extremely premature births occurring outside perinatal centers in the state of New South Wales, Australia.

METHODS. The intervention included additional, network-coordinated, perinatal telephone advice to optimize in utero transfers and centralization of the neonatal retrieval system, with preferential admission of retrieved infants (outborn infants) to perinatal centers instead of freestanding pediatric hospitals, from the middle of 1995. Population birth and NICU admission cohorts of infants of 23 to 28 weeks of gestation were studied. Outcomes of epoch 1 (1992 to the middle of 1995; 1778 births and 1100 NICU admissions) were compared with those of epoch 2 (1997–2002; 3099 births and 2100 NICU admissions), after an 18-month washout period.

RESULTS. There were 25% fewer nontertiary hospital live births (19.7% vs 14.9%) and more prenatal steroid use. Despite an 11.4% average annual increase in NICU admissions between the 2 epochs, fewer infants were outborn (12.0% vs 9.3%) and outborn mortality rates decreased significantly (39.4% vs 25.1%), particularly for those between 27 and 28 weeks of gestation. The overall improvement was equivalent to 1 extra survivor per 16 New South Wales births. There were also significantly fewer serious outcome morbidities in outborn infants during epoch 2, over the improvements in inborn infants.

CONCLUSIONS. Statewide coordinated strategies in reducing nontertiary hospital births and optimizing transport of outborn infants to perinatal centers have improved considerably the outcomes of extremely premature infants. These findings have vital implications for health outcomes and resource planning.

Key Words: premature infant • outcome • perinatal services • neonatal retrieval • perinatal mortality

Abbreviations: OR—odds ratio • CI—confidence interval • NSW—New South Wales • PSN—Pregnancy and Newborn Services Network • PAL—Perinatal Advice Line • ACT—Australian Capital Territory • NICUS—Neonatal Intensive Care Units' • NETS—Newborn and Pediatric Emergency Transport Service

Accepted Jul 27, 2006.


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