Variations in practice and outcomes in the Canadian NICU network: 1996-1997

Background. Previous reports of variations in outcomes among neonatal inten sive care units (NICUs) examined only specific subpopulations of interest ( eg, very low birth weight [VLBW] infants <1500 g of birth weight [BW]). Objectives. We report on current practice and outcomes variations in a popu lation-based national study of Canadian NICUs from January 8, 1996 to Octob er 31, 1997. Method. Information on 20 488 admissions to 17 tertiary level NICUs across Canada was prospectively collected by trained abstractors using a standard manual of operations and definitions. Data were verified and analyzed in co ncert with a steering committee comprising experienced researchers and neon atologists. Patient information included demographic information, antenatal history, mode of delivery, problems at delivery, status of infant and prob lems at birth, illness severity (Clinical Risk Index for Babies, Score for Neonatal Acute Physiology, Score for Neonatal Acute Physiology-Version II), therapeutic intensity (Neonatal Therapeutic Intensity Scoring System [NTIS S]), selected NICU practices and procedures, use of technology and resource s, and selected patient outcomes. Patients were hacked until death or disch arge home. Results. The mean number of annual admissions to an NICU was 657, with 26% outborn infants. Fifty-three percent were <2500 g BW, 20% were <1500 g BW ( VLBW), and 65% were preterm (<38 weeks' gestational age [GA]). Only 2% of m others received no prenatal care. Antenatal steroids were given to 58%, but there was wide variation in use (23%-76%). Congenital anomalies were prese nt in 14%, and 4% were small for GA (less than the third percentile). Admis sion illness severity was lowest among infants 33 to 37 weeks of GA and cor related with risk of death. Ninety-six percent of patients survived until d ischarge, but fewer survived at lower GA. No infant <22 weeks' GA survived. Seven percent of infants had at least 1 episode of infection, but 75% rece ived antibiotics in the NICU. Forty-three percent received respiratory supp ort, and 14% received surfactant. Nitric oxide was given to 150 term infant s and to 102 preterm infants. Selected outcomes of VLBW infants were: survi val rate (87%); chronic lung disease (26%); <greater than or equal to>stage 3 retinopathy of prematurity (ROP; 11%); greater than or equal to grade 3 intraventricular hemorrhage (IVH; 10%); nosocomial infection (22%); necroti zing enterocolitis (NEC; 7%). Sixty-nine percent of VLBW infants survived w ithout major morbidity (greater than or equal to grade 3 IVH, chronic lung disease, NEC, greater than or equal to grade 3 ROP). The mean duration of N ICU stay was 19 days. Forty-seven percent of infants were discharged from t he hospital, and 43% were retrotransferred to a community facility before d ischarge home. Significant variation in practices and outcomes were observe d in all aspects of NICU care. Conclusion. This study provides population-based information about NICU out comes. Significant variation in NICU practices and outcomes was observed de spite Canada's universal health insurance system. This national database pr ovides valuable information for planning research, allocating resources, de signing health and public policy, and serving as a basis for longitudinal s tudies of NICU care in Canada.