Neonatology

The BIDMC Department of Neonatology is responsible for all clinical and academic activity related to BIDMC newborns. It includes 23 academic physicians (14 practicing neonatologists, seven general pediatricians, two senior physician-scientists) and 12 masters-prepared nurse practitioners (NPs). The clinical service is further supported by more than 300 Boston Children’s Hospital (BCH) medical and surgical sub-specialists.

CLINICAL

More than 5000 babies are born annually at BIDMC. Each year, the Neonatology faculty provide care to more than 800 patients in the BIDMC Klarman Family Neonatal Intensive Care Unit (NICU) and 3500 newborns in the Mother-Baby Unit. Department physicians are also responsible for neonatal care in the Level IB continuing care nursery at Beth Israel Deaconess-Plymouth Hospital. In addition to these responsibilities, faculty provide clinical support to Boston Medical Center and other neonatal units in the BIDMC and BCH community hospital networks.

The BIDMC NICU is a 48-bed unit with Level III, Level II, and triage beds. A full range of neonatal intensive care services- including high frequency ventilation, nitric oxide therapy, and therapeutic hypothermia are provided. An attending neonatologist and two neonatal nurse practitioners (NPs) are always on-site. During day time coverage, two attending neonatologists, a Harvard neonatal-perinatal fellow, two NPs, and a neonatal hospitalist care for NICU patients, cover high risk deliveries, and provide consultation to newborns in the Mother-Baby and Labor and Delivery units. Other departments with dedicated personnel in the NICU are respiratory therapy, nutrition, pharmacy, social work, occupational/physical therapy, and case management.

In addition to serving inborn patients, the BIDMC NICU provides care for patients transferred from its community hospital affiliates, including Anna Jaques, Beth Israel Deaconess-Plymouth, Cambridge, and Mount Auburn hospitals. These transports are coordinated through the BCH Transport Team with the BIDMC attending physician serving as medical control. BIDMC inborn neonatal patients with major surgical and cardiac diagnoses are transferred to BCH for care. Additionally, in concordance with the Massachusetts system of regionalized perinatal care, BIDMC maintains active relationships with community hospitals to facilitate infant transfer from the NICU to level II and level IB in hospitals in their local communities.

The Quality Improvement (QI) Program of the Department of Neonatology supports clinicians and providers in their pursuit of delivering the safest and highest quality care to BIDMC newborns and their families. The program is organized around three major platforms, described below:

1. Patient safety: Errors, adverse events, and other notable clinical cases are identified through a variety of reporting systems and automated queries, and are reviewed by department leadership, with selected events brought to a monthly multidisciplinary departmental morbidity and mortality conference. Cause-mapping is utilized to conduct structured root cause analysis of events when needed.

2. Quality assurance: A robust, balanced dashboard provides a regularly updated summary of a range of quality and safety metrics, reviewed monthly at department leadership meetings. The dashboard includes externally reported metrics requested by groups such as the Massachusetts Department of Public Health and the Joint Commission, and internal metrics that reflect the priorities of the department, including detailed satisfaction ratings from family surveys; the measures on the dashboard are updated annually. In addition, the department supports a culture of ‘everyday readiness’, and seeks to continually achieve and exceed standards for national patient safety goals set by the Joint Commission and other organizations.

3. Quality improvement: The department aggressively seeks opportunities to improve care, and supports a number of ongoing improvement initiatives each year. Multidisciplinary staff involvement is essential to these efforts, and many initiatives are done in collaboration with other NICUs in the state or across the country. The department is committed to a rigorous, structured approach to QI, including the use of appropriate outcome, process, and balancing measures, and the use of statistical process control methods for data tracking and data analysis.

The QI program functions within the Department’s administrative structure. The primary management of the QI program lies with the NICU Leadership Committee (NLC) and the Mother-Baby Leadership Committee (MBLC), multi-disciplinary committees co-chaired by the Neonatologist-In-Chief that provide oversight to clinical activities in the NICU and mother-baby unit respectively. Additional departmental activities that support the QI program include a monthly morbidity and mortality conference, chaired by the department Quality Improvement Director, and daily improvement systems in both the NICU and the Mother-Baby Unit, which are visually-based idea systems supported by electronic databases that facilitate real-time review and monitor implementation of improvement opportunities identified by clinical staff.

The NICU Family Advisory Council is a multi-disciplinary group- composed of NICU graduate families, clinical staff, and both unit and executive leadership- whose primary purpose is to improve the experience of NICU families. Established in 2005, the NICU Family Advisory Board was the first family-focused advisory council at BIDMC. Family satisfaction data and quality improvement initiatives are reviewed at quarterly meetings. The presence of parents on rounds and the incorporation of family members as active members of NICU standing committees are examples of operational and structural changes that were faciliatated through the Council. Several family-focused NICU renovations have been funded by grateful families and the Department of Neonatology. The NICU Family Program has an affiliation with the March of Dimes, which provides access to rigorous staff training in family-centered skills, as well as robust tools and translated family materials.

LEADERSHIP

BIDMC faculty serve as national leaders in several clinical, educational, and research organizations. These efforts reflect the prominent standing of the Department of Neonatology, but more importantly its role in innovation in newborn medicine. The Neonatologist-in-chief is a past chair of the American Academy of Pediatrics Section on Perinatal Pediatrics- an organization of more than 3500 neonatologists- whose major responsibilities include advocacy for and education concerning North American newborns and neonatal care. The current chair-elect of the Section is the BIDMC Neonatology Associate Chief. Other positions currently and recently held by BIDMC faculty are chair-elect of the American Board of Pediatrics Neonatal-Perinatal Medicine Sub-Board; chair of NeoPrep, the AAP-sponsored specialty certification course; editor of NeoReviews, the largest provider of CME for neonatologists; member of the Patient Safety Council of the Vermont-Oxford Network (VON), a quality collaborative of more than 900 NICUs around the world; and coordinator for the VON statewide quality care collaboratives. Finally, the authors of Neonatology Review, the best-selling neonatology board review textbook in the world, are BIDMC neonatologists.

ACADEMIC

The BIDMC Department of Neonatology educates future leaders in Neonatal-Perinatal Medicine, and contributes to discovery of new knowledge in the field through translational investigation in the NICU and perinatal health services research. The Department has achieved substantial visibility in safety, quality, and health services research emphasizing neonatal physiologic illness severity scoring, cost-effectiveness of NICU care, organization of delivery of newborn services, and understanding the consequences of NICU practice variation. Fourteen of the 16 full-time faculty have masters or doctoral level research qualifications.

RESEARCH

Since its inception, the Department of Neonatology has focused its research activities on clinical epidemiology and health services research, systematically recruiting faculty with training and expertise in these areas. The program has pioneered comparative quality assessment in neonatology through its development and use of a key illness severity normalization tool, the Score for Neonatal Acute Physiology (SNAP), to establish inter-institutional variations in care amenable to quality improvement (QI) efforts. This early work has fostered collaboration among all the NICUs in the state and has led to the development of an active, state-wide collaboration in QI, established and co-directed by a BIDMC neonatologist. This collaborative has resulted in reductions in nosocomial infections at a rate faster than national benchmarks. It also led to an extension of linking cost-benefit analyses to randomized trials to assess the impact of interventions that saves lives. One stream of research explores the use of novel analytic approaches (e.g., network analysis) in quality assessment. The Department actively participates in multi-site trials, and has upgraded the organization and infrastructure of its research program to expand this effort. Over recent years faculty (including RO-1 and K-23 funded investigators) have enjoyed a very successful expansion into translational investigation, as well as educational scholarship.

EDUCATION

The Department of Neonatology educational pipeline is robust. The Department sponsors a range of activities from high school and undergraduate experiences through post residency fellowship training and continuing medical education (CME). The Harvard Neonatal-Perinatal Medicine (NPM) fellowship (until recently under the direction of a BIDMC neonatologist) is world-renowned and, in collaboration with Children’s, Massachusetts General, and Brigham and Women’s hospitals, provides training for six fellows per year (total 18 fellows), thus comprising one of the two largest NPM fellowship programs in the country. The vast majority of these trainees remain in academic medicine. Faculty in the Department have achieved Rabkin Fellowship funding; participate actively in the instruction of 1st, 2nd, 3rd and 4th year HMS students and within the HMS Academy; and have authored several chapters and textbooks in Neonatal-Perinatal medicine, including a textbook on the primary care of the premature infant, and the best-selling board review textbook in Neonatology. Department sponsored conferences include weekly Neonatal Epidemiology and Clinical Research and Neonatology Works-in-Progress (NeoWIP) seminars, and a monthly NICU Multi-Disciplinary conference. Neonatal resuscitation instruction is provided for initial and ongoing certification, and for mock code training, by an experienced multi-disciplinary group of certified instructors utilizing a high fidelity neonatal simulator. Department faculty teach Harvard neonatal-perinatal fellows, Boston Children’s Hospital/Boston Medical Center pediatrics residents, BIDMC obstetric and anesthesiology residents, and Harvard Medical School medical students in core curriculum didactic sessions focused on neonatology clinical topics.