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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 13-17

Estimating the neonatal length of stay for preterm babies in a saudi tertiary hospital


Department of Neonatology, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Submission23-Oct-2019
Date of Decision04-Dec-2019
Date of Acceptance26-Dec-2019
Date of Web Publication29-Jan-2020

Correspondence Address:
Dr. Abdulrahman Al-Matary
Department of Neonatology, King Fahad Medical City, P.O. Box: 59046, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_115_19

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  Abstract 


Introduction: The most frequent cause of morbidity and mortality in neonatal care units worldwide is prematurity. It represents the second leading cause of neonatal death after congenital anomalies and a significant determinant of newborn and infant morbidity. Objective: The objective is to have a local estimate of the length of stay (LOS) and risk of death for babies admitted to neonatal intensive care units, which facilitate planning and family counseling. Materials and Methods: This study is a retrospective review for all babies born at 23–36 weeks of gestational age (GA) and admitted to the neonatal unit from January 2010 to April 2019. We calculated the actual median LOS for babies and compared them with days to due date based on the GA and birth weight (BW). Results: There were 2913 babies born at 23–36 weeks GA admitted to the neonatal unit. In addition, the majority of babies (2845) did not require surgical intervention; only 61 babies did require surgical intervention. There was a negative correlation between the LOS median (interquartile range) and each of the GA or BW of the babies (LOS decreased as the week of GA and BW increased), while GA had a positive association with the BW. The total number of babies discharge from neonatal care was 2605 (89.7%). Conclusion: BW and GA are inherent factors that allow for a simple and objective prediction of the LOS in the neonatal unit, which can estimate on the 1st day of life.

Keywords: Length of stay, low birth weight, preterm


How to cite this article:
AlJohani E, Qaraqei M, Al-Matary A. Estimating the neonatal length of stay for preterm babies in a saudi tertiary hospital. J Clin Neonatol 2020;9:13-7

How to cite this URL:
AlJohani E, Qaraqei M, Al-Matary A. Estimating the neonatal length of stay for preterm babies in a saudi tertiary hospital. J Clin Neonatol [serial online] 2020 [cited 2020 Jul 14];9:13-7. Available from: http://www.jcnonweb.com/text.asp?2020/9/1/13/277223




  Introduction Top


Babies born very preterm, described as <32 weeks' gestational age (GA), and others requiring in-patient neonatal care usually need admission to a neonatal unit following their birth.[1] Around one in eight babies are admitted to neonatal care, and almost all babies born <32 weeks GA who survive the initial period after birth receive care in a neonatal unit.[2]

The length of stay (LOS) of babies admitted to a neonatal unit can vary dramatically. Babies born at term, near their due date, form a heterogeneous group in terms of their care needs.[3] Some may need a small amount of time in the neonatal unit, such as a few hours of monitoring. Others may have a more prolonged period of hospitalization, like those that require cardiac surgery for a heart defect. Babies born very preterm, often require mechanical ventilation and their stay prolonged due to prematurity and other underlying diseases. These babies often need weeks to several months of specialist neonatal care.[4]

The ability to predict the LOS in neonatal care has become increasingly crucial as survival improvements have resulted in more premature babies requiring long hospitalization periods. LOS estimates are needed to facilitate conversations between parents and clinicians about the expected LOS of a baby.[5]

There is often little warning and little time to prepare the parents with a very premature baby. Where admission to a neonatal unit follows the birth, their initial concerns typically focus on the baby's chances of survival and the risk of long-term neurodevelopmental outcome. Once after the early stabilization phase, however, they often want to know how long their baby.[6]

Historically, most pediatricians and neonatal nurses have told preterm infant parents that the baby is likely to go home around the time the baby is born, the estimated delivery date (EDD). Although there is considerable evidence that the length of hospital stay has gradually shortened over recent years for many moderately preterm infants.[7],[8]

In 2011, they found in a survey of neonatal units in the UK that most staff still used the EDD as the expected date of discharge.[9]

Several new types of research have reported complex models using detailed information on infant condition and pathophysiology that allows estimating the likely duration of preterm infants' stay, and hence the date of discharge.[5],[10],[11]


  Materials and Methods Top


This study is a retrospective review for all babies born at 23–36 weeks GA and admitted to the neonatal unit in King Fahad Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia started from January 2010 to April 2019. Data extracted from our database, a population-based information source for admissions to neonatal care in KFMC, created from information submitted to an electronic patient recording system.

Babies excluded if have discharge home before 34 weeks' GA as it was not until this point that the majority of babies acquire the ability to feed orally well and maintain the temperature in a cot. Moreover, babies who stayed in the neonatal unit longer than 180 days have discharged on home care also excluded babies with significant congenital anomalies and unusual hospital courses. Finally, babies transferred to another facility excluded.

We calculated the actual median LOS for babies and compared them with days to due date based on the GA and birth weight (BW).

Statistical methodology

Data were statistically described in terms of mean ± SD for continuous data and in frequencies (number of cases). For comparative purposes between groups in all continuous data, an independent t-test or Mann Whitney t-test was adopted. X2-square and Fisher tests were used for assessing association in categorical data. P values less than 0.05 were considered statistically significant. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 21 for Microsoft Windows.

Data analysis

Data collected and then converted to SPSS program version 24, and data were analyzed as follows: completed weeks of GA after birth calculated because it is important parameter for mortality[7] and LOS; we calculate time-dependent effects to allow for differences in the risk of death or discharge between the weeks of GA over time. Further methodological details for competing for risk approaches, including their application in the estimation of neonatal LOS, can be found elsewhere.[5],[11] The percentage of babies, by GA, dying or surviving to discharge from neonatal care was estimated over time and displayed graphically. Estimates of median LOS calculated from the data.


  Results Top


There were 2913 babies born at 23–36 weeks GA discharged from neonatal care between 2010 and 2019. The majority of babies admitted to neonatal care had GA between 34 and 36 weeks. 54.8% of included babies were male, 43.9% were female, and 1.3% were unknown gender. Approximately two-thirds (62.2%) of babies did not need intubation, while one-third (37.1%) needed it. The majority of babies (2845) did not require surgical intervention; only 61 babies required surgical intervention. The mean BW of babies was 1875 ± 670.2, and the median was 1840 (236–5540). The mean LOS was 28.37 ± 31.81, and the median was 14.5 (1–178). The mean corrected GA was 38.89 ± 3.7, and the median was 38 (29–52) [Table 1].
Table 1: Summary statistics of the babies who were admitted to the neonatal care at birth from 23 to 36 weeks from 2010 to 2019

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[Table 2] indicates that the mean LOS was significantly higher with lower GA. There is an inverse association between LOS and the GA. The most immature babies born at 23 and 24 weeks of gestation had a LOS for over threefold as long as those born at 30–31 weeks. Babies with 35–36 weeks of pregnancy had the least LOS (10.4831 ± 12.31988–9.5888 ± 13.41456) in the neonatal care unit.
Table 2: Mean length of stay according to gestational age

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[Table 3] indicates that 294 babies died before discharge. Of 2905 babies in the present review, 2605 (89.7%) were discharged from neonatal care, while 0.2% of the babies discharged against medical advice represented in six babies.
Table 3: Discharge rate of the babies who were admitted to the neonatal care at birth from 23 to 36 weeks

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[Table 4] indicates that there was a negative correlation between the LOS median (interquartile range) and the GA or the BW of the babies (LOS decreased as the week of GA and BW increased), while GA had a positive correlation with BW [Figure 1] and [Figure 2]. In addition, the smallest babies at 570–700 g BW had more than 100 days LOS in the neonatal care unit, while babies >2000 g BW had the least LOS around 7 days. Survived to discharge babies from 23 to 24 weeks had a median LOS of 122 and 119 days, respectively, which is slightly longer than the time remaining until their EDD (discharge at 40.2 and 41 weeks corrected age, respectively). Babies born at 27–30 weeks had almost similar median LOS to the time remaining to their due date. Babies born at 34–36 weeks had a slightly shorter median LOS than the time remaining to their due date.
Table 4: Median and interquartile range according to gestational age

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Figure 1: Scatter diagram showed a negative correlation between gestational age and length of stay, R =-0.76, P <0.001. The length of stay was significantly higher with lower gestational age. There is an inverse association between length of stay and gestational age

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Figure 2: Scatter diagram showed a negative correlation between birth weight and length of stay r = -0.664, P <0.001. The length of stay was significantly higher with lower birth weight. There is an inverse association between length of stay and birth weight

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  Discussion Top


Preterm babies require care in specialized neonatal units before they can discharge home. Their LOS in hospital is influenced primarily by their GA at birth and medical conditions leading to more extended stays.[12],[13]

Low BW or BW of below 2500 g is one of the main determinants of neonatal and postnatal morbidity. Low BW neonates are sub-grouped according to the first weight determination after birth: low BW between 1500 and 2499 g, very low BW <1500 g, and extremely was <1000 g.[14]

According to the WHO statistics, the rate of low BW is 17% in the whole world.[15] Over the past two decades, low BW rate has increased primarily because of an increase in preterm births.[16] Low BW and prematurity are the second leading causes of infant mortality after congenital anomalies but contribute disproportionately to the infant death rates in the 1st year after birth.[17]

The present study included 2913 babies born at 23–36 weeks of GA discharged from neonatal care between 2010 and 2019, the mean BW of babies was 1875 ± 670.2, and the median was 1840 (236–5540). The LOS was significantly higher with lower BW. There is an inverse association between LOS and BW.

Our findings are similar to previous data from 30 neonatal units in the UK, in which a range of descriptive variables was inspected to identify those which had the most consistent influence on the LOS, which was unsurprisingly GA and BW.[7]

The ability to predict the LOS in neonatal care units is essential as the very preterm babies who had smaller GA require more extended care. Our results found that babies born at 23 and 24 weeks who survived to discharge had a median LOS of 122 and 119 days, respectively, which is slightly longer than the time remaining until their EDD, while babies born at 34–36 weeks had a somewhat shorter median LOS.

A study from the United Kingdom (UK) showed that the time for discharge decreased as the week of GA increased, and babies discharge before their due date. Survived babies born at 24 weeks who went home had a median LOS of 123 days, which is slightly longer than the time remaining until their EDD (discharge at 41.6 weeks corrected age). Babies born at 26–28 weeks had a somewhat shorter median LOS than the time remaining to their due date. Babies born at 30 and 31 weeks, however, were discharged home sooner, with a median LOS about 30 days less than their due date.[11]

In our sample, 89.7% of preterm babies survived and discharged to home; the mortality rate was 10.1% compared to 8.3% in the UK study.[11] This difference can be explained by the fact that most of our deliveries to un-booked mothers and did not receive antenatal steroids. It reported that neonatal survival varies with the quality of medical care. The leading cause of death was prematurity and congenital anomalies in babies.[18] About two-thirds of all newborn deaths occur in the neonatal period caused by congenital disabilities, maternal health conditions, low BW, and insufficient access to appropriate care during delivery.[19]

This research has provided estimates of the median LOS for babies. This study can be used in clinical practice to aid the counseling of parents regarding the LOS. One potential limitation of this study is data from a single center; therefore, the composition of the population, departmental protocols, resources, and staffing characteristics are possible limiting to the generalizability of our results.


  Conclusion Top


Birth weight and GA are inherent factors that allow for a simple and objective prediction of the LOS in the neonatal unit, which can be calculated on the 1st day of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
National Neonatal Audit Programme. Annual Report on 2016 data. 2017. Availabe from: https://www.rcpch.ac.uk/sites/default/files/2018-10/nnap_national_annual_report_2017.pdf. [Last accessed on 2018 Apr 24].  Back to cited text no. 1
    
2.
Lawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, et al. Born too soon: Care for the preterm baby. Reprod Health 2013;10 Suppl 1:S5.  Back to cited text no. 2
    
3.
Lee HC, Bennett MV, Schulman J, Gould JB, Profit J. Estimating length of stay by patient type in the neonatal intensive care unit. Am J Perinatol 2016;33:751-7.  Back to cited text no. 3
    
4.
Hinchliffe SR, Seaton SE, Lambert PC, Draper ES, Field DJ, Manktelow BN. Modelling time to death or discharge in neonatal care: An application of competing risks. Paediatr Perinat Epidemiol 2013;27:426-33.  Back to cited text no. 4
    
5.
Altman M, Vanpée M, Cnattingius S, Norman M. Moderately preterm infants and determinants of length of hospital stay. Arch Dis Child Fetal Neonatal Ed 2009;94:F414-8.  Back to cited text no. 5
    
6.
Maier RF, Blondel B, Piedvache A, Misselwitz B, Petrou S, Van Reempts P, et al. Duration and time trends in hospital stay for very preterm infants differ across European regions. Pediatr Crit Care Med 2018;19:1153-61.  Back to cited text no. 6
    
7.
Manktelow B, Draper ES, Field C, Field D. Estimates of length of neonatal stay for very premature babies in the UK. Arch Dis Child Fetal Neonatal Ed 2010;95:F288-92.  Back to cited text no. 7
    
8.
Bender GJ, Koestler D, Ombao H, McCourt M, Alskinis B, Rubin LP, et al. Neonatal intensive care unit: Predictive models for length of stay. J Perinatol 2013;33:147-53.  Back to cited text no. 8
    
9.
Fleming PJ, Ingram J, Johnson D, Blair PS. Estimating discharge dates using routinely collected data: Improving the preparedness of parents of preterm infants for discharge home. Arch Dis Child Fetal Neonatal Ed 2017;102:F170-2.  Back to cited text no. 9
    
10.
Lee HC, Bennett MV, Schulman J, Gould JB. Accounting for variation in length of NICU stay for extremely low birth weight infants. J Perinatol 2013;33:872-6.  Back to cited text no. 10
    
11.
Seaton SE, Barker L, Draper ES, Abrams KR, Modi N, Manktelow BN, et al. Estimating neonatal length of stay for babies born very preterm. Arch Dis Child Fetal Neonatal Ed 2019;104:F182-6.  Back to cited text no. 11
    
12.
Seaton SE, Barker L, Jenkins D, Draper ES, Abrams KR, Manktelow BN. What factors predict length of stay in a neonatal unit: A systematic review. BMJ Open 2016;6:e010466.  Back to cited text no. 12
    
13.
Numerato D, n preterm infants: A EuroHOPE Study. PLoS One 2015;10:e0131685.  Back to cited text no. 13
    
14.
Islami Z, Fallah R, Mosavian T, Pahlavanzadeh MR. Growth parameters of NICU admitted low birth weight preterm neonates at corrected ages of 6 and 12 month. Iran J Reprod Med 2012;10:459-64.  Back to cited text no. 14
    
15.
Bellamy C. The state of the world's children, 2000. In: Progress since the World Summit for Children: A Statistical Review. New York: United Nations Children's Fund; 2001.  Back to cited text no. 15
    
16.
Stoll BJ, Adams-Chapman I. The high-risk infant. In: Behrman RE, Kliegman RM, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders; 2007. p. 698-711.  Back to cited text no. 16
    
17.
Hamilton BE, Miniño AM, Martin JA, Kochanek KD, Strobino DM, Guyer B. Annual summary of vital statistics: 2005. Pediatrics 2007;119:345-60.  Back to cited text no. 17
    
18.
Stahlman MR. Newborn intensive care: Success or failure? Obstet Gynecol Survey 1985;40:83-5.  Back to cited text no. 18
    
19.
Hack M, Wright LL, Shankaran S, Tyson JE, Horbar JD, Bauer CR, et al. Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Network, November 1989 to October 1990. Am J Obstet Gynecol 1995;172:457-64.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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