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POLICY STATEMENT
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children
ABSTRACT. The concept of designations for hospital atively scarce and concentrated in academic medical
facilities that care for newborn infants according to the centers.2
level of complexity of care provided was first proposed During the past 2 decades, the number of neo-
in 1976. Subsequent diversity in the definitions and ap- natologists in the United States has increased and
plication of levels of care has complicated facility-based NICUs have proliferated.2 However, no consistent
evaluation of clinical outcomes, resource allocation and
utilization, and service delivery. We review data support-
relationship seems to exist between neonatal mortal-
ing the need for uniform nationally applicable defini- ity and the number of NICU beds within a service
tions and the clinical basis for a proposed classification area.2 The effect of the availability of highly special-
based on complexity of care. Facilities that provide hos- ized personnel and resources on other neonatal out-
pital care for newborn infants should be classified on the comes is not known. In addition, no standard defi-
basis of functional capabilities, and these facilities nitions exist for the graded levels of complexity of
should be organized within a regionalized system of care that NICUs provide, making it difficult to com-
perinatal care. Pediatrics 2004;114:1341–1347; neonatal in- pare outcomes of care.
tensive care, high-risk infant, regionalization, health pol- Development of uniform definitions of levels of
icy, very low birth weight infant, nurseries, hospital new- care offers at least 4 advantages that may improve
born care services.
the assessment of outcomes for high-risk newborn
infants and provide the basis for policy decisions that
ABBREVIATIONS. NICU, neonatal intensive care unit; TIOP, To- affect allocation of resources. First, standard defini-
ward Improving the Outcome of Pregnancy; TIOP II, Toward Improving tions will permit comparisons for health outcomes,
the Outcome of Pregnancy: The 90s and Beyond; VLBW, very low
birth weight; OR, odds ratio; ECMO, extracorporeal membrane
resource utilization, and costs among institutions.
oxygenation. Second, standardized nomenclature will be informa-
tive to the public, especially high-risk maternity pa-
OBJECTIVES tients who may seek an active role in selecting a
delivery service. Third, uniformity in definitions of
T
he objectives of this statement are to review the
current status of the designation of neonatal levels of care published by a professional organiza-
intensive care units (NICUs) in the United tion will minimize the perceived need for businesses
States and the association of the designated level of that purchase health insurance for their employees to
care of the site with neonatal outcomes and to make develop their own standards.3,4 Finally, uniform def-
recommendations for uniform nationally applicable initions will facilitate the development and imple-
definitions of levels of neonatal intensive care that mentation of consistent standards of service pro-
are based on the capability of facilities to provide vided for each level of care.
increasing complexity of quality care.
Regionalized Neonatal Care
BACKGROUND In 1993, Toward Improving the Outcome of Pregnancy:
The availability of neonatal intensive care has im- The 90s and Beyond5 (TIOP II) reaffirmed the impor-
proved outcomes for high-risk infants including tance of an integrated system of regionalized care.
those born preterm or with serious medical or sur- The designations were changed from levels I, II, and
gical conditions. The concept of regionalized perina- III to basic, specialty, and subspecialty, respectively,
tal care was articulated in the 1976 March of Dimes and the criteria were expanded. These definitions are
report Toward Improving the Outcome of Pregnancy included in the fifth edition of Guidelines for Perinatal
(TIOP).1 The report included criteria that stratified Care.6
maternal and neonatal care into 3 levels of complex- Within the regionalized system, personnel and
ity and recommended referral of high-risk patients to technology at each level should be appropriate for
centers with the personnel and resources needed for patient needs to facilitate optimal outcomes. Level I,
their degree of risk and severity of illness. At the or basic neonatal care, is the minimum requirement
time, resources for the most complex care were rel- for any facility that provides inpatient maternity
care. The institution must have the personnel and
doi:10.1542/peds.2004-1697
equipment to perform neonatal resuscitation, evalu-
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- ate healthy newborn infants and provide postnatal
emy of Pediatrics. care, and stabilize ill newborn infants until transfer
Updated Information & including high resolution figures, can be found at:
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References This article cites 38 articles, 17 of which you can access for free at:
http://pediatrics.aappublications.org/content/114/5/1341#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Current Policy
http://www.aappublications.org/cgi/collection/current_policy
Committee on Fetus & Newborn
http://www.aappublications.org/cgi/collection/committee_on_fetus__
newborn
Fetus/Newborn Infant
http://www.aappublications.org/cgi/collection/fetus:newborn_infant_
sub
Neonatology
http://www.aappublications.org/cgi/collection/neonatology_sub
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