Why are the NICU Levels of Care Essential in Medico-legal Cases?

Care of a newborn baby, especially one requiring NICU services, is increasingly more complicated. Modern NICUs are staffed by trained subspecialist pediatricians called neonatologists, neonatal nurse practitioners, nurses, respiratory therapists, pharmacists, and many others. In addition, Intensive care units where we treat tiny babies need complex and expensive equipment. Examples include ventilators, various monitors, infusion pumps, intravascular catheters, and phototherapy lamps.

Smaller hospitals with limited numbers of births can only afford to invest some money in equipment and human resources if they are not used frequently. In addition, it is challenging for professionals to maintain their skills in low-volume hospitals. 

Given these implications, professional organizations and state authorities decided to develop guidelines regarding the requirements for the hospital NICU to provide a certain level of care to its neonatal patients. 

Below, I will describe guidelines developed by the American Academy of Pediatrics (recently published in 2017). Of note, different states have a unique approach to this subject. Some are very strict and put similar guidelines in the law; others are more relaxed. While reviewing a neonatal case, each reviewer should find the local recommendations and requirements regarding neonatal care in each state. 

Below, I will first describe levels of care guided by AAP publications (source article). After that, I will discuss how a neonatal chart reviewer should approach this issue in his work. 

I want to emphasize here that in all cases where the care for the patient differed from the expected care based on the assigned level of care for the NICU, both the neonatologist and hospital may be found responsible for bad outcomes.

Levels of care in neonatology

Please note that designation of NICU levels of care by AAP and most state agencies is based on available resources (equipment and people) and not on the volume of patients and quality of care provided. These approaches could be and should be improved. 

Level 1 Neonatal Care

Level 1 unit will also be called “well baby nursery.” 

The hospital should be able to provide the following services:

• neonatal resuscitation at every delivery
• postnatal care for stable term newborns
• stabilization and care for babies born at 35-37 weeks of gestation and who are physiologically stable
• stabilization of newborns who are sick or were born before 35 weeks of gestation until transfer to a higher level of care hospital

In most cases, level 1 nurseries will be staffed only by pediatricians or family physicians and neonatal nurse practitioners. It would be unusual to find neonatologists in such hospitals. Ideally, hospitals of this type should have a plan for handling patients who do not meet the criteria for level 1.

Level 2 Neonatal Care

We often use the name “special care nursery”(SCN) or “intermediate care nursery” (ICN) to describe level 2 nurseries.

Level 2 hospitals should be providing the following services:

• care for babies born at 32 weeks of gestation or later and, with a birth weight of 1500gm or more, and who are moderately ill. Their problems should be expected to be resolved relatively quickly. Babies cared for here should not need urgent subspecialty services. 
• care for infants discharged or transferred from intensive care units (level 3 units)
• providing mechanical ventilation or CPAP for up to 24 hrs
• stabilization of critically sick infants or babies born at less than 32 weeks of gestation or with birth weight lesser than 1500 gm until their transfer to a higher level of care

Personnel staffing level 2 units usually consist of various combinations of trained nurses, pediatric hospitalists, neonatologists, and neonatal nurse practitioners. It is unusual to encounter many pediatric subspecialists in such hospitals.

Level 3 Neonatal Care

Level 3 nurseries are often called “neonatal intensive care units” (NICU), (source article).

Level 3 units should be equipped to care for almost every type of patient, with only minor exceptions. These units are expected to have continuously available neonatologists, neonatal nurses, respiratory therapists, pharmacists, and equipment to provide life support for as long as needed. 

Level 3 NICU will have the following capabilities:

• complete care for all neonates, particularly those born before 32 weeks of GA and with birth weight less than 1500 gm. 
• comprehensive care to all infants with critical illness
• access to a full range of pediatric subspecialists, including but not limited to ophthalmologists, anesthesiologists, and pediatric surgeons.
• full range of respiratory support (ECMO and iNO may sometimes not be available)
• advanced imaging studies for neonates, including CT, MRI, ECHO, and their timely interpretation

Personnel staffing level 3 hospitals and nurseries will consist of neonatologists and many other pediatric subspecialists. 

Level 4 Neonatal Care

Level 4 nursery may also be called a “regional neonatal intensive care unit.” They are almost always located within the institution that can provide surgical repair of complex congenital or acquired conditions. In addition to pediatric surgeons, they will have available pediatric surgical subspecialists and pediatric anesthesiologists. 

Regional NICUs will also facilitate neonatal transport for their area, monitor the quality of care, and provide outreach education.

Level 4 regional NICU designation is usually given only to nurseries located in university centers or pediatric hospitals. 

NICU Levels of care and chart review for legal or compliance purposes

First, the neonatal chart reviewer needs to determine the designated level of care for the institution where the patient received treatment.