A Novel Care Model for Neonatal Intestinal Failure Patients Is Associated With Cost Savings and Improved Outcomes

Neonates with intestinal failure (IF) have prolonged admissions in the neonatal intensive care unit (NICU) and require lifelong follow-up with gastroenterology (GE) as outpatients. Inpatient management of these patients typically relies on many rotating practitioners and currently discharge criteria do not exist. We sought to create standardized discharge criteria with a continuity care model for neonatal IF patients.

Inpatient care was streamlined to two GE physicians with weekly consultations. We implemented standardized discharge goals for both enteral and total parental nutrition (TPN) by: 1) Enteral feedings of at least 5 mL/h were tolerated; 2) Stable central venous access was intact; 3) TPN was cycled to 20 h/day or less; and 4) No other medical issues required NICU admission. Patient records were reviewed after 18 months of implementing standardized discharge criteria and we compared their outcomes to a historical cohort of IF patients.

Optimal discharge criteria were met in 12 patients and a cohort of 26 historical patients was used for comparison. Patients in optimal versus historical groups had similar baseline characteristics (medians, all P values = non-significant (NS)): gestational age (36 vs. 35 weeks), birth weight (1,990 vs. 2,076 g), birth length (45 vs. 44 cm), and small bowel length after definitive surgery (63 vs. 55 cm). Compared to the historical group, the optimal cohort was discharged earlier (median length of stay 69 vs. 126 days, P < 0.01), with a reduced total stay of 684 NICU days, fewer central line-associated bloodstream infections (CLABSIs) (4 vs. 10 per 1,000 patient days, P = 0.04), and had fewer readmissions (7 vs. 17 per 1,000 patient days, P < 0.01), respectively.

Concentrating the care of IF patients to a GE team invested in long-term care, while implementing safe discharge criteria, resulted in a dramatic length of stay reduction with fewer CLABSIs and readmissions compared to historical management. At approximately 4,000 dollars per day in NICU hospital charges, this program saved over 2.7 million dollars in care costs while allowing families and their infants more time at home. The safety and applicability of the optimal discharge criteria presented here should be studied further. Similar programs may be effective at other large NICUs.