Bridging the Gap for Underdeveloped Preterm Infants from the Hospital to the

Home

IRIS LUANNE DE LA CALZADA, OTR/L

DECEMBER 12, 2009

Underdeveloped babies as a result of preterm birth in young mothers who have had Caesarian section

Health Care cost: $7.4 billion a year – 15 times greater than full term babies in their first year of life

Average cost: $41,610 for premature babies vs. $2,830 for a healthy, full term baby

Reference:

P.R. Newswire. (2005, March 28). March of Dimes analysis finds direct health care costs for preemies nearly 15 times greater than full term babies. Retrieved on November 9, 2009 at website:

http://wwwmarchofdimes.comaboutus/14458_15365.asp

In 2006, 12.3% of births in the United States are preterm(<37 weeks of gestation)

31% increase in the preterm birth rate since 1981 [Raju, et al. (2006)]

Largest contribution to this increase was from births between 34 and 36 completed weeks of gestation

In Texas, there were 54,621 preterm births – 13.7% of total number of births documented

63.1 teen births per 1000 residents References: Raju, T., Higgins, R., Stark, A., Leveno, K. (2006). Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the National Institutes of Child Health and Human Development. Pediatrics, 118(3), 1207-1214.

The Henry J. Kaiser Foundation. Texas Births in 2006. Retrieved online on November 11, 2009 from website: http://www.statehealthfacts.org/profileind.isp?cat=2&sub=11&rgn=45

Brownsville, TX Profile based on 2000 U.S. Census

Unemployment rates – only 52.4% in the labor force

High-school drop-out rates – only 17.2% with high school education, 10% with higher education

Socio-economic status – average of $24,468 per household, $9,762 per capita income

Age of population – median age of 27.7 years

Reference:

United States Census for Brownsville, Texas. (n.d.). 2000 Brownsville, TX Demographics. Retrieved online on November 2, 2009 from website:

http://brownsville.texas.com/demographics.html

Late preterm infants have higherfrequencies of: respiratory distress temperature instability hypoglycemia kernicterus apnea seizures feeding problems rates of hospitalization

High correlation between high rates of elective and non-elective Caesarian sections and premature births and mental retardation

Changing obstetric practices in the U.S.

Need to develop primary, secondary and tertiary prevention

Community Need: Lack of well-structured NICU Occupational Therapy Programs

References:

Aucott, S., Donohue, P., Atkins, S., Allen, M. (2002). Neurodedvelopmental care in the NICU. Mental Retardation and Developmental Research Reviews, 8(4), 298-308.Fuchs, K. and Wapner, R. (2006). Elective cesarian section and induction and their impact on late preterm births. Clinics in Perinatology, 33(4), 793-801. Weiss, S. (2006). Origins of tactile vulnerability in high-risk infants. Advances in Neonatal Care, 6(1), 25-36.

Predisposing factors:1. Early exposure and

engagement in sexual activity of female teenagers in the region

2. Low socio-economic status of households in the region

3. Lack of prenatal care and informed consent on risks involved in C-section

4. High immigrant population, unemployment and high school drop-out rates in the region

Enabling factor: Lack of awareness among health professionals and the general public of existing well-structured NICU Occupational Therapy Programs

Reinforcing factor: Lack of good communication among medical, allied health professionals and parents affecting smooth transition to the home

Using the PRECEDE-PROCEED Model, the goal of this

health promotion program is to improve clientsatisfaction and quality of care for underdevelopedpreterm infants and their families through seamlesshospital-home transition. With occupational therapyintervention in the NICU implemented by May 2010,

theobjectives of this program therefore are as follows:

1. Consistent staff documentation2. Streamlined protocol for referral for

occupational therapy services3. Regular family case conferences4. Creation of printed educational material5. Formal classes to focus on the empowerment of

womenand first-time parents

Chosen to address the lack of communication at the individual level

Designed to instill intentional change

Focuses on decision-making

Relies on self-report

References:

Velicer, W., Prochaska, J., Fava, J. Norman, G., Redding, C. (1998). Smoking cessation and stress management: Applications of the transtheroretical model of behavioral change.

Homeostasis, 38, 216-233.

Chosen to address the problem at the community level

ATTRIBUTE EXAMPLERELATIVE ADVANTAGEThe degree to which an innovation is perceived as better than the previous idea

The Rainbow program would facilitate better lines of communication among medical and allied health professionals, as well as with parents of underdeveloped babies.

COMPATIBILITYThe degree to which an innovation is consistent with existing values, experiences and needs of the adopters

The Rainbow Program is consistent with the needs of this underserved population in communities challenged by educational, health-related, and socio-economic needs.

COMPLEXITYThe degree to which an innovation is perceived to be difficult to understand or use

The Rainbow Program will provide the necessary service (Occupational Therapy) to improve the process of discharge planning. There is already an existing discharge planning committee that exists within this facility where OT is also a part. The addition of patients from the NICU during this weekly meeting would be a minor adjustment.

ATTRIBUTE EXAMPLETRIALABILITYThe degree to which an innovation may be tested or experimented with on a limited basis

The Rainbow Program can be pilot tested for 2-3 months or one quarter of a year. Program will consist of staff in-services, hosting of continuing education courses in the facility.

OBSERVABILITYThe degree to which the outcomes of an innovation is visible to others

Outcomes are measured through increase in patient satisfaction scores, perceived improvement in service quality based on a needs assessment survey among teenage mothers and parents of NICU babies, and increase in staff satisfaction scores in the NICU and Women’s Department. Scores would be posted in the hospital intranet system.

Reference:

U.S. Department of Health and Human Services. National Cancer Institute. Theory at a glance: A guide for health promotion practice. Retrieved on November 20, 2009 from website:

http://moodle.embanet.com/ot/mod/assignment/view.php?id=17018

Language barriers between service receptors and a culturally diverse staff

Communication barriers typical of a paternalistic biomedical model of patient intervention

LIMITATIONS: Limited staffing, time and budget

STRENGTHS: Better organized discharge planning and referral

system Smoother (faster) lines of communication Improved quality of patient care Increased patient satisfaction and quality of life

“I am putting my bow in the clouds. It will be the sign of my covenant

with the world.” – Genesis 9:13

Althabe F. & Belizan J. (2006). Caesarean section: The paradox. The Lancet, 368, 1472-1473.

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American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.

American Occupational Therapy Association. (2007). Specialized knowledge and skills in feeding, eating, and swallowing for occupational therapy practice. American Journal of Occupational Therapy, 61, 686-700.

Aucott, S., Donohue, P., Atkins, S., Allen, M. (2002). Neurodedvelopmental care in the NICU. Mental Retardation and Developmental Research Reviews, 8(4), 298-308.

Bigsby, R., Vergara, E. (2004). Developmental and therapeutic interventions in the NICU. Baltimore, MD: Paul H. Brookes Publishing Co.

Carvajal, S. (2005). Standard of Care for the NICU Infant. Retrieved on November 7, 2009, from Brigham and Women’s Hospital, A Teaching Affiliate of Harvard Medical School at website: http://www.brighamandwomens.org/GlobalFiles/search.aspx?st=0&site=BWH_CI&qt=NICU+protocol&submitButton.x=0&submitButton.y=0&submitButton=Go

Chen, X., Wen, S., Fleming, N. Demissie, K., Rhoads, G., Walker, M. (2007). Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. International Journal of Epidemiology, 36(2), 368-73.

Childbirth Connection, Inc. (2008, July). Why does the national U.S. cesarian section rate keep going up? Retrieved on November 2, 2009 from website: http://www.childbirthconnection.org/article.asp?ck=10456

Clark, G., Cox, B., Ward, S., Webber, H. (2009, June). Occupational therapy feeding challenges in early intervention. Early Intervention and School Special Interest Section Quarterly, 16(2), 1-3.

Davis, D., Sweeney, J., Turnage-Carrier, C., Graves, C., Rector L. (2004). Early intervention beyond the newborn period. In C. Kenner & J.M. McGrath (Eds.), Developmental care of newborns and infants: A guide for health professionals (pp. 373-410). St. Louis, MO: Mosby.

Fuchs, K. and Wapner, R. (2006). Elective cesarian section and induction and their impact on late preterm births. Clinics in Perinatology, 33(4), 793-801.

Galvan Gonzales, F., Mirchandani, G., McDonald, J., Ruiz, M., Echegollen Guzman, A., Castrucci, B., et al. (2008) Characteristics of young women who gave birth in the US-Mexico border region: The Brownsville-Matamoros sister city project for women’s health. Preventing Chronic Disease, 5(4), 1-14.

Gorga, D. (1994). Nationally Speaking – The evolution of occupational therapy practice for infants in the neonatal intensive care unit. American Journal of Occupational Therapy, 48, 487-489.

Holloway, E. (1994). Parent and occupational therapist collaboration in the neonatal intensive care unit. American Journal of Occupational Therapy, 48, 535-538.

Hunter, J.G. (2001). Neonatal intensive care unit. In J. Case-Smith (Ed.), Occupational therapy for children (4th ed., 636-689). St. Louis, MO: Mosby.

Malacova, E., Li, J., Leonard, H., Klerk, N., Stanley, F. (2008). Association of birth outcomes and maternal, school, and neighborhood characteristics with subsequent numeracy achievement. American Journal of Epidemiology, 168(1), 21-29.

Oldham, A. (2008, September). Trends of occupational therapy in the neonatal intensive care unit. School System Special Interest Section Quarterly, 15(3), 1-3.

Primary caesarian section: Risk-adjusted utilization rates. (n.d.). Texas Health Care Information Collection: Texas Hospital Inpatient Discharge Public Use Data File 2004, Indicators of Inpatient Care in Texas Hospitals (2004). Retrieved online on November 2, 2009 from website: http://www.dshs.state.tx.us/THCIC/publications/hospitals/IQIReport2004/Chart33.pdf

P.R. Newswire. (2005, March 28). March of Dimes analysis finds direct health care costs for preemies nearly 15 times greater than full term babies. Retrieved online on November 9, 2009 at website: http://www.marchofdimes.com/aboutus/14458_15365.asp

Raju, T., Higgins, R., Stark, A., Leveno, K. (2006). Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics 118(3), 1207-1214.

The Henry J. Kaiser Foundation. Texas Births in 2006. Retrieved online on November 11, 2009 from website: http://www.statehealthfacts.org/profileind.jsp?cat=2&sub=11&rgn=45

U.S. Department of Health and Human Services. National Cancer Institute. Theory at a glance: A guide for health promotion practice. Retrieved on November 20, 2009 from website: http://moodle.embanet.com/ot/mod/assignment/view.php?id=17018

United States Census for Brownsville, Texas. (n.d.). 2000 Brownsville, TX Demographics. Retrieved online on November 2, 2009 from website: http://brownsville.texas.com/demographics.html

Velicer, W., Prochaska, J., Fava, J. Norman, G., Redding, C. (1998). Smoking cessation and stress management: Applications of the transtheroretical model of behavioral change. Homeostasis, 38, 216-233.

Weiss, S. (2006). Origins of tactile vulnerability in high-risk infants. Advances in Neonatal Care, 6(1), 25-36.