Cleveland Clinic Children's Outcomes

The Department of Neonatology at the Cleveland Clinic Children's Hospital (CC Children's) has 87 beds with level IV and level III capacities serving at Main Campus, Fairview and Hillcrest hospitals. Obstetrics services receive 9-10,000 deliveries per year among the three hospitals with 12-1300 admissions to the NICU.

Infants born at the edge of viability - at a low gestational age (GA) of less than 25 weeks and an extremely low birth weight (BW) of equal to or less than 750 grams (g) - are at the highest risk of death during the hospital stay.

At CC Children's, a 4-year rolling total survival rates of infants with BW of equal to or less than the 750 g which were successfully resuscitated in the delivery room, in 2021 were 71.4%, 67.9%, and 75.6% for gestational weeks of equal to or more than 22 weeks, 23 weeks, and 24 weeks. For all GA categories the survival remains above the national average for the last 3 weeks.

* The number of infants in this weight and gestational age categories is very few. Therefore, a large variability in survival rate may exist from year to year.

Human milk provides many health benefits to the vulnerable infant. These benefits include reduction in the incidence of hospital-acquired infections and necrotizing enterocolitis during the hospital stay; as well as improved visual acuity and higher scores on tests of neurocognitive and developmental outcomes following discharge. Furthermore, studies demonstrate that there is a dose response effect of human milk on the development of white matter in the brain. Our department conducted a performance improvement project to enhance use of breast milk at discharge. The overall rate of BM use in infants discharged from the NICU improved to above 80% in 2019 and 2020-2021, comparable with the top Children’s Hospitals as measured by the U.S. News and World Report Pediatric Survey.

CDC. (2020). Breastfeeding report card. https://www.cdc.gov/breastfeeding/data/reportcard.htm

Meier PP, Engstrom JL, Patel AL, Jegier BJ, Bruns NE. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010;37(1):217-245. doi:10.1016/j.clp.2010.01.013

Chronic lung disease (CLD) is a common complication encountered in premature infants, especially those supported by mechanical ventilation. Incidence of CLD is higher in infants born before 30 weeks of gestation and with a birth weight of less than 1500g. CLD is associated with poor growth and a worse neurodevelopmental outcome. In 2018, a bubble CPAP (b-CPAP) strategy was implemented for respiratory support of premature infants born at the Cleveland Clinic Children’s Hospital. Avoidance of intubation and invasive respiratory support strategies, in combination with the application of b-CPAP, aimed to reduce the incidence of CLD in preterm infants. Overall in CCC's level III NICUs, implementation of b-CPAP resulted in a reduction of CLD incidence rate from 37.6% and 39.9% in 2016 and 2017 respectively (prior to b-CPAP use) to 6.3% and 8.1% in 2020 and 2021, the lowest rate in the nation.

Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Preterm Birth: Causes, Consequences, and Prevention. Washington (DC): National Academies Press (US); 2007. 10, Mortality and Acute Complications in Preterm Infants. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11385/ https://www.ncbi.nlm.nih.gov/books/NBK11385/

Cleveland Clinic's three Neonatal Intensive Care Units (NICUs) take care of extremely low birth weight infants with complex pathology which depend on nutrition and medications delivered through central intravenous lines. Central line associated blood stream infection (CLABSI) is one of the hospital conditions that worsen infant’s clinical condition, prolong the hospital stay, and increase the healthcare cost. In 2020, the Neonatal Quality Council conducted a robust gap analysis, resulting in a number of preventive practices spreading across the three NICUs to standardize practice. This led to a decrease in the CLABSI rate from 1.37 per 1000 central line days in 2019 to 0.2 in 2021.

Unplanned Extubation (UE) in mechanically ventilated infants can place them at risk for significant complications. A multidisciplinary Neonatal Quality Council monitors preventive practices ensuring standardization and sharing of good practices across the enterprise's neonatal ICUs (NICUs). The implementation of a standardized UE preventive bundle in all three NICU locations in 2019 resulted in decreasing of the UE rate from 1.42 and 1.82 per 100 non-tracheostomy ventilation days in 2017 and 2018, to 0.66 and 0.78 in 2019 and 2020 respectively. Implementation of the novel method to secure breathing tubes in 2021 allowed to further decrease UE rate to 0.24, comparable with the top Children's Hospitals as measured by the U.S. News and World Report Pediatric Survey.