Ballot, D.E.

Rothberg, A.D.

Smith, R.E.

English

AJOL - African Journals Online

24. Moser KM, Maurer J. Jassy L. et al. Sensitivity, specificity, and risk of diagnosticprocedures in a canine model of Streptococcus pneumoniae pneumonia. Am RevRespir Dis 1982; 125: 436-442.25. Crane VS. Pharmacoeconomics: therapeutic and economic considerations intreating the critically ill patient. DICP 1990; 24 (11): suppl, S24-S27.26. Knaus WA, Draper EA. Wagner DP, Zimmerman JE. APACHE 2: a severity of diseaseclassification system. Grit Care Med 1985; 13: 818·829.27. Fagon J-Y. Chastre J, Novarra A, Medioni P, Gibert C. Characterization of intensivecare unit patients using a model based on the presence or absence of organdysfunction and/or infection: the OOIN model. Intensive care Med 1993; 19: 137-144.28. Knaus WA, Draper EA. Wagner DP. Prognosis in acute organ system failure. AnnSurg 1985; 202: 685-690.29. Chang RWS, Jacobs S. Lee B. Predicting outcome among intensive care unitpatients using a computerised trend analysis of daily APACHE 11 scores correctedfor organ system failure. Intensive Care Med 1988; 14: 558-566.30. Knaus WA, Wagner Dp, Draper EA. The APACHE 111 prognostic system. Chest 1991;100: 1619-1636.31. Zimmerman JE, Shortell SM, Rousseau OM, et al. Value and cost of teachinghospitals: a prospective, multicenter. inception cohort study. Crit Care Med 1993;21: 1432-1442.32. Potgieter PO, Unton OM. The value of critical care in total health care. S Atr Med J1990; 78: 431.Accepted 8 Aug 1994.Maternal booking status asa criterion for admissionfor neonatal intensive careR. E. Smith, D. E. Ballot, A. D. RothbergObjective. To evaluate maternal booking status as anadmission criterion for neonatal intensive care.Design. Retrospective analysis to relate maternalbooking status to short-term outcome.Setting. Johannesburg Hospital neonatal intensive careunit (NICU).Subjects. All neonates admitted for veritilation to theNICU. Exclusions were neonates with surgical problemsand/or admission age over 48 hours.Outcome measures. Death before discharge, duration ofstay in the NICU, ventilation and hospitalisation.Results. Significantly more babies of unbooked motherswere admitted to the NiCU; however, the duration ofventilation and mortality rate were similar for the bookedand unbooked groups. Hospital stay was longer in theunbooked group, but this reflected lower birth weight andgestational age rather than severity of disease. Maternalbooking status was not an independent predictor of anyoutcome variable.Conclusion. Maternal booking status is not a validcriterion for admission to an NICU.S Afr Med J 1995; 85: 428-429.Department of Paediatrics, Johannesburg Hospital and University ofthe Witwatersrand, Johannesburg .R. E. Smith, FC.F' (SA)D. E. Ballot, FC.P. (SA), PHD.A. D. Rothberg, FC.P. (SA), PHD.Limited availability of neonatal intensive care facilitiesresulted in the University of the Witwatersrand academichospitals adopting a policy of only ventilating neonates witha birth weight above 1 000 g, as suggested at the 10thConference on Priorities in Perinatal Care in 1991. Sincethen, owing to rapid urbanisation and desegregation of thehospitals, an additional patient load has further increasedthe demand for neonatal intensive care facilities. Given thisstrain on resources, neonatal intensive care unit (NICU) staffare under pressure to admit only those patients with thebest prognosis or, conversely, to deny access to those witha worse prognosis. Because neonates born to unbookedmothers who have received inadequate or no antenatal careare at increased risk for perinatal morbidity and mortality,"'"staff members often ask whether NICU access should berestricted for such neonates. The aim of this study was todetermine whether maternal booking status should beincluded in the criteria for admission to an NICU.Subjects and methodsAll ventilated neonates admitted to the JohannesburgHospital NICU between July 1992 and March 1993 wereincluded in the study. Exclusion criteria were an age atadmission over 48 hours and/or surgical problems. Datawere retrieved from the computer database of the NICU.The following information was collected for each patient:maternal age at delivery, parity, marital status (married orsingle), race (white/coloured/black/Asian), gestational age(weeks), birth weight (grams), age at admission to the NICU(hours), and duration of NICU stay (days), ventilation (days)and hospitalisation (days). Outcome variables includeddeath before discharge and the duration of stay in the NICU,ventilation and hospitalisation.Mothers were classified as having received inadequateantenatal care if they had had fewer than 3 visits. While thisdefinition may be inappropriate, because many motherstend to book late: it was in common use at JohannesburgHospital during the study period and was therefore used inthis study. Furthermore, in a study by Kirtley et al." infants ofmothers who had had no antenatal care or 1, 2 or 3 visitshad similar outcomes when compared with those who hadhad more than 3 visits.Statistical analysis, including multivariate analysis,descriptive statistics, correlation t-tests and x2-squareanalysis, was done on a personal computer using STATPAKversion 4.1 (Northwest Analytical, Portland, Oregon).ResultsA total of 155 records was reviewed. The majority of patientswere black (127 of 155; 82%). The mean gestational age(± SO) was 34,4 ± 3,9 weeks and the mean birth weight2 018 + 807 g. The mean age at admission to the NICU was5,1 ± 10,2 hours, the duration of ventilation 5,2 ± 5,9 daysand the duration of hospitalisation 18,7 ± 16,8 days. Theoverall mortality rate was 17%.The booking status of 4 mothers was not available, sothese patients were excluded from the subsequent analysis.Mothers who had inadequate antenatal care were moreVolume 85 No. 5 May 1995 SAMJlikely to be black and single than their adequately bookedcounterparts, and on average were younger (Table I).Significantly more babies of unbooked mothers wereadmitted to the NICU (72 of 628 v. 79 of 3 373; P < 0,0001;odds ratio (OR) 12,29; 95% confidence interval (Cl)7,79 - 19,05).Table I. Comparison of booked and unbooked subgroupsBooked Unbooked P-valueNo. 79 52% 72 48%Black 57 72% 66 92% 0,0034Married 22 28% 6 8% 0,0000Neonatal mortality 10 13% 13 18% NSMaternal ageat delivery (yrs) 27,7 ± 6,6 24,7 ± 5,9 0,0044Parity 1,4 ± 1,2 1,4 ± 1,3 NSGestational age (wks) 35,3 ± 3,9 33,2 ± 3,7 0,0005Birth weight (g) 2 282,6 ± 868,6 1 714,5 ± 628,2 0,0000Admission age (h) 6,3 ± 12,5 3,44 ± 6,7 NSVentilation (d) 4,6 ± 5,5 6,0 ± 6,6 NSNICU stay (d) 6,1 ± 5,8 8,0 ± 7,2 NSHospital stay (d) 15,8 ± 17,1 22,9 ± 15,8 0,0125-min Apgar score 7,7 ± 2,1 7,4 ± 2,1 NSThe mean duration of ventilation was similar in the twogroups; however, significantly more babies born tounbooked mothers needed to stay in the NICU for over 1week (29/72 v. 19/79; P < 0,05; OR 2,10; 95% Cl 1,06 -4,16), and the duration of hospitalisation was significantlylonger for the unbooked group (Table I). These results areprobably related to the fact that both mean birth weight andmean gestational age of babies born to unbooked motherswere significantly lower than those of babies in the bookedgroup (Table I). In multivariate and frequency analysis,booking status was not an independent predictor of any ofthe above outcome variables. The mortality rates for thebooked and unbooked groups were comparable (Table I).DiscussionIdentification of neonates likely to have a poor outcomeand/or require a prolonged stay in the NICU is necessary tomaximise the benefit of this scarce resource. In this study,although unbooked status increased the likelihood ofrequiring admission to the NICU, once in the unit theoutcome for the unbooked group was comparable to that ofthe booked group. Although more babies born to unbookedthan to booked mothers had an NICU stay longer than 1week, and on average the unbooked group spent longer inhospital, this reflects their lower birth weight and gestationalage and not more complicated disease or greater morbidity.Maternal booking status alone was not predictive of death orduration of ventilation or hospital stay. We therefore concludein the context of this particular sample that maternal bookingstatus should not be factored into the criteria for admission toan NICU. It might be important for other units to evaluate thisaspect of neonatal care, since the previously acknowledgedassociation between unbooked status and perinatal morbidityin South Africa' could influence the nature and quality of caregiven to such infants.,SAMJCRITICAl,- CAREREFERENCES1. Nagey OA. The content of prenatal care. Obstet Gynecol 1ga9; 74: 516.2. Moore TR, Grigel W, Key lC, Resnick R. The perinatal economic impact ofprenatal care in a low socioeconomic population. Am J Obstet Gynecol 1986;154: 29-33.3. Mhlanga E. A new look at antenatal care. Proceedings of the 4th Conference onPriorities in Perinatal Care in South Africa, Orakensberg Gardens, Natal, 12 - 15March 1985. .4. Kirtley LM, Ballot DE. Jansen P, Rothberg AD. The unbooked patient -demography or personality? Proceedings of the 13th Conference on Priorities inPerinatal Care in South Africa, Rustenburg. Tvl. 8 - 11 March 1994.5. Hamilton RA, Periman T, de Souza JJL. 200 unbooked women in the Transvaal -an overview. Proceedings of the 4th Conference on Priorities in Perinatal Care inSouth Africa, Drakensberg Gardens, Natal, 12 - 15 March 1985.Accepted 22 Nov 1994.TheCritical CareSociety ofSouthern AfricaThere are many advantages to be gained from being amember of the Critical Care Society of Southern Africa.Not the least of these is that your name will be added tothe subscription list of this Journal, and every issue will bemailed to you direct on publication COMPLETELY FREE.If you are not already a member of the Society, please fillin this form and return to:THE SECRETARYCRITICAL CARE SOCIE1YOF SOUTHERN AFRICAP.O. BOX 521MELVILLE 2109APPLICATION FORMNameAddress _Qualifications _Connection with or interest in Critical Care MedicineMEMBERSHIP FEES AND APPLICATION SHOULD BE ENCLOSEDInitial enrolment R50,OOMedically qualified persons, nurses and paramedics R20,OOAffiliate membership R5,OO~PLEASE MAKE ALL CHEQUES PAYABLE TO'THE CRITICAL CARE SOCIE1Y'SAMJ Volume 85 No.5 May /995

Maternal booking status as a criterion for admission for neonatal intensive care

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Maternal booking status as a criterion for admission for neonatal intensive care

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