Continuity of care from a skilled team is critically important for babies born with congenital diaphragmatic hernia (CDH). Knowing this, eight years ago, CHOP's Division of Neonatology and Division of General, Thoracic and Fetal Surgery collaborated to create the Neonatal Surgical Team. Made up of a neonatologist, surgeon, surgical APNs, surgical fellow and specialized team of neonatal surgical nurses, the team provides comprehensive care for babies whose primary diagnosis is surgical. The team knows these families well and cares for them prenatally, through their time in the Newborn/Infant Intensive Care unit (N/IICU) and following discharge.
“This type of team doesn’t exist anywhere,” says Natalie Rintoul, MD, attending neonatologist and medical director of CHOP's Neonatal ECMO Program. “The Special Delivery Unit (SDU), N/IICU and surgical teams provide an unmatched continuity of care, from before birth to post discharge.”
While some hospitals see only a few CDH cases a year, CHOP often sees two or three prenatal consults a week and has more than 30 CDH admissions to the N/IICU per year. the experience gleaned from this large volume — along with findings from our Center for Fetal Research — has helped the team create optimal care guidelines that ensure care is standardized and outcomes can be measured. These guidelines are continuously reevaluated and revised based on what’s working and what needs improvement.
Before babies with CDH are born in our SDU, the Neonatal Surgical Team reviews prenatal imaging, develops the plan for the baby, and discusses that plan with families so they know what to expect. If something unexpected arises, an unmatched level of combined experience caring for surgical neonates helps them adjust quickly and expertly.
“Although prenatal imaging provides extensive information about the fetus, there is no fetal lung test, so it’s important to have an experienced team prepared for every contingency,” says Rintoul. “Members of our team are ready for anything.”
Immediately after birth, the baby is stabilized in the SDU and taken to the N/IICU for continued care. Every day, the surgical and neonatal attendings round with the team and work through each patient’s plan of care together, sharing their different perspectives and knowledge.
Because babies with CDH are extremely sensitive to noise and even the slightest changes in environment, the team goes to great lengths to maintain a quiet zone in the N/IICU and focuses on gentle ventilation. When it’s time for surgery, the team turns the baby’s room into an operating room according to Association of Perioperative Registered Nurses (AORN) standards to avoid the risk of deteriorating pulmonary status related to movement of the baby to an operating room.
“If you’re not continually aware of their fragile state, it’s easy to tip these babies over that proverbial edge,” says Tracy Widmer, MS, CRNP, manager of the surgical APNs on the Neonatal Surgical Team.
ECMO Center Earns Highest Honor
Babies with severely compromised or fragile lungs who require ECMO are in the hands of one of the most experienced programs in the country. Each baby’s ECMO care is overseen by a dedicated team. Since opening our Special Delivery Unit in 2008, our ECMO rate for CDH babies has decreased, proving the importance of having a core team manage care from the very beginning. Our Pulmonary Hypoplasia Program meets babies in the N/IICU and provides care on a longitudinal basis through childhood.
"This is such an incredible way of practicing,” says Rintoul. “We’ve got all the supports in place and such a depth of experience. Whatever comes up, we have seen it, dealt with it and are ready for it.”