These pediatric hospitals that built fetal programs to deliver care at the most appropriate time share their lessons learned.
By Rick Majzun, M.H.A., FACHE; Sarah Riggs, M.H.A.; and Jennifer Olson, MBA
More than 35 years ago, Michael Harrison, M.D., a pediatric surgeon at the University of California, San Francisco, proposed operating on babies in utero to treat conditions that would likely be lethal during pregnancy, such as bladder outlet obstruction.
Since then, the pool of candidates for open fetal surgery has expanded to include those who would likely benefit from prenatal surgery for non-lethal conditions, including, most commonly, myelomeningocele, a neural tube defect that is a severe form of spina bifida.
Today, in addition to surgical procedures, fetal care centers at children's hospitals provide diagnostic testing, access to maternal-fetal medicine doctors, family-centered care and advanced-level NICUs. While there are some operational challenges, these centers can play a role in children's hospitals' growth strategies for the future.
Here's a look at three children's hospitals that are moving upstream with the creation of comprehensive fetal care programs. As a result, they have increased volume, strengthened their market positions and advanced their missions.
Diagnosing and treating complex fetal conditions
In the fall of 2009, leaders from St. Louis Children's Hospital (SLCH), which serves as the pediatric hub for a 15-hospital system, joined colleagues from Barnes-Jewish Hospital (BJH) and Washington University School of Medicine to discuss forming a partnership to grow fetal care services.
Initially, the program only offered education, prenatal diagnostics, assessment and counseling. The organizations agreed that SLCH and BJH would run the fetal care program jointly, and over the next five years, the program grew at a slow pace.
After 24 months, the center hit its growth projections for evaluations. It was 5 percent over projections for NICU admissions but was down 32 percent on deliveries. The fetal care center offered a limited range of procedures, and most volume was in laser twin-to-twin interventions. Following the departure of its maternal-fetal medicine interventionalist, the program went into a 12-month holding pattern.
In 2013, SLCH and BJH examined the fetal care center with renewed focus. Leadership realized success would be elusive until a culture of collaboration and a willingness to make a major financial commitment was in place. The group made improvements to family support programs and increased genetics and genomic diagnostic services, advanced minimally invasive procedures and fetal/placental imaging.
Then, spurred by the successful management of a myelomeningocele trial, hospital leadership decided to offer these capabilities, which accelerated the development of a comprehensive open fetal surgery program. This also meant making a significant financial investment in the highly specialized equipment necessary to perform fetal interventions and recruiting a fetal surgeon who could provide a broad range of interventions.
A year after the surgeon started, new patient evaluations were up 70 percent, deliveries were up 12 percent and NICU admissions were up 12 percent.
Keep eyeing the future
Even for established children's hospitals that are part of major academic medical centers, successfully providing fetal care services requires hard work and a little bit of good fortune. One key to success is planning for the future.
As SLCH's fetal medicine efforts move into the next few years, the organization will continue expanding in vitro fertilization services; recruit a partner for the maternal-fetal interventionalist; advance clinical care by better understanding primary developmental mechanisms early in pregnancy; integrate molecular biology, genetics and molecular imaging; and develop advanced non-surgical pharmacologic fetal interventions.
Before establishing fetal care centers, evaluate the local, regional and national needs. Assess the organization's culture—collaboration is important, and everyone must buy in and be willing to work with obstetrics and maternal-fetal medicine partners.
Also, assess the organization's willingness to make a substantial commitment and realize fetal medicine is more than an operating room and a surgeon—it requires new infrastructure, such as nurse coordinators, social workers, genetic counselors, marketing, social media, outreach education, follow-up services, research support and outcome evaluation.
From prenatal care to beyond delivery
At the Colorado Fetal Care Center at Children's Hospital Colorado, mother and baby can be treated under one roof with a spectrum of maternal, perinatal and pediatric care services. The hospital offers an array of treatments, including open fetal surgery, fetoscopy and ex utero intrapartum treatment procedures.
From fetal diagnosis through discharge from the NICU or cardiac intensive care unit to pediatric subspecialty care, Children's Colorado provides a continuum of care for patients.
During mom's first appointment, she meets with the care team: pediatric/fetal radiology, maternal-fetal medicine, fetal surgery, genetics, fetal cardiology, psychology, neonatology and all relevant post-natal pediatric providers.
The hospital's fetal care center brings this team together to streamline the process for patients, while ensuring a responsive and comprehensive care plan is in place. With a focus on each child's long-term quality of life, the care model also integrates with the hospital's pediatric subspecialty programs.
When it's time for delivery, the maternal fetal care center has a 10-bed labor, delivery and postpartum unit located within Children's Colorado, so babies with complex needs can be transported just down the hall to the Level 4 NICU or the cardiac ICU immediately after birth. The maternal care unit is staffed with in-house obstetric hospitalists, anesthetic and obstetric nurses. Support from a psychologist and social work case management is also available.
As the hub of the largest neonatal network across the region, the Colorado Fetal Care Center has cared for high-risk fetuses since 2010 and performed more than 1,200 fetal surgeries. The center also leads research initiatives such as 3D printing and bioengineering solutions for fetoscopic myelomeningocele repair and fetoscopic tracheal occlusion for congenital diaphragmatic hernia.
Establishing the fetal program required a partnership between adult and pediatric providers. The Colorado Fetal Care Center is located at Children's Colorado, so a key to success was integrating adult providers into the pediatric environment. When developing this program, the Children's Colorado team worked to design an environment that would best serve this patient population.
The Colorado Fetal Care Center has an outpatient clinic, 24/7 labor, delivery and postpartum unit, a fetal intervention suite and one delivery operating room.
Building the program required financial investment and buy-in from leadership at Children's Colorado and UCHealth, Children's Colorado's adult partner. Formalizing the agreement between the entities was critical for success and includes a provider-based joint operating agreement.
Shared governance between UCHealth and Children's Colorado unifies program leadership, integrates clinical care, research and education and creates economic alignment based on contribution margin.
Downstream effects on other service lines
Developing a fetal program will have effects on an organization's neonatal service line. Since the inception of the program at Children's Colorado, NICU discharges have increased 30 percent, and fetal cardiology volume has more than doubled. The fetal patients born in the Colorado Fetal Care Center are very complex and have affected the length of stay in the NICU and cardiac ICU. The numbers of neonatal surgeries have also grown in parallel to neonatal discharges.
Continuum of care for high-risk pregnancies
Children's Minnesota is a children's health system with 428 beds in the heart of Minneapolis and St. Paul. Neonatology fills a significant portion of those inpatient beds—194 beds and nearly 55,000 patient days. In 2008, two physicians recognized an opportunity to enhance the continuum of care and solidify the perinatal-neonatal connection, so they took the lead on developing a fetal care program from the ground up.
Today, Children's Minnesota operates the Midwest Fetal Care Center (MWFCC), one of the more high-volume centers, in partnership with adult-focused provider Allina Health.
The MWFCC team offers laser ablation therapy, surgical procedures and care coordination for all complex prenatal diagnoses. In 2016, the center added open fetal surgery to its list of services, performing its first myelomeningocele that year. In one year, the team completed five successful cases with growth to 10 cases a year.
The group also conducts research on congenital lung malformations, congenital diaphragmatic hernia, twin-to-twin transfusion syndrome and single ventricle cardiac disease.
The organization's multidisciplinary approach to fetal care started with training, detailed strategic planning and programmatic investment. This allowed the team and services to grow; there are now two pediatric surgeons and three perinatal specialists who participate in open cases and laser ablations, as well as dedicated colleagues across disciplines who specialize in advancing fetal care.
Leverage wide-ranging expertise
Over the years, Children's Minnesota has learned it takes a village to launch and maintain a successful fetal care program. The breadth and depth of skill within the clinical care team is important—from physicians and care coordinators to genetic counselors.
The original MWFCC team members trained in Belgium and subsequently drew on expertise from The University of Texas at Houston and University of California, San Francisco, where fetal care techniques have been pioneered. For the most complex cases, the team uses the critical care simulation room and the fetal operating room to simulate a case and clarify the roles for every team member.
Philanthropy has been an important component of MWFCC's development. With the support of donors, the center recruited the care team, created a clinic space and built an integrated operating room where the team performs complex procedures and conducts training.
The organization will continue to seek funding to help in the development of interventions and research in congenital lung malformations, congenital diaphragmatic hernia, gastroschisis and single ventricle cardiac disease.
Partnering for better outcomes
Fetal care services for high-risk pregnancies and unborn babies with fetal conditions are the frontier for improving a child's health into adulthood. By implementing fetal care programs, children's hospitals are advancing care for many conditions and patient populations.
This increases the focus on improving the health care experience—and outcomes—for patients and families. Hospitals that implement a fetal care strategy can serve many interests.
Children's Hospitals Today Editorial Advisory Council Member Rick Majzun, M.H.A., FACHE, is vice president, Operations at St. Louis Children's Hospital and Women & Infants at Barnes Jewish and St. Louis Children's Hospitals; Sarah Riggs, M.H.A., is director, Business Operations at Children's Hospital Colorado; and Jennifer Olson, MBA, is senior vice president, System Operations and chief strategy officer at Children's Minnesota. Send questions or comments to firstname.lastname@example.org.