Neonatology

Neonatal Intensive Care Units

University of Washington Medical Center-Montlake Neonatal Intensive Care Unit (Level IV)

Kirti Upadhyay, MD, Medical Director
Sarah Kolnik, MD, MBA, Medical Director
Tiffany Stanley, ARNP,, NNP Program Manager

The UWMC NICU admits critically ill newborns from one of the highest risk obstetric services in the nation. The multi‐professional perinatal and NICU teams have special expertise in management of the most fragile growth‐restricted and extremely premature fetuses and newborns. The high‐risk perinatal program receives obstetrics referrals from throughout the WWAMI region for fetal abnormalities, severe maternal illness, and extreme prematurity and is the site of delivery for the most complex birth defects, including infants requiring EXIT procedures for airway anomalies. Additional advanced services include therapeutic hypothermia and the full range of ventilation strategies including inhaled nitric oxide, high –frequency oscillatory and jet ventilation. The NICU medical team includes neonatal faculty, neonatal fellows, neonatal nurse practitioners, neonatal hospitalists, pediatric residents, interns and medical students. The inter‐professional team includes dedicated respiratory therapists, neonatal pharmacists, dieticians, physical therapists, speech language pathologists and social work support. The nursing team includes three tiers of RN expertise and leadership. A state‐of‐the‐art 50‐bed NICU opened October 2012. The NICU includes 42 single‐bed rooms with space for a family member to stay with their infant plus several additional rooms for multiples as well as an integrated OR for surgical procedures. Patients are cared for by one of two multi‐disciplinary teams, a resident‐based team, and an NNP/hospitalist team. The UWMC NICU’s care model includes 24/7 coverage by in‐house residents and, mid‐level intensivists (fellow or NNP/PA), under the direction of attending neonatologists. In 2020, the UWMC had 1961 deliveries with 469 NICU admissions. The average daily census was 28 with 17 preterm infants weighing less than 1500 grams at birth and an average daily census of 1.6 on ventilators.

Seattle Children’s Hospital Neonatal Intensive Care Unit (Level IV)

Zeenia Billimoria, MD, Medical Director 
April Morris, MN, ARNP, Director, Advance Practice Services
Melissa Koll, MN, ARNP, Supervisor of SCH NICU APPs
Mihai Puia-Dumitrescu, MD, MPH, CMQ, Assoc. Medical Director
Sarah Handley, MD, Assoc. Medical Director

The Neonatal Intensive Care Unit at Seattle Children’s Hospital is the highest rated Level IV NICU in the Seattle area and serves as the major quaternary referral center for medically and surgically complex neonates in the Pacific Northwest. Seattle Children’s NICU admits 500 patients annually and has over 500 affiliated faculty that represent all pediatric subspecialties including– more than any other hospital in the region. The Children’s NICU provides the full spectrum of neonatal medical care including therapeutic hypothermia for acute hypoxic ischemic encephalopathy, seizures, high frequency ventilation, inhaled nitric oxide and ECMO for severe respiratory failure, renal replacement therapy including dialysis and surgical expertise in the areas of congenital diaphragmatic hernia, intestinal failure, bowel atresia, craniofacial anomalies, reconstructive pelvic medicine, post‐hemorrhagic hydrocephalus, neural tube defects and neurovascular malformations. In addition, we offer multidisciplinary care teams providing neuro‐critical care, congenital diaphragmatic hernia and management of bronchopulmonary dysplasia.

Daily rounds with the medical team incorporate the patient’s family, NICU nurses, dieticians, pharmacists and respiratory therapists. The NICU team accepts admissions of critically ill neonates up to 44 weeks’ post menstrual age from the 5‐state WAMI region. The Seattle Children’s Hospital NICU’s care model includes an in‐house fellow or NNP and attending neonatologist 24/7. Seattle Children's Prenatal Diagnosis and Treatment Program partners with the University of Washington to provide care for pregnant women and their families when pregnancy is complicated by known or suspected conditions in the developing fetus. Our program integrates obstetric, neonatology and pediatric specialty care for families facing complicated pregnancy management or decision‐making. Seattle Children’s NICU participates in research and quality improvement initiatives via its active participation in a number of national and/or international collaborative associations including the Children’s Hospital Neonatal Consortium, Congenital Diaphragmatic Hernia Study Group, Bronchopulmonary Dysplasia Collaborative and the Extracorporeal Life Support Organization.

UW Medicine/Valley Medical Center Neonatal Intensive Care Unit (Level III)

Christina Long, DO, Medical Director 
Toby Cohen, MD, Assoc. Medical Director 
Carol Otto MSN, ARNP, Supervisor, Valley Medical Center

In July 2017, Neonatologists and Advanced Neonatal Practitioners from University of Washington/Seattle Children’s Hospital began a collaborative effort to staff the NICU at UW/Valley Medical Center. The unit has a 29‐bed capacity. The single‐bed rooms provide space and privacy for our patients and their families. Two, unique, infant stabilization rooms allow immediate resuscitation of infants in the NICU after birth without requiring transport after stabilization. Valley has a robust high‐ risk perinatal clinic and the Neonatologists work closely in conjunction with the high‐risk team to provide consults for families prenatally. The Valley NICU uses a multi‐disciplinary approach to patient care with NICU dedicated pharmacists, dieticians, physical therapists, speech therapists, respiratory therapists, social work, and NICU nurses. This multi‐disciplinary staff meets with families to provide the best family‐centered care for our patients. Advanced services provided at Valley include therapeutic hypothermia with 24/7 Pediatric Neurology support and a large range of ventilation strategies including high‐frequency oscillatory ventilation. Advanced Neonatal Practitioners staff the NICU with 24/7 in‐ house coverage under the direction of attending Neonatologists. In AY 2018, Valley had 3474 number of deliveries with 212 NICU admissions.

Providence Regional Medical Center Everett Neonatal Intensive Care Unit (Level III)

Michael D. Neufeld, MD, MPH, Medical Director
Maya Kaneyasu, BSN, MN, ARNP Supervisor, Providence Regional Medical Center Everett

Providence Regional Medical Center Everett’s 29‐bed capacity NICU opened on Mother’s Day in 2002. The unit was developed through the efforts of an alliance between PRMCE and Seattle Children’s Hospital. Individual rooms provide privacy for patients and their families. The multidisciplinary team meets daily with parents and concentrates on family‐centered care, teaching parents how to take care of their infants, especially those with special needs. In preparation for discharge, parents are provided in‐depth instruction on how to manage emergencies that may arise in the home, including the need for CPR. The unit cares for infants of all gestational ages and has HFJV, HFOV, and iNO in addition to conventional ventilation. The care model at PRMCE is 24/7 in‐house Advanced Neonatal Practitioners and Physician Assistants under the direction of an attending neonatologist. In AY 2020, PRMCE had 4162 deliveries with 588 NICU admissions. The average daily census was 23.5 with 59 preterm infants weighing less than 1500 grams at birth.

Virgina Mason Franciscan Health; St Joseph Medical Center (Level III); St Francis Hospital (Level II); St Michael Medical Center (Level II); St Anne Hospital (Level II); Virginia Mason Medical Center (Level II)

Robin LaGrandeur, MD - Interim Medical Director St Joseph NICU and VMFH Neonatology Service Line
Krista Birnie, MD - St Anne SCN Medical Director
Angel Rios, MD - VMMC SCN Medical Director
Justine Wood, ARNP, NNP-BC, Neonatal APP Supervisor VMFH

Franciscan Health Care System includes a network of hospitals with approximately 9,000 deliveries annually at its 5 obstetrical facilities: St Joseph Medical Center in Tacoma, St Francis Hospital in Federal Way, St Elizabeth Hospital in Enumclaw, St Michael Medical Center in Silverdale, and St Anne Hospital in Burien. St Joseph Medical Center has a licensed capacity of 34 neonatal beds and has 24/7 in‐house Advanced Neonatal Practitioners supported by faculty neonatologists. St. Francis Hospital has a licensed capacity of 10 Level II beds that receive medical care from local pediatricians, with consultation and attendance at high‐risk deliveries as needed from SCH Advanced Neonatal Practitioners and/or neonatologists. For 12 hours/day, Saint Francis has in house coverage with the Advanced Neonatal Practitioners with support from Neonatology Providers and for the other 12 hours/day, Neonatology provides coverage directly and via telemedicine. St Anne Hospital has a licensed capacity of 5 Level II beds, with inpatient Level II care and consultative services provided by Seattle Children’s Neonatologists on call. St. Elizabeth is a critical access hospital with 345 deliveries a year. Seattle Children’s Hospital partnered with the Franciscan Health Care System to begin providing Neonatology services and medical direction on April 1, 2013, and St. Joseph Medical Center opened its new Level III NICU in June 2013, and St Anne Hospital began its collaboration with Seattle Children’s in November 2018. This partnership has made it possible for the vast majority of patients to stay within their community while receiving excellent care for their fragile newborns. On 1/22/18, we lowered the gestational age at which we would manage patients at SJMC to 25 weeks as our threshold of care at SJMC. With the continued emphasis on non‐invasive ventilation as our primary mode of respiratory support, we average between 4 and 6 babies on nasal CPAP per day and less than one baby per day on invasive ventilatory support. In September of 2018, we expanded our care to provide inhaled nitric oxide for infants with hypoxic respiratory failure and we utilized it on three patients with excellent clinical responses. In AY 2018, St. Joseph’s had approximately 4100 deliveries with 480 NICU admissions. Our average daily census was 17.0 with 44 premature infants weighing less than 1500 and 14 weighing less than 1000 grams at birth.

University of Washington Medical Center - Northwest Neonatal Intensive Care Unit (Level II)

Angel Rios, MD, Pediatric Section Head

In November of 2018 Northwest Hospital Special Care Nursery, a Level II NICU began a collaborative effort with the UW Division of Neonatology and Seattle Children’s Hospital to support care for infants born prematurely at greater than 32 weeks, as well as term infants who may be suffering from a variety of neonatal conditions including but not limited to breathing difficulties and infections. Northwest Hospital delivery service sees approximately 1100 newborn infants annually. Although historically the service delivers primarily low risk patients there is always the potential need for the expertise provided by 24/7 in house coverage by our team of Advanced Neonatal Practitioners who have immediate access to consultation with UW/SCH neonatologists and a premier critical care neonatal transport system. The unit is being remodeled to support the focus on family centered care with increased opportunity and available space for couplet care.

Clinical Programs

Neonatal Consultation and Transport Program

Zeenia Billimoria, MD, Medical Director; Christopher Baker, MSN, MBA, RN C-NPT, Clinical Manager

The Division provides 24/7 neonatal consultation services for the 5-state WWAMI region.  Neonatal transport services for Seattle Children’s and its affiliated hospital partners is provided by dedicated teams from Seattle Children’s and Airlift Northwest. Our transport team are leaders in safe newborn transport and have ground, rotor and fixed wing capability. Teams are comprised of specially trained transport nurses and respiratory therapists. Infants from referral centers throughout the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region are transported to Seattle Children’s. Services provided include various modes of non-invasive support, high frequency ventilation, administration of nitric oxide, blood gas analysis and mobile extracorporeal membrane oxygenation for critically ill patients too unstable to move via conventional support.

Telemedicine Program

Rachel Umoren MBBCh, MS, Inpatient Medical Director for Telehealth
Core Team: Chris Cooper, Craig Jackson, Megan Gray, Taylor Sawyer

Since 2019, a dedicated neonatal telehealth team staffed by trained neonatologists and advanced practice providers has provided neonatal teleconsultation services including telerounding, teleconsultation and teleresuscitation.

Prenatal Diagnosis Programs

Prenatal Diagnosis and Treatment Program at Seattle Children’s Hospital

Craig Jackson, MD, MHA; Robert DiGeronimo, MD, and Zeenia Billimoria, MD

This multidisciplinary clinic is held Monday through Friday in the Springbrook office center which is across the street from the main hospital. Patients are referred from Washington,  Alaska,  Montana,  and Idaho. More than 1000 patients are seen annually for fetal imaging with ultrasound, echocardiogram, and MRI, and for multidisciplinary counseling by our UW maternal‐fetal medicine specialists, pediatric medical and surgical specialists, prenatal nurses, and by our genetic counselor and prenatal social worker. About half of the visits are for fetal cardiac evaluation for known or suspected fetal cardiac defects such as ductal‐dependent cyanotic heart disease, fetal arrhythmias, or for maternal health risk factors for fetal congenital heart disease. The remainder are referred for suspected fetal surgical problems (e.g., congenital diaphragmatic hernia, congenital pulmonary airway malformations, gastroschisis), neurodevelopmental disorders (e.g., open neural tube defects, ventriculomegaly), renal or urologic problems (e.g., urinary tract obstruction, renal dysplasia), and genetic issues (e.g., trisomy 13, 18, and 21 and numerous specific genetic conditions). Neonatologists are asked to join the multidisciplinary counseling for patients with fetal conditions that are complex, likely to require advanced delivery room resuscitation or admission to SCH, or which raise the possibility of offering palliative care. Research projects during 2020 included the following:

Principle Investigator	Project Title
Bhawna Arya	Fetal anatomy and physiology and associations with fetal and perinatal outcomes in DTGA/IVS: a collaborative, multicenter, multi-arm prospective study
Hannah Tully, Dan Doherty	“Retrospective Review of Prenatally Diagnosed Fetal Central Nervous System Abnormalities”
Aarti Bhat	Prenatal detection of HLHS and dTGA: significant socioeconomic and geographic barriers
Kiana Siefkas	Biallelic SCN5A Variants Cause Prenatal Onset of Complex Cardiac Arrhythmias
Bhawna Arya, Kim Riehle	Utility of maternal hyperoxygenation testing in predicting outcomes in fetuses at risk for developing PPHN
Bhawna Arya	Prenatal predictors of coarctation of the aorta
Bhawna Arya, Mikki Clouse	Cerebral Doppler pattern in coarctation of the aorta
Bhawna Arya	Fetal predictors of PAIVS outcomes
Bhawna Arya	Fetal predictors of mitral valve dysplasia outcomes
Bhawna Arya	Umbrella IRB for fetal CHD retrospective studies
Ian Glass	Donation of Embryonic & Fetal Tissue for Research (BDRL)
Daniel Doherty	NDV Disorders & Hindbrain Malformations
Colin Studholme	Fetal Imaging/MRI Brain Development
William Walker	Evaluation of the Best Urologic Management for Newborns and Young Children with Spina Bifida
Elizabeth Caris	Resiliency in Families affected by Congenital Heart Disease
Bailey Brinks	Prenatal Tour Study: Evaluating Newborn Hospitalization Preparedness In Families With Prenatal Diagnosis

 

Prenatal Diagnosis Program at University of Washington Medical Center

Craig Jackson, MD, MHA; Dennis Mayock, MD; Maneesh Batra, MD, MPH; and Davia Loren, MD

This clinic is held in the Maternal Infant Care Center (MICC) at UWMC where maternal‐fetal medicine specialists primarily see patients with suspected or known fetal defects for close monitoring during pregnancy, with ultrasound and non‐stress tests as needed, and genetic testing as appropriate. Neonatologists are asked to counsel patients with fetal defects about a month before the expected delivery of newborns who are at risk of needing admission to the UWMC NICU or be transported to Seattle Children’s Hospital. They also see pregnant patients with hypertension, multiple‐gestation, diabetes, and high‐risk for prematurity. Palliative care consultation from the UWMC NICU palliative care physician is available as needed. Current research projects include:

1. Establishing growth curves for gastroschisis
2. Prenatal bowel dilation in gastroschisis: predictors for timing of delivery and outcome
3. cfDNA and maternal-fetal trafficking studies

Neuro-NICU Program

Ulrike Mietzsch, MD, - Neonatal Co-director; Nina Natarajan, MD – Pediatric Neurology Co-director

The neonatal neurocritical care program at Seattle Children’s Hospital is a specialized service to improve the care and outcome of critically ill newborns with neurological and/or neurosurgical problems diagnosed in or before the newborn period. This advanced care service provides multidisciplinary care from experts in Neonatology, Neonatal Neurology, Neurosurgery, Pediatric Neuroradiology, Pediatric Neurophysiology, Neurogenetics, Developmental Pediatrics, Occupational & Physical therapists, audiologists and speech/language pathologists.

Conditions treated: Hypoxic ischemic encephalopathy (HIE)/birth asphyxia, Neonatal seizures, Brain malformations, Neonatal stroke, Metabolic encephalopathy, Meningitis/Encephalitis, Neuromuscular disorders, Hydrocephalus,  Intracranial hemorrhage, White matter injury (PVL or diffuse), ECMO monitoring, Myelomeningocele.

Services provided: 24-hour continuous video monitoring – including electrophysiologists specialized in neonatal EEG, Whole-body hypothermia therapy, Active hypothermia during neonatal critical care transports (air and ground), Near-Infrared Spectroscopy Monitoring, Magnetic resonance imaging and spectroscopy, Neonatal EMG testing, Advanced neurogenetic diagnostics, Specialized small-baby care bundles, Comprehensive multidisciplinary High-Risk Infant Follow Up program including General Movement Assessment.

Approximately 30‐40% (~180 patients) of patients admitted to the Level IV NICU at Seattle Children’s Hospital receive supplemental care through the NeuroNICU service annually. In addition, a close collaboration has been established between the NICU at UW Medical Center and the NeuroNICU at Seattle Children’s in addition to referrals and consultations from the entire State of Washington, Idaho, Montana, and Alaska, for which the NeuroNICU team is providing consultation and outreach services.

 

Infant Development Followup-up Clinic

Emily Myers, MD; Kendell German, MD; Nina Natarajan, MD

The University of Washington Institute on Human Development and Disability offer the Infant Development Follow‐Up Clinic (IDFC) and the Late and Moderate Preterm Baby Clinic (LAMBs) to provide interdisciplinary neurodevelopmental assessments for infants at risk for developmental differences. Infants receive standard evaluations at 3, 9, 12, 18, and 24 months, then annually through 5 years old. Developmental Pediatrics, Neonatal Neurology, Neonatology, Advanced Practice Nursing, Psychology, Speech/Language Pathology, Audiology, Nutrition, Occupational Therapy, Physical Therapy and Social Work staff the clinic. The clinic sees approximately 2500 infants and children annually. The clinic also provides interdisciplinary training and follow‐up for patients in clinical research studies.

Infants who qualify to be seen in these clinics are those that meet any of the following criteria:

• Infants born before 37 weeks’ gestation
• Birthweight of <1500g
• Infants exposed in-utero to drugs or alcohol
• Infants with prenatal, perinatal, or neonatal brain injuries (IVH, HIE, stroke)
• Infants with complex medical disease requiring selected surgical interventions
• Infants who required a neonatal intensive care unit hospitalization

Recent changes to these clinics include the introduction of the Reach Out and Read program and telehealth services which were employed during COVID restrictions. Ongoing research in the clinic includes follow‐up for the HEAL trial, the evaluation of the Reach Out and Read program in the NICU and follow‐up clinics and the creation of a patient database to facilitate quality improvement and outcomes research.

Neonatal-Perinatal Clinical Collaboratives

Vermont-Oxford Network

Michael D. Neufeld, MD, MPH; Thomas P. Strandjord, MD, Database Coordinators

The University of Washington Medical Center Neonatal Intensive Care Unit maintains a quality improvement and research NICU database that includes all infants admitted to the NICU, as well as all infants delivered at UWMC over 22 weeks' gestation. The database is maintained by Division staff and faculty. In addition, since 2000, the University of Washington NICU has participated in the Vermont‐Oxford Network (VON) database for 401‐1500‐gram infants. Data is selected for inclusion in the NICU database by consensus of the neonatology faculty and fellows. The NICU database contains a superset of the data required by the VON database and as such includes extensive admission, diagnostic, outcome and local QA/QI data. The outcome (morbidity and mortality) data are generated annually and reviewed with the faculty and fellows. In addition, ad hoc queries are performed at the request of fellows and faculty and reviewed as a group. 

Children’s Hospital Neonatal Consortium

Elizabeth Jacobson, MD, Site Physician Sponsor; Robert DiGeronimo, MD, Co-Sponsor

Seattle Children’s Hospital belongs to the Children’s Hospitals Neonatal Consortium (CHNC) of 40 children's hospital Level IV NICUs. This allows for involvement in benchmarking, quality evaluation, and improvement initiatives for the SCH NICU through the Children’s Hospitals Neonatal Database and focus groups on specific diagnoses, such as severe bronchopulmonary dysplasia, congenital diaphragmatic hernia, and hypoxic‐ischemic encephalopathy. Many of our neonatal faculty are members of one or more of the CHNC’s focus groups, including those mentioned as well as Fetal Therapy, ECMO, Necrotizing enterocolitis, Resuscitation, and Neurosurgery. In addition, Elizabeth Jacobson co‐leads the CHNC’s national Gastroschisis Focus Group. Publications from these efforts are listed in the Translational, Clinical, and Quality Improvement Research section of this Annual Report.

Extracorporeal Life Support Organization

Robert DiGeronimo, MD, Site Physician Co-Sponsor

Seattle Children’s Hospital belongs to the Extracorporeal Life Support Organization (ELSO), an international non‐profit consortium of over 350 health care institutions dedicated to the development and evaluation of novel therapies to support organ failure. Participation in ELSO affords the opportunity to participate in and query the extracorporeal membrane oxygenation database to support clinical research, quality improvement and evidence‐based guideline recommendations.

National Airway Registry for Neonates (NEAR4NEOS)

Taylor Sawyer, DO, MEd, Site Lead UWMC and SCH, Shilpi Chabra, MD, UWMC Site Co-Lead; Mihai Puia-Dumitrescu, MD, MPH, SCH Site Co-Lead  

Both the University of Washington NICU and the Seattle Children’s Hospital NICU belong to the National Airway Registry for Neonates (NEAR4NEOS), an international collaboration of 16 academic neonatal intensive care units dedicated to improving the safety of neonatal intubation. Participation in NEAR4NEOS affords the opportunity to participate in clinical research and quality improvement projects around neonatal intubation.

Regional Neonatology Outreach Program

Taylor Sawyer, MD

The Division of Neonatology Regional Outreach program started around 1980 when the WA State Department of Health received matching federal funds for regionalization of OB and neonatal services into four centers, including the University of Washington. The UW program split into OB at UW Medical Center and neonatal at Seattle Children’s Hospital (SCH) in about 1990. After federal funding for the program ended in about 2000, SCH continued to support a neonatal educator salary until about 2010 to do needs‐assessments for referring hospitals and to teach NRP. By then, most level II and III NICUs had their own clinical nurse specialists or educators. Our neonatal outreach program initially focused on addressing the training needs of level I and II delivery hospitals, and then helped interested level II centers become level III centers. In the early 1990s, SCH began to build more durable referral relationships through LLC arrangements and neonatal/pediatric hospitalist service contracts. In the early 2000s, SCH hired a neonatologist for the level III NICU at Kadlec (until they partnered with Prov‐Sacred Heart a few years later). The neonatology outreach leader began frequent trips to sites in central WA and western MT to build personal relationships, primarily by giving didactic presentations requested by the neonatologists and reviewing the outcomes of neonatal patients they sent to SCH or UW with brief educational comments. In about 2010, our neonatology outreach program expanded to include our level III/IV NICU medical directors. We meet regularly with SCH Neonatology director Jake Hawksworth and leaders in the SCH Strategic Planning and Business Development office. In 2019, we worked with them to develop a contract to support neonatal training services in Bozeman, MT.