This program targets infants at high-risk for infant mortality (determined by birth-death certificate linked files). 20% of newborns discharged from the hospital met the high-risk criteria; Milwaukee Health Department nurses visited approximately half of these newborns. The goal of the program is to decrease the nurse work load and at the same time increase their effectiveness in reaching the newborn babies most at risk of infant mortality, and thereby have the greatest impact on infant mortality. The expected outcome is to decrease in infant mortality rates (IMR), specifically deaths due to SIDS/SUDI and positional or mechanical asphyxiation.
This practice addresses the problem of high urban infant mortality. In 2000, Milwaukee's infant mortality rate (IMR) ranked at 40th among the 50 largest cities, at 11 per 1,000 live births, compared with the U.S. rate of 7 per 1,000 live births. The literature tells us that nusre visits can decrease infant mortality, so the problem of infant mortality (and scarce resources) has been addressed by better targeting nurse visits via an evidence-based data analysis of birth certificates and Fetal-Infant Mortality Review data to determine which infants are at highest risk of dyign after discharge from their birth hospital, as well as guide nurse educational messages about preventing the most common causes of home deaths.
Newborn nurse home visiting programs are a typical part of health department practices. However, home selection for visits, if done, is usually only the result of a diffuse list of risk factors gleaned in the literature on all infant mortality (as opposed to infant mortality after discharge from the birth hospital in this practice, i.e. those cases where newborn visits can actually have an impact).
Agency Community RolesDuring 2001 all levels of Milwaukee Health Department staff in conjunction with community partners were busy working on how the Department could better deliver services to improve key outcomes. A group of nurses, educators, and pre-natal care coordination workers (primarily to health maintenance organizations) met to address the outcome goal of decreasing infant mortality. One of the first concerns discussed was how to be effective in the face of nursing shortages, decreased budgets and other displacements of nurses' time. Since the health department has access to data, the newly-arrived, epidemiology-trained, Associated Medical Director came up with this innovative analysis to help solve the problem by targeting visits.
This program also required buy-in from hospital discharge nurses at all the birthing hospitals in the city, so that the correct referrals would be made for health department newborn nurse home visits. This was done in a group meeting and since then this group of Health Department and hospital workers have met regularly to tackle infant mortality issues and awareness at many different levels. Additionally the health department-initiated Fetal-Infant Mortality Review (FIMR) team (physicians, NICU nurses, bereavement counselors, social workers, child protective services, and various interested parties in the community) fed information gleaned fromt heri detailed reviews of infant deaths for system improvements and necessary educational messages to prevent future deaths.
Costs and ExpendituresThis program was very sustainable, because it is based on the re-targeting of resources already available to the health department. Additional input in data analysis and epidemiology was required, but after the initial investment of time (approximately 2 months full-time) is truncated to a few days. No additional funds were used. As this is health department driven, we expect this practice will continue indefinitely. The creation of the group of hospital workers and health department workers with feedback regularly refreshes the continued community-wide acceptance and new input into this practice.
ImplementationThe plan began with an estimate of how many newborn nurse home visits (including long-term follow-up) are possible in a given year. For Milwaukee, it was estimated that 1,800 newborns could be visited, realizing that many would not need long-term follow-up and that a percentage of the newborns might not be reached due to infectious disease outbreak follow-up require of the same nurses, as well as not being able to locate some. The next step was data-drive and so evidence-based to determine which birth certificate factors cause the highest relative risk of infant mortality. The cut-off in Milwaukee was statistically determined risk factors which increased the risk of post-birth-hospital-discharge mortality 3-fold or more, because approximately 1,800 infants met these criteria.
Once the analysis was completed, the methodology and reasons behind this change was explained in detail to all the health department newborn home visiting nurses. Next, all the hospital discharge nurses were educated about the new program so that correct referrals would be made. The entire program took one year to set up. The data analysis is updated almost yearly for changes in community risk patterns.
Currently the best method of outcome evaluation is the data trends in infant mortality. The IMR has decreased every year since the program's initiation, and the improvement appears to have specifically impacted African Americans (which if this is truly a trend would be the first improvement in 15 years). Furthermore, improvement has been specifically in decreasing Sudden Infant Death Syndrome, Sudden Unexpected Death of Infancy, and positional ro mechanical asphyxiation all of which are possible for the newborn nurse home visits to impact. It would be inaccurate to say that a single program caused a decrease in the infant mortality rate, since the many medical and social situations associated with the IMF suggest that a plethora programs reachign a wide variety of people at many levels are needed. However, when the new statewide database linking birth certificates with newborn nurse home visiting and mortality becomes available, it will be possible to determine how correctly the program has been implemented and the intervention-specific infant mortality.
Key elements to replicate the practice: Data analysis of birth-death certificate linked files. Determine the relative risk of various factors on the birth certificate; select those which have an associated at least 3-fold increased risk of infant mortality.