NEONATOLOGY ON THE WEB

Chicago Plan for Care of Premature Infants By Julius H. Hess, M.D., Chicago JAMA 146(10):891-893, July 7, 1951

The importance of proper care for premature infants has been slow in being recognized. While my interest in this phase of the practice of medicine goes back to 1906, it was not until 1922 that a premature infant station of size was finally established in the Sarah Morris Hospital of Michael Reese Hospital in Chicago. This station was willing to accept premature infants from all sources, whether born in a home, at Michael Reese Hospital or at some other hospital where necessary equipment and nursing care were not available. The success in establishing and operating our premature station has been due to the efforts and interests of the Infants' Aid Society of Chicago, a group of philanthropic women now numbering over 1,100 active members, who have supplied most of the equipment for the station, have provided care for a high percentage of our charitable and semicharitable cases, and have established an endowment fund, the income from which may be used only for the employment of nurses in the station or the procurement of breast milk in necessary instances. These activities of the Infants' Aid Society have been given in some detail as a helpful suggestion to other institutions desiring to have a premature station.

In 1922, when our premature infant station was opened, it was obvious that infants born in homes or other hospitals could not be accepted into the clean newborn nursery in Michael Reese Hospital and for this reason the station was located in the Sarah Morris Hospital for Children. The possibilities of the station were slow in being recognized by the medical profession, and the wisdom of opening such a station in a hospital for children was not immediately admitted, as evidenced by the fact that only 19 patients were accepted for care in 1922, 28 in 1923, 47 in 1924, 66 in 1925, and 106 in 1926. From that point on the admissions increased until 492 premature infants were admitted in 1947, 488 in 1948, and 435 in 1949.

By 1932 the demands on the station had reached a point where it could no longer provide for all the applicants who were referred for care, and the small station previously established at Cook County Hospital was enlarged. At the present time the Sarah Morris Hospital station has a maximum bed capacity of 35, and the Cook County Hospital station, a somewhat larger capacity. From 1932 to 1934 these two stations were operated independently but with encouragement from the Chicago Board of Health.

In 1934 the city-wide plan for the care of premature infants was inaugurated, and the Chicago Board of Health and the premature stations at Sarah Morris and Cook County Hospitals combined their facilities for the care of these infants in Chicago and Cook County. The seven basic principles which were established at our station and which are considered necessary to the operation of a qualified premature infant station were included in the Chicago city-wide plan and are discussed briefly.

1. It is obvious that to be of service to the infant the Board of Health must know of its birth. Therefore, in the city of Chicago, all premature births must be reported to the Board of Health by telephone within one hour after delivery, followed by written confirmation within 24 hours. As soon as the report of a premature birth is made, the Board of Health contacts the physician, if one has been in attendance, for his permission to transport the infant to a premature station if such request was not made at the time of reporting the birth. All transportation of these babies, whether from a home to a hospital or from one hospital to another, is done by the Board of Health in a specially designed and equipped ambulance. The nurse who accompanies the ambulance has had special training in the handling of the infant during transportation, especially in emergency treatment. If the baby is in another hospital and is in poor condition, it is suggested that it be kept in an incubator and given oxygen until its condition improves, waiting from 8 to 24 hours before removal to a premature station. If the baby is born at home and is in poor condition, oxygen is administered by the nurse from the Board of Health, and the infant remains in a warm crib supplied by the Board of Health until there is definite improvement in respiration and circulation and is then transported to a premature station. Regardless of where the baby is born, it must be protected against chilling from the time of delivery until transported to a special station. Oxygen is given, at least temporarily, to all premature infants received in our station. Any patient brought to the station from outside is examined only for cyanosis, trauma, and congenital deformities at the time of admission, limiting exposure to a minimum. Thorough physical examination is delayed until the infant's general condition warrants such procedure,

2. The premature infant stations are supplied with incubators or some type of heated beds, as well as special equipment for oxygen and other emergency therapy.

3. Premature infant stations must have nursing and medical care by trained personnel. It has at all times been our contention that skilled nursing care is the prime essential in reducing premature infant mortality. Best results are obtained if well-trained graduate nurses are in charge. The supervising nurse of the station should be responsible to the pediatrician and should, therefore, be pediatrics-minded. All student nurses taking care of premature babies must receive adequate instruction and must be closely supervised. For the 24-hour period, the nursing personnel should average one nurse for every two to four infants, the number of nurses required depending upon whether graduate or undergraduate nurses tire in charge of these babies. In our station there are also nursery maids, who have been trained for one year in the care of newborn and young infants. They spend part of their training period in the obstetric nursery and part in the children's hospital in which the premature station is located. Since they remain in the station for longer periods than the average nurse in training, the personnel is changed less frequently, which is a great advantage, decreasing the amount of personnel instruction necessary.

It is my belief that care of premature infants should be assigned to the pediatric department and that a long period of service in the station should be considered desirable for the pediatrician and resident as compared with the usual short-term rotation service. It has been our experience that an inadequately trained house staff is soon evidenced by increased morbidity and mortality in the station.

4. Breast milk for the infants in our station is supplied or obtained from wet nurses and visiting mothers. The mothers of the babies who are patients in the station express their milk at home and send it to the hospital to be used. The Chicago Board of Health maintains a breast milk station which makes breast milk available without cost to the hospital when it is needed to supplement our own supply.

S. A field nursing service has been developed for instruction of the mothers in the care of infants following their graduation from the station. Special attention is also given to the promotion of breast milk secretion. Breast milk in the home reduces the number of hospital clays, and most mothers can be taught hand expression. Psychology plays in important role here.

6, A simple type of heated bed is loaned to graduates for use in the home. This is of great value in reducing the number of cases returned to the hospital due to acute illnesses after graduation from the station.

7, An outpatient clinic is maintained for instruction of mothers and for the care and supervision of graduates. It was recognized early in our station that such a clinic was most desirable because many of our patients come from families in the lower income bracket and frequently do not have private physicians. Many times the private physician in attendance will request that the baby be: returned to the clinic during the early months after graduation. It is important that the follow-up clinic have as its objective good physical growth and mental development in the child, factors which are as important as a low mortality and morbidity rate. The increasing importance of our outpatient clinic is shown in the following statistics:

Illinois through its Department of Public Health in Springfield, has a well-defined program for the care of premature infants. Three stations are now in operation outside Cook County, and plans for six more are being completed. Through the use of premature centers that meet the standards of location, space, physical equipment, and specialized medical and nursing care, the Illinois Department of Public Health provides hospital and nursing care not available in all localities for the premature infants of all economic levels, gives economic assistance to families who lack the necessary funds for specialized medical service in caring for their premature infants, and thus provides a means to aid in diminishing mortality attributable to prematurity. Through grants of funds from the Children's Bureau the centers have been paid for hospitalization of infants who would otherwise be denied this special care. Similar financial arrangements have enabled the Department of Public Health to pay, where necessary, for the ambulance transportation of infants from outlying areas of the state to the centers. Funds have also been made available for providing special training for nurses serving in these centers. Integration of the phase of hospital care with later home care has been accomplished through the cooperation of local health departments and public health nurses.

To meet the needs of and the increasing demands for trained personnel, voluntary training centers must be established throughout the United States. Michael Reese Hospital has encouraged a program of special training for physicians in the care of the premature infant, and many physicians, supervisors of state and city boards of health, and supervisors of individual hospitals have taken advantage of in opportunity for observation in our station. A six-weeks' course for nurses is given at the Sarah Morris Hospital premature station, covering not only the theoretical but also the practical application of care of the premature baby, the latter including experience in the station, in the outpatient department, and on home visitation, Various training programs for nurses are being offered in other qualified centers, such as the Harriet Lane Home of the Johns Hopkins Hospital in Baltimore; Columbia-Presbyterian Medical Center and New York Hospital-Cornell Medical Center in New York; Cook County Hospital premature station, Chicago; Los Angeles General Hospital; Colorado General Hospital, Denver; Oklahoma University Hospital, Oklahoma City; Charity Hospital, New Orleans, and the Margaret Hague Hospital in Jersey City. It is unfortunate that there are so few training centers in this country and that these are so limited in the number of nurses that can be trained. It is my belief that nurses must be offered this type of training at the expense either of the state or the individual hospital to which they will return at the completion of the training period.

Having become interested in state-wide programs for the care of premature infants as they are carried out in this country, in 1949 I wrote to the Divisions of Maternal and Child Health in all of the states as well as Alaska and Hawaii in an effort to determine what progress had been made'in those localities, The replies received from 44 states and the two territories indicated as many variations in the program as there are Divisions of Maternal and Child Health. Although no state has established a fully satisfactory state-wide program, nevertheless, much progress has been made.

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