Centripetal referral of newborns requiring mechanical ventilation to tertiary NICUs has been the established model of perinatal regionalization for roughly twenty years. Data justifying this model are mostly of the same vintage. We wondered whether advances in technology, pharmacology, and skill allowed for alternative regionalization models of equivalent efficacy.

Methods: We compared the outcomes of infants born at two referring hospitals with differing models of regionalized care -- obligatory(OBLIG) vs optional (OPTION) transfer of intubated infants. We correlated markers of illness severity (b.w., g.a., race, gender, APGAR 1, APGAR 5, max appropriate FiO2 in 1st 12 hrs, max BE in 1st 12 hrs, CRIB score) with outcomes (mortality, length of stay, days on ventilator, and discharge on O2).

Results: 107 and 127 infants requiring mechanical ventilation were born in the OBLIG vs OPTION hospitals respectively. All OBLIG hospital patients were transferred to the U of C., while only 55 pts (43%) were transferred from the OPTION hospital. There were no differences in markers of illness severity comparing infants born at the two institutions (b.w: 2002 vs 2002g; g.a: 33 vs 33 wks;% males:.58 vs.62;% black:.60 vs.70; APGAR 1:5.7 vs 5.7; APGAR 5:7.3 vs 7.4; Max FiO2: 65.1 vs 60.3; worst BE: -6.7 vs -6.1; CRIB 3.9 vs 3.2]. OPTION infants who were transferred were significantly smaller and sicker than those who remained. All outcome variables were equivalent comparing infants born at the two hospitals: mortality (.11 vs.12); length of stay (24.0 vs 27.5 days); days on vent (6.5 vs 6.8 days) or home on O2 (.12 vs.17). The total number of tertiary pt days saved by the OPTIONAL model accounted for ≈42% of the NICU days devoted to pts born at the OPTIONAL center, whose daily costs were roughly 1/2 of the tertiary referral center.

Conclusions: 1) Newborns requiring mechanical ventilation can be safely cared for in regionalization networks employing either optional or obligatory transport strategies. 2) Optional transport defers roughly 50% of patient vent days from the tertiary to secondary NICU. 3) Determinations of the preferable regionalization model for individual hospitals require consideration of institution- and locale-specific factors. A priori arguments favoring obligatory transfer of ventilated newborns may no longer be decisive.