Just a few days after the new Golisano Children's Hospital's Neonatal Intensive Care Unit opened in July, a new mother and father endured the most painful goodbye of their lives.
“Despite everyone’s best efforts, we had a baby who passed,” says professor of Pediatrics (Neonatology) Patricia Chess, MD, who directs the Neonatal-Perinatal Medicine fellowship program. “It was very sad, but it was also beautiful, because everything happened right there in that room. Our team of physicians and nurses and subspecialists communicated with the parents every step of the way. The family was there the whole time and never needed to leave their baby’s side. We had the opportunity to give the family a crucial amount of privacy and support in those final moments with their child, and it was very peaceful.”
Although the success stories of infants in the NICU are far more frequent, this experience perfectly illustrates the intimate, family-centered atmosphere the unit has fostered, she says.
“Everything we do here—whether it’s providing the very best patient care, teaching, learning, or conducting research—depends on us working as a team with families,” says Chess, who completed her residency and fellowship at UR. “The new setting reinforces those close, personal relationships, and what we accomplish as a result is amazing.”
This marks the third NICU Chess has worked in during her 28-year career in the Medical Center, the most recent being the former 60-bed unit on 3-3400, which was divided into pods, each containing six babies.
“Our previous units were wonderful in terms of care, but they evolved based on need, without a lot of foresight,” says Chess. “Space was very limited, so if a baby was not doing well, the only way to give the family some seclusion was to pull curtains around the isolette so the parents could squeeze inside them. We’ve come such a long way in creating a more nurturing, healing space that embraces the personal needs of the families and supports them as partners.”
In terms of patient volume, the new 68-bed Gosnell Family NICU is the largest unit in the Medical Center, often functioning at peak capacity, and caring for more than 1,200 babies annually from across upstate New York needing highly specialized care. Although preemies born as early as 23 weeks remain on the unit the longest, about half of the patients at any time are full-term babies being treated for congenital anomalies, infection, pneumonia, or recovering from respiratory distress during delivery.
The large, airy, private rooms are comfortably designed and furnished so parents can stay with their babies and create a “home away from home” with knick-knacks, photos, blankets, and stuffed animals.
“These are all of the things that you could never do in a six-pod nursery,” says Chess. “From the check-in area, to the family meeting and relaxation rooms, to the beautiful colors, everything says ‘welcome.’ Many of our babies are here for months, and for some this is the only nursery they may ever know. From day one, this gives the families such a different experience than we could ever give them before.”
An Incubator for Learning
But it’s not only families who are benefitting from the transformed NICU.
“From a learning and teaching perspective, you could not ask for a better platform,” says Chess, who currently oversees eight neonatology fellows, three of whom are ‘first-years’ selected from a pool of 47. “This year we hit an all-time high in applicants. We’re getting more complex referrals from Buffalo and Syracuse and Pennsylvania, and that in turn makes for a stronger training program because people recognize they’re going to see a greater breadth and depth of clinical issues.”
Limiting the number of fellows to eight ensures that each receives ample personal attention, she says.
“There’s a fine line between having enough fellows so that each pediatrician isn’t overburdened with clinical responsibilities, and not having so many that you can’t help them with career growth, especially mentoring those interested in research,” she says. “We strive for that balance.”
The present NICU is divided into three teams—blue, gold, and green—each overseen by an attending neonatologist. The blue team is run by fellows, who round and function under the guidance of the attending.
“Early on in a fellow’s career, the attending is ever-present, giving a lot of feedback, but then as they get more experienced and wiser in their decision-making, the attending gives them more independence, yet is always aware and ultimately responsible,” says Chess.
Toward the end of their three years, each fellow does a pre-attending rotation where they act as the attending, running rounds independently with a junior fellow, and seeking the attending only for questions.
“While we’re always in the background, and always checking on the babies, the pre-attending rotation gives the fellows a real sense of responsibility and confidence before starting their first position,” says Chess, adding that over half of the faculty on the unit (including NICU medical director and Neonatology associate professor Timothy Stevens, MD, MPH), completed their fellowships at the UR.
“We trust who we train,” she says. “Our fellows never have trouble finding a position because they’re well-trained academically and clinically, and many move on to academic and research positions. It’s a great source of pride to be able to say that.”
Chess says that the high level of clinical research being conducted in the NICU is of particular interest to scientifically-oriented fellows and residents, as well as medical students who often gain hands-on experience writing grant applications during their clinical rotations.
As one of 20 Neonatal Research Centers in the country, the unit is funded by the National Institute of Child Health and Development to take part in clinical research trials of medications and treatments to optimize patient care in NICUs. Every clinical trial first must be deemed safe and appropriate by all attending neonatologists, and before a family is approached about participating, their specific attending must agree it is appropriate for that particular child, says Chess.
“Our first focus is making sure every single baby gets the best possible care today,” says Chess. “But we also want to make sure the care we give tomorrow is even better, and that can’t happen without research.”
Because of this, NICU families at GCH have access to interventions unavailable elsewhere. For example, premature babies in respiratory distress had access to life-saving synthetic surfactants in Rochester long before their FDA approval, due to the pioneering clinical trials conducted here.
"A Pure Addiction"
Recently, one of the many longtime NICU nurses showed first-year neonatology fellow Laura Price, MD, a photo of a grinning 5-year-old girl.
“She was a baby who, when I was working as a hospitalist, we had resuscitated in the delivery room,” says Price. “She was teeny, weighing just over a pound, very high-risk, and we really didn’t know if she would make it. But now, here she is out running around in the world, and you can say you were there at the beginning. That’s what it’s all about for me.”
At age 40, Price is beginning her own new chapter as a neonatology fellow after completing both her general pediatric and chief residencies at UR, and working several years as a private pediatrician and a URMC hospitalist in the newborn nursery, birth center and NICU. She’s now on a three-year journey to become a board-certified neonatologist who will share clinical research and educational roles.
“I am loving fellowship,” says Price, who fittingly possesses a youthful energy and enthusiasm for her work. “To care for patients at such a high volume with great preceptors, and also have a lot of time for just learning and teaching is such a luxury. Having worked as a pediatrician—and now to learn the research and understand the ‘why’ behind everything—is so gratifying. It’s such a wonderful mix of clinical exposure to very complex, high acuity patients, all backed by huge academic resources, great teachers, and research inventories. And it’s all right here.”
Price sees NICU patients six days-a-week for two weeks in a row, then rotates to nights for five days. Eighty-hour weeks are common. Research work and conferences, plus rotations at a community hospital, a pediatric developmental unit, and NICU follow-up clinic mean her home remodeling projects have been put on hold for awhile.
“I really think of this as my home,” says Price, while stopping to check on, and snuggle with one of the babies in her care who will soon be going home.
“Just look at her sweet face…How could there be a better place than this to be?”
Besides stealing occasional “mommy moments,” she says one of the best parts of her work is providing cooperative care.
“The daily clinical decisions you need to make in the NICU are infinitesimal, but the decisions are based on expertise from all of the practice groups,” she says. “Teamwork happens really well here. There is this little human being that parents entrusted you with, and we are all focused on the same goal. One of the biggest differences we are making is with very sick full-term and near-term babies who not long ago would have had shortened lives. Being able to intervene in those first few seconds, and weeks, and change their whole life trajectory, is a great feeling. The care of an infant is such a pure addiction.”
Price, whose current research interest is in the neurodevelopmental effects of maternal diabetes, says that the new NICU offers the perfect setting to learn from Chess and other preceptors, as well as from care providers across the unit.
“When we round, we round with the baby and the parents, med students, interns, residents, fellows and attendings, nurse practitioners...” she says. “In a room with the family, we have full privacy and can have full conversations without having to taper anything based on the worry of others hearing. You can have true family-centered rounds. It’s a more relaxed place to be a parent, and a more relaxed place to be a learner.”
Setting the Bar
Nina Schor, MD, PhD, the William H. Ellinger chair of Pediatrics, says the new GCH sets the bar for how a children’s hospital can integrate and elevate its patient care, education and research missions.
“For medical students, residents and fellows, this shows them what the ‘state-of-the-art’ is,” says Schor. “It was wonderful to see the wide-eyed expressions on the faces of the first groups of residents and medical students learning their way around the new building. With the on-call rooms, conference rooms, break rooms, separate elevators for trainees, and tons of administrative space—in addition to improved space for rounding and bedside learning—it’s truly organized for the way we teach today.”
Associate professor of Pediatric Nephrology William Varade, MD, who directs the pediatric residency program, says last year’s graduating class of third-year residents were “more than a little jealous” they didn’t have an opportunity to work in the new building.
“But we made sure they got tours, because they had input in its design and it’s something they were very proud of,” he says. “Many of them are working across the country now and there’s no doubt they’ll be talking about what’s going on here.”
Varade says the way the new hospital was constructed with the involvement of people across departments and disciplines speaks to the foresight of the University.
“One of my applicants asked me once, ‘Why are you still here?’” says Varade, whose career with URMC has spanned 25 years. “I tell them it’s the institution and the way they do things. It’s not all top down. For this project, they involved people in the trenches, including residents, and that makes sense because they