OHSU Doernbecher head physician on the challenges of providing neonatal care

Recent reporting from InvestigateWest found that overcrowding in the neonatal intensive care unit at Oregon Health & Science University is raising concerns among staff and patients.

Plans to expand capacity by building a new wing of OHSU’s Doernbecher Children’s Hospital have largely stalled, despite rising demand for neonatal intensive care nationwide.

Dana Braner is the physician-in-chief at Doernbecher Children’s Hospital. He joins us to talk about the challenges hospitals are facing in providing neonatal and pregnancy care.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Geoff Norcross: From the Gert Boyle studio at OPB, this is Think Out Loud. I’m Geoff Norcross. The neonatal and pregnancy care operation at Oregon Health and Science University occupies a critical place in the state’s medical landscape. As one of only two so-called Level IV NICUs in the state, OHSU Doernbecher Children’s Hospital gets patients from all around the region in need of specialized maternity care. The problem is space. The facility finds itself at or over capacity a lot. Current and former nurses say that overcrowding is compromising care. Yesterday we spoke with Danielle Dawson at InvestigateWest about her reporting on the problem. Today we hear from the hospital. Dana Braner is the physician in chief at OHSU Doernbecher Children’s Hospital, and he joins us now. Doctor Braner, welcome to the show.

Dr. Dana Braner: Hey, thanks Geoff. It’s great to be here. Thanks again for having me. And once again, thank you so much for shining a light on this really important subject.

Norcross: Well, here’s the problem. According to the article, the leadership at Doernbecher has been talking about space issues at the NICU for a decade now, but plans to expand the facility were shelved because of financing and shifting priorities. Is that a fair characterization?

Braner: Well, I think it’s an interesting characterization, and if it’s okay with you, I’d like to broaden it for a second. If we look at neonatal care in Oregon today, we see a total of 92 level 4 beds available in the entire state for a population of roughly 4.5 million plus.

Norcross: Split between you and Randall Children’s Hospital.

Braner: Yeah. If you look at the occupancy today, once again this morning, we have 97 patients in those 92 beds. Here’s the issue, Geoff, and I think it’s pretty stark and pretty simple. If you’re going to have a child who’s going to need the services of a Level IV NICU in Oregon, the last thing in the world you want is to be sent to Seattle or San Francisco or Los Angeles or Denver. Think about that for a moment from a patient perspective. Here you are, hopefully one of the most exciting times in your life, and all of a sudden you find that you have to pick up and leave for a place hundreds, potentially thousands of miles away.

Given neonatal care now, we can take care of these kids for months on end. No support system. Maybe your job is at risk. Maybe your kids need to be at school. I think the worst thing we can do here is not provide care to these families. Remember, more than one out of two kids born in Oregon is on Medicaid, and most of our families at Doernbecher, the only public children’s hospital, are on Medicaid. We do more than 60%. So families may not have the means to be elsewhere. So making sure that we care for every child and family is really the mission of Doernbecher.

Now there is no question that our NICU is overcrowded, and there’s no question that our nurses are working in difficult conditions. But the care in our NICU, I believe, is exceptional. We never, ever, ever, admit a child to our NICU that we cannot care for both safely and effectively.

Norcross: But there are capacity problems, no doubt about it, and there have been plans for a new wing at Doernbecher proposed repeatedly over the years for the last decade. Could that project be resurrected?

Braner: So that project absolutely needs to be resurrected. We need a space that is the equal of both our families and our staff. Today, that means a space with 60 private rooms to make sure that every family gets the best care and that our staff is working in the best conditions. There is no question about this. I’ll be honest, Geoff, having worked on this now for more than a decade, I’m more optimistic now than I ever have been. We have a president, Shereef Elnahal, who literally from day one has been discussing this issue, has visited our current space multiple, multiple times, and has been up and down the state with me and others looking for philanthropic opportunities as well as other ways to finance a new space.

For the first time in a long time, we have a president who is open, who is loud, and who is definitive about their beliefs about what we need to do. So the answer to your question here, Geoff, is absolutely we need a new space.

Norcross: Are you optimistic enough to be able to give me a timeline right now?

Braner: No, I’m not optimistic enough to give you a timeline right now. I will say though that any project to improve our NICU will have to happen in two phases. The first phase has to be to decompress our current NICU. We have to be able to get patients out of our current space into a wider space to give our families more room, as well as our nurses and staff more room to take care of them.

The second phase has to be the development of a new NICU, which we have already designed, which we have permitted for, which we know exactly where the dishes will go, where the sinks will go. We have to get to that place. Right now, the price tag for that facility though is something over $400 million and right now we don’t have that exact amount of money to start construction.

So two phases. First phase, decompress our current NICU. Second phase, build a brand new space that’s equal to our patients and our staff.

Norcross: Since you brought up finances, it’s worth noting that OHSU recently posted an operating game of $65 million after years of losses. I’m wondering what that might mean for the possible expansion at Doernbecher?

Braner: I mean clearly, if you look at OHSU’s balance sheet over the last several years, it’s been a lot of red ink. And that’s not surprising, COVID and everything else. But under Doctor Elnahal’s leadership, we are posting a margin for the first time. Even though it’s a smaller margin than would be necessary to start construction on this building, it is a positive margin. Again, that gives me optimism about the future.

Norcross: According to recent reporting, feeling from nurses in both the labor and delivery and NICU sites has been that their departments just aren’t prioritized highly enough by the leadership at OHSU. I’m wondering what you say about that.

Braner: I think it’s a really good question, Geoff. Having had this project shelved and having had this project be on the books for so long, I don’t think you can fault anyone for feeling that way. That said, I think it’s almost impossible to go back in time and we can’t really do that. All we can do is look forward. The forward look here is new leadership and Dr. Elnahal and what he has said quite clearly multiple times – the latest being just last Friday – that building a new NICU, improving this space, making sure that our youngest, most complex patients get the best care possible, is a moral imperative both for him and for the rest of us at OHSU.

Norcross: What can be done right now though to relieve some of the pressure on the NICU within the space constraints that you have?

Braner: Yeah, that’s a fantastic question, Geoff, thanks for asking it. So within the space constraints we have, there really is only one answer. That is, we have to get additional space. To get additional space, that’s going to mean that we need to move other things out and be able to move space for neonates and mothers in. Then we’re able to go ahead and expand not only the space that we currently have, but the space that we need into the future. As we talk about a two-phased approach, that has to be part of phase one. We call that a bridge plan.

Norcross: What can be moved out?

Braner: So at a large place like OHSU where crowding is frankly not limited to our NICU, that’s going to be a very interesting question. I will say that currently we are looking at areas. I don’t have anything specific for you, but we have been doing this planning literally since Dr. Shereef started on his first day. I’m hopeful that we’ll be able to have something fairly soon.

Norcross: Dr. Braner, I’d like to get a broader view on all this. You’ve made it clear that the need for these services that you provide there at Doernbecher Children’s Hospital is just growing and is going to grow. I’m wondering if you have an idea why that is?

Braner: So Geoff, I’ve been a pediatric ICU physician now for 36 years. On the day I started my career, the limits of viability for a neonate were about 31, maybe 32 weeks of gestation. Those limits of viability now have come down to about 22 weeks. So just about half the time a child would normally gestate, and we can get that child to term. Needless to say, that child’s going to be more ill, going to require more complex care, and most importantly, is going to require a lot more time in the NICU.

It is not uncommon to have babies in our NICU for months upon months upon months. In addition, advances throughout medicine, cardiac medicine, kidney medicine, fetal surgery, a number of other fields have led to the ability to bring babies safely, to be successful at curing and helping those babies live that we never could be before. Personally, I think this is almost miraculous. Kids are literally the only future we have, and every single child brings the potential into the world that we’ve never had before.

Not sure about you, Geoff, but right now it’s an interesting situation out in the world, and I’m excited about the future’s ability to take care of that. So taking care of babies from their first day, I think it’s one of the most important things that we can do. We have a saying at Doernbecher: The earliest start leaves the widest wake. We also have one other saying in pediatrics, and that is: Only in pediatrics can you save a lifetime. So these advances, these miraculous advances, these unbelievable advances have also led to a tremendous amount of strain on the system.

Norcross: Part of the problem here is just the scarcity of facilities that can do this work. There’s you, there’s Randall Children’s Hospital, but outside of that as you mentioned earlier, you might be sending parents to Seattle or San Francisco. I’m wondering if there’s a health system in Oregon that could step up?

Braner: I think that’s a fantastic question, but the answer is incredibly complex. At Doernbecher Children’s Hospital, we have hundreds and hundreds and hundreds of pediatric specialties, literally in every possible field. We have a neuroimmunologist, someone who deals with immunological disorders of the nervous system. To make sure that we can care for these kids in the absolute best way possible, that infrastructure needs to be huge. Right now, that infrastructure only exists at Doernbecher and Randall Children’s Hospital. And right now that infrastructure only exists for, again, 92 bed spaces for a population of about 4.5 million.

So we do have something called the Oregon Perinatal Network, where we have visibility on every NICU in the state. Kids who don’t need the specialized care at Doernbecher and Legacy Emanuel can go elsewhere. We make sure that we try as hard as we can, that we don’t have to send kids and families way out of state, so far from their support systems. But the ultimate answer to this, Geoff, is going to be expanding our capacity throughout the system.

Norcross: For any parents to be who are planning to have their babies at Doernbecher or may have to be transferred there for specialty care, what is your message to them?

Braner: Geoff, if you have a minute, let me tell you a quick story. My daughter’s an archaeologist and she was in Iraq a year and a half ago and became very, very sick. I went out and got her, we stopped in London at a famous hospital, and they couldn’t help us, and I brought her here to Portland. Sitting in the waiting room of the ED, the triage doctor looked at her and said, wow, she’s sick. Brought her back. Within 10 minutes, she had been transfused, she had gotten medications to help her breathing, and the people there were unbelievably amazing, even though the ER was super crowded.

We then spent the next couple of days in what we call additional space, so we were boarders in the emergency room because there was not a bed in the hospital. Was it comfortable? It wasn’t great, Geoff. Did they save my daughter’s life when no one else did? Absolutely they did. Would I do it again? In a heartbeat. Every single person at OHSU that interacted with my daughter during that hospitalization came to her with love, and did unbelievable work. I would say to families going to the NICU, we will take care of you and your baby. We will make sure that you get the best care possible, and you should be comfortable coming to Doernbecher. Do we need to improve it going forward? We absolutely do. That is our mission.

Norcross: Doctor Braner, thank you so much for this. I appreciate it.

Braner: Geoff, once again, thank you so much for bringing light to this incredibly important issue. We appreciate you doing that so much. It’s been an absolute pleasure talking to you, sir.

Norcross: Dana Braner is the physician in chief at OHSU Doernbecher Children’s Hospital. You can read more about OPB’s reporting at OHSU at our website, OPB.org.

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