A New Level of Neonatal Intensive Care at University Hospital

By Josh Garcia
Friday, January 12, 2018

University Hospital has received Level IV NICU designation from the American Academy of Pediatrics (AAP) and the state of Texas, further cementing the hospital’s commitment to providing exceptional care for newborns with complex conditions and their families.

Alice Gong, MD, Professor of Neonatology at UT Health San Antonio (left), with a participant of University Health System’s PREMIEre program

University Hospital has been designated a Level IV NICU — the highest designation possible — by the AAP and the state. It is the first in San Antonio to be verified a Level IV NICU by the AAP. It is able to provide on-site care for the most critical neonatal cases through a collaborative effort of physicians, surgeons and specialists.

Texas legislators recently determined that hospitals providing neonatal care must receive Level I, II, III or IV NICU designation from the Texas Department of State Health Services in order to be reimbursed by Medicaid. The new measure is aimed at improving neonatal and maternal care across Texas and lowering the statewide neonatal mortality rate. Designation guidelines were established by the newly formed Perinatal Advisory Council and adopted by the state in 2016.

Hospitals with NICUs are required to undergo a verification process performed by either the AAP or the Texas EMS Trauma and Acute Care Foundation. Both are survey entities that forward results to the Texas Department of State Health Services for final NICU designation.

“Even before the legislation was passed, University Hospital met all the Level IV NICU requirements that the state put in place,” says Cynthia Blanco, MD, Professor of Neonatology at UT Health San Antonio, Medical Director of the Neonatal Nutrition and Bone Institute at University Health System and Medical Director of the Neonatal Transport Team at University Hospital. “The AAP found no deficiencies during the two-day verification process.”

Through documentation and constant communication, the various subspecialists and physicians within the Level IV NICU stay up-to-date on patients and perform daily rounds with residents and medical students. This communication extends outside of the NICU to other departments within University Hospital and the larger University Health System.

Above and Beyond

University Hospital has access to a multitude of resources that go beyond the Level IV NICU requirements. For example, the University Children’s Pediatric and Congenital Heart Center is located above the Level IV NICU, allowing for the convenient transfer of infants in the event of a cardiac diagnosis. The Pediatric and Congenital Cardiac Care Unit within the Heart Center includes 18 variable acuity rooms that provide intensive care while still providing the amenities of a regular hospital room. The Heart Center is not required by Level IV NICU guidelines.

“We also have access to the Neonatal Nutrition and Bone Institute, which provides unique compositional analysis into the developmental health of newborns that no one else in San Antonio can perform,” Dr. Blanco says. “Resources like the University Transplant Center, dietitians and lactation support specialists provide patients and families access to all the treatment options they need in a single location.”

The Neonatal Nutrition and Bone Institute is made up of a multidisciplinary team dedicated to researching the effects of nutrition and bone health on infant development and overall health. Specialized procedures such as dual-energy X-ray absorptiometry and air displacement plethysmography allow staff to follow up with children months or years after birth to study now nutrients affect body composition.

Transfers to the Heart Center, Nutrition and Bone Institute and other departments are handled smoothly — many specialists are already well-versed in a patient’s situation before a diagnosis or complication requires that the infant be moved to their care.

“During our site visit, the AAP found that we had a clear commitment to provide integrated care to patients,” Dr. Blanco says. “They found that we had strong interactions between all multidisciplinary team members and seamless collaboration with UT Health San Antonio, which gives us access to research and clinical trials that can benefit premature babies.”

Upcoming Level IV Maternal Designations

The Perinatal Advisory Council established by the Texas legislature is currently drafting maternal level of care designations to be used alongside NICU designations across the state.

Cynthia Blanco, MD, Professor of Neonatology at UT Health San Antonio, Medical Director of the Neonatal Nutrition and Bone Institute at University Health System and Director of the Neonatal Transport Team at University Hospital, is a member of the Perinatal Advisory Council.

“I became involved with the Perinatal Advisory Council in 2015,” Dr. Blanco says. “I joined because I wanted to make lives better for babies and their mothers.”

University Hospital already has a large number of maternal fetal medicine specialists and support for mothers in the ICU and is preparing documentation for verification once the maternal care guidelines are established. Elly Xenakis, MD, Professor and Chief of the Division of Maternal-Fetal Medicine at UT Health San Antonio, is also a member of the Perinatal Advisory Council and works alongside Dr. Blanco in developing those guidelines.

Research and Clinical

University Hospital takes part in a number of clinical trials aimed at improving NICU care. Many of these studies result in the advent of treatment or best practices that become the preferred method of care nationwide.

Cynthia Blanco, MD, Professor of Neonatology at UT Health San Antonio, Medical Director of the Neonatal Nutrition and Bone Institute at University Health System and Medical Director of the Neonatal Transport Team at University Hospital

“Mothers who participated in a certain trial 10 or 15 years ago were able to deliver human milk nutrition to their infants through the use of fortifiers,” Dr. Blanco says. “Today, that’s the standard of care, which means that those infants were receiving the standard before anybody else.”

Clinical trials give parents a greater choice of treatment options and technologies, from new ventilators that are designed to be gentler on infant lungs to specialists who focus on the physical and emotional health of infants and their families and teach parents how to bond with premature infants. Alice Gong, MD, Professor of Neonatology at UT Health San Antonio, is performing research on the latter by examining the developmental effects on infants who form a strong emotional bond with their mothers. Preliminary data shows that this bonding may be beneficial to development.

Dr. Blanco is also working on a study as part of the Neonatal Nutrition and Bone Institute.

“We’re learning if an infant’s body composition is affected by the mother’s health,” Dr. Blanco says. “For example, we want to see how diabetes and obesity in pregnant mothers can change a newborn’s development and body composition trajectory and whether we can modify that trajectory with nutrients.”

In addition to promoting research, the academic environment at University Hospital’s NICU provides attending physicians, residents and students with access to state-of-the-art technology and information about the latest treatment therapies. Because the hospital is a teaching environment, it’s able to provide complex treatments, specialized care, and advanced surgeries and procedures that might not be available in the community setting. Medical residents and students can look into extra options to accommodate families and patients while learning to become well-rounded community physicians.

Zika Testing for Expectant Mothers

The infectious disease services offered at University Hospital include testing and follow up for the Zika virus, which is spread by mosquitoes and can cause birth defects. The center is led by Patrick Ramsey, MD, Professor of Obstetrics and Gynecology at UT Health San Antonio.

While most institutions must wait weeks for testing results from the CDC, University Hospital can perform testing on-site, allowing expectant mothers to receive results and make decisions earlier. Once testing is completed, results are then forwarded to the CDC so it can collect data on the virus.

“With all of the hurricanes and flooding happening lately, the climate is perfect for the breeding of mosquitoes,” says Cynthia Blanco, MD, Professor of Neonatology at UT Health San Antonio, Medical Director of the Neonatal Nutrition and Bone Institute at University Health System and Medical Director of the Neonatal Transport Team at University Hospital. “We’re trying to get prepared ahead of time in case there is an outbreak of new Zika infections.”


Well-established technologies and methods such as extracorporeal membrane oxygenation (ECMO) are available at University Hospital in addition to clinical trial and research options. The ECMO program can perform lung, heart and kidney functions for infants who are in between surgeries or are recovering from procedures. In some cases, surgeries can be performed while the infant is still utilizing ECMO.

Additional technology at University Hospital is used to encourage bonding between premature infants and their parents. Mothers who are ill after birth may not be able to visit their infants from the ICU, and others may have a difficult time returning to work while their infant continues to receive treatment in the NICU. Technologies like Angel Eye and Baby Chat allow mothers to see their children no matter where they are.

“We have nurses that are trained with the technology,” Dr. Blanco says. “Mothers can take pictures and watch their children through cameras placed above infants’ beds. The technology is available 24/7 — so long as infants aren’t undergoing additional procedures — and parents can log in securely using a password wherever they are.”

The Neonatal Intensive Care Unit at University Hospital

Transport and Community Outreach

The Neonatal Transport Team at University Hospital has access to customized air and ground vehicle transportation. Dr. Blanco describes the custom ambulance as “a NICU on wheels.” These vehicles contain ventilators, life support and more to provide treatment for infants as they are being moved from hospitals throughout Texas to University Hospital. In addition to transporting patients to and from University Hospital, these transports are also used to provide support to communities with lower level NICUs.

“State guidelines state that we need to do outreach by providing support and education,” Dr. Blanco says. “We have a robust teaching program with simulation that can be used at other facilities, and we’ve been doing this type of outreach for over a decade.”

University Health System’s Neonatal Transport Team

Building for Tomorrow

When infants are discharged from University Hospital, the NICU Graduate Clinic and PREMIEre Program continue to address their needs with specialized care. The NICU Graduate Clinic offers follow-ups for infants during their first two years of life, and the PREMIEre Program follows infants with risk of developmental delays, providing evaluations every three to six months for neurologic and developmental issues. University Hospital encourages patients and families to stay involved with the NICU program long after treatment is over.

“Our 36th annual NICU PREMIEre reunion is happening this year,” Dr. Blanco says. “We have former patients who are in college or professional careers now who still attend.”

The University Hospital NICU cares for about 700 infants from throughout Texas every year. A recently announced expansion includes the creation of a 250-bed Women and Children’s Tower that will house a larger NICU and provide more services for infants and families under one roof. The Women and Children’s Tower is expected to open in 2022.

For more information about University Hospital’s NICU, visit universityhealthsystem.com/services/pregnancy-childbirth/nicu, or call 210-358-TALK (8255).