While fewer than 1 in 20 infants born locally will need a Neonatal Intensive Care Unit, having an advanced-level NICU available just in case is one reason more than 25 percent of expectant mothers chose to go out-of-county last year for labor and delivery instead of having their baby at Cleveland Clinic Indian River Hospital.

In recent months, with Cleveland Clinic completing a $7 million renovation of the Vero hospital’s Labor and Delivery facilities, that has given rise to extended discussion of whether local taxpayers should underwrite the $1.5 million to $2 million annual cost of upgrading the current Level One NICU so more Indian River County babies will be born here.

Maternity issues were not expected to take center stage tonight when the county Hospital District holds a final public hearing on how it’s going to allocate taxpayer dollars in its 2025-26 budget, even though it was announced at the last minute Wednesday that Cleveland Clinic had submitted a written request for $2 million to support maternity care in the coming fiscal year. 

But the future of labor and delivery services locally is expected to be a major issue in the year ahead.

Vero’s hospital has a basic Level One NICU nursery staffed and supported by Nemours Children's Hospital.  This allows doctors in Vero to deliver babies born up to five weeks early or 35 weeks gestation, and to treat most routine newborn problems, including administering IV medicines and employing emergency short-term ventilation.

Anything more complicated might require transport to a Level Two or Level Three NICU. Should the baby require certain types of surgeries, a Level Four NICU would be required.

HCA Lawnwood Hospital in Fort Pierce, Cleveland Clinic's chief competitor for labor and delivery patients, has a Level Three NICU. Holmes Regional Medical Center in Melbourne has a Level Two NICU. 

Cleveland Clinic's Tradition Hospital already has a Level Two NICU, also staffed and supported by Nemours doctors, with plans to achieve Level Three status in the near future. Orange County has Level Four NICUs at Nemours' Orlando and Orlando Health's Winnie Palmer Children's Hospital.

“When I first started in the role about 1 year ago our team eagerly explored the potential to expand to a Level II NICU with Nemours, starting with the delivery volumes and demographics in the community,” said Dr. Richard Rothman, vice president and chief medical officer at Cleveland Clinic Indian River Hospital.

“The process highlighted the potential value such an addition could bring in the future, however the projected patient volumes were insufficient to offer sustainable care with incremental operating losses that would range between $1.5 million to $2 million per year, and, what weighed more on the decision was that the low volume of babies would not allow our clinical teams to build and maintain the proficiencies needed to be best in class,” Rothman said.

But with Cleveland Clinic preparing to unveil its $7 million renovation of the hospital’s Labor and Delivery facilities in December – with modern private suites, upgraded amenities and the latest equipment – the number of births locally seems to be trending upward.

“We anticipate being the preferred choice for expectant mothers, delivering about 900 babies or nearly 80 percent of all births within the county, with some of the best mother-baby outcomes in the State of Florida,” Rothman said.

Unfortunately, though, that’s still not enough births for the Vero hospital to break even financially. Operating and staffing the Labor and Delivery Unit results in a loss of nearly $3.5 million per year. The additional $1.5 million to $2 million to support a higher-level NICU would compound that situation, Rothman said.

While the changes of an expectant mother needed a higher-level NICU are fewer than one in 20, knowing a hospital has one can provide prospective parents peace of mind.

The American Academy of Pediatrics publishes national guidelines about what a hospital needs to have and do to achieve each level, and Florida’s Agency for Health Care Administration or AHCA updated its general rule for NICU operations in May 2023.

A Level Two NICU, according to AHCA, can accommodate newborns up to 10 weeks premature or 30 weeks gestation, and weigh at least 2.75 pounds. Obtaining a Level Two license requires a director who is a full-time pediatrician with neonatal training, a transfer agreement with a nearby Level Three NICU and 24-hour emergency transport for acutely ill newborn patients.

A board-certified or board eligible neonatologist or neonatal specialist must either be on-site or on-call closer than 30 minutes away at all times. The NICU team must be specially trained, supervised by a Registered Nurse, with access to cardiac, neurology, respitatory, opthalmogy, radiology and other specialists. The Level Two NICU must offer prenatal screening and maternal-fetal medicine services, which Cleveland Clinic Indian River Hospital already provides.

A Level Two NICU can keep a newborn on a ventilator for up to 72 hours, but if ventilation is needed longer than 72 hours the baby must be transferred to a Level Three NICU.

Staffing, training, certification and equipment requirements escalate for the Level Three NICU, where certain neonatal surgeries can be performed with a full neonatal surgery team on-site, and babies born earlier than 10 weeks can get the complex support and one-on-one nursing care they need.

Level Four NICUs have a wide range of neonatal surgical specialists on-board, as well as pediatric dialysis, pediatric oncology care, palliative care and advanced pediatric rehabilitative facilities.  

At least one elected member of the Hospital District has expressed interest in enhancing the hospital’s NICU capabilities. Trustee Paul Westcott said he’s not opposed to giving Cleveland Clinic additional money to help ensure moms have a place to deliver in Vero for generations to come, but he does not want to simply write a check without getting something meaningful in return for county taxpayers.

“One of my criticisms of government is that we react to a problem rather than respond to it. So you look at a short-term problem, you react to it with a short-term mindset and you don’t do as much as you can do, and you don’t do it as deliberatively or as thoughtfully as you could,” Westcott said.

“In this situation, I’ve looked at Labor and Delivery, and I’ve heard enough in the community that our not having a NICU drives some of the families’ decisions on where they have the baby.”

Plus there’s the issue of the indigent mothers and babies the Hospital District was established to serve being the patients the least likely to seek out an out-of-county NICU as an option due to a lack of transportation, inadequate health insurance or not having a strong support system.

Westcott believes a NICU upgrade is something local philanthropy would support, with the Hospital District as a partner. The Hospital District could even commit certain taxpayer dollars as a match challenge to the community to double the impact of their donations to support a Level Two or eventually a Level Three NICU.

Nemours is eager to provide the neonatal services at Cleveland Clinic’s Indian River Hospital.

“We have made it clear as their partner in Pediatric care, we will help CCIRH grow and develop their NICU capabilities as they see fit.  We have the staff and personal to train and educate the nursing and ancillary staff and the knowledge of what each level NICU requires,” neonatologist and associate professor of pediatrics Dr. Jane Ierardi, Nemours’ former chief partnership officer.

Beyond its own branded hospital NICUs in Florida and Delaware and the Cleveland Clinic Tradition NICU, Nemours staffs neonatal units in Pensacola, Kissimmee, Jacksonville, Tallahassee, St. Augustine, Lake Nona and Oviedo.

Expanding Nemours’ scope of services to include standing up a Level Two or Level Three NICU would bring other benefits to Vero Beach, apart from providing life-saving care to newborns. It would give Indian River County parents much-needed access to a wider range of pediatric specialists through Nemours’ network, as each NICU level certification requires an increasing variety of specialists to be on-site, on-call and rotating on-site at the hospital.

“In addition to providing Neonatologists, Neonatal Hospitalists, Advanced Practice providers we provide Pediatric sub-specialists to consult on ill neonates,” Ierardi said.

Ierardi acknowledged the training issues due to lack of volume of NICU cases that Rothman identified as a potential challenge, but said that could be easily overcome.

“Having the team see a consistent volume of high acuity babies will help maintain their skill set. This can be accomplished either by having a high volume of patients or having staff rotate through other NICU’s with a high volume of high acuity infants,” she said.

Having a Level Two or Level Three NICU with neonatal and pediatric specialists to learn from would also make Cleveland Clinic Indian River Hospital a more attractive teaching hospital destination for medical students, residents, nurses, midwives and physician assistants. This could bolster the Edward Via College of Osteopathic Medicine’s efforts to establish a medical school and residency program in Vero, and support the existing training program with Florida State University medical school.

Rothman is ready to take another look at NICU expansion, if that’s something the Hospital District wants to invest in for the community’s future.

“Indeed in 2025, We recognize the potential value a Level II NICU could offer a select group of patients, and I am eager to reassess this as the delivery volumes increase,” Rothman said.