P1.240: The Changing Landscape of Periviability in Southern California: A Case for Regional Collaboration and Standardization

Purpose/Objectives: Periviability remains a rapidly evolving focus in neonatology. Advances in care challenge clinicians to manage younger, smaller, and less mature neonates. Despite progress, mortality and morbidity remain significant concerns. Institutional differences, resource availability, and generational perspectives contribute to practice variability. Given the interconnected nature of regional healthcare, collaboration and standardization could benefit both families and providers, fostering confidence in a unified regional guideline.
Our objective was to assess interest among Southern California NICUs in:
• Sharing periviability practices
• Exchanging optimal clinical strategies
• Collaborating on quality improvement and research
• Establishing a regional standardized approach

Design/Methods: To enhance care for extremely premature infants, we surveyed institutional practices across six large children's hospitals in Southern California. The survey, conducted via phone interviews with NICU medical directors, examined antepartum best practices, neonatal resuscitation, and related strategies.

Results: Variability in Practices
• Lack of a unified approach: All centers struggle with standardizing periviability care due to differences among providers and interdisciplinary teams.
• Endotracheal tube use: Four centers discourage 2.0 tubes, one does not offer them, and one routinely uses them.
• Resuscitation thresholds: Two centers resuscitate above 22+0 weeks, two above 23+0 weeks, one above 22+5 weeks, and one above 21+5 weeks. Half resuscitate above 24+0 weeks, while the other half start above 25+0 weeks.
• Ventilation strategies: Five centers use high-frequency ventilation (alone or in combination), with one transitioning to first-line high-frequency ventilation.
• Long-term outcomes data: No center has sufficient data on key outcomes such as discharge on oxygen, G-tube need, or tracheostomy.

All six centers reported similar challenges:
• Lack of consensus between neonatology, MFM, and obstetrics in counseling and treatment.
• Need for more OT/PT support throughout developmental stages.
• Gaps in understanding physiology at different gestational ages.
• Variability in practice due to individual and generational differences.
• Improved consistency when a named, respected small baby director is present.

Conclusion/Discussion: Despite working independently, centers face similar clinical and ethical challenges. Regional practices are gradually aligning with national and international trends. There is a growing perception that resuscitation is being initiated at lower gestational ages, highlighting the need for structured discussions.
Future collaboration efforts include:
• California Small Baby Consortium meetings.
• Regional discussions at Cool Topics meetings.
• Enhanced communication platforms for informal discussions leading to formal collaboration.
• Potential development of a regional consensus guideline to improve periviability care.
By sharing experiences and aligning practices, neonatal centers can collectively enhance outcomes, strengthen provider confidence, and improve care for extremely premature infants.