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Shah S, Myers P, Enciso JM, Davis AS, Crouch EE, Scheurer AM, Song C, Lakshminrusimha S. Should neonatal-perinatal medicine move to two-year fellowships? J Perinatol 2024:10.1038/s41372-024-02020-3. [PMID: 38851854 DOI: 10.1038/s41372-024-02020-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/25/2024] [Accepted: 05/24/2024] [Indexed: 06/10/2024]
Abstract
The duration of the majority of fellowships in pediatrics has been three-years. With increasing shortages of some outpatient-based pediatric subspecialists, shorter two-year fellowships are being considered for clinically oriented trainees not interested in a career based on research. Shortening the duration of fellowship may have some financial merits such as achieving a higher salary earlier after shorter training. However, we feel that continuing with a three-year duration for neonatology is more pragmatic at this time due to reductions in intensive care rotations during residency, time required to achieve procedural excellence, the need for exposure to quality assurance methodology, proficiency in novel techniques such as bedside ultrasound, and to maintain the physician-scientist pipeline. The demand for neonatal fellowship continues to be high. Ongoing evaluation of the job market, training needs and fellowship curriculum is needed to determine if the duration of fellowship should be altered in the future.
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Affiliation(s)
- Shetal Shah
- Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY, USA.
| | - Patrick Myers
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Josephine M Enciso
- Department of Pediatrics, Division of Neonatology and Developmental Biology, University of California Los Angeles, Los Angeles, CA, USA
| | - Alexis S Davis
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Elizabeth E Crouch
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
| | - Andrea M Scheurer
- Department of Pediatric and Adolescent Medicine, Homer Stryker School of Medicine, Western Michigan University, Kalamazoo, MI, USA
- Neonatal Intensive Care, Bronson Children's Hospital, Kalamazoo, MI, USA
| | - Clara Song
- Department of Neonatal-Perinatal Medicine, Southern California Permanente Medical Group, Anaheim, CA, USA
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Davidson J, Malhotra Y, Shay R, Arunachalam A, Sink D, Barry JS, Meyers J. Building a NICU quality & safety infrastructure. Semin Perinatol 2024; 48:151902. [PMID: 38692996 DOI: 10.1016/j.semperi.2024.151902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.
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Affiliation(s)
- Jessica Davidson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - Yogangi Malhotra
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Rebecca Shay
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Athis Arunachalam
- Department of Pediatrics, Texas Childrens Hospital & Baylor College of Medicine, Houston, TX, United States
| | - David Sink
- Department of Pediatrics, University of Connecticut School of Medicine, Hartford, CT, United States
| | - James S Barry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jeffrey Meyers
- Department of Pediatrics, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States
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Rysavy MA, Bennett MM, Ahmad KA, Patel RM, Shah ZS, Ellsbury DL, Clark RH, Tolia VN. Neonatal Intensive Care Unit Resource Use for Infants at 22 Weeks' Gestation in the US, 2008-2021. JAMA Netw Open 2024; 7:e240124. [PMID: 38381431 PMCID: PMC10882422 DOI: 10.1001/jamanetworkopen.2024.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Importance During the past decade, clinical guidance about the provision of intensive care for infants born at 22 weeks' gestation has changed. The impact of these changes on neonatal intensive care unit (NICU) resource utilization is unknown. Objective To characterize recent trends in NICU resource utilization for infants born at 22 weeks' gestation compared with other extremely preterm infants (≤28 weeks' gestation) and other NICU-admitted infants. Design, Setting, and Participants This is a serial cross-sectional study of 137 continuously participating NICUs in 29 US states from January 1, 2008, through December 31, 2021. Participants included infants admitted to the NICU. Data analysis was performed from October 2022 to August 2023. Exposures Year and gestational age at birth. Main Outcomes and Measures Measures of resource utilization included NICU admissions, NICU bed-days, and ventilator-days. Results Of 825 112 infants admitted from 2008 to 2021, 60 944 were extremely preterm and 872 (466 [53.4%] male; 18 [2.1%] Asian; 318 [36.5%] Black non-Hispanic; 218 [25.0%] Hispanic; 232 [26.6%] White non-Hispanic; 86 [9.8%] other or unknown) were born at 22 weeks' gestation. NICU admissions at 22 weeks' gestation increased by 388%, from 5.7 per 1000 extremely preterm admissions in 2008 to 2009 to 27.8 per 1000 extremely preterm admissions in 2020 to 2021. The number of NICU admissions remained stable before the publication of updated clinical guidance in 2014 to 2016 and substantially increased thereafter. During the study period, bed-days for infants born at 22 weeks increased by 732%, from 2.5 per 1000 to 20.8 per 1000 extremely preterm NICU bed-days; ventilator-days increased by 946%, from 5.0 per 1000 to 52.3 per 1000 extremely preterm ventilator-days. The proportion of NICUs admitting infants born at 22 weeks increased from 22.6% to 45.3%. Increases in NICU resource utilization during the period were also observed for infants born at less than 22 and at 23 weeks but not for other gestational ages. In 2020 to 2021, infants born at less than or equal to 23 weeks' gestation comprised 1 in 117 NICU admissions, 1 in 34 of all NICU bed-days, and 1 in 6 of all ventilator-days. Conclusions and Relevance In this serial cross-sectional study of 137 US NICUs from 2008 to 2021, an increasing share of resources in US NICUs was allocated to infants born at 22 weeks' gestation, corresponding with changes in national clinical guidance.
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Affiliation(s)
- Matthew A Rysavy
- Department of Pediatrics, McGovern Medical School at UTHealth Houston, Houston, Texas
| | | | - Kaashif A Ahmad
- The Woman's Hospital of Texas, Houston, Texas
- Department of Clinical Sciences, University of Houston, Houston, Texas
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Ravi M Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Zubin S Shah
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
- Texas A&M Health Science Center School of Medicine, Dallas, Texas
| | - Dan L Ellsbury
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- MercyOne Children's Hospital, Des Moines, Iowa
| | - Reese H Clark
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Veeral N Tolia
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
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Mohammed S, Savage T, Smith J, Shepley MM, White RD. Reimagining the NICU: a human-centered design approach to healthcare innovation. J Perinatol 2023; 43:40-44. [PMID: 38086966 DOI: 10.1038/s41372-023-01794-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 12/18/2023]
Abstract
Design charettes have been utilized in architectural and design practice to generate innovative ideas. The Reimagining Workshop is a version that combines practical and blue-sky thinking to improve healthcare facility design. The workshop engages diverse stakeholders who follow a human-centered design framework. The Reimagining the Neonatal Intensive Care Unit workshop sought to generate ideas for the future, optimal NICU without specific site or client constraints. Key themes include family-centered care, technology-enabled care, neighborhood and village design and investing in the care team. Recommendations include a supportive physical environment, celebrating milestones, complementary and alternative medicine, enhancing the transition of care, aiding the transition period, and leveraging technology. The workshop showcased the potential for transformative change in NICU design and provided a roadmap for future advancements. These findings can inform regulatory standards for NICU design and drive improvements in family-centered care, patient experiences, and outcomes within the NICU environment.
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Affiliation(s)
- Sabah Mohammed
- Planning+Strategies, Perkins&Will, Atlanta, GA, 30309, USA.
| | | | - Judy Smith
- Smith Hager Bajo, Inc., Scottsdale, AZ, 85259, USA
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Flannery DD, Zevallos Barboza A, Mukhopadhyay S, Wade KC, Gerber JS, Shu D, Puopolo KM. Antibiotic Use Among Infants Admitted to Neonatal Intensive Care Units. JAMA Pediatr 2023; 177:1354-1356. [PMID: 37812442 PMCID: PMC10562984 DOI: 10.1001/jamapediatrics.2023.3664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/18/2023] [Indexed: 10/10/2023]
Abstract
This cross-sectional study examines antibiotic exposure, days of therapy, types of antibiotics, and changes in use patterns among newborns in neonatal intensive care units (NICUs) across the US from 2009 to 2021.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alvaro Zevallos Barboza
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly C Wade
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Di Shu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mehl SC, Portuondo JI, Tian Y, Raval MV, King A, Rialon KL, Vogel AM, Wesson DE, Shah SR, Massarweh NN. Hospital Variation in Mortality and Failure to Rescue after Surgery for High-Risk Neonatal Diagnoses. Neonatology 2023; 121:34-45. [PMID: 37844560 DOI: 10.1159/000533825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/23/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION A large proportion of postoperative mortality after pediatric surgery occurs among neonates with specific high-risk diagnoses. The extent to which there is hospital-level mortality variation among patients with these diagnoses and whether this variation is associated with differences in failure to rescue (FTR) is unclear. METHODS The Pediatric Health Information System® database (2012-2020) was used to identify patients who underwent surgery for eight high-risk neonatal diagnoses: gastroschisis; volvulus; necrotizing enterocolitis; intestinal atresia; meconium peritonitis; tracheoesophageal fistula; congenital diaphragmatic hernia; and perinatal intestinal perforation. Hospitals were stratified into tertiles of reliability-adjusted inpatient mortality rates (lower than average mortality - tertile 1 [T1]; higher than average mortality - tertile 3 [T3]). Multivariable hierarchical regression was used to evaluate the association between hospital-level, reliability-adjusted mortality and FTR. RESULTS Overall, 20,838 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 4.0% (95% CI, 0.0-8.2) to 16.3% (12.2-20.4). Median case volume (range, 80-1,238) and number of NICU beds (range, 24-126) were not significantly different across hospital tertiles. Compared to the hospitals with the lowest postoperative mortality (T1), the odds of FTR were significantly higher in hospitals with the highest (T3) postoperative mortality (odds ratio 1.97 [1.50-2.59]). CONCLUSIONS Significant variation in neonatal hospital mortality for high-risk diagnoses does not appear to be explained by hospital structural characteristics. Rather, difference in FTR suggests quality improvement interventions targeting early recognition and management of postoperative complications could improve surgical quality and safety for high-risk neonatal care.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Kristy L Rialon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - David E Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | | | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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