Characterization of neonatal personnel time inputs and prediction from clinical variables--a time and motion study

A systematic review of neonatal treatment intensity scores and their potential application in low-resource setting hospitals for predicting mortality, morbidity and estimating resource use

BACKGROUND

Treatment intensity scores can predict mortality and estimate resource use. They may therefore be of interest for essential neonatal care in low resource settings where neonatal mortality remains high. We sought to systematically review neonatal treatment intensity scores to (1) assess the level of evidence on predictive performance in predicting clinical outcomes and estimating resource utilisation and (2) assess the applicability of the identified models to decision making for neonatal care in low resource settings.

METHODS

We conducted a systematic search of PubMed, EMBASE (OVID), CINAHL, Global Health Library (Global index, WHO) and Google Scholar to identify studies published up until 21 December 2016. Included were all articles that used treatments as predictors in neonatal models. Individual studies were appraised using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS). In addition, Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used as a guiding framework to assess certainty in the evidence for predicting outcomes across studies.

RESULTS

Three thousand two hundred forty-nine articles were screened, of which ten articles were included in the review. All of the studies were conducted in neonatal intensive care units with sample sizes ranging from 22 to 9978, with a median of 163. Two articles reported model development, while eight reported external application of existing models to new populations. Meta-analysis was not possible due heterogeneity in the conduct and reporting of the identified studies. Discrimination as assessed by area under receiver operating characteristic curve was reported for in-hospital mortality, median 0.84 (range 0.75-0.96, three studies), early adverse outcome and late adverse outcome (0.78 and 0.59, respectively, one study).

CONCLUSION

Existing neonatal treatment intensity models show promise in predicting mortality and morbidity. There is however low certainty in the evidence on their performance in essential neonatal care in low resource settings as all studies had methodological limitations and were conducted in intensive care. The approach may however be developed further for low resource settings like Kenya because treatment data may be easier to obtain compared to measures of physiological status.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034205.

A meta-analysis of educational interventions designed to enhance cultural competence in professional nurses and nursing students

OBJECTIVES

Increasing professional nurses' and nursing students cultural competence has been identified as one way to decrease the disparity of care for vulnerable and minority groups, but effectiveness of training programs to increase competence remains equivocal. The purpose of this project is to synthesize educational interventions designed to increase cultural competence in professional nurses and nursing students.

DESIGN

A systematic review and meta-analysis was conducted to synthesize all existing studies on increasing cultural competence.

DATA SOURCES

A comprehensive search and screen procedures was conducted to locate all cultural competence interventions implemented with professional nurses and nursing students.

REVIEW METHODS

Two independent researchers screened and coded the included studies. Effect sizes were calculated for each study and a random-effects meta-analysis was conducted.

RESULTS

A total of 25 studies were included in the review. Two independent syntheses were conducted given the disparate nature of the effect size metrics. For the synthesis of treatment-control designed studies, the results revealed a non-statistically significant increase in cultural competence (g¯=.38, 95% CI: -.05, .79, p=.08). Moderator analyses indicated significant variation as a function of the measurements, participant types, and funding source. The pretest-posttest effect size synthesis revealed a significant increase in overall cultural competence (g¯=.45, 95% CI: .24, .66, p<.01). Moderator analyses indicated, however, that the effect sizes varied as functions of the measurement, funding source, and publication type.

CONCLUSIONS

Interventions to increase cultural competence have shown varied effectiveness. Greater research is required to improve these interventions and promote cultural competence.

Cost estimate of hospital stays for premature newborns of adolescent mothers in a Brazilian public hospital

Objective:

To estimate the direct costs of hospital stay for premature newborns of adolescent mothers, in a public hospital.

Methods:

A cost estimate study conducted between 2009 and 2011, in which direct hospital costs were estimated for premature newborns of adolescent mothers, with 22 to 36 6/7 gestational weeks, and treated at the neonatal unit of the hospital.

Results:

In 2006, there were 5,180 deliveries at this hospital, and 17.8% (922) were newborns of adolescent mothers, of which 19.63% (181) were admitted to the neonatal unit. Out of the 181 neonates, 58% (105) were premature and 80% (84) of them were included in this study. These 84 neonates had a total of 1,633 days in-patient hospital care at a total cost of US$195,609.00. Approximately 72% of this total cost (US$141,323.00) accounted for hospital services. The mean daily costs ranged from US$97.00 to US$157.00.

Conclusion:

This study demonstrated that the average cost of premature newborns from adolescent mothers was US$2,328.00 and varied according to birth weight. For those weighing <1,000g at birth, the mean direct cost was US$8,930.00 per stay as opposed to a cost of US$642.00 for those with birth weight >2,000g. The overall estimated direct cost for the 84 neonates in the study totaled US$195,609.00.

A Tool for Calculating the Nursing Staff at Neonatal Intensive Care Units

La gestión del cuidado de enfermería supone la utilización de métodos y herramientas que de manera práctica permitan una aproximación a las necesidades de cuidado de los pacientes y ayuden a planear los requerimientos humanos y técnicos para tal fin. Objetivo: identificar la utilidad del Neonatal Therapeutic Intervention Scoring System (NTISS) en el cálculo de personal de enfermería en la unidad de cuidado intensivo (UCIN) e intermedio neonatal (UCEN) de la Clínica Universitaria Bolivariana (CUB) en Medellín, Colombia. Método: estudio descriptivo, transversal, realizado durante el mes de abril de 2007. La población estuvo conformada por los neonatos ingresados y hospitalizados en la UCIN y UCEN, para lo que fue necesario aplicar el instrumento al final de cada turno. Se calculó una muestra de 384 instrumentos (proporción desconocida y un intervalo de confianza de 0,5). La consistencia interna del instrumento se determinó con el alfa de Cronbach (0,8). Resultados: se recolectaron 425 instrumentos diligenciados de 22 neonatos. Las patologías más frecuentes fueron las de tipo respiratorio. El puntaje total de los NTISS analizados fue de 5.200 puntos, con un promedio de 12,3, equivalentes a 123 minutos de trabajo de enfermería por turno de 6 horas. Del total de intervenciones el 62% están asignadas a las enfermeras, el 22% a las auxiliares de enfermería y el 16% a terapia respiratoria. Se calculó el requerimiento de 4 enfermeras por turno en la UCIN y UCEN. Conclusiones: el NTISS es útil para la asignación y el cálculo del personal de enfermería y contribuye a mejorar los procesos de gestión del cuidado.

Clinical benefits, costs, and cost-effectiveness of neonatal intensive care in Mexico

BACKGROUND

Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.

METHODS AND FINDINGS

A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.

CONCLUSIONS

Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

Nurse staffing in relation to risk-adjusted mortality in neonatal care

OBJECTIVE

To assess whether risk-adjusted mortality in very low birthweight or preterm infants is associated with levels of nursing provision.

DESIGN

Prospective study of risk-adjusted mortality in infants admitted to a random sample of neonatal units.

SETTING

Fifty four UK neonatal intensive care units stratified by: patient volume; consultant availability; nurse:cot ratios.

PATIENTS

A group of 2585 very low birthweight (birthweight <1500 g) or preterm (<31 weeks gestation) infants.

MAIN OUTCOME MEASURE

Death before discharge or planned deaths at home, excluding lethal malformations, after adjusting for initial risk 12 hours after birth using gestation at birth and measures of illness severity in relation to nursing provision calculated for each baby's neonatal unit stay.

RESULTS

A total of 57% of nursing shifts were understaffed, with greater shortages at weekends. Risk-adjusted mortality was inversely related to the provision of nurses with specialist neonatal qualifications (OR 0.67; 95% CI 0.42 to 0.97). Increasing the ratio of nurses with neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality of 48% (OR: 0.52, 95% CI: 0.33, 0.83).

CONCLUSIONS

Risk-adjusted mortality did not differ across neonatal units. However, survival in neonatal care for very low birthweight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. The findings could be used to support specific standards of specialist nursing provision in neonatal and other areas of intensive and high dependency care.

Retrospective economic evaluation of a controlled trial of indomethacin prophylaxis for patent ductus arteriosus in premature infants

OBJECTIVE

To determine the incremental cost-effectiveness of indomethacin prophylaxis in extremely low birth weight infants enrolled in the Trial of Indomethacin Prophylaxis in Preterms (TIPP).

STUDY DESIGN

Participants in this economic evaluation were 428 infants enrolled at 9 Canadian TIPP centres. The study took a third-party payer perspective. Prior to the analysis of clinical trial data, direct medical costs were derived from chart review of 89 items of resource utilization, for each day from admission to hospital discharge. Unit costs for each resource were obtained from a provincially standardized cost-accounting system. Incremental cost-effectiveness analysis was performed, with estimation of cost-effectiveness acceptability curves through non-parametric bootstrapping.

RESULTS

The mean (SD) cost was $68,279 (40,317) for the placebo group and $69,629 (37,989) for the indomethacin group. Indomethacin prophylaxis cost an additional $67,500 per death or impairment averted. However, the precision of this estimate was low, such that the probability that the estimate was lower than $300,000 per death or impairment averted was only 61%. The results were similar when surgical costs were assumed to be 500% of those measured in the trial.

CONCLUSIONS

This study does not provide an economic rationale for the use of indomethacin prophylaxis in ELBW infants.