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Welch B, Stanton Tully J, Horan J, Thomas A, Lien I, Barbato A. Quality improvement initiative to impact Golden Hour timeliness using a dedicated delivery team. J Perinatol 2024; 44:452-457. [PMID: 37474753 DOI: 10.1038/s41372-023-01731-3] [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: 05/30/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Golden Hour (GH) care impacts immediate and long-term outcomes for premature infants. We hypothesized that creation of a dedicated delivery team, the Stork Team, would improve delivery of GH care. METHODS A GH quality improvement initiative was created for infants born at <32 weeks and implemented in July 2018. Data were collected from GH checklists and the electronic medical record. RESULTS Following Stork Team implementation there was special cause variation noted in the minute of life (MOL) for administration of dextrose containing fluids and antibiotics. Dextrose containing fluid time improved from 111 to 67 MOL, with an increase in the percentage of patients receiving fluids by 60 MOL. Antibiotic administration improved from 180 to 82.5 MOL. GH checklist completion increased from 77% to 98% and time to isolette closure improved from 88 to 62 MOL. CONCLUSION Implementation of the Stork Team was associated with improvements in timeliness of GH care.
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Affiliation(s)
- Blair Welch
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA.
| | | | - Jessica Horan
- Riley Children's Health, Indiana University Health, Bloomington, IN, USA
| | - Anna Thomas
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Izlin Lien
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Alana Barbato
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
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Sheng L, Zhong G, Xing R, Yan X, Cui H, Yu Z. Quality improvement in the golden hour for premature infants: a scoping review. BMC Pediatr 2024; 24:88. [PMID: 38302960 PMCID: PMC10832117 DOI: 10.1186/s12887-024-04558-9] [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: 04/13/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Evidence-based research has shown that golden hour quality improvement (QI) measures can improve the quality of care and reduce serious complications of premature infants. Herein, we sought to review golden hour QI studies to evaluate the impact on the outcome of preterm infants. METHODS A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, and SinoMed databases from inception to April 03, 2023. Only studies describing QI interventions in the golden hour of preterm infants were included. Outcomes were summarized and qualitative synthesis was performed. RESULTS Ten studies were eligible for inclusion. All studies were from single centers, of which nine were conducted in the USA and one in Israel. Seven were pre-post comparative studies and three were observational studies. Most included studies were of medium quality (80%). The most common primary outcome was admission temperatures and glucose. Five studies (n = 2308) reported improvements in the admission temperature and three studies (n = 2052) reported improvements in hypoglycemia after QI. Four studies (n = 907) showed that the incidence of bronchopulmonary dysplasia (BPD) was lower in preterm infants after QI: 106/408 (26.0%) vs. 122/424(29.5%) [OR = 0.68, 95% CI 0.48-0.97, p = 0.04]. CONCLUSIONS Our study showed that the golden hour QI bundle can improve the short-term and long-term outcomes for extremely preterm infants. There was considerable heterogeneity and deficiencies in the included studies, and the variation in impact on outcomes suggests the need to use standardized and validated measures. Future studies are needed to develop locally appropriate, high-quality, and replicable QI projects.
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Affiliation(s)
- Lijuan Sheng
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Guichao Zhong
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Ruirui Xing
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Xudong Yan
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Huanjin Cui
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Zhangbin Yu
- Department of Neonatology, Shenzhen People's Hospital, (The Second Clinical Medical College, Jinan University;The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.
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Chiu M, Mir I, Adhikari E, Heyne R, Ornelas N, Tolentino-Plata K, Thomas A, Burchfield P, Simcik V, Ramon E, Brown LS, Nelson DB, Wyckoff MH, Kakkilaya V. Risk Factors for Admission Hyperthermia and Associated Outcomes in Infants Born Preterm. J Pediatr 2024; 265:113842. [PMID: 37995929 DOI: 10.1016/j.jpeds.2023.113842] [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: 07/03/2023] [Revised: 10/11/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
Maternal, placental, and neonatal factors were compared between infants born at ≤29 weeks of gestational age with admission hyperthermia (>37.5○C) and euthermia (36.5-37.5○C). Admission hyperthermia was associated with longer duration of face-mask positive-pressure ventilation and infant's temperature ≥37.5○C in the delivery room. Infants born preterm with admission hyperthermia had greater odds of developing necrotizing enterocolitis and neurodevelopmental impairment.
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Affiliation(s)
- Melody Chiu
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Imran Mir
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Emily Adhikari
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Roy Heyne
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Kristine Tolentino-Plata
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anita Thomas
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Patti Burchfield
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Emma Ramon
- Parkland Health & Hospital Systems, Dallas, TX
| | | | - David B Nelson
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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Liebowitz M, Kramer KP, Rogers EE. All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:399-420. [PMID: 37201988 DOI: 10.1016/j.clp.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.
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Affiliation(s)
- Melissa Liebowitz
- Envision Physician Services, St. Francis Hospital, 6001 East Woodmen Road, Colorado Springs, CO 80923, USA
| | - Katelin P Kramer
- Department of Pediatrics, University of California, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA; University of California, Benioff Children's Hospital, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA.
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA; University of California, Benioff Children's Hospital, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA. https://twitter.com/eerogersmd
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Lamary M, Bertoni CB, Schwabenbauer K, Ibrahim J. Neonatal Golden Hour: a review of current best practices and available evidence. Curr Opin Pediatr 2023; 35:209-217. [PMID: 36722754 DOI: 10.1097/mop.0000000000001224] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Recommendations made by several scientific bodies advocate for adoption of evidence-based interventions during the first 60 min of postnatal life, also known as the 'Golden Hour', to better support the fetal-to-neonatal transition. Implementation of a Golden Hour protocol leads to improved short-term and long-term outcomes, especially in extremely premature and extreme low-birth-weight (ELBW) neonates. Unfortunately, several recent surveys have highlighted persistent variability in the care provided to this vulnerable population in the first hour of life. RECENT FINDINGS Since its first adoption in the neonatal ICU (NICU) in 2009, published literature shows a consistent benefit in establishing a Golden Hour protocol. Improved short-term outcomes are reported, including reductions in hypothermia and hypoglycemia, efficiency in establishing intravenous access, and timely initiation of fluids and medications. Additionally, long-term outcomes report decreased risk for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). SUMMARY Critical to the success and sustainability of any Golden Hour initiative is recognition of the continuous educational process involving multidisciplinary team collaboration to ensure coordination between providers in the delivery room and beyond. Standardization of practices in the care of extremely premature neonates during the first hour of life leads to improved outcomes. VIDEO ABSTRACT http://links.lww.com/MOP/A68 .
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Affiliation(s)
| | - C Briana Bertoni
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
| | - Kathleen Schwabenbauer
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
| | - John Ibrahim
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
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Dumpa V, Avulakunta I, Bhandari V. Respiratory management in the premature neonate. Expert Rev Respir Med 2023; 17:155-170. [PMID: 36803028 DOI: 10.1080/17476348.2023.2183843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Indirapriya Avulakunta
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, the Children's Regional Hospital at Cooper, Camden, NJ, USA
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7
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Hemingway M, Raju M, Vora N, Raju V, Mallett LH, Govande V. Improving delivery room and admission efficiency and outcomes for infants < 32 weeks: ELGAN+ (Extremely Low Gestational Age Neonate). J Neonatal Perinatal Med 2022; 16:33-37. [PMID: 36591661 DOI: 10.3233/npm-210881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the implementation of a systematic approach to improve the resuscitation, stabilization, and admission of infants < 32 weeks gestation and also to ascertain its effect on organization, efficiency, and clinical outcomes during hospitalization. METHODS Retrospective study involving a multidisciplinary team with checklists, role assignment, equipment organization, step by step protocol, and real time documentation for the care of infants < 32 weeks gestation in the delivery room to the neonatal intensive care unit. Pre-data collection (cases) period was from Aug, 2015 to July, 2017, and post-data collection(controls) period was from Aug, 2017 to Aug, 2019. RESULTS 337 infants were included (179 cases; 158 controls). Increase surfactant use in the resuscitation room (41% vs. 27%, p = 0.007) and reduction in median time to administer surfactant (34 minutes (range, 6-120) vs. 74 minutes (range, 7-120), p = 0.001) observed in control-group. There was a significant reduction in incidence of bronchopulmonary dysplasia (27% vs. 39%), intraventricular hemorrhage (11% vs. 17%), severe retinopathy of prematurity (3% vs. 9%), and necrotizing enterocolitis (4% vs. 6%), however these results were not statistically significant after controlling for severity of illness. CONCLUSIONS A systematic approach to the care of infants < 32 weeks gestation significantly improved mortality rates and reduced rates of comorbidities.
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Affiliation(s)
- M Hemingway
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
| | - M Raju
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
| | - N Vora
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
| | - V Raju
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
| | - L H Mallett
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
| | - V Govande
- Department of Neonatology, Baylor Scott and White Health, Temple, Texas, USA
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Chang TP, Elkin R, Boyle TP, Nishisaki A, Walsh B, Benary D, Auerbach M, Camacho C, Calhoun A, Stapleton SN, Whitfill T, Wood T, Fayyaz J, Gross IT, Thomas AA. Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation. Simul Healthc 2022. [DOI: 10.54531/drkq7209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings.
We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking.
Small groups (n = 121) and survey ranking (n = 54) were used with
This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of
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Affiliation(s)
- Todd P Chang
- 1Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles/Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rachel Elkin
- 2Division of Pediatric Emergency Medicine, New York-Presbyterian Morgan Stanley Children’s Hospital-Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Tehnaz P Boyle
- 3Division of Pediatric Emergency Medicine, Boston Medical Center/Boston University School of Medicine, Boston University, Boston, MA, USA
| | - Akira Nishisaki
- 4Division of Pediatric Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara Walsh
- 5Division of Emergency Medicine, Boston Children’s Hospital, Harvard University, Boston, MA, USA
| | - Doreen Benary
- 6Division of Pediatric Emergency Medicine, NYU Langone Medical Center, New York University, New York, NY, USA
| | - Marc Auerbach
- 7Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Cheryl Camacho
- 8Simulation and Outreach Education, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Aaron Calhoun
- 9Division of Critical Care, Norton Children’s Hospital, University of Louisville, Louisville, KY, USA
| | - Stephanie N Stapleton
- 10Department of Emergency Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Travis Whitfill
- 7Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Trish Wood
- 11Starship Child Health, Auckland, New Zealand
| | - Jabeen Fayyaz
- 12Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Isabel T Gross
- 13Division of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Anita A Thomas
- 14Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA, USA
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Bahr N, Huynh TK, Lambert W, Guise JM. Characterization of teamwork and guideline compliance in prehospital neonatal resuscitation simulations. Resusc Plus 2022; 10:100248. [PMID: 35607396 PMCID: PMC9123265 DOI: 10.1016/j.resplu.2022.100248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/19/2022] Open
Abstract
Aim Neonatal cardiopulmonary arrests are rare but serious events. There is limited information on compliance to best-practice guidelines due to rarity, but deviations can have dire consequences. This research aimed to characterize compliance with and deviations from Neonatal Resuscitation Program (NRP) guidelines and their association with teamwork. Methods We observed Emergency Medical Service (EMS) teams responding to standardized neonatal resuscitation simulations following a precipitous home delivery. A Clinical expert evaluated teamwork during simulations using the Clinical Teamwork Scale (CTS™). A neonatologist evaluated technical performance in blinded video review according to NRP guidelines. We report the types, counts, and severity of observed deviations. Logistic regression tested the association of CTS™ factors with the occurrence of deviations. Results Forty-five (45) teams of 265 EMS personnel from fire and transport agencies participated in the simulations. Eighty-seven percent (39/45) of teams were rated as having good teamwork according to CTS™. Nearly all teams (44 of 45) delayed or did not perform one or more of the initial steps of dry, warm, or stimulate; delayed bag-valve mask ventilation (BVM); or performed continuous compressions instead of the recommended 3:1 compression-to-ventilation ratio. Logistic regression revealed an 82% (p < 0.04) decrease in the odds of airway errors for each level of improvement in teams' decision-making. Conclusion Drying, warming, and stimulating, and ventilation tailored to the physiologic needs of infants continue to be top priorities in neonatal care for out-of-hospital settings. EMS teamwork is good and higher quality of decision-making appears to decrease the odds of ventilation errors.
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Affiliation(s)
- Nathan Bahr
- Department of Obstetrics and Gynecology, Oregon Health and Science University
| | - Trang Kieu Huynh
- Department of Pediatrics, Oregon Health and Science University, United States
| | - William Lambert
- Public Health and Preventative Medicine, Oregon Health and Science University
| | - Jeanne-Marie Guise
- Department of Obstetrics and Gynecology, Oregon Health and Science University
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Arbour K, Lindsay E, Laventhal N, Myers P, Andrews B, Klar A, Dunbar AE. Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability. Am J Perinatol 2022; 39:869-877. [PMID: 33111279 DOI: 10.1055/s-0040-1719071] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers. STUDY DESIGN A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset. RESULTS In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%). CONCLUSION There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions. KEY POINTS · Within the past decade, there has been a shift in the gray zone from 23-24 to 22-23 weeks gestation.. · Attitudes around resuscitation of infants are nonuniform despite perceived standardized approaches.. · Institutional variability in resources may contribute to variation in outcomes of periviable infants..
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Affiliation(s)
- Kaitlyn Arbour
- Department of Pediatrics, UT Southwestern, Dallas, Texas
| | | | - Naomi Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Patrick Myers
- Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Bree Andrews
- Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Angelle Klar
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Alston E Dunbar
- Department of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana
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12
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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Ferretti E, Daboval T, Rouvinez-Bouali N, Lawrence SL, Lemyre B. Extremely low gestational age infants: Developing a multidisciplinary care bundle. Paediatr Child Health 2021; 26:e240-e245. [PMID: 34630783 PMCID: PMC8491076 DOI: 10.1093/pch/pxaa110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical experience in managing extremely low gestational age infants, particularly those born <24 weeks' gestation, is limited in Canada. Our goal was to develop a bedside care bundle for infants born <26 weeks' gestation, with special considerations for infants of <24 weeks, to harmonize and improve quality of care. METHODS We created a multidisciplinary working group with experience in caring for preterm infants, searched the literature from 2000 to 2019 to identify best practices for the care of extremely preterm infants and consulted colleagues across Canada and internationally. Iterative improvements were made following the Plan-Do-Study-Act methodology. RESULTS A care bundle, created in October 2015, was divided into three time periods: initial resuscitation/stabilization, the first 72 hours and days 4 to 7, with each period subdivided in 8 to 12 care themes. Revisions and practice changes were implemented to improve skin integrity, admission temperature, timing of initiation of feeds, reliability of transcutaneous CO2 monitoring and ventilation. Of 127 infants <26 weeks admitted between implementation and end of 2019, 78 survived to discharge (61%). CONCLUSION It will be important to determine, with ongoing auditing and further evaluation, whether our care bundle led to improvements of short- and long-term outcomes in this population. Our experience may be useful to others caring for extremely low gestational age infants.
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Affiliation(s)
- Emanuela Ferretti
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Thierry Daboval
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Nicole Rouvinez-Bouali
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Sarah L Lawrence
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Brigitte Lemyre
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
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14
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Zorro C, Dassios T, Hickey A, Arasu A, Bhat R, Greenough A. Introduction of 24 h Resident Consultant Cover in a Tertiary Neonatal Unit-Impact on Mortality and Clinical Outcomes. CHILDREN-BASEL 2021; 8:children8100865. [PMID: 34682129 PMCID: PMC8534735 DOI: 10.3390/children8100865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/26/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022]
Abstract
Background: We aimed to determine whether the introduction of 24 h cover by resident consultants in a tertiary neonatal unit affected mortality and other clinical outcomes. Methods: Retrospective cohort study in a tertiary medical and surgical neonatal unit between 2010–2020 of all liveborn infants admitted to the neonatal unit. Out of hours cover was rearranged in 2014 to ensure 24 h presence of a senior trained neonatologist (resident consultant). Results: In the study period, 4778 infants were included: 2613 in the pre-resident period and 2165 in the resident period. The median (IQR) time to first consultation by a senior member of staff was significantly longer in the pre-resident period [1.5 (0.6–4.3) h] compared to the resident period [0.5 (0.3–1.5) h, p < 0.001]. Overall, mortality was similar in the pre-resident and the resident periods (3.2% versus 2.3%, p = 0.077), but the mortality of infants born at night was significantly higher in the pre-resident (4.5%) compared to the resident period (2.5%, p = 0.016). The resident period was independently associated with an increased survival to discharge (adjusted p < 0.001, odds ratio: 2.0) after adjusting for gestational age, admission temperature and duration of ventilation. Conclusions: Following introduction of a resident consultant model the mortality and time to consultation after admission decreased.
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Affiliation(s)
- Carolina Zorro
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK; (C.Z.); (A.H.); (A.A.); (R.B.)
| | - Theodore Dassios
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK; (C.Z.); (A.H.); (A.A.); (R.B.)
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE5 9RS, UK;
- Correspondence:
| | - Ann Hickey
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK; (C.Z.); (A.H.); (A.A.); (R.B.)
| | - Anusha Arasu
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK; (C.Z.); (A.H.); (A.A.); (R.B.)
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK; (C.Z.); (A.H.); (A.A.); (R.B.)
| | - Anne Greenough
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE5 9RS, UK;
- Asthma UK Centre for Allergic Mechanisms in Asthma, King’s College London, London SE5 9RS, UK
- NIHR Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London SE1 9RT, UK
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15
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Zhou L, Taylor J, Kidman A, Stewart A, Bhatia R. Staff awareness and bundling reduce skin breaks and blood tests in neonatal intensive care. J Paediatr Child Health 2021; 57:1485-1489. [PMID: 33938084 DOI: 10.1111/jpc.15532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/01/2021] [Accepted: 04/17/2021] [Indexed: 11/27/2022]
Abstract
AIM Skin breaks (SBs) for procedures and blood sampling are common in neonatal intensive care units (NICU), contributing to pain, infection risk and anaemia. We aimed to document their prevalence, identify areas for improvement and, through staff awareness, reduce their frequency. METHODS Quality improvement project via prospective audit at a tertiary-level NICU in Australia was conducted. All infants admitted to the NICU for >24 h during two audit periods were included in the study. A specifically designed bedside audit tool was used to prospectively document all SB and blood tests performed on infants during a 4-week audit period (audit 1). Results were reviewed to identify areas for improvement, and disseminated to staff at unit meetings, shift handover and email. Following education and awareness, the audit was repeated (audit 2), and data were compared. Frequency of SB and blood tests performed was measured. Data were tested for normality and analysed using parametric or non-parametric tests where appropriate. RESULTS There were 52 NICU admissions during each audit period (104 total), with 34 (65%) and 31 (60%) having audit sheets completed, respectively. Median (interquartile range) gestational age and mean (standard deviation) birthweight were 29 (26.3-35) weeks and 1836 (1185) g for audit 1, 30 (28.5-31.5) weeks and 1523 (913) g for audit 2. The reduction in total blood tests (mean) was 36.3%, skin breaks per admitted baby day reduced by 60% and total blood volume sampled (mean) by 37.7%. CONCLUSIONS A quality improvement project by prospective audit and staff education was associated with reductions in frequency of skin breaks and blood tests in the NICU.
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Affiliation(s)
- Lindsay Zhou
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Jacqueline Taylor
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Anna Kidman
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Alice Stewart
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Risha Bhatia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
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16
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Hodgson KA, Owen LS, Lui K, Shah V. Neonatal Golden Hour: A survey of Australian and New Zealand Neonatal Network units' early stabilisation practices for very preterm infants. J Paediatr Child Health 2021; 57:990-997. [PMID: 33543835 DOI: 10.1111/jpc.15360] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/25/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023]
Abstract
AIM To identify current 'Golden Hour' practices for initial stabilisation of very preterm infants <32 weeks' gestational age (GA) within tertiary neonatal intensive care units (NICUs) in the Australian and New Zealand Neonatal Network (ANZNN). METHODS A 76-question survey regarding delivery room (DR) and NICU stabilisation practices was distributed electronically to directors of tertiary perinatal NICUs in the ANZNN in January 2019. Responses were categorised into GA subgroups: 23-24, 25-27 and 28-31 weeks' GA. RESULTS The response rate was 100% (24/24 units). Delayed cord clamping (DCC) was practised 'always' or 'often' by 21 units (88%). All units used oximetry to target oxygen saturations, and 23/24 (96%) commenced resuscitation in <40% oxygen. Ten units (42%) routinely used DR electrocardiography monitoring. CPAP was preferred as primary respiratory support in one-third of units for infants born 23-24 weeks' GA, compared with 19 units (79%) at 25-27 weeks' GA and 23 units (96%) at 28-31 weeks' GA. DR skin-to-skin care was uncommon, particularly at lower GAs. Five units (21%) used minimally invasive surfactant therapy for non-intubated infants at 23-24 weeks' GA, 13 units (54%) at 25-27 weeks' GA and 16 units (67%) at 28-31 weeks' GA. CONCLUSIONS Most Golden Hour stabilisation practices align with international guidelines. Consistency exists with respect to DCC, oxygen saturation targeting and primary CPAP use for infants 25 weeks' GA and above. Where evidence is less certain, practices vary across ANZNN NICUs. Time targets for stabilisation measures may help standardise practice for this population.
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Affiliation(s)
- Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Kei Lui
- Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
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17
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王 晴, 徐 静, 肖 湘, 朴 梅, 韩 彤. [Association between time of birth and resuscitation outcomes in extremely preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:702-706. [PMID: 34266527 PMCID: PMC8292653 DOI: 10.7499/j.issn.1008-8830.2104031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/13/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To study whether there are differences in the resuscitation process and early outcomes between the extremely preterm infants delivered on off-hours (6 pm to 8 am of working days, weekends, and national holidays) and those delivered on working hours. METHODS A retrospective analysis was performed on the medical data of extremely preterm infants who were born in the Peking University Third Hospital from January 1, 2010 to December 31, 2020 and transferred to the neonatal intensive care unit (NICU). According to the time of birth, they were divided into two groups:working hours (n=77) and off-hours (n=98). The resuscitation process and early outcomes were compared between the two groups. RESULTS Compared with the working hours group, the off-hours group had a significantly lower proportion of infants with the use of full-dose dexamethasone before delivery (P < 0.05) and a significantly higher proportion of infants with a 1-minute Apgar score of < 7, positive pressure ventilation, or tracheal intubation (P < 0.05). The incidence rates of neonatal respiratory distress syndrome and intrauterine pneumonia in the off-hours group were significantly higher than those in the working hours group (P < 0.05). CONCLUSIONS Extremely preterm infants delivered on off-hours tend to have a low Apgar score at 1 minute after birth, with a higher proportion of infants requiring positive pressure ventilation or tracheal intubation during resuscitation than those delivered on working hours, and they tend to develop neonatal respiratory distress syndrome and intrauterine pneumonia. This suggests that it is important to make adequate preparations in terms of personnel and supplies for resuscitation of extremely preterm infants after birth and that NICUs should develop a detailed management plan for extremely preterm infants at each period of time before, during, and after birth.
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Affiliation(s)
- 晴晴 王
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 静 徐
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 湘 肖
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 梅花 朴
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 彤妍 韩
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
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18
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Huynh TK, Schoonover A, Harrod T, Bahr N, Guise JM. Characterizing prehospital response to neonatal resuscitation. Resusc Plus 2021; 5:100086. [PMID: 34223352 PMCID: PMC8244404 DOI: 10.1016/j.resplu.2021.100086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/08/2021] [Accepted: 01/17/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate performance of initial steps of newborn resuscitation according to the American Heart Association and American Academy of Pediatrics' Neonatal Resuscitation Program (NRP) guidelines in the prehospital setting. Study Design Observational study of 265 paramedics and Emergency Medical Technicians (EMTs) from 45 EMS teams recruited from public fire and private transport agencies in a major metropolitan area. Participants completed a baseline questionnaire assessing demographics, experience, and comfort in caring for children. Simulations were conducted April 2015 to March 2016. Technical performance was evaluated by blinded video review. NRP actions were assessed using a structured performance tool. Results Two hundred sixty-five EMS providers responded to survey questions and participated in simulations. In total, 16% reported feeling very or extremely comfortable caring for children <30 days of age (vs. 71% for children aged 12-18 years). Among 45 EMS teams participating in simulations, 22% (n = 10) dried, 18% (n = 8) stimulated, and 2% (n = 1) warmed within 30 s from arrival and 11% (n = 5) provided BMV within 60 s from arrival, as recommended by NRP. All teams provided BMV. Eighty-eight percent bagged below NRP rate recommendations and 96% bagged with tidal volume exceeding guidelines. Looking over the entire 10-min simulation for ever performing measures, 73% started to dry the baby within a median of 51 (range 0-539) seconds from arrival, 38% started to stimulate the baby within a median of 34 s (range 0-181), and 44% started to warm the baby within a median 291 s (range 27-575 s). Conclusions These data from field simulations suggest NRP steps recommended for the first minute after birth are seldom performed in a timely manner and suggests opportunities for improvement.
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Affiliation(s)
- Trang Kieu Huynh
- Department of Pediatrics, Oregon Health and Science University, United States
| | - Amanda Schoonover
- Department of Obstetrics and Gynecology, Oregon Health and Science University, United States
| | - Tabria Harrod
- Department of Obstetrics and Gynecology, Oregon Health and Science University, United States
| | - Nathan Bahr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, United States
| | - Jeanne-Marie Guise
- Department of Obstetrics and Gynecology, Oregon Health and Science University, United States
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19
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Carter EH, Lee HC, Lapcharoensap W, Snowden JM. Resuscitation outcomes for weekend deliveries of very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:656-661. [PMID: 32414815 DOI: 10.1136/archdischild-2019-317807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To characterise the association between weekend (Saturday and Sunday) deliveries of very low birthweight (VLBW) infants and delivery room outcomes in the 'golden hour' after birth. DESIGN AND SETTING A retrospective cohort study using California Perinatal Quality Care Collaborative data from participating neonatal intensive care units. PATIENTS The study population after exclusions was 26 515 VLBW infants born in California from 2010 to 2016. MAIN OUTCOME MEASURES Delivery room outcomes assessed included: chest compressions, epinephrine, intubation prior to continuous positive airway pressure ventilation, 5 min Apgar <4, admission hypothermia and death within 12 hours. To adjust for potential confounders, we fit multivariate regression models controlling for two sets of infant, maternal and hospital characteristics. RESULTS Infants delivered on weekends were less likely to have been prenatally diagnosed with intrauterine growth restriction but were otherwise not significantly different in gestational age, ethnicity, sex or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends, while vaginal deliveries were consistent across all days. After adjusting for sex and race, weekend delivery was associated with delivery room chest compressions (OR: 1.12, 95% CI 1.02 to 1.24) and lower 5 min Apgar (OR: 1.11, 95% CI 1.01 to 1.21). CONCLUSION In this population-based study of VLBW infants, there was an increase in chest compressions for infants born on the weekend. More research is needed on the differences between populations born on weekdays versus weekends, and how these may contribute to observed associations.
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Affiliation(s)
- Emily Hawkins Carter
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry C Lee
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | | | - Jonathan M Snowden
- Department of Obstetrics & Gynecology/Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
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20
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Bhatt DR, Reddy N, Ruiz R, Bustos DV, Peacock T, Dizon RA, Weerasinghe S, Braun DX, Ramanathan R. Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years. J Investig Med 2020; 68:1256-1260. [PMID: 32690596 PMCID: PMC7525784 DOI: 10.1136/jim-2020-001334] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2020] [Indexed: 11/11/2022]
Abstract
Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity and mortality, decreased length of stay and hospital costs. We designed a thermoregulation bundle to decrease hypothermia (<36.5°C) in ELBW infants with a multidisciplinary perinatal quality improvement initiative that included the following key interventions: dedicated delivery room (DR)/operating room (OR) for all preterm deliveries of ≤32 weeks with DR/OR temperature set 24/7 at 74°F by the hospital engineering staff, use of exothermic mattress, preheated radiant warmer set at 100% for heat prior to delivery, servo-controlled mode after the neonate is placed on the warmer, and use of plastic wrap, head cap and warm towels. A total of 200 ELBW infants were admitted to our NICU between January 1, 2014 and December 31, 2019. Hypothermia (<36.5°C) occurred in 2.5% of infants, normothermia (36.5°C–37.5°C) in 91% of infants and transitional hyperthermia (>37.5°C) in 6.5% of ELBW infants. No case of moderate hypothermia (32°C–36°C) was seen in our infants. Our target rate of less than 10% hypothermia was reached in ELBW infants over the last 2 years with no cases of moderate hypothermia in 6 years. Eliminating hypothermia among ELBW remains a challenge and requires team effort and continuous quality improvement efforts.
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Affiliation(s)
- Dilip R Bhatt
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Nirupa Reddy
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Reynaldo Ruiz
- Obstetrics, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Darla V Bustos
- Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Torria Peacock
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Roman-Angelo Dizon
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | | | - David X Braun
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Rangasamy Ramanathan
- Pediatrics/Division of Neonatology, LAC USC Medical Center, Los Angeles, California, USA
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21
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Gogcu S, Aboudi D, Kase J, LaGamma E, Brumberg HL. Presence of neonatal intensive care services at birth hospital and early intervention enrollment in infants ≤1500 g. J Perinat Med 2020; 48:/j/jpme.ahead-of-print/jpm-2019-0393/jpm-2019-0393.xml. [PMID: 32284452 DOI: 10.1515/jpm-2019-0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
Objectives To determine whether the receipt of therapeutic services of very-low-birth-weight (VLBW; ≤1500 g) neonates inadvertently delivered at community Level 2 and 3 neonatal intensive care units (NICUs) compared with those born at a well-baby nursery (WBN; Level 1) differed. Methods This is a retrospective study of neonates who were born at Level 1 (WBN), 2, 3, and 4 NICUs and discharged from a Level 4 hospital (n = 529). All infants were evaluated at the Regional Neonatal Follow-up Program at 12 ± 1 months corrected gestational age (CA) and assessed for use of therapeutic services including: early intervention (EI), occupational therapy (OT), physical therapy (PT), speech therapy (ST), and special education (SE). Results Compared to infants born at community Level 2 and 3 NICU hospitals, those outborn at a community Level 1 WBN had significantly higher utilization of EI (90% vs. 62%) and PT (83% vs. 61%) at 12 months CA. This association persisted when controlling for covariates. Infants who required EI had significantly lower Bayley-III cognitive scores at 3 years of age. Conclusion VLBW infants outborn at WBN (Level 1) hospitals required more outpatient therapeutic services than those born at hospitals with NICU facilities. These results suggest that delivering at the appropriate community hospital level of care might be advantageous for long-term outcomes.
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Affiliation(s)
- Semsa Gogcu
- Wake Forest University, Brenner Children's Hospital, Winston-Salem, NC, USA
| | - David Aboudi
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Jordan Kase
- Maria Fareri Children's Hospital at Westchester Medical Center, Division of Newborn Medicine, Department of Pediatrics, Valhalla, NY, USA
| | - Edmund LaGamma
- Maria Fareri Children's Hosp-NY Med College, Peds - Newborn Med, Valhalla, NY, USA
| | - Heather Lynn Brumberg
- Maria Fareri Children's Hospital at Westchester Medical Center, Division of Newborn Medicine, Department of Pediatrics, Valhalla, NY, USA
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22
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The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit. J Perinatol 2020; 40:530-539. [PMID: 31712659 PMCID: PMC7222905 DOI: 10.1038/s41372-019-0545-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth. METHODS Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92). RESULTS There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed. CONCLUSIONS Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.
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23
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Fathi O, Bapat R, G. Shepherd E, Wells Logan J. Golden Hours: An Approach to Postnatal Stabilization and Improving Outcomes. NEONATAL MEDICINE 2019. [DOI: 10.5772/intechopen.82810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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24
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De Carolis MP, Casella G, Serafino E, Pinna G, Cocca C, De Carolis S. Delivery room interventions to improve the stabilization of extremely-low-birth-weight infants. J Matern Fetal Neonatal Med 2019; 34:1925-1931. [PMID: 31394952 DOI: 10.1080/14767058.2019.1651278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To retrospectively verify whether the positioning of the umbilical venous catheter (UVC) in the delivery room (DR) and the early start of the preheated infusion of 10% glucose solution conditioned temperature and glycemia values of ELBW neonates in the first hours of life. METHODS Neonates (N = 137) were divided into two groups on the basis of timing of positioning of the UVC. In Group I the UVC was placed in DR, while in Group II after Neonatal Intensive Care Unit (NICU) admission. Data were assessed in different times: body temperature at neonatal admission to NICU (T1); after 2 hours (T2); then, every 2 hours until normothermia; glycemia value at NICU admission, every 1-2 hours in the first 12 hours, every 4 hours from 12 to 24 hours, and every 6-12 hours until normalization. Time slot childbirth was also detected since only in the morning shift there was a dedicated resuscitation team always present in DR, while during the afternoon and night it was available on-call. Preventive measures to limit heat dispersion were adopted in both Groups. RESULTS In Group I respect to Group II, both at T1 and T2: (a) the rate of normothermic neonates was higher and (b) the rate of neonates with moderate hypothermia was lower. The hourly temperature increase was similar between the groups and the time needed to reach normothermia was significantly lower in Group I than in Group II. Glycemic values at T1 were lower in Group II. In Group II, after UVC positioning and glucose solution administration, the 42.2% of infants immediately brought glycemia back to normal, while the 57.8% needed specific treatment. The majority of newborns of Group I was born during the morning shift. CONCLUSIONS The early UVC placement by a dedicated interdisciplinary team is a relevant intervention to carry out during the "Golden minutes" to improve the ELBW stabilization soon after birth.
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Affiliation(s)
- Maria Pia De Carolis
- Department of Pediatrics, Fondazione Policlinico "A. Gemelli" IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanna Casella
- Department of Obstetrics and Gynecology, Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Erika Serafino
- Department of Pediatrics, Fondazione Policlinico "A. Gemelli" IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Pinna
- Department of Pediatrics, Fondazione Policlinico "A. Gemelli" IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Carmen Cocca
- Department of Pediatrics, Fondazione Policlinico "A. Gemelli" IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Sara De Carolis
- Department of Obstetrics and Gynecology, Policlinico Universitario Agostino Gemelli, Rome, Italy
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25
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Chiriboga N, Cortez J, Pena-Ariet A, Makker K, Smotherman C, Gautam S, Trikardos AB, Knight H, Yeoman M, Burnett E, Beier A, Cohen I, Hudak ML. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project. J Perinatol 2019; 39:143-151. [PMID: 30348961 DOI: 10.1038/s41372-018-0257-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Our specific, measurable, attainable, relevant, and time-limited (SMART) aim was to reduce the incidence of severe intracranial hemorrhage (ICH) among preterm infants born <30 weeks' gestation from a baseline of 24% (January 2012-December 2013) to a long-term average of 11% by December 2015. STUDY DESIGN We instituted an ICH bundle consisting of elements of the "golden hour" (delayed cord clamping, optimized cardiopulmonary resuscitation, improved thermoregulation) and provision of cluster care in the neonatal intensive care unit (NICU). We identified key drivers to achieve our SMART aims, and implemented quality improvement (QI) cycles: initiation of the ICH bundle, education of NICU staff, and emphasis on sustained adherence. We excluded infants born outside our facility and those with congenital anomalies. RESULTS Using statistical process control analysis (p-chart), the ICH bundle was associated with successful reduction in severe ICH (grade 3-4) in our NICU from a prebundle rate of 24% (January 2012-December 2013) to a sustained reduction over the next 4 years to an average rate of 9.7% by December 2017. Results during 2016-2017 showed a sustained improvement beyond the goal for 2014-2015. Over the same interval, there was improvement in admission temperatures [median 36.1 °C (interquartile range: 35.3-36.7 °C) vs. 37.1 °C (36.8-37.5 °C), p < 0.01] and a decrease in mortality rate [pre: 16/117 (14%) vs. post: 16/281 (6%), P < 0.01]. CONCLUSION Our multidisciplinary QI initiative decreased severe ICH in our institution from a baseline rate of 24% to a lower rate of 9.7% over the ensuing 4 years. Intensive focus on sustained implementation of an ICH bundle protocol consisting of improved delivery room management, thermoregulation, and clustered care in the NICU was temporally associated with a clinically significant reduction in severe ICH.
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Affiliation(s)
- Nicolas Chiriboga
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Josef Cortez
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA.
| | - Adriana Pena-Ariet
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Kartikeya Makker
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Shiva Gautam
- Center for Health Equity and Quality Research, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Allison Blair Trikardos
- Department of Women's and Children's Nursing Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Holly Knight
- Department of Rehabilitation Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Mark Yeoman
- Department of Women's and Children's Nursing Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Erin Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Alexandra Beier
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Inbal Cohen
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Mark L Hudak
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
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Ehret DEY, Edwards EM, Greenberg LT, Bernstein IM, Buzas JS, Soll RF, Horbar JD. Association of Antenatal Steroid Exposure With Survival Among Infants Receiving Postnatal Life Support at 22 to 25 Weeks' Gestation. JAMA Netw Open 2018; 1:e183235. [PMID: 30646235 PMCID: PMC6324435 DOI: 10.1001/jamanetworkopen.2018.3235] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Although evidence of antenatal steroids (ANS) efficacy at 22 to 25 weeks' gestation is limited, increasingly these infants are treated with postnatal life support. OBJECTIVES To estimate the proportion of infants receiving postnatal life support at 22 to 25 weeks' gestation who had exposure to ANS, and to examine if the provision of ANS was associated with a higher rate of survival to hospital discharge and survival without major morbidities. DESIGN, SETTING, AND PARTICIPANTS This multicenter observational cohort study consisted of 33 472 eligible infants liveborn at 431 US Vermont Oxford Network member hospitals between January 1, 2012, and December 31, 2016. We excluded infants with recognized syndromes or major congenital anomalies. Of the eligible infants, 29 932 received postnatal life support and were included in the analyses. Data analysis was conducted from July 2017 to July 2018. EXPOSURE Antenatal steroids administered to the mother at any time prior to delivery. MAIN OUTCOMES AND MEASURES Survival to hospital discharge, major morbidities among survivors, and the composite of survival to discharge without major morbidities. RESULTS Among 29 932 infants who received postnatal life support, 51.9% were male, with a mean (SD) gestational age of 24.12 (0.86) weeks and mean (SD) birth weight of 668 (140) g; 26 090 (87.2%) had ANS exposure and 3842 (12.8%) had no ANS exposure. Survival to hospital discharge was higher for infants with ANS exposure (18 717 of 25 892 [72.3%]) compared with infants without ANS exposure (1981 of 3820 [51.9%]); the adjusted risk ratio for 22 weeks was 2.11 (95% CI, 1.68-2.65), for 23 weeks was 1.54 (95% CI, 1.40-1.70), for 24 weeks was 1.18 (95% CI, 1.12-1.25), and for 25 weeks was 1.11 (95% CI, 1.07-1.14). Survival to hospital discharge without major morbidities was higher for infants with ANS exposure (3777 of 25 833 [14.6%]) compared with infants without ANS exposure (347 of 3806 [9.1%]); the adjusted risk ratio for 22 through 25 weeks was 1.67 (95% CI, 1.49-1.87). CONCLUSIONS AND RELEVANCE Concordant receipt of ANS and postnatal life support was associated with significantly higher survival and survival without major morbidities at 22 through 25 weeks' gestation compared with life support alone. Although statistically higher with ANS, survival without major morbidities remains low at 22 and 23 weeks. There is an opportunity to reevaluate national obstetric guidelines, allowing for shared decision making at the edge of viability with concordant obstetrical and neonatal treatment plans.
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Affiliation(s)
- Danielle E. Y. Ehret
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington
| | | | - Ira M. Bernstein
- Department of Obstetrics, Gynecology, and Reproductive Services, Robert Larner College of Medicine, University of Vermont, Burlington
| | - Jeffrey S. Buzas
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington
| | - Roger F. Soll
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
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Aboudi D, Shah SI, La Gamma EF, Brumberg HL. Impact of neonatologist availability on preterm survival without morbidities. J Perinatol 2018; 38:1009-1016. [PMID: 29743659 DOI: 10.1038/s41372-018-0103-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit. METHODS Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival. RESULTS Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV). CONCLUSIONS When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.
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Affiliation(s)
- David Aboudi
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Shetal I Shah
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Edmund F La Gamma
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Heather L Brumberg
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA.
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28
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Shah V, Hodgson K, Seshia M, Dunn M, Schmölzer GM. Golden hour management practices for infants <32 weeks gestational age in Canada. Paediatr Child Health 2018; 23:e70-e76. [PMID: 30038535 PMCID: PMC6007305 DOI: 10.1093/pch/pxx175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine 'Golden Hour' resuscitation and stabilization practices for infants <32 weeks gestational age in Canadian neonatal intensive care units (NICUs). METHODS A survey was distributed to investigators of the Evidence-based Practice for Improving Quality study within the Canadian Neonatal Network in June 2014. The questionnaire was designed to obtain information on antenatal counselling, resuscitation environment, resuscitation and management practices, including respiratory and nutritional practices in the first hour of life. Responses to these categories were stratified into gestational age groupings: 230/7-236/7, 240/7-256/7, 260/7-276/7 and 280/7-316/7 weeks. Findings were summarized using descriptive statistics. RESULTS Investigators from 14 of the 23 (61%) NICUs responded. Antenatal counselling was provided to >75% of expectant parents by Staff Neonatologists and Neonatal Fellows. Most NICUs (78%) provided resuscitation in a room adjacent to the high-risk delivery room or the NICU, while few (36%) resuscitated in the delivery room only. Twelve (86%) NICUs practiced delayed cord clamping while two practiced milking of the cord (14%) and 100% used thermal wrap for infants <28 weeks' gestation. All, with the exception of three NICUs used fraction of inspired oxygen ≤0.3 for initial resuscitation and 12/14 (86%) centres applied continuous positive airway pressure for spontaneously breathing infants <256/7 weeks' gestation. CONCLUSIONS Participating Canadian NICUs reported that they generally follow Neonatal Resuscitation Program recommendations for stabilization of preterm infants; however, considerable variation exists in the application of evidence-based interventions. Our findings can be used to inform quality improvement initiatives to improve clinical outcomes for this vulnerable population.
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Affiliation(s)
- Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Kate Hodgson
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario
| | - Mary Seshia
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba
| | - Michael Dunn
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
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29
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Shah PS, McDonald SD, Barrett J, Synnes A, Robson K, Foster J, Pasquier JC, Joseph KS, Piedboeuf B, Lacaze-Masmonteil T, O'Brien K, Shivananda S, Chaillet N, Pechlivanoglou P. The Canadian Preterm Birth Network: a study protocol for improving outcomes for preterm infants and their families. CMAJ Open 2018; 6:E44-E49. [PMID: 29348260 PMCID: PMC5878956 DOI: 10.9778/cmajo.20170128] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Preterm birth (birth before 37 wk of gestation) occurs in about 8% of pregnancies in Canada and is associated with high mortality and morbidity rates that substantially affect infants, their families and the health care system. Our overall goal is to create a transdisciplinary platform, the Canadian Preterm Birth Network (CPTBN), where investigators, stakeholders and families will work together to improve childhood outcomes of preterm neonates. METHODS Our national cohort will include 24 maternal-fetal/obstetrical units, 31 neonatal intensive care units and 26 neonatal follow-up programs across Canada with planned linkages to provincial health information systems. Three broad clusters of projects will be undertaken. Cluster 1 will focus on quality-improvement efforts that use the Evidence-based Practice for Improving Quality method to evaluate information from the CPTBN database and review the current literature, then identify potentially better health care practices and implement identified strategies. Cluster 2 will assess the impact of current practices and practice changes in maternal, perinatal and neonatal care on maternal, neonatal and neurodevelopmental outcomes. Cluster 3 will evaluate the effect of preterm birth on babies, their families and the health care system by integrating CPTBN data, parent feedback, and national and provincial database information in order to identify areas where more parental support is needed, and also generate robust estimates of resource use, cost and cost-effectiveness around preterm neonatal care. INTERPRETATION These collaborative efforts will create a flexible, transdisciplinary, evaluable and informative research and quality-improvement platform that supports programs, projects and partnerships focused on improving outcomes of preterm neonates.
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Affiliation(s)
- Prakesh S Shah
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Sarah D McDonald
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Jon Barrett
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Anne Synnes
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Kate Robson
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Jonathan Foster
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Jean-Charles Pasquier
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - K S Joseph
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Bruno Piedboeuf
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Thierry Lacaze-Masmonteil
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Karel O'Brien
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Sandesh Shivananda
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Nils Chaillet
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
| | - Petros Pechlivanoglou
- Affiliations: Department of Paediatrics (Shah, O'Brien), Mount Sinai Hospital; Department of Pediatrics (Shah, O'Brien), University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence, and Impact (McDonald), McMaster University, Hamilton, Ont.; Women and Babies Program (Barrett), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Pediatrics (Synnes, Shivananda), University of British Columbia, Vancouver, BC; Canadian Premature Babies Foundation (Robson, Foster), Toronto, Ont.; Women and Babies Program (Robson), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Obstetrics and Gynecology (Pasquier), Université de Sherbrooke, Sherbrooke, Que.; Department of Obstetrics and Gynaecology (Joseph), University of British Columbia, Vancouver, BC; Department of Pediatrics (Piedboeuf), Université Laval, Québec, Que.; Department of Pediatrics (Lacaze-Masmonteil), Alberta Health Services and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Obstetrics and Gynecology (Chaillet), Université Laval, Québec, Que.; Child Health Evaluative Sciences (Pechlivanoglou), The Hospital for Sick Children, Toronto, Ont
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30
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Abstract
"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.
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Affiliation(s)
- Deepak Sharma
- National Institute of Medical Science, Jaipur, Rajasthan India
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31
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Abstract
Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.
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Affiliation(s)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305,California Perinatal Quality Care Collaborative, Stanford, CA 94305
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Balakrishnan M, Falk-Smith N, Detman LA, Miladinovic B, Sappenfield WM, Curran JS, Ashmeade TL. Promoting teamwork may improve infant care processes during delivery room management: Florida perinatal quality collaborative's approach. J Perinatol 2017; 37:886-892. [PMID: 28406486 DOI: 10.1038/jp.2017.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND LOCAL PROBLEM: Inadequate understanding of compliance with standardized evidence-based DR management. INTERVENTIONS Promote inter-professional teamwork and a bundle of interventions focusing on resuscitation team roles, equipment check, and debriefing using QI methodology. Optimize delivery room (DR) management to achieve 10-min SPO2 targets, delayed-cord clamping (DCC), team role assignment and debriefings in >50% of deliveries, and achieve normothermia in >75% of infants. METHODS Over 15 months (Epoch 1 to 5), nine Florida hospitals implemented a DR management plan for infants <31 weeks gestational age or <1500 g (N=814) using quality improvement methodology. RESULTS There was increased compliance of DCC (36 to 66%), role assignment (53 to 98%), debriefing rates (33 to 76%) and having all seven pre-delivery preparedness components fulfilled (34 to 75%). There were no significant improvements in admission temperatures or SPO2 targeting. When 7 vs 0 items of pre-delivery preparedness were completed, we saw improvements in thermoregulation (57% vs 72%), SPO2 targeting (60% vs 78%) and DCC compliance (43 to 67%). CONCLUSION Promoting teamwork by increasing pre-delivery preparedness is associated with improvement of thermoregulation, SPO2 targeting and DCC compliance.
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Affiliation(s)
- M Balakrishnan
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - N Falk-Smith
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - L A Detman
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - B Miladinovic
- Center for Comparative Effectiveness Research, Division of Evidence-Based Medicine, Department of Internal Medicine, University of South Florida Health, Tampa, FL, USA
| | - W M Sappenfield
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - J S Curran
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - T L Ashmeade
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
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33
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Dukhovny D. 'Does ________ predict neurodevelopmental impairment in former preterm infants?' Is this the right question to be asked? J Perinatol 2017; 37:467-468. [PMID: 28446812 DOI: 10.1038/jp.2017.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- D Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
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34
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Abstract
"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.
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Lambeth TM, Rojas MA, Holmes AP, Dail RB. First Golden Hour of Life: A Quality Improvement Initiative. Adv Neonatal Care 2016; 16:264-72. [PMID: 27391563 DOI: 10.1097/anc.0000000000000306] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Very low birth-weight (<1500 g) infants are vulnerable to their environment during the first hour after birth. We designed an evidence-based golden hour protocol (GHP) with a goal to stabilize and perform admission procedures within 1 hour of birth at a level IIIB neonatal intensive care unit (NICU). PURPOSE The aim of this quality improvement project was to ascertain whether an evidence-based GHP would improve care efficiency and short-term outcomes. METHODS Rapid cycles of change using Plan Do Study Act were utilized to document progress and gain knowledge during the quality improvement project. Measures were plotted with statistical process control methods (SPC), which analyzed improvement over time. RESULTS Both admission temperature and glucose-level means were within reference range throughout the project and predicted a stable process. We observed significantly decreased time to initiation of intravenous fluids and antibiotics. An upward trend of surfactant administration within the first 2 hours of life was also observed. IMPLICATIONS FOR PRACTICE The use of a GHP provided an organized approach to admission procedures and care. By using a checklist and recording intervention times, NICU caregivers were more aware of time management for each intervention and were able to decrease time to initiation of intravenous fluids and antibiotics. IMPLICATIONS FOR RESEARCH Future research should focus on establishing normal blood pressure ranges and safe pain management during the "golden hour" and beyond. Future quality improvement should focus on improving subsequent temperature and blood glucose levels after admission umbilical artery and venous catheter placement.
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36
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Patel PN, Banerjee J, Godambe SV. Resuscitation of extremely preterm infants - controversies and current evidence. World J Clin Pediatr 2016; 5:151-8. [PMID: 27170925 PMCID: PMC4857228 DOI: 10.5409/wjcp.v5.i2.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/24/2015] [Accepted: 01/16/2016] [Indexed: 02/06/2023] Open
Abstract
Despite significant advances in perinatal medicine, the management of extremely preterm infants in the delivery room remains a challenge. There is an increasing evidence for improved outcomes regarding the resuscitation and stabilisation of extremely preterm infants but there is a lack of evidence in the periviable (gestational age 23-25 wk) preterm subgroup. Presence of an experienced team during the delivery of extremely preterm infant to improve outcome is reviewed. Adaptation from foetal to neonatal cardiorespiratory haemodynamics is dependent on establishing an optimal functional residual capacity in the extremely preterm infants, thus enabling adequate gas exchange. There is sufficient evidence for a gentle approach to stabilisation of these fragile infants in the delivery room. Evidence for antenatal steroids especially in the periviable infants, delayed cord clamping, strategies to establish optimal functional residual capacity, importance of temperature control and oxygenation in delivery room in extremely premature infants is reviewed in this article.
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37
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Hartung JC, Wilitzki S, Thio-Lluch M, te Pas AB, Schmalisch G, Roehr CC. Reliability of Single-Use PEEP-Valves Attached to Self-Inflating Bags during Manual Ventilation of Neonates--An In Vitro Study. PLoS One 2016; 11:e0150224. [PMID: 26914209 PMCID: PMC4767411 DOI: 10.1371/journal.pone.0150224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/10/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction International resuscitation guidelines suggest to use positive end-expiratory pressure (PEEP) during manual ventilation of neonates. Aim of our study was to test the reliability of self-inflating bags (SIB) with single-use PEEP valves regarding PEEP delivery and the effect of different peak inflation pressures (PIP) and ventilation rates (VR) on the delivered PEEP. Methods Ten new single-use PEEP valves from 5 manufacturers were tested by ventilating an intubated 1kg neonatal manikin containing a lung model with a SIB that was actuated by an electromechanical plunger device. Standard settings: PIP 20cmH2O, VR 60/min, flow 8L/min. PEEP settings of 5 and 10cmH2O were studied. A second test was conducted with settings of PIP 40cmH2O and VR 40/min. The delivered PEEP was measured by a respiratory function monitor (CO2SMO+). Results Valves from one manufacturer delivered no relevant PEEP and were excluded. The remaining valves showed a continuous decay of the delivered pressure during expiration. The median (25th and 75th percentile) delivered PEEP with standard settings was 3.4(2.7–3.8)cmH2O when set to 5cmH2O and 6.1(4.9–7.1)cmH2O when set to 10cmH2O. Increasing the PIP from 20 to 40 cmH2O led to a median (25th and 75th percentile) decrease in PEEP to 2.3(1.8–2.7)cmH2O and 4.3(3.2–4.8)cmH2O; changing VR from 60 to 40/min led to a PEEP decrease to 2.8(2.1–3.3)cmH2O and 5.0(3.5–6.2)cmH2O for both PEEP settings. Conclusion Single-use PEEP valves do not reliably deliver the set PEEP. PIP and VR have an effect on the delivered PEEP. Operators should be aware of these limitations when manually ventilating neonates.
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Affiliation(s)
- Julia C. Hartung
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Silke Wilitzki
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Marta Thio-Lluch
- Department of Neonatology, The Royal Women’s Hospital, Parkville, Victoria, Australia
| | - Arjan B. te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Schmalisch
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Charles C. Roehr
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
- Newborn Services, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Australia
- * E-mail:
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38
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Abstract
Neurocritical care is a multidisciplinary subspecialty that combines expertise in critical care medicine, neurology, and neurosurgery, and has led to improved outcomes in adults who have critical illnesses. Advances in resuscitation and critical care have led to high rates of survival among neonates with life-threatening conditions such as perinatal asphyxia, extreme prematurity, and congenital malformations. The sequelae of neurologic conditions arising in the neonatal period include lifelong disabilities such as cerebral palsy and epilepsy, as well as intellectual and behavioral disabilities. Centers of excellence have adapted the principles of neurocritical care to reflect the needs of the developing newborn brain, including early involvement of a neurologist for recognition and treatment of neurologic conditions, attention to physiology to help prevent secondary brain injury, a protocol-driven approach for common conditions like seizures and hypoxic-ischemic encephalopathy, and education of specialized teams that use brain monitoring and imaging to evaluate the effect of critical illness on brain function and development.
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