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Adams SY, Fry JT, Henner N. What Is Culture Made of? An Exploratory Study of Ethical Cultures and Provider Perspectives on the Care of Periviable Neonates. Am J Perinatol 2024. [PMID: 39299244 DOI: 10.1055/a-2405-3336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
OBJECTIVE Studies examining intercenter variation in neonatal intensive care unit practices at the limits of fetal viability have hypothesized that institutional "culture" can be one of many factors that impact patient care. This study aimed to describe institutional culture at a single, large academic center with regard to the antenatal consultation, resuscitation, and postnatal management of periviable neonates. STUDY DESIGN Members of six clinical groups-attending and fellow maternal-fetal medicine physicians, attending and fellow neonatal-perinatal medicine physicians, neonatal nurses, advanced practiced neonatal nurses, pediatric hospitalist physicians, and neonatal respiratory therapists-were invited to complete qualitative, semi-structured interviews. All audio recordings were transcribed. Dedoose software was used to complete team-based coding and thematic analysis. RESULTS Twenty-two interviews were completed. Thematic analysis revealed three central themes described by participants as contributory to institutional culture: Perception, referring to factors based on individual attitudes and insights, Statements of Information, referring to factors anchored in more objective concepts such as outcomes data and institutional policy, and Dynamic Factors, referring to the relatively fluid factors of institutional culture that interact with both Perception and Statements of Information. Participants were more likely to mention factors in the Perception category (n = 430) compared with factors in the Information category (n = 225), and although the latter were described as critical components of antenatal counseling and perinatal management, the philosophy of our unit appeared to be more heavily rooted in institutional memory and individual belief systems. CONCLUSION Our data demonstrate a personal undertone to institutional culture at the limits of viability, with an emphasis on individual attitudes and subjective interpretations of fact rather than empirical data. As the landscape of neonatology continues to change, understanding those factors that contribute to culture remains a necessary step toward deconstructing institutional belief systems and optimizing clinical care. KEY POINTS · Institutional culture is the collective norms and attitudes that help guide organizational behavior.. · Institutional culture may be one of many factors that impact the care of periviable neonates.. · Deconstructing culture helps us better understand our clinical environment and optimize patient care..
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Affiliation(s)
- Shannon Y Adams
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jessica T Fry
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Natalia Henner
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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LoRe D, Groden CM, Schuh AR, Holmes C, Ostilla L, Vogel MM, Murray PD, Yamasato K, Tonismae T, Anani UE, Henner N, Famuyide M, Leuthner SR, Laventhal N, Andrews BL, Tucker Edmonds BM, Brennan KG, Feltman DM. Variability of Care Practices for Extremely Early Deliveries. Pediatrics 2024; 154:e2023065521. [PMID: 39129496 PMCID: PMC11350101 DOI: 10.1542/peds.2023-065521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/11/2024] [Accepted: 05/14/2024] [Indexed: 08/13/2024] Open
Abstract
OBJECTIVES Assess temporal changes, intercenter variability, and birthing person (BP) factors relating to interventions for extremely early deliveries. METHODS Retrospective study of BPs and newborns delivered from 22-24 completed weeks at 13 US centers from 2011-2020. Rates of neonatology consultation, antenatal corticosteroids, cesarean delivery, live birth, attempted resuscitation (AR), and survival were assessed by epoch, center, and gestational age. RESULTS 2028 BPs delivering 2327 newborns were included. Rates increased in epoch 2-at 22 weeks: neonatology consultation (37.6 vs 64.3%, P < .001), corticosteroids (11.4 vs 29.5%, P < .001), live birth (66.2 vs 78.6%, P < .001), AR (20.1 vs 36.9%, P < .001), overall survival (3.0 vs 8.9%, P = .005); and at 23 weeks: neonatology consultation (73.0 vs 80.5%, P = .02), corticosteroids (63.7 vs 83.7%, P < .001), cesarean delivery (28.0 vs 44.7%, P < .001), live birth (88.1 vs 95.1%, P < .001), AR (67.7 vs 85.2%, P < .001), survival (28.8 vs 41.6%, P < .001). Over time, intercenter variability increased at 22 weeks for corticosteroids (interquartile range 18.0 vs 42.0, P = .014) and decreased at 23 for neonatology consultation (interquartile range 23.0 vs 5.2, P = .045). In BP-level multivariate analysis, AR was associated with increasing gestational age and birth weight, Black BP race, previous premature delivery, and delivery center. CONCLUSIONS Intervention rates for extremely early newborns increased and intercenter variability changed over time. In BP-level analysis, factors significantly associated with AR included Black BP race, previous premature delivery, and center.
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Affiliation(s)
- Danielle LoRe
- Department of Pediatrics, Columbia University, New York, New York
| | | | - Allison R. Schuh
- Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Chondraah Holmes
- Department of Pediatrics, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Lorena Ostilla
- Department of Pediatrics, Lurie Children’s Hospital, Chicago, Illinois
| | - Maggie M. Vogel
- Department of Pediatrics, Advocate Christ Hospital, Oak Lawn, Illinois
| | - Peter D. Murray
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Kelly Yamasato
- Department of Obstetrics, Gynecology, and Women’s Health, University of Hawaii, Honolulu, Hawaii
| | | | - Uchenna E. Anani
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Natalia Henner
- Department of Pediatrics, Lurie Children’s Hospital, Chicago, Illinois
| | - Mobolaji Famuyide
- Division of Newborn Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Naomi Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Dalia M. Feltman
- Division of Neonatology, Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois
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Meadow J, Arzu J, Rychlik K, Henner N. Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e794-e802. [PMID: 36096150 DOI: 10.1055/a-1941-4285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel. STUDY DESIGN A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios. RESULTS Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22-23 vs. 24-25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios. CONCLUSION NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a "trial of therapy" framework. KEY POINTS · NICU personnel have variable criteria for WLST.. · Parents have little say in whether WLST is offered.. · Disclosure of variable criteria is not routine..
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Affiliation(s)
- Jacqueline Meadow
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen Rychlik
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Natalia Henner
- Division of Neonatology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Laventhal N. Negative Studies and the Future of Prenatal Counseling at the Margin of Gestational Viability. J Pediatr 2023; 258:113440. [PMID: 37088184 DOI: 10.1016/j.jpeds.2023.113440] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Naomi Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, MI.
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Kim BH, Feltman DM, Schneider S, Herron C, Montes A, Anani UE, Murray PD, Arnolds M, Krick J. What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey. Am J Perinatol 2021; 40:657-665. [PMID: 34100274 DOI: 10.1055/s-0041-1730430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study aimed to better understand how neonatology and maternal fetal medicine (MFM) physicians convey information during antenatal counseling that requires facilitating shared decision-making with parents facing options of resuscitation versus comfort care after extremely early delivery STUDY DESIGN: Attending physicians at US centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. The survey assessed information conveyed, processes for facilitating shared decision-making (reported separately), and clinical experiences. Neonatology and MFM responses were compared. Multivariable logistic regression analyzed topics often and seldom discussed by specialty groups with respect to respondents' clinical experience and resuscitation option preferences at different gestational weeks. RESULTS In total, 74 MFM and 167 neonatologists representing 94% of the 81 centers surveyed responded. Grouped by specialty, respondents were similar in counseling experience and distribution of allowing choices between resuscitation and no resuscitation for delivery at specific weeks of gestational ages. MFM versus neonatology reported similar rates of discussing long-term health and developmental concerns and differed in all other categories of topics. Neonatologists were less likely than MFM to discuss caregiver impacts (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.11-0.18, p < 0.001) and comfort care details (OR: 0.19, 95% CI: 0.15-0.25, p < 0.001). Conversely, neonatology versus MFM respondents more frequently reported "usually" discussing topics pertaining to parenting in the NICU (OR: 1.5, 95% CI: 1.2-1.8, p < 0.001) and those regarding stabilizing interventions in the delivery room (OR: 1.8, 95% CI: 1.4-2.2, p < 0.001). Compared with less-experienced respondents, those with 17 years' or more of clinical experience had greater likelihood in both specialties to say they "usually" discussed otherwise infrequently reported topics pertaining to caregiver impacts. CONCLUSION Parents require information to make difficult decisions for their extremely early newborns. Our findings endorse the value of co-consultation by MFM and neonatology clinicians and of trainee education on antenatal consultation education to support these families. KEY POINTS · Neonatology versus MFM counselors provide complementary information.. · More experience was linked to discussing some topics.. · Co-consultation and trainee education is supported.. · What information parents value requires study..
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Affiliation(s)
- Brennan Hodgson Kim
- Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Dalia M Feltman
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois
| | - Simone Schneider
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Constance Herron
- Graduate Student Intern, School of Health Studies, Northern Illinois University, DeKalb, Illinois
| | - Andres Montes
- Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Peter D Murray
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Marin Arnolds
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois.,Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jeanne Krick
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington
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Chen YJ, Yu WH, Chen LW, Huang CC, Kang L, Lin HS, Iwata O, Kato S, Hussein MH, Lin YC. Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015. CHILDREN-BASEL 2021; 8:children8010023. [PMID: 33406755 PMCID: PMC7824697 DOI: 10.3390/children8010023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 01/11/2023]
Abstract
Periviable infants (PIs) born at 22–25 weeks gestational age (wGA) have a variable survival rate (49.7–86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this study has implemented the renewed guideline for PIs. We retrospectively reviewed and analyzed the survival and clinical variables of PIs before and after implementation of the guideline, which included a 10-year cohort in a single center in Taiwan. There were 168 PIs enrolled between 2010 and 2019 (Epoch-I, 2010–2015; Epoch-II, 2016–2019), after excluding those with congenital anomalies and parent-decided comfort care. Compared to those in Epoch-I, the PIs in Epoch-II had significantly higher odds ratios (2.602) (95% confidence interval: 1.170–5.789; p = 0.019) for survival. Younger gestational age, small size for gestational age, cesarean delivery, low blood pH at birth, and surfactant therapeutic treatment were found to be significant risk factors associated with the survival of PIs (p < 0.05 for each). The altered threshold of viability by NRP 2015 may impact the survival of PIs. However, long-term follow-up for surviving PI is required in the future.
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Affiliation(s)
- Yen-Ju Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan; (Y.-J.C.); (W.-H.Y.); (L.-W.C.); (C.-C.H.)
| | - Wen-Hao Yu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan; (Y.-J.C.); (W.-H.Y.); (L.-W.C.); (C.-C.H.)
| | - Li-Wen Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan; (Y.-J.C.); (W.-H.Y.); (L.-W.C.); (C.-C.H.)
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan; (Y.-J.C.); (W.-H.Y.); (L.-W.C.); (C.-C.H.)
| | - Lin Kang
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan;
| | - Hui-Shan Lin
- Department of Nursing, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan;
| | - Osuke Iwata
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Science, Nagoya, Aichi 467-8601, Japan; (O.I.); (S.K.)
| | - Shin Kato
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Science, Nagoya, Aichi 467-8601, Japan; (O.I.); (S.K.)
| | - Mohamed Hamed Hussein
- Department of Neonatology, Center of Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama 350-8550, Japan
- Correspondence: (M.H.H.); (Y.-C.L.); Tel.: +81-492-283-727 (M.H.H.); +886-62353535-3236 (Y.-C.L.)
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 70457, Taiwan; (Y.-J.C.); (W.-H.Y.); (L.-W.C.); (C.-C.H.)
- Correspondence: (M.H.H.); (Y.-C.L.); Tel.: +81-492-283-727 (M.H.H.); +886-62353535-3236 (Y.-C.L.)
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