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Kieffer H, Carlton K, Adams S, Jozwik J, Cabacungan E, Cohen SS. Quality improvement sustainability to decrease utilization drift for therapeutic hypothermia in the NICU. J Perinat Med 2023; 51:956-961. [PMID: 36976872 DOI: 10.1515/jpm-2022-0421] [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: 08/28/2022] [Accepted: 03/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES Therapeutic hypothermia (TH) is now standard of care for the neuroprotection of patients with moderate to severe hypoxic-ischemic encephalopathy (HIE). TH misuse results in increased medical complication rates and high health care resource utilization. Quality improvement (QI) methodology can address drift from clinical guidelines. Assessment of sustainability of any intervention over time is an integral part of the QI methodology. METHODS Our prior QI intervention improved medical documentation using an electronic medical record-smart phrase (EMR-SP) and demonstrated special cause variation. This study serves as Epoch 3 and investigates the sustainability of our QI methods to decrease TH misuse. RESULTS A total of 64 patients met the diagnostic criteria for HIE. Over the study period, 50 patients were treated with TH, and 33 cases (66%) used TH appropriately. The number of appropriate TH cases between cases of misuse increased to an average of 9 in Epoch 3 from 1.9 in Epoch 2. Of the 50 cases, 34 (68%) had EMR-SP documentation included. Length of stay and TH complication rates did not vary between cases of TH misuse and appropriate TH use. CONCLUSIONS Our study confirmed a sustained decrease in TH misuse, despite inconsistent use of EMR-SP. We speculate that culture change involving increased awareness of guidelines through education may have contributed more to a lasting change.
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Affiliation(s)
| | - Katherine Carlton
- Medical College of Wisconsin Affiliated Hospitals, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Samuel Adams
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jenna Jozwik
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erwin Cabacungan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan S Cohen
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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2
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O'Bryant SC, Cruz AT, Fielder EK. Post-Circumcision Hemorrhage From Disseminated Herpes Simplex Virus-2. Clin Pediatr (Phila) 2022; 61:679-683. [PMID: 35686359 DOI: 10.1177/00099228221101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shelease C O'Bryant
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA.,Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Elaine K Fielder
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
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Rey Y Formoso V, Barreto Mota R, Soares H. Developmental hemostasis in the neonatal period. World J Pediatr 2022; 18:7-15. [PMID: 34981411 DOI: 10.1007/s12519-021-00492-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hemostatic system is complex and evolves continuously since gestation and well into the adult years, in a process known as "developmental hemostasis." DATA SOURCES A comprehensive review was performed after an extensive literature search on PubMed/MEDLINE concerning developmental hemostasis during the neonatal period. Relevant cross references were also included. RESULTS Although part of a system, each component of the hemostatic system evolves differently, with many displaying both quantitative and qualitative age-related differences. This leads to drastic disparities between the coagulation system of neonates and both other children's and adults', while still maintaining a generally balanced and physiological hemostasis. The motives behind this process remain to be fully elucidated but may be, at least in part, related to non-hemostatic factors. CONCLUSIONS Knowledge regarding "developmental hemostasis" is essential for everyone caring for newborns or even children in general and in this review, we describe each hemostatic system component's neonatal characteristics and age-related progression as well as explore some of the possible physiological motives behind the process.
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Affiliation(s)
- Vicente Rey Y Formoso
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Ricardo Barreto Mota
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Henrique Soares
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Faculty of Medicine, Porto University, Porto, Portugal
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Moiseiwitsch N, Brown AC. Neonatal coagulopathies: A review of established and emerging treatments. Exp Biol Med (Maywood) 2021; 246:1447-1457. [PMID: 33858204 DOI: 10.1177/15353702211006046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite the relative frequency of both bleeding and clotting disorders among patients treated in the neonatal intensive care unit, few clear guidelines exist for treatment of neonatal coagulopathies. The study and treatment of neonatal coagulopathies are complicated by the distinct hemostatic balance and clotting components present during this developmental stage as well as the relative scarcity of studies specific to this age group. This mini-review examines the current understanding of neonatal hemostatic balance and treatment of neonatal coagulopathies, with particular emphasis on emerging treatment methods and areas in need of further investigative efforts.
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Affiliation(s)
- Nina Moiseiwitsch
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC 27695, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, USA
| | - Ashley C Brown
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC 27695, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, USA
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Carlton K, Cabacungan E, Adams SJ, Cohen SS. Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management. J Perinat Med 2021; 49:389-395. [PMID: 33141108 DOI: 10.1515/jpm-2020-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/15/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines. METHODS A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied. RESULTS We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score. CONCLUSIONS Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.
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MESH Headings
- Clinical Reasoning
- Documentation/methods
- Documentation/standards
- Eligibility Determination/methods
- Eligibility Determination/standards
- Female
- Humans
- Hypothermia, Induced/methods
- Hypothermia, Induced/statistics & numerical data
- Hypoxia-Ischemia, Brain/epidemiology
- Hypoxia-Ischemia, Brain/therapy
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/therapy
- Intensive Care Units, Neonatal/standards
- Intensive Care Units, Neonatal/statistics & numerical data
- Male
- Practice Guidelines as Topic
- Procedures and Techniques Utilization/statistics & numerical data
- Quality Improvement/organization & administration
- Retrospective Studies
- United States/epidemiology
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Affiliation(s)
| | - Erwin Cabacungan
- Medical College of Wisconsin, Pediatrics, Milwaukee, Wisconsin, USA
| | - Samuel J Adams
- Medical College of Wisconsin, Neurology, Milwaukee, Wisconsin, USA
| | - Susan S Cohen
- Medical College of Wisconsin, Pediatrics, 999 N. 92nd Street, CCC 410, Milwaukee, 53226-0509, Milwaukee, Wisconsin, USA
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Munoz FM, Weisman LE, Read JS, Siberry G, Kotloff K, Friedman J, Higgins RD, Hill H, Seifert H, Nesin M. Assessment of safety in newborns of mothers participating in clinical trials of vaccines administered during pregnancy. Clin Infect Dis 2014; 59 Suppl 7:S415-27. [PMID: 25425720 PMCID: PMC4303057 DOI: 10.1093/cid/ciu727] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
A panel of experts convened by the Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, developed proposed guidelines for the evaluation of adverse events in newborns of women participating in clinical trials of maternal immunization in the United States.
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Affiliation(s)
- Flor M. Munoz
- Department of Pediatrics
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer S. Read
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases
| | - George Siberry
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Karen Kotloff
- Department of Pediatrics, University of Maryland, Baltimore
| | - Jennifer Friedman
- Center for International Health Research, Rhode Island Hospital and Department of Pediatrics, Alpert Medical School of Brown University, Providence
| | - Rosemary D. Higgins
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda
| | | | - Harry Seifert
- GlaxoSmithKline Vaccines, King of Prussia, Pennsylvania
| | - Mirjana Nesin
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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McMillan DD, Grenier D, Medaglia A. Canadian Paediatric Surveillance Program confirms low incidence of hemorrhagic disease of the newborn in Canada. Paediatr Child Health 2004; 9:235-8. [PMID: 19655015 PMCID: PMC2720503 DOI: 10.1093/pch/9.4.235] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the incidence of hemorrhagic disease of the newborn (HDNB) in Canada and its relationship to the administration of vitamin K(1) (hereafter referred to as vitamin K) following birth. METHODS The Canadian Paediatric Surveillance Program sent monthly surveys to over 2100 Canadian paediatricians requesting identification of infants with defined criteria for HDNB. Reports were confirmed with subsequent case-specific data, including coagulation test results. RESULTS Of the 26 reports (10 in 1997, eight in 1998, four in 1999, four in 2000), two were from before the start of the study, three were duplicate reports, four cases erroneously identified hemolytic disease of the newborn, three had coagulation studies which were normal or not done, and seven had other disorders with bleeding. Of the six confirmed cases of infants with HDNB (one classic, five late), all had intracranial bleeding and five suffered neurological sequelae. The estimated incidence of HDNB in Canada (including infants who had oral vitamin K prophylaxis or did not receive vitamin K) is approximately 0.45/100,000. CONCLUSION This study confirmed the relatively low incidence of HDNB in Canada and validated the Canadian Paediatric Society's recommendation that all newborns should be given intramuscular vitamin K shortly following birth. To alleviate confusion with haemolytic disease of the newborn, Britain and Australia modified the title of their subsequent HDNB study to vitamin K deficiency bleeding.
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Elliott EJ, Nicoll A, Lynn R, Marchessault V, Hirasing R, Ridley G. Rare disease surveillance: An international perspective. Paediatr Child Health 2001; 6:251-60. [PMID: 20084246 PMCID: PMC2804555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and met formally for the first time in Ottawa, Ontario in June 2000. OBJECTIVES To document the methodology and activities of existing national paediatric surveillance units; the formation of INoPSU; the diseases studied by INoPSU members; and the impact of such studies on education, public health and paediatric practice. METHODS Directors of paediatric surveillance units in Australia, Britain, Canada, Germany, the Netherlands, Latvia, Malaysia, Papua New Guinea, New Zealand and Switzerland were asked to provide information on each unit's affiliations, funding and staffing; the method of case ascertainment, the mailing list and response rates; and diseases studied. Original articles that reported data derived from units were identified by a search of an electronic database (MEDLINE), and additional information was obtained from units' annual reports. RESULTS Worldwide, 10 units (established from 1986 to 1997), use active national surveillance of more than 8500 clinicians each month to identify cases of rare or uncommon diseases in a childhood population (younger than 15 years of age) of over 47 million (monthly response rate 73% to 98%). By January 1999, units had initiated 147 studies on 103 different conditions, and 63 studies were completed. CONCLUSION INoPSU enhances collaboration among units from four continents, providing a unique opportunity for simultaneous cross-sectional studies of rare diseases in populations with diverse geographical and ethnic characteristics. It facilitates the sharing of ideas regarding current methodology, ethics, the most appropriate means of evaluating units and their potential application.
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Affiliation(s)
- Elizabeth J Elliott
- University of Sydney, Royal Alexandra Hospital for Children, Sydney, Australia
- Australian Paediatric Surveillance Unit, Sydney, Australia
| | - Angus Nicoll
- Public Health Laboratory Service, Communicable Disease Surveillance Centre, London, United Kingdom
- British Paediatric Surveillance Unit, London, United Kingdom
| | - Richard Lynn
- British Paediatric Surveillance Unit, London, United Kingdom
| | - Victor Marchessault
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, and Canadian Paediatric Surveillance Program, Ottawa, Ontario
| | - Remy Hirasing
- TNO Prevention and Health, Leiden, and Netherlands Paediatric Surveillance, Leiden, the Netherlands
| | - Greta Ridley
- Australian Paediatric Surveillance Unit, Sydney, Australia
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