A systematic review of administrative and clinical databases of infants admitted to neonatal units

A Multifunctional, Low Cost and Sustainable Neonatal Database System

Continuous improvement in the clinical performance of neonatal intensive care units (NICU) depends on the use of locally relevant, reliable data. However, neonatal databases with these characteristics are typically unavailable in NICUs using paper-based records, while in those using electronic records, the inaccuracy of data and the inability to customize commercial data systems limit their usability for quality improvement or research purposes. We describe the characteristics and uses of a simple, neonatologist-centered data system that has been successfully maintained for 30 years, with minimal resources and serving multiple purposes, including quality improvement, administrative, research support and educational functions. Structurally, our system comprises customized paper and electronic components, while key functional aspects include the attending-based recording of diagnoses, integration into clinical workflows, multilevel data accuracy and validation checks, and periodic reporting on both data quality and NICU performance results. We provide examples of data validation methods and trends observed over three decades, and discuss essential elements for the successful implementation of this system. This database is reliable and easily maintained; it can be developed from simple paper-based forms or used to supplement the functionality and end-user customizability of existing electronic medical records. This system should be readily adaptable to NICUs in either high- or limited-resource environments.

Implementation of a Regional Standardised Model for Perinatal Electronic Medical Records

Electronic recording of newborn health information contributes to improving the quality of care. Nonetheless, there is limited evidence on the implementation of perinatal electronic medical records models. We describe the development and implementation of an electronic recording model that includes data on the health care provided to both the mother and the newborn, standardised for six hospitals of a regional health care system. The implementation process was developed in 2 stages. During stage 1, the tool was introduced in hospitals to stablish first contact with the healthcare staff. The second stage consisted in designing a new strategy to stabilise the model. Technical issues were fixed, and a new version was drawn up based on multidisciplinary agreement. Indicators to monitor implementation were measured in both stages and compared using the chi-squared test. During stage 1, nearly every newborn got its electronic medical record with an appropriate connection to the mother's data. However, certain forms that were meant to be filled in by staff were frequently neglected (completion rates: 36.7%-55.3%). In stage 2, there was a statistically significant increase in the completion rates of all these forms. As a result, a standardised discharge report was provided to every newborn at the end of stage 2. The PCR model implemented in the Region of Murcia is an innovative example of how the digitalisation and standardisation of data related to the care of healthy newborns at maternity wards is feasible across an entire network of hospitals.

Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care

Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.

[Modern non-drug technologies for medical rehabilitation of children with consequences of perinatal affection of the central nervous system]

The article is devoted to the issues of medical rehabilitation of children with consequences of perinatal affection of the central nervous system (CNS). An important and principal aspect of the medical rehabilitation of children with perinatal pathology is the minimization of drugs, in this regard, in children in the first year of life, the leading role is given to non-drug methods of exposure. Among the important challenges of the medical rehabilitation of children with perinatal pathology are: improvement of blood supply and metabolic processes in the brain tissue, normalization of the central and peripheral regulation of muscle tone, improvement of neuromuscular conduction, stimulation of psychomotor development. In this case, kinesitherapy technologies are of leading importance: massotherapy, therapeutic exercises, reflex kinesitherapy according to V. Vojta; fitball gymnastics, method of fine finger training, dry floatation, etc. Along with physical rehabilitation methods, physiotherapy methods are actively used, which makes it possible to increase the effectiveness of treatment. The analysis of the literature showed that the use of modern non-drug technologies in children with perinatal CNS pathology, and their introduction into practice can significantly increase the effectiveness of medical rehabilitation of such children.

The Denominator Matters! Lessons from Large Database Research in Neonatology

Observational studies from large datasets are becoming more common in neonatology. In this review, we highlight the importance of the denominator in study design and interpretation including examples of bias from source data, weight-based categories, age-related bias, and diagnosis-based denominators.

Information technology infrastructure, quality improvement and research: the UK National Neonatal Research Database

Technological developments, coupled with strengthened governance and data security have led to increasing recognition of the potential of real-world health data to benefit patient care and health services. Real-world health data are those captured in the course of routine care. Here I describe a mature source of real-world health data, the UK National Neonatal Research Database and provide examples of the many types of uses it supports.

Neonatal abstinence syndrome: a systematic review of current databases and registries

OBJECTIVES

Registries are considered as rich sources of data for determination of infants with neonatal abstinence syndrome (NAS), the improvement of provided care and research. The aims of this study were: (1) to investigate the existing studies including NAS registries, (2) to identify and extract the required data elements.

METHODS

The following electronic databases were searched: PubMed, Scopus, Web of Science, ProQuest, Embase/Medline, and Psych Info. In addition, a review of gray literature was undertaken to identify relevant studies in English covering the period from 1 January 2009 to 1 November 2018 including registries and databases. Screening of titles, abstracts, and full-texts were conducted independently by two researchers based on PRISMA guidelines. The basic registry information, scope, registry type, data source, the purpose of registry, important variables were extracted and analyzed.

RESULTS

Twenty-five articles were eligible and included in the review; they reported 37 registries and databases related to NAS at the national and state levels in 11 countries from 1876 to 2013. We proposed a NAS registry design framework based on well-known data-information-knowledge (DIK) structure due to Ackoff's DIK hierarchy has a defined role as a central model of information systems, information management, and knowledge management.

CONCLUSIONS

To the best of our knowledge, this is the first study which has systematically reviewed NAS-related registries. Since there are no international standards to develop new NAS registries, the proposed framework in this article can be beneficial. This framework is essential not only to facilitate the NAS registry design but also to help the collection of high-value clinical data necessary for the acquisition of better clinical knowledge.

Challenges in Advancing Necrotizing Enterocolitis Research

Progressing necrotizing enterocolitis research is difficult because the disease is variable in presentation, there are difficulties in making a precise diagnosis, a reliable agreed case-definition is currently lacking, and there is a paucity of preclinical research to identify etiologic targets. The major challenges of the cost of clinical trials and need for long-term outcome ascertainment could be eased through incorporation of novel randomization approaches and data collection into routine care, and collaboration between public-sector and industry funders.

Implementation of an individual patient prospective database of hospital births in Sri Lanka and its use for improving quality of care

OBJECTIVES

This study was aimed at piloting a prospective individual patient database on hospital deliveries in Colombo, Sri Lanka, and at exploring its use for developing recommendations for improving quality of care (QoC).

DESIGN

Observational study.

SETTING

De Soysa Maternity Hospital, the largest referral hospital for maternity care in Sri Lanka.

DATA COLLECTION AND ANALYSIS

From July 2015 to June 2017, 150 variables were collected for each delivery using a standardised form and entered into a database. Data were analysed every 8 months, and the results made available to local staff. Outcomes of the study included: technical problems; data completeness; data accuracy; key database findings; and use of data.

RESULTS

7504 deliveries were recorded. No technical problem was reported. Data completeness exceeded that of other existing hospital recording systems. Less than 1% data were missing for maternal variables and less than 3% for newborn variables. Mistakes in data collection and entry occurred in 0.01% and 0.09% of maternal and newborn data, respectively. Key QoC indicators identified in comparison with international standards were: relatively low maternal mortality (0.053%); relatively high maternal near-miss cases (3.4%); high rate of induction of labour (24.6%), caesarean section (30.0%) and episiotomy (56.1%); relatively high rate of preterm births (9.4%); low birthweight rate (16.5%); stillbirth (0.97%); and of total deaths in newborn (1.98%). Based on key indicators identified, a list of recommendations was developed, including the use checklists to standardise case management, training, clinical audits and more information for patients. A list of lessons learnt with the implementation of the data collection system was also drawn.

CONCLUSIONS

The study shows that the implemented system of data collection can produce a large quantity of reliable information. Most importantly, this experience provides an example on how database findings can be used for discussing hospital practices, identifying gaps and to agree on recommendations for improving QoC.

The United Kingdom National Neonatal Research Database: A validation study

Background

The National Neonatal Research Database (NNRD) is a rich repository of pre-defined clinical data extracted at regular intervals from point-of-care, clinician-entered electronic patient records on all admissions to National Health Service neonatal units in England, Wales, and Scotland. We describe population coverage for England and assess data completeness and accuracy.

Methods

We determined population coverage of the NNRD in 2008–2014 through comparison with data on live births in England from the Office for National Statistics. We determined the completeness of seven data items on the NNRD. We assessed the accuracy of 44 data items (16 patient characteristics, 17 processes, 11 clinical outcomes) for infants enrolled in the multi-centre randomised controlled trial, Probiotics in Preterm Study (PiPs). We compared NNRD to PiPs data, the gold standard, and calculated discordancy rates using predefined criteria, and sensitivity, specificity and positive predictive values (PPV) of binary outcomes.

Results

The NNRD holds complete population data for England for infants born alive from 25⁺⁰ to 31⁺⁶ (completed weeks) of gestation; and 70% and 90% for those born at 23 and 24 weeks respectively. Completeness of patient characteristics was over 90%. Data were linked for 2257 episodes of care received by 1258 of the 1310 babies recruited to PiPs. Discordancy rates were <5% for 13/16 patient characteristics (exceptions: mode of delivery 8.7%; maternal ethnicity 10.2%, Lower layer Super Output Area 16.5%); <5% for 9/16 processes (exceptions: medical treatment for Patent ductus arteriosus 6.1%, high-dependency days 10.2%, central line days 11.2%, type of first milk 22.3%; and during first 14 days, summary of types of milk 13.8%; number of days of antibiotics 9.0%; whether antacid given 5.1%); and <5% for 10/11 clinical outcomes (exception: Bronchopulmonary dysplasia, defined as oxygen dependency at 36 weeks postmenstrual age 3.3%). The specificity of NNRD data was >85% for all outcomes; sensitivity ranged from 50–100%; PPV ranged from 58.8 (95% CI 40.8–75.4%) for porencephalic cyst to 99.7 (95% CI 99.2, 99.9%) for survival to discharge.

Conclusions

The completeness and quality of data held in the NNRD is high, providing assurance in relation to use for multiple purposes, including national audit, health service evaluations, quality improvement, and research.

Neonatal brain injuries in England: population-based incidence derived from routinely recorded clinical data held in the National Neonatal Research Database

OBJECTIVE

In 2015, the Department of Health in England announced an ambition to reduce 'brain injuries occurring during or soon after birth'. We describe the development of a pragmatic case definition and present annual incidence rates.

DESIGN

Retrospective cohort study using data held in the National Neonatal Research Database (NNRD) extracted from neonatal electronic patient records from all National Health Service (NHS) neonatal units in England, Wales and Scotland. In 2010-2011, population coverage in the NNRD was incomplete, hence rate estimates are presented as a range; from 2012, population coverage is complete, and rates (95% CIs) are presented. Rates are per 1000 live births.

SETTING

NHS neonatal units in England.

PATIENTS

Infants admitted for neonatal care; denominator: live births in England.

MAIN OUTCOME MEASURE

'Brain injuries occurring at or soon after birth' defined as infants with seizures, hypoxic-ischaemic encephalopathy, stroke, intracranial haemorrhage, central nervous system infection and kernicterus and preterm infants with cystic periventricular leucomalacia.

RESULTS

In 2010, the lower estimate of the rate of 'Brain injuries occurring at or soon after birth' in England was 4.53 and the upper estimate was 5.19; in 2015, the rate was 5.14 (4.97, 5.32). For preterm infants, the population incidence in 2015 was 25.88 (24.51, 27.33) and 3.47 (3.33, 3.62) for term infants. Hypoxic-ischaemic encephalopathy was the largest contributor to term brain injury, and intraventricular/periventricular haemorrhage was the largest contributor to preterm brain injury.

CONCLUSIONS

Annual incidence rates for brain injuries can be estimated from data held in the NNRD; rates for individual conditions are consistent with published rates. Routinely recorded clinical data can be used for national surveillance, offering efficiencies over traditional approaches.

Better medicines for neonates: Improving medicine development, testing, and prescribing

Pharmacotherapy is a powerful tool to improve the outcome of neonates. Unfortunately, the potential health impact of pharmacotherapy in neonates remains underexplored. This necessitates a structured approach to go beyond the current practice of trial and error, reflected in off-label prescription. The existing regulatory framework hereby provides a structure to reflect about aspects like pharmacokinetic models for dose selection and outcome assessment, including long-term safety. Future medicine development should also be driven by neonatal needs, diseases and pathophysiology, since surfactant is the latest product developed for preterm neonates. The potential impact is illustrated by ongoing repurposing (propranolol, allopurinol, erythropoietin, Insulin-like Growth Factor-1) projects. Clinical researchers will be crucial to close the knowledge gap by developing dose selection tools and outcome assessment tools and by exploring pathophysiological mechanisms. The final step of such a structured approach cycle is the subsequent translation of accumulated knowledge into improved prescribing.

eNewborn: The Information Technology Revolution and Challenges for Neonatal Networks

Among preterm infants, 1-2% are born before 32 weeks of gestation or have a birth weight below 1,500 g. They contribute disproportionately to the burden of mortality and morbidity related to preterm birth, whether in the neonatal period or later in life. They are the target population studied in neonatal networks. Improving neonatal care and later outcome is a major issue in public health. Neonatologists, health care providers, public authorities, parents and families, industry, and all organizations dedicated to infant health must bring their efforts together and dedicate their actions in order to do so. Neonatal networks are the strongest platforms through which to achieve this goal. The progressive information technology (IT) revolution is leading to a new approach. The power of search engines and new technological devices opens extraordinary new perspectives in terms of speed, storing, sharing, and innovative approaches in providing health care. However, difficulties are expected with old applications that cannot evolve in the new IT environment. Security and privacy in data collection are future challenges to be addressed. Here, we describe the eNewborn project and its original software. The main functionalities are interactive navigation, harmonization with other formats, linkage with other databases, and strict security and privacy procedures.