Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project

Early Discharge of Newborns Born to Mothers with COVID-19: A Possible Safe Strategy

OBJECTIVE

In this study, we evaluated the safety of early discharge (ED) of newborns born to coronavirus disease 2019 (COVID-19)-positive mothers.

STUDY DESIGN

All ED newborns from the postpartum wards of the Fondazione Policlinico Gemelli between January 1, 2022, and February 28, 2022, were retrospectively analyzed. Newborns from mothers with COVID-19 and those from uninfected mothers were considered. The primary outcome was to evaluate whether the rate of the composite outcome, which was the percentage of rehospitalization/access in emergency room (RH/ER) within the first week from discharge, differed between neonates born to mother with COVID-19 (COVID-19 group) and those born to uninfected mothers (no COVID-19 group). The secondary outcomes were to assess the quality of feeding and number of outpatient visits in the follow-up clinic between the two cohorts of patients.

RESULTS

One hundred and thirty-four newborns in the no COVID-19 group and 26 in the COVID-19 group were analyzed. The rate of RH/ER in the no COVID-19 group was of 6 over 134 newborns (0.045, 95% confidence image [CI]: 0.017-0.095), while in COVID-19 group, it was of 2 over 26 newborns (0.077), which does not differ from the expected rate (1.17 over 26 newborns, 0.045, 95% CI: 0.017-0.095).

CONCLUSION

ED for newborns from mothers with COVID-19 could be an actionable safe strategy.

KEY POINTS

· We evaluated the feasibility of early discharge (ED) of mothers with COVID-19 and their newborns.. · Rate of rehospitalization between newborns from uninfected mothers and infected ones was comparable.. · ED could be an actionable practice for newborns from mothers with COVID-19..

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Interventions delivered in secondary or tertiary medical care settings to improve routine vaccination uptake in children and young people: a scoping review

OBJECTIVE

To identify and analyse the interventions delivered opportunistically in secondary or tertiary medical settings, focused on improving routine vaccination uptake in children and young people.

DESIGN

Scoping review.

SEARCH STRATEGY

We searched CINAHL, Web of Science, Medline, Embase and Cochrane Database of Systematic Reviews for studies in English published between 1989 and 2021 detailing interventions delivered in secondary or tertiary care that aimed to improve childhood vaccination coverage. Title, abstract and full-text screening were performed by two independent reviewers.

RESULTS

After deduplication, the search returned 3456 titles. Following screening and discussion between reviewers, 53 studies were included in the review. Most papers were single-centre studies from high-income countries and varied considerably in terms of their study design, population, target vaccination, clinical setting and intervention delivered. To present and analyse the study findings, and to depict the complexity of vaccination interventions in hospital settings, findings were presented and described as a sequential pathway to opportunistic vaccination in secondary and tertiary care comprising the following stages: (1) identify patients eligible for vaccination; (2) take consent and offer immunisations; (3) order/prescribe vaccine; (4) dispense vaccine; (5) administer vaccine; (6) communicate with primary care; and (7) ongoing benefits of vaccination.

CONCLUSIONS

Most published studies report improved vaccination coverage associated with opportunistic vaccination interventions in secondary and tertiary care. Children attending hospital appear to have lower baseline vaccination coverage and are likely to benefit from vaccination interventions in these settings. Checking immunisation status is challenging, however, and electronic immunisation registers are required to enable this to be done quickly and accurately in hospital settings. Further research is required in this area, particularly multicentre studies and cost-effectiveness analysis of interventions.

Increasing the exclusive breastfeeding rate in a private hospital in UAE through quality improvement initiatives

BACKGROUND

Mother's milk is the best, and ideal method for infant feeding. We found that this practice was not being followed in our hospital. A survey was conducted in the unit with regards to breastfeeding practices which revealed that most babies who were discharged from our nursery were on formula supplements. Our goal was to improve established breastfeeding rates in the unit by increasing the number of full-term healthy babies who were discharged on exclusive Breastfeeding.

METHOD

A project team was formed, and data were collected through direct observations and direct interviews with postnatal mothers. Exclusive Breastfeeding at discharge was defined as a baby being fully on breastfeed with no additional formula supplements for at least 12 hours prior to discharge. The primary outcome was to increase the percentage of babies being discharged on exclusive Breastfeeding. We used the FOCUS PDCA model to measure improvements and 8 PDCA cycles of 4 weeks duration were implemented to test the changes.

RESULTS

The interventions we put in place led to a considerable nine times overall improvement in the established breastfeeding rates. Among all the interventions, the most promising results were observed during the PDCA cycles involving staff education, the introduction of antenatal classes for mothers, skin to skin contact and rooming in.

CONCLUSION

Breastfeeding rates in the private sector with nursery services can be improved by reinforcing breastfeeding education for mothers in addition to training the maternal care staff, empowering them to promote and assist in breastfeeding.

Comparing JM-105 and MBJ-20 Transcutaneous Bilirubinometers According to the Area Tested in Ethnically Diverse Late-Preterm and Term Neonates

This study aims to evaluate the correlation between the results of transcutaneous bilirubin (TcB) levels measured by the 2 transcutaneous bilirubinometers according to the area tested and to compare the TcB measurements and the serum bilirubin (SBR) levels. We screened 78 neonates born at more than 35 weeks of gestation and aged less than 168 hours for jaundice. We used JM-105 and MBJ-20 to measure the TcB at the forehead and the chest. For newborns who had high TcB measurements, we obtained blood samples during the subsequent 30 minutes. There was a strong correlation between the TcB measurements by JM-105 and MBJ-20 and this correlation was stronger when they were used on the sternum. The mean differences between the TcB measurements on the forehead and the sternum and the SBR levels were similar for the JM-105 and the MBJ-20. There was a strong correlation between SBR and the measurements using the 2 devices on the sternum (JM-105: r = 0.805; MBJ-20: r = 0.801), unlike measurements taken on the forehead by each device (r = 0.777 and r = 0.751, respectively). Both devices had high sensitivity and negative predictive values at SBR level of less than 230 μmol/L (<13.4 mg/dL) and high specificity and positive predictive values at SBR level of 230 μmol/L and greater (>13.4mg/dL). Both devices equally overestimated the actual SBR and had more reliable results if used on the sternum.

Risk Factors Associated with Neonatal Jaundice: A Cross-Sectional Study from Iran

BACKGROUND

Neonatal jaundice is one of the main causes of the patient's admission in the neonatal period and is potentially linked to morbidity.

AIM

This study aimed to determine the possible risk factors for neonatal jaundice.

METHODS

We investigated the case of infants who were admitted to the neonatal department of Ziyaeian hospital and Imam Khomeini Hospital for jaundice. Simple random sampling was used to evaluate variables related to maternal and neonatal predisposing factors based on the medical records and clinical profiles. All variables in this study were analysed using SPSS software.

RESULTS

In this study, about 200 mothers and neonates were examined. Our findings depicted that mother's WBC, Hb, PLT, and gestational age were associated with jaundice (P < 0.05). Furthermore, there were significant relationships between different degrees of bilirubin with TSH, T4 levels and G6PD (P < 0.05). In fact, TSH, T4 levels and G6PD were found to be linked to neonatal hyperbilirubinemia. The risk factors for jaundice in our study population comprise some predisposing factors such as WBC, Hb, PLT, gestational age, TSH, and T4 levels, as well as G6PD. Neonates at risk of jaundice are linked to some maternal and neonatal factors that can provide necessary interventions to reduce the burden of the disease. Therefore, identification of associated factors can facilitate early diagnosis, and reduce subsequent complications.

CONCLUSION

Neonatal jaundice should be considered as the main policy in all health care settings of the country. Therefore, identification of factors affecting the incidence of jaundice can be effective in preventing susceptible predisposing factors in newborns and high-risk mothers.

Length of stay for childbirth in Trentino (North-East of Italy): the impact of maternal characteristics and organizational features of the maternity unit on the probability of early discharge of healthy, term infants

Early discharge (ED) of healthy term infants has become a common practice due to current social and economic needs. The primary objective of the present study was to evaluate trends in early discharge of healthy term neonates (≥ 37 gestational weeks) by delivery method (cesarean and vaginal) in maternity units in the Province of Trento. The secondary objective was to identify the socio-demographic characteristics (including the area of residence and distance from the designated hospital) and clinical characteristics of mothers whose infants were discharged early. This retrospective study reviewed records of live births from 2006 to 2016, for a total of 45, 314 healthy term infants. The trend for ED grew significantly during the period 2006-2016, for both cesarean and vaginal deliveries. The multiple logistic regression analysis shows how the determinants of ED are maternal age, birth order, citizenship of mother, maternal smoking, maternal employment status, and the number of births at the hospital on the day of birth.

CONCLUSION

The post-partum length of stay should be adjusted based on the characteristics and needs of the mother-infant dyad, identifying the criteria for safe discharge. In Trento, various procedures and programs are becoming more uniform today with the intention to provide family assistance service. What is Known: • Admission for childbirth is one of the primary causes of hospitalization in industrialized countries. • The length of stay for childbirth has been steadily declining in recent decades, with the aim of reducing costs while also demedicalizing pregnancy. What is New: • A higher rate of early discharge (ED) was recorded for neonates of women having foreign citizenship, < 30 years, pluriparous, smoked during pregnancy, housewife, and, if emplyed, entrepreneurs, self-employed professionals or managers. • ED was more common when the new mother gave birth on a day in which there was a higher number of births at the hospital, indicating overcrowding in the maternity unit.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

Italian guidelines for management and treatment of hyperbilirubinaemia of newborn infants ≥ 35 weeks' gestational age

Hyperbilirubinaemia is one of the most frequent problems in otherwise healthy newborn infants. Early discharge of the healthy newborn infants, particularly those in whom breastfeeding is not fully established, may be associated with delayed diagnosis of significant hyperbilirubinaemia that has the potential for causing severe neurological impairments. We present the shared Italian guidelines for management and treatment of jaundice established by the Task Force on hyperbilirubinaemia of the Italian Society of Neonatology.

The overall aim of the present guidelines is to provide an useful tool for neonatologists and family paediatricians for managing hyperbilirubinaemia.

Quality improvement initiatives in neonatal intensive care unit networks: achievements and challenges

Neonatal intensive care unit networks that encompass regions, states, and even entire countries offer the perfect platform for implementing continuous quality improvement initiatives to advance the health care provided to vulnerable neonates. Through cycles of identification and implementation of best available evidence, benchmarking, and feedback of outcomes, combined with mutual collaborative learning through a network of providers, the performance of health care systems and neonatal outcomes can be improved. We use examples of successful neonatal networks from across North America to explore continuous quality improvement in the neonatal intensive care unit, including the rationale for the formation of neonatal networks, the role of networks in continuous quality improvement, quality improvement methods and outcomes, and barriers to and facilitators of quality improvement.

The national improvement partnership network: state-based partnerships that improve primary care quality

Improvement partnerships (IPs) are a model for collaboration among public and private organizations that share interests in improving child health and the quality of health care delivered to children. Their partners typically include state public health and Medicaid agencies, the local chapter of the American Academy of Pediatrics, and an academic health care organization or children's hospital. Most IPs also engage other partners, including a variety of public, private, and professional organizations and individuals. IPs lead and support measurement-based, systems-focused quality improvement (QI) efforts that primarily target primary care practices that care for children. Their projects are most often conducted as learning collaboratives that involve a team from each of 8 to 15 participating practices over 9 to 12 months. The improvement teams typically include a clinician, office manager, clinical staff (nurses or medical assistants), and, for some projects, a parent; the IPs provide the staff and local infrastructure. The projects target clinical topics, chosen because of their importance to public health, local clinicians, and funding agencies, including asthma, attention-deficit/hyperactivity disorder, autism, developmental screening, obesity, mental health, medical home implementation, and several others. Over the past 13 years, 19 states have developed (and 5 are exploring developing) IPs. These organizations share similar aims and methods but differ substantially in leadership, structure, funding, and longevity. Their projects generally engage pediatric and family medicine practices ranging from solo private practices to community health centers to large corporate practices. The practices learn about the project topic and about QI, develop specific improvement strategies and aims that align with the project aims, perform iterative measures to evaluate and guide their improvements, and implement systems and processes to support and sustain those improvements. Since 2008, IPs have offered credit toward Part 4 of Maintenance of Certification for participants in some of their projects. To date, IPs have focused on achieving improvements in care delivery through individual projects. Rigorous measurement and evaluation of their efforts and impact will be essential to understanding, spreading, and sustaining state/regional child health care QI programs. We describe the origins, evolution to date, and hopes for the future of these partnerships and the National Improvement Partnership Network (NIPN), which was established to support existing and nurture new IPs.

A quality project to improve compliance with AAP guidelines for inpatient management of neonatal hyperbilirubinemia

OBJECTIVE

The goal of this study was to improve compliance with published guidelines regarding management of neonatal hyperbilirubinemia in infants admitted to a general pediatric hospital ward and to improve support for their breastfeeding mothers.

METHODS

This quality improvement project was conducted by using Plan-Do-Study-Act cycles and statistical process control methods. Study subjects were infants > 35 weeks' gestation admitted for hyperbilirubinemia to the general inpatient ward of a large, freestanding pediatric hospital. We developed and implemented a guideline for the inpatient management of jaundiced neonates, with ongoing feedback given to the faculty on group performance. Outcome measures included monthly compliance scores based on American Academy of Pediatrics (AAP) guidelines for management of neonates > 35 weeks' gestation and the percentage of admitted jaundiced, breastfeeding infants whose mothers received lactation consultation during hospitalization. To determine the AAP compliance score, we reviewed and assigned points to each patient admission for completion of a standard evaluation, avoidance of unnecessary intravenous (IV) fluids and peripheral IV line placement, avoidance of rebound bilirubin checks while in the hospital, and the bilirubin level at discharge.

RESULTS

Mean monthly AAP compliance scores increased from 60.5% of total possible points during the baseline period (January 2010-December 2010) to 90.4% during the intervention period (January 2011-December 2011). Lactation consultations increased from 48% during our baseline period to 63% during our early intervention period and to 90% during the last 5 months of our intervention. Length of stay was unchanged during the baseline and intervention periods.

CONCLUSIONS

Interprofessional collaboration between nurses and physicians combined with a thoughtful campaign to increase awareness of published guidelines were successful in improving the care of infants admitted with unconjugated hyperbilirubinemia.

Development of the breastfeeding quality improvement in hospitals learning collaborative in New York state

Exclusive breastfeeding is a public health priority. A strong body of evidence links maternity care practices, based on the Ten Steps to Successful Breastfeeding, to increased breastfeeding initiation, duration and exclusivity. Despite having written breastfeeding policies, New York (NY) hospitals vary widely in reported maternity care practices and in prevalence rates of breastfeeding, especially exclusive breastfeeding, during the birth hospitalization. To improve hospital maternity care practices, breastfeeding support, and the percentage of infants exclusively breastfeeding, the NY State Department of Health developed the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative. The BQIH Learning Collaborative was the first to use the Institute for Health Care Improvement's Breakthrough Series methodology to specifically focus on increasing hospital breastfeeding support. The evidence-based maternity care practices from the Ten Steps to Successful Breastfeeding provided the basis for the Change Package and Data Measurement Plan. The present article describes the development of the BQIH Learning Collaborative. The engagement of breastfeeding experts, partners, and stakeholders in refining the Learning Collaborative design and content, in defining the strategies and interventions (Change Package) that drive hospital systems change, and in developing the Data Measurement Plan to assess progress in meeting the Learning Collaborative goals and hospital aims is illustrated. The BQIH Learning Collaborative is a model program that was implemented in a group of NY hospitals with plans to spread to additional hospitals in NY and across the country.

A quality improvement project to increase breast milk use in very low birth weight infants

OBJECTIVE

To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.

METHODS

Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.

RESULTS

The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.

CONCLUSIONS

Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

A description of barriers and facilitators to childhood vaccinations in the military health system

PURPOSE

To perform a literature review of barriers to and facilitators of parents' decisions to have their children vaccinated. Both differences and similarities between the civilian sector and the military health system (MHS) were explored.

DATA SOURCES

Articles and documents were identified from the following databases: CINAHL, PubMed, Defense Technical Information Center (DTIC), ISI, and Google Scholar. Reference lists from articles were reviewed.

CONCLUSIONS

Common themes identified in the civilian sector and the MHS included an electronic registry, care access issues, provider characteristics, and child illness. Several themes served as a barrier in one system while being a facilitator in the other, such as provider characteristics. Literature addressing the MHS and factors affecting vaccine coverage is scant; however, a large disparity in vaccination coverage exists between the MHS and the civilian sector.

IMPLICATIONS

The theme of provider characteristics was seen as a barrier in both systems; a better understanding of this theme (i.e., provider effectiveness at interacting with parents) would benefit primary care practice. An electronic vaccine registry and targeted education and media campaign used to facilitate vaccinations in the MHS should be piloted in the civilian sector. Additionally, future studies should be performed on identified themes in the MHS.

Development and validation of serum bilirubin nomogram to predict the absence of risk for severe hyperbilirubinaemia before discharge: a prospective, multicenter study

Background

Early discharge of healthy late preterm and full term newborn infants has become common practice because of the current social and economic necessities. Severe jaundice, and even kernicterus, has developed in some term infants discharged early. This study was designed to elaborate a percentile-based hour specific total serum bilirubin (TSB) nomogram and to assess its ability to predict the absence of risk for subsequent non physiologic severe hyperbilirubinaemia before discharge.

Methods

A percentile-based hour-specific nomogram for TSB values was performed using TSB data of 1708 healthy full term neonates. The nomogram's predictive ability was then prospectively assessed in five different first level neonatal units, using a single TSB value determined before discharge.

Results

The 75 ^th percentile of hour specific TSB nomogram allows to predict newborn babies without significant hyperbilirubinemia only after the first 72 hours of life. In the first 48 hours of life the observation of false negative results did not permit a safe discharge from the hospital.

Conclusion

The hour-specific TSB nomogram is able to predict all neonates without risk of non physiologic hyperbilirubinemia only after 48 to 72 hours of life. The combination of TSB determination and risk factors for hyperbilirubinemia could facilitate a safe discharge from the hospital and a targeted intervention and follow-up.

A cross-sectional survey of the prevalence of environmental tobacco smoke preventive care provision by child health services in Australia

Background

Despite the need for a reduction in levels of childhood exposure to environmental tobacco smoke (ETS) being a recognised public health goal, the delivery of ETS preventive care in child health service settings remains a largely unstudied area. The purpose of this study was to determine the prevalence of ETS preventive care in child health services; differences in the provision of care by type of service; the prevalence of strategies to support such care; and the association between care support strategies and care provision.

Method

One-hundred and fifty-one (83%) child health service managers within New South Wales, Australia completed a questionnaire in 2002 regarding the: assessment of parental smoking and child ETS exposure; the provision of parental smoking cessation and ETS-exposure reduction advice; and strategies used to support the provision of such care. Child health services were categorised based on their size and case-mix, and a chi-square analysis was performed to compare the prevalence of ETS risk assessment and ETS prevention advice between service types. Logistic regression analysis was used to examine associations between the existence of care support strategies and the provision of ETS risk assessment and ETS exposure prevention advice.

Results

A significant proportion of services reported that they did not assess parental smoking status (26%), and reported that they did not assess the ETS exposure (78%) of any child. Forty four percent of services reported that they did not provide smoking cessation advice and 20% reported they did not provide ETS exposure prevention advice. Community based child and family health services reported a greater prevalence of ETS preventive care compared to other hospital based units. Less than half of the services reported having strategies to support the provision of ETS preventive care. The existence of such support strategies was associated with greater odds of care provision.

Conclusions

The existence of major gaps in recommended ETS preventive care provision suggests a need for additional initiatives to increase such care delivery. The low prevalence of strategies that support such care delivery suggests a potential avenue to achieve this outcome.

Translating infant safe sleep evidence into nursing practice

The authors describe a 4-year demonstration project (2004-2007) to reduce infant deaths related to sleep environments by changing attitudes and practices among nurses who work with African American parents and caregivers in urban Michigan hospitals. An approach was developed for creating sustainable change in nursing practice by implementing nursing practice policies that could be monitored through quality improvement processes already established within the hospital organization. Following the policy change effort, nurses changed their behavior and placed infants on the back to sleep.

The Massachusetts baby-friendly collaborative: lessons learned from an innovation to foster implementation of best practices

Collaborative efforts among hospitals can facilitate the exchange of ideas, provide a forum for discussing the development of new policies or practices or changes to existing policies and practices, and increase the implementation of best practices. In November 2008, the Massachusetts Breastfeeding Coalition formed a collaborative of maternity facilities wishing to pursue Baby-Friendly designation. Members provided insights from experiences and shared models and examples from outside. We describe highlights from the first 15 months of the Collaborative and present 4 recommendations for overcoming barriers: (1) manage expectations of patients, family/friends, and staff; (2) restrict access to materials that can undermine breastfeeding; (3) adopt the appropriate perspectives to creatively implement change; and (4) bundle, reframe, and harness larger forces. The strategies can be applied across diverse hospital settings.

Improving the prevention, early recognition, and treatment of pediatric obesity by primary care physicians

To determine if participation in a learning collaborative (LC) would improve care processes for prevention, early recognition, and treatment of childhood obesity by primary care physicians (PCP), the authors conducted pre-post evaluations of the use of obesity related care processes by 18 primary care practices following participation in a 9-month LC based on the Model for Improvement. Prior to the LC, chart audits revealed that 55% of patients had a BMI recorded; this rose to 97% of patients at its conclusion. Following the LC, 11 practices had implemented systematic prevention advice to parents of infants compared with 3 prior to the LC. All practices developed plans for evaluation and management of children with an elevated BMI. Participation in an LC increased the number of primary care practices that provided anticipatory guidance regarding obesity prevention and that identified and treated overweight or obese children.

Improving follow-up to newborn hearing screening: a learning-collaborative experience

Although approximately 95% of US newborns are now screened for hearing loss at birth, more than half of those who do not pass the screen lack a documented diagnosis. In an effort to improve the quality of the follow-up process, teams from 8 states participated in a breakthrough-series learning collaborative. Teams were trained in the Model for Improvement, a quality-improvement approach that entails setting clear aims, tracking results, identifying proven or promising change strategies, and the use of small-scale, rapid-cycle plan-do-study-act tests of these changes. Parents acted as equal partners with professionals in guiding system improvement. Teams identified promising change strategies including ensuring the correct identification of the primary care provider before discharge from the birthing hospital; obtaining a second contact number for each family before discharge; "scripting" the message given to families when an infant does not pass the initial screening test; and using a "roadmap for families" as a joint communication tool between parents and professionals to demonstrate each family's location on the "diagnostic journey." A learning-collaborative approach to quality improvement can be applied at a state-system level. Participants reported that the collaborative experience allowed them to move beyond a focus on improving their own service to improving connections between services and viewing themselves as part of a larger system of care. Ongoing quality-improvement efforts will require refinement of measures used to assess improvement, development of valid indicators of system performance, and an active role for families at all levels of system improvement.

Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates

OBJECTIVE

The objective of this study was to provide data on transcutaneous bilirubin (TcB) levels for the first 120 postnatal hours and to develop an hour-specific TcB nomogram for healthy term and near-term neonates.

METHODS

From September 2005 to August 2008, we obtained 14864 TcB measurements from 2818 healthy neonates (gestational age >or= 35 weeks and birth weight >or= 2000 g). All measurements were performed with the BiliCheck bilirubinometer, at designated times from 12 to 120 postnatal hours. TcB percentiles for each designated time were calculated and used for the development of an hour-specific nomogram. TcB percentiles for neonates who required phototherapy are also presented.

RESULTS

The developed TcB nomogram reflects the natural history of TcB levels in healthy neonates up to the fifth postnatal day. A different pattern of TcB increasing rate was noted in neonates who did and did not require phototherapy but with substantial overlap of TcB values between the 2 groups.

CONCLUSIONS

We provide data on TcB levels for the first 120 postnatal hours from a large population of white, healthy, term and near-term neonates. We also present a percentile-based TcB nomogram designated for noninvasive and hour-specific evaluation of neonatal hyperbilirubinemia.

Transcutaneous bilirubin nomogram for prediction of significant neonatal hyperbilirubinemia

OBJECTIVE

The goal was to develop a predictive nomogram, based on transcutaneous bilirubin (TcB) measurements, for assessment of the risk of significant hyperbilirubinemia in healthy term and near-term neonates.

METHODS

A total of 10382 TcB measurements were performed with 2039 healthy neonates (gestational age of > or =35 weeks and birth weight of > or =2000 g), with a BiliCheck bilirubinometer (SpectRx, Norcross, GA), at designated time points between 12 and 120 hours of life. According to their severity, these TcB measurements were selectively cross-checked with a direct spectrophotometric device, and significant hyperbilirubinemia was defined on the basis of the hour-specific threshold values for phototherapy proposed by the American Academy of Pediatrics. With the use of likelihood ratios (LRs), the high- and low-risk demarcators for each designated time were calculated and presented on an hour-specific nomogram.

RESULTS

Significant hyperbilirubinemia was documented for 122 neonates (6%). At 24 hours of life, the high-risk zone of the nomogram had 73.9% sensitivity and a positive LR of 12.1 in predicting significant hyperbilirubinemia, whereas the low-risk zone had 97.7% sensitivity and a negative LR of 0.04. At 48 hours, the high-risk zone had 90% sensitivity and a positive LR of 12.1, whereas the low-risk zone had 98.8% sensitivity and a negative LR of 0.02. In our study population, the probability of significant hyperbilirubinemia would be >35% for values in the high-risk zone and <0.5% for values in the low-risk zone of the nomogram.

CONCLUSIONS

We provide a predictive TcB tool that could allow for a noninvasive, risk-based approach to neonatal hyperbilirubinemia.

Closing the quality gap: promoting evidence-based breastfeeding care in the hospital

Evidence shows that hospital-based practices affect breastfeeding duration and exclusivity throughout the first year of life. However, a 2007 CDC survey of US maternity facilities documented poor adherence with evidence-based practice. Of a possible score of 100 points, the average hospital scored only 63 with great regional disparities. Inappropriate provision and promotion of infant formula were common, despite evidence that such practices reduce breastfeeding success. Twenty-four percent of facilities reported regularly giving non-breast milk supplements to more than half of all healthy, full-term infants. Metrics available for measuring quality of breastfeeding care, range from comprehensive Baby-Friendly Hospital Certification to compliance with individual steps such as the rate of in-hospital exclusive breastfeeding. Other approaches to improving quality of breastfeeding care include (1) education of hospital decision-makers (eg, through publications, seminars, professional organization statements, benchmark reports to hospitals, and national grassroots campaigns), (2) recognition of excellence, such as through Baby-Friendly hospital designation, (3) oversight by accrediting organizations such as the Joint Commission or state hospital authorities, (4) public reporting of indicators of the quality of breastfeeding care, (5) pay-for-performance incentives, in which Medicaid or other third-party payers provide additional financial compensation to individual hospitals that meet certain quality standards, and (6) regional collaboratives, in which staff from different hospitals work together to learn from each other and meet quality improvement goals at their home institutions. Such efforts, as well as strong central leadership, could affect both initiation and duration of breastfeeding, with substantial, lasting benefits for maternal and child health.

Infant hearing screening

PURPOSE OF REVIEW

Infant hearing screening has progressed markedly over the past year. Although uncommon in the past, now almost 95% of infants in the United States are screened for hearing loss. Recent literature has expanded on several important components of hearing screening.

RECENT FINDINGS

A major revision of the American Academy of Pediatrics policy statement on infant hearing screening was published. This statement identifies a number of important principles and guidelines for infant hearing screening. Improvements in diagnostic techniques have been described including the need for auditory brainstem response screening in premature infants. Risk factors for congenital-hearing loss have been updated. An etiologic diagnosis for infants with hearing loss is increasingly possible with advances in genetics and molecular diagnosis. Finally, several articles provide further information on optimizing follow-up and diagnostic testing as well as early intervention.

SUMMARY

Despite the challenges still present in infant hearing screening, screening continues to identify infants at a very young age, and improve the early communication skills of infants with hearing loss through early diagnosis and early intervention.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.