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Quinn MK, Lee HC, Profit J, Chu A. Trends in Retinopathy of Prematurity Among Preterm Infants in California, 2012 to 2021. JAMA Ophthalmol 2024:2824069. [PMID: 39361320 DOI: 10.1001/jamaophthalmol.2024.3909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2024]
Abstract
Importance The incidence of retinopathy of prematurity (ROP) has been increasing in the US since 2003. Understanding the progression of and racial disparities in ROP incidence in California can provide a contrasting perspective that may guide future research and practice in the management and prevention of ROP. Objective To describe how the screening and incidence of ROP among very preterm infants in California changed from January 1, 2012, to December 31, 2021. Design, Setting, and Participants This study used a cohort of very preterm infants (defined as infants born prior to 32 weeks' gestational age or weighing less than 1500 g) admitted to 60 neonatal intensive care units across California from January 1, 2012, to December 31, 2021. Among this cohort, several factors were examined, including (1) the clinical and sociodemographic covariates of the population with and without ROP, (2) trends in screening for ROP, and (3) the incidence of ROP in total and by race and ethnicity. Data analysis was performed in April 2024. Exposures Race and ethnicity and other birthing parental and infant descriptive characteristics. Main Outcomes and Measures Incidence rates of ROP and severe ROP. The primary measures were rates of ROP screening and incidence rates of ROP and severe ROP. Time trends in the risk of ROP and severe ROP were estimated using robust Poisson regression models. Results In this cohort of 39 269 very preterm infants (<32 weeks' gestational age) eligible for ROP screening, the mean (SD) infant gestational age was 28.6 (2.6) weeks. The mean (SD) birth weight was 1075 (274) g, and 48.6% of infants were female. The birthing parents of the population were 12.6% Asian, 13.3% Black, 44.9% Hispanic White or Hispanic other race, 0.7% Native American/Alaskan, 24.7% non-Hispanic White, and 1.0% Pacific Islander. From January 1, 2012, to December 31, 2021, in California, ROP screening rates remained steady at 95% or greater for eligible infants less than 30 weeks of gestational age for all race and ethnic subgroups. In this study cohort among all very preterm infants (<32 weeks' gestational age), the incidence of ROP decreased from 31% in 2012 to 29% in 2021. Incidence rates of ROP among Asian and Hispanic individuals decreased the most quickly compared to other racial and ethnic groups, narrowing disparities. Conclusions and Relevance In this cohort study, in contrast to increasing national trends, the total incidence of and racial and ethnic disparities in ROP incidence remained steady or decreased from 2012 to 2021 in California.
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Affiliation(s)
- M K Quinn
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Center of Academic Medicine, Stanford University, Stanford, California
| | - Henry C Lee
- Division of Neonatology, Department of Pediatrics, University of California, San Diego, School of Medicine, La Jolla
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alison Chu
- Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles
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Ortiz-Movilla R, Beato-Merino M, Funes Moñux RM, Martínez-Bernat L, Domingo-Comeche L, Royuela-Vicente A, Román-Riechmann E, Marín-Gabriel MÁ. What Is the Opinion of the Health Care Personnel Regarding the Use of Different Assistive Tools to Improve the Quality of Neonatal Resuscitation? Am J Perinatol 2024; 41:1645-1651. [PMID: 38190977 DOI: 10.1055/a-2240-2094] [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: 01/10/2024]
Abstract
OBJECTIVE It is important to determine whether the use of different quality improvement tools in neonatal resuscitation is well-received by health care teams and improves coordination and perceived quality of the stabilization of the newborn at birth. This study aimed to explore the satisfaction of personnel involved in resuscitation for infants under 32 weeks of gestational age (<32 wGA) at birth with the use of an assistance toolkit: Random Real-time Safety Audits (RRSA) of neonatal stabilization stations, the use of pre-resuscitation checklists, and the implementation of briefings and debriefings. STUDY DESIGN A quasi-experimental, prospective, multicenter intervention study was conducted in five level III-A neonatal intensive care units in Madrid (Spain). The intervention involved conducting weekly RRSA of neonatal resuscitation stations and the systematic use of checklists, briefings, and debriefings during stabilization at birth for infants <32 wGA. The satisfaction with their use was analyzed through surveys conducted with the personnel responsible for resuscitating these newborns. These surveys were conducted both before and after the intervention phase (each lasting 1 year) and used a Likert scale response model to assess various aspects of the utility of the introduced assistance tools, team coordination, and perceived quality of the resuscitation. RESULTS Comparison of data from 200 preintervention surveys and 155 postintervention surveys revealed statistically significant differences (p < 0.001) between the two phases. The postintervention phase scored higher in all aspects related to the effective utilization of these tools. Improvements were observed in team coordination and the perceived quality of neonatal resuscitation. These improved scores were consistent across personnel roles and years of experience. CONCLUSION Personnel attending to infants <32 wGA in the delivery room are satisfied with the application of RRSA, checklists, briefings, and debriefings in the neonatal resuscitation and perceive a higher level of quality in the stabilization of these newborns following the introduction of these tools. KEY POINTS · RRSA, checklists, briefings, and debriefings improve the quality of neonatal resuscitation at birth.. · These tools, when used together, are well-received and enhance perceived resuscitation quality.. · Perception of utility and quality improvement is consistent across roles and experience..
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Affiliation(s)
- Roberto Ortiz-Movilla
- Pediatric Service, Neonatology Unit, Puerta de Hierro-Majadahonda University Hospital, Universidad Autónoma de Madrid, Majadahonda, Madrid, Spain
| | - Maite Beato-Merino
- Pediatric Service, Neonatology Unit, Severo Ochoa University Hospital, Leganés, Madrid, Spain
| | - Rosa María Funes Moñux
- Pediatric Service, Neonatology Unit, Príncipe de Asturias University Hospital, Universidad de Alcalá de Henares, Madrid, Spain
| | - Lucía Martínez-Bernat
- Pediatric Service, Neonatology Unit, Getafe University Hospital, Getafe, Madrid, Spain
| | - Laura Domingo-Comeche
- Pediatric Service, Neonatology Unit, Fuenlabrada University Hospital, Fuenlabrada, Madrid, Spain
| | - Ana Royuela-Vicente
- Biostatistics Unit, Puerta de Hierro Biomedical Research Institute, CIBERESP, Madrid, Spain
| | - Enriqueta Román-Riechmann
- Pediatric Service, Puerta de Hierro-Majadahonda University Hospital, Universidad Autónoma de Madrid, Majadahonda, Madrid, Spain
| | - Miguel Ángel Marín-Gabriel
- Pediatric Service, Neonatology Unit, Puerta de Hierro-Majadahonda University Hospital, Universidad Autónoma de Madrid, Majadahonda, Madrid, Spain
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Payton KSE, Bennett MV, Schulman J, Benitz WE, Stellwagen L, Darmstadt GL, Quinn J, Kristensen-Cabrera AI, Breault CC, Bolaris M, Lefrak L, Merrill J, Sharek PJ. 28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use. J Perinatol 2024; 44:1061-1068. [PMID: 38378826 PMCID: PMC11226396 DOI: 10.1038/s41372-024-01885-8] [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: 06/08/2023] [Revised: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention. CONCLUSION Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.
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Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA.
| | - Mihoko V Bennett
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph Schulman
- CA Department of Health Care Services, California Children's Services, Sacramento, CA, USA
| | - William E Benitz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Stellwagen
- Department of Pediatrics, Division of Academic General Pediatrics, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jenny Quinn
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | | | - Courtney C Breault
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | - Michael Bolaris
- Department of Pediatrics, Division of Infectious Disease, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Linda Lefrak
- California Department of Public Health, Center for Health Care Quality, Health Care Associated Infections Program, Richmond, CA, USA
| | - Jeff Merrill
- Sutter Health Summit Medical Center, Oakland, CA, USA
| | - Paul J Sharek
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
- Department of Pediatrics, Division of Hospitalist Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Division of Hospitalist Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, WA, USA
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Mende S, Ahmed S, DeShea L, Szyld E, Shah BA. Electronic Heart (ECG) Monitoring at Birth and Newborn Resuscitation. CHILDREN (BASEL, SWITZERLAND) 2024; 11:685. [PMID: 38929264 PMCID: PMC11202155 DOI: 10.3390/children11060685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/27/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations. METHODS This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit. RESULTS An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality. CONCLUSIONS Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.
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Affiliation(s)
- Sarah Mende
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
| | - Syed Ahmed
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lise DeShea
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
| | - Edgardo Szyld
- Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Birju A. Shah
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
- Neonatal-Perinatal Medicine, Oklahoma Children’s Hospital at OU Health, 1200 North Everett Drive, 7th Floor North Pavilion ETNP #7504, Oklahoma City, OK 73104, USA
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Quinn J, Quinn M, Lieu B, Bohnert J, Halamek LP, Profit J, Fuerch JH, Chitkara R, Yamada NK, Gould J, Lee HC. Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis. Adv Neonatal Care 2023; 23:425-434. [PMID: 37399571 PMCID: PMC10524557 DOI: 10.1097/anc.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment. PURPOSE This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU). METHODS Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes. RESULTS There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support. IMPLICATIONS FOR PRACTICE AND RESEARCH NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.
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Affiliation(s)
- Jenny Quinn
- California Perinatal Quality Care Collaborative (CPQCC), Stanford (Drs Jenny Quinn, Profit, Gould, and Lee, Mr Lieu, and Ms Bohnert); NorthBay Medical Center, Fairfield, California (Dr Jenny Quinn); Oregon Health & Science University, School of Nursing, Portland (Dr Megan Quinn); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California (Drs Halamek, Profit, Fuerch, Chitkara, Yamada, and Gould); Center for Advanced Pediatric & Perinatal Education (CAPE), Palo Alto, California (Drs Halamek, Fuerch, Chitkara, and Yamada); and Division of Neonatology, Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California (Dr Lee)
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Payton KSE, Gould JB. Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives. Healthcare (Basel) 2022; 11:7. [PMID: 36611468 PMCID: PMC9818599 DOI: 10.3390/healthcare11010007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Variation in patient outcomes among institutions and within institutions is a major problem in healthcare. Some of this variation is due to differences in practice, termed practice variation. Some practice variation is expected due to appropriately personalized care for a given patient. However, some practice variation is due to the individual preference or style of the clinicians. Quality improvement collaboratives are commonly used to disseminate quality care on a wide scale. Practice variation is a notable barrier to any quality improvement effort. A detailed and accurate understanding of practice variation can help optimize the quality improvement efforts. The traditional survey methods do not capture the complex nuances of practice variation. Vignette methods have been shown to accurately measure the actual practice variation and quality of care delivered by clinicians. Vignette methods are cost-effective relative to other methods of measuring quality of care. This review describes our experience and lessons from implementing vignette research methods in quality improvement collaboratives in California neonatal intensive care units. Vignette methodology is an ideal tool to address practice variation in quality improvement collaboratives, actively engage a large number of participants, and support more evidence-based practice to improve outcomes.
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Affiliation(s)
- Kurlen S E Payton
- Cedars-Sinai Medical Center, Department of Pediatrics, Division of Neonatology, Los Angeles, CA 90048, USA
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
| | - Jeffrey B Gould
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
- Department of Pediatrics, Division of Neonatology, Stanford University, Stanford, CA 94305, USA
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Does active treatment in infants born at 22-23 weeks correlate with outcomes of more mature infants at the same hospital? An analysis of California NICU data, 2015-2019. J Perinatol 2022; 42:1301-1305. [PMID: 35361887 PMCID: PMC9522931 DOI: 10.1038/s41372-022-01381-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To investigate whether hospital rates of active treatment for infants born at 22-23 weeks is associated with survival of infants born at 24-27 weeks. STUDY DESIGN We included all liveborn infants 22-27 weeks of gestation delivered at California Perinatal Quality Care Collaborative hospitals from 2015 to 2019. We assessed (1) the correlation of active treatment (e.g., endotracheal intubation, epinephrine) in 22-23 week infants and survival until discharge for 24-27 week infants and (2) the association of active treatment with survival using multilevel models. RESULT The 22-23 week active treatment rate was associated with infant outcomes at 22-23 weeks but not 24-27 weeks. A 10% increase in active treatment did not relate to 24-25 week (adjusted OR: 1.00 [95% CI: 0.95-1.05]), or 26-27 week survival (aOR: 1.02 [0.95-1.09]). CONCLUSION The hospital rate of active treatment for infants born at 22-23 weeks was not associated with improved survival for 24-27 week infants.
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Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
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Decreasing Intubation for Ineffective Ventilation after Birth for Very Low Birth Weight Neonates. Pediatr Qual Saf 2022; 7:e580. [PMID: 35928022 PMCID: PMC9345641 DOI: 10.1097/pq9.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/25/2022] [Indexed: 11/18/2022] Open
Abstract
Despite recommendations promoting noninvasive delivery room (DR) ventilation, local historical preterm DR noninvasive ventilation rates were low (50%−64%). Project aims were to improve DR noninvasive ventilation rate in very low birth weight (VLBW) neonates (<1500 g) with a focus on decreasing DR intubations for ineffective positive pressure ventilation (PPV).
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de Almeida MFB, Guinsburg R, Weiner GM, Penido MG, Ferreira DMLM, Alves JMS, Embrizi LF, Gimenes CB, Mello E Silva NM, Ferrari LL, Venzon PS, Gomez DB, do Vale MS, Bentlin MR, Sadeck LR, Diniz EMA, Fiori HH, Caldas JPS, de Almeida JHCL, Duarte JLMB, Gonçalves-Ferri WA, Procianoy RS, Lopes JMA. Translating Neonatal Resuscitation Guidelines Into Practice in Brazil. Pediatrics 2022; 149:186998. [PMID: 35510495 DOI: 10.1542/peds.2021-055469] [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] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Brazilian Neonatal Resuscitation Program releases guidelines based on local interpretation of international consensus on science and treatment recommendations. We aimed to analyze whether guidelines for preterm newborns were applied to practice in the 20 Brazilian Network on Neonatal Research centers of this middle-income country. METHODS Prospectively collected data from 2014 to 2020 were analyzed for 8514 infants born at 230/7 to 316/7 weeks' gestation. The frequency of procedures was evaluated by gestational age (GA) category, including use of a thermal care bundle, positive pressure ventilation (PPV), PPV with a T-piece resuscitator, maximum fraction of inspired oxygen (Fio2) concentration during PPV, tracheal intubation, chest compressions and medications, and use of continuous positive airway pressure in the delivery room. Logistic regression, adjusted by center and year, was used to estimate the probability of receiving recommended treatment. RESULTS For 3644 infants 23 to 27 weeks' GA and 4870 infants 28 to 31 weeks' GA, respectively, the probability of receiving care consistent with guidelines per year increased, including thermal care (odds ratio [OR], 1.52 [95% confidence interval (CI) 1.44-1.61] and 1.45 [1.38-1.52]) and PPV with a T-piece (OR, 1.45 [95% CI 1.37-1.55] and 1.41 [1.32-1.51]). The probability of receiving PPV with Fio2 1.00 decreased equally in both GA groups (OR, 0.89; 95% CI, 0.86-0.93). CONCLUSIONS Between 2014 and 2020, the resuscitation guidelines for newborns <32 weeks' GA on thermal care, PPV with a T-piece resuscitator, and decreased use of Fio2 1.00 were translated into clinical practice.
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Affiliation(s)
| | - Ruth Guinsburg
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Marcia G Penido
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - José Mariano S Alves
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | | | | | - Dafne B Gomez
- Instituto de Medicina Integral Prof Fernando Figueira, Recife, Pernambuco, Brazil
| | | | - Maria Regina Bentlin
- Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Lilian R Sadeck
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Edna M A Diniz
- Hospital Universitário da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Humberto H Fiori
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jamil P S Caldas
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | - João Henrique C L de Almeida
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Luis M B Duarte
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Walusa A Gonçalves-Ferri
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Renato S Procianoy
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - José Maria A Lopes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Rio de Janeiro, Rio de Janeiro, Brazil
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Bi SY, Yu YH, Li C, Xu P, Xu HY, Li JH, Liu QY, Li M, Liu XJ, Wang H. A standardized implementation of multicenter quality improvement program of very low birth weight newborns could significantly reduce admission hypothermia and improve outcomes. BMC Pediatr 2022; 22:281. [PMID: 35568937 PMCID: PMC9107002 DOI: 10.1186/s12887-022-03310-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
Background Admission hypothermia (AH, < 36.5℃) remains a major challenge for global neonatal survival, especially in developing countries. Baseline research shows nearly 89.3% of very low birth weight (VLBW, < 1500 g) infants suffer from AH in China. Therefore, a prospective multicentric quality improvement (QI) initiative to reduce regional AH and improve outcomes among VLBW neonates was implemented. Methods The study used a sequential Plan—Do—Study—Act (PDSA) approach. Clinical data were collected prospectively from 5 NICUs within the Sino-Northern Neonatal Network (SNN) in China. The hypothermia prevention bundle came into practice on January 1, 2019. The clinical characteristics and outcomes data in the pre-QI phase (January 1, 2018– December 31, 2018) were compared with that from the post-QI phase (January 1, 2019–December 31, 2020). Clinical characteristics and outcomes data were analyzed. Results A total of 750 in-born VLBW infants were enrolled in the study, 270 in the pre-QI period and 480 in the post- QI period, respectively. There were no significant differences in clinical characteristics of infants between these two phases. Compared with pre-QI period, the incidence of AH was decreased significantly after the QI initiative implementation in the post-QI period (95.9% vs. 71.3%, P < 0.01). Incidence of admission moderate-to-severe hypothermia (AMSH, < 36℃) also decreased significantly, manifesting a reduction to 38.5% in the post-QI (68.5% vs 30%, P < 0.01). Average admission temperature improved from after QI (35.5 \documentclass[12pt]{minimal}
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\begin{document}$$\pm$$\end{document}± 0.6℃, P < 0.01). There was no increase in proportion the number of infants with a temperature of > 37.5 °C or thermal burns between the two groups. The risk ratio of mortality in infants during the post-QI period was significantly lower in the post-QI period as compared to the pre-QI period [adjusted risk ratio (aRR): 0.26, 95% confidence interval (CI): 0.13–0.50]. The risk ratio of late-onset neonatal sepsis (LOS) also significantly lowered in the post-QI period (aRR: 0.66, 95% CI: 0.50–0.87). Conclusion Implementation of multicentric thermoregulatory QI resulted in a significant reduction in AH and AMSH in VLBW neonates with associated reduction in mortality. We gained a lot from the QI, and successfully aroused the attention of perinatal medical staff to neonatal AH. This provided a premise for continuous quality improvement of AH in the future, and might provide a reference for implementation of similar interventions in developing countries. Trial registration Trial registration number: ChiCTR1900020861. Date of registration: 21 January 2019(21/01/2019). Prospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03310-5.
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Affiliation(s)
- Shu-Yu Bi
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Yong-Hui Yu
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
| | - Cong Li
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, Shandong, China
| | - Ping Xu
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, Shandong, China
| | - Hai-Yan Xu
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Jia-Hui Li
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Qiong-Yu Liu
- Department of Neonatology, Women and Children's Healthcare Hospital of Linyi, Linyi, 276000, Shandong, China
| | - Min Li
- Department of Neonatology, Women and Children's Healthcare Hospital of Linyi, Linyi, 276000, Shandong, China
| | - Xin-Jian Liu
- Department of Neonatology, Hebei Petro China Central Hospital, Langfang, 065000, Hebei, China
| | - Hui Wang
- Department of Neonatology, Hebei Petro China Central Hospital, Langfang, 065000, Hebei, China
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12
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Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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13
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Bettinger K, Mafuta E, Mackay A, Bose C, Myklebust H, Haug I, Ishoso D, Patterson J. Improving Newborn Resuscitation by Making Every Birth a Learning Event. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121194. [PMID: 34943390 PMCID: PMC8700033 DOI: 10.3390/children8121194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 06/14/2023]
Abstract
One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.
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Affiliation(s)
- Kourtney Bettinger
- Department of Pediatrics, University of Kansas School of Medicine, 3901 Rainbow Blvd, MS 4004, Kansas City, KS 66103, USA
| | - Eric Mafuta
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Amy Mackay
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Helge Myklebust
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Ingunn Haug
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Daniel Ishoso
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Jackie Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
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14
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Young A, Azeez F, Godad SP, Shetty P, Sharma A. A multimodal quality improvement approach to promote normothermia in very preterm infants. Acta Paediatr 2021; 110:2745-2752. [PMID: 34185925 DOI: 10.1111/apa.16009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/07/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
AIM To achieve the National Neonatal Audit Programme (NNAP) standard of 90% normothermia among preterm infants born under 30 weeks of gestation. METHODS Project SHIP (Stopping Hypothermia In Premmies) was a quality improvement programme to improve admission normothermia. Phase 1 of the project implemented low-fidelity simulations during 2011-2016. In Phase 2 (2017), a multimodal approach to quality improvement was used, including in situ simulations, videos of simulated scenarios, an allocated team member for thermal care, a clear protocol for thermal care, a coordinating 'lollipop man' role and monthly performance feedback. Additionally, continuous temperature monitoring using servo-control during stabilisation was introduced during Phase 2. Phase 3 (2018-2019) focused on embedding practice and maintaining performance. RESULTS Phase 1 initiatives resulted in improvement of normothermia rates from 58% to 75%. However, the results plateaued. During Phase 2, the hypothermia rate fell from 16% to 3%. During Phase 3, this improvement in the hypothermia rate was sustained, achieving the standard of 90% normothermia in 2018 and falling just short in 2019 due to an increased hyperthermia rate. CONCLUSION A multimodal quality improvement approach achieved sustained improvement in normothermia. Continuous temperature monitoring during stabilisation allows resuscitating teams to plan interventions to treat hypothermia and hyperthermia.
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Affiliation(s)
- Aneurin Young
- Department of Neonatal Medicine and Surgery NIHR Southampton Biomedical Research Centre Princess Anne Hospital Southampton Southampton UK
| | - Fameesh Azeez
- Department of Neonatal Medicine and Surgery Princess Anne Hospital Southampton Southampton UK
| | - Santan Pawalu Godad
- Department of Neonatal Medicine and Surgery Princess Anne Hospital Southampton Southampton UK
| | - Preethish Shetty
- Department of Paediatrics Royal Hampshire County Hospital Winchester UK
| | - Alok Sharma
- Department of Neonatal Medicine and Surgery Princess Anne Hospital Southampton Southampton UK
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15
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Heo JS, Kim SY, Park HW, Choi YS, Park CW, Cho GJ, Oh AY, Jang EK, Kim HS, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 8. Neonatal resuscitation. Clin Exp Emerg Med 2021; 8:S96-S115. [PMID: 34034452 PMCID: PMC8171175 DOI: 10.15441/ceem.21.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/05/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
- Ju Sun Heo
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Su Yeong Kim
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye Won Park
- Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea
| | - Yong-Sung Choi
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Ah Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Jang
- Office of Patient Safety, Yonsei University Severance Hospital, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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16
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Carter EH, Lee HC, Lapcharoensap W, Snowden JM. Resuscitation outcomes for weekend deliveries of very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:656-661. [PMID: 32414815 DOI: 10.1136/archdischild-2019-317807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To characterise the association between weekend (Saturday and Sunday) deliveries of very low birthweight (VLBW) infants and delivery room outcomes in the 'golden hour' after birth. DESIGN AND SETTING A retrospective cohort study using California Perinatal Quality Care Collaborative data from participating neonatal intensive care units. PATIENTS The study population after exclusions was 26 515 VLBW infants born in California from 2010 to 2016. MAIN OUTCOME MEASURES Delivery room outcomes assessed included: chest compressions, epinephrine, intubation prior to continuous positive airway pressure ventilation, 5 min Apgar <4, admission hypothermia and death within 12 hours. To adjust for potential confounders, we fit multivariate regression models controlling for two sets of infant, maternal and hospital characteristics. RESULTS Infants delivered on weekends were less likely to have been prenatally diagnosed with intrauterine growth restriction but were otherwise not significantly different in gestational age, ethnicity, sex or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends, while vaginal deliveries were consistent across all days. After adjusting for sex and race, weekend delivery was associated with delivery room chest compressions (OR: 1.12, 95% CI 1.02 to 1.24) and lower 5 min Apgar (OR: 1.11, 95% CI 1.01 to 1.21). CONCLUSION In this population-based study of VLBW infants, there was an increase in chest compressions for infants born on the weekend. More research is needed on the differences between populations born on weekdays versus weekends, and how these may contribute to observed associations.
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Affiliation(s)
- Emily Hawkins Carter
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry C Lee
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | | | - Jonathan M Snowden
- Department of Obstetrics & Gynecology/Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
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17
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Gould JB. Building the First Statewide Quality Improvement Collaborative, the CPQCC: A Historic Perspective. CHILDREN-BASEL 2020; 7:children7100177. [PMID: 33053628 PMCID: PMC7599918 DOI: 10.3390/children7100177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
The California Perinatal Quality Improvement Collaborative (CPQCC), founded in 1997, was the country’s first statewide perinatal quality improvement collaborative. Our goal was to improve the quality and outcomes of perinatal healthcare in California by developing a collaborative network of public and private obstetric and neonatal providers, insurers, public health professionals, and business groups to support a system for benchmarking and performance improvement activities for perinatal care. In this presentation, we describe how viewing the CPQCC as a complex value-driven organization, committed to identifying and addressing the needs of both its stakeholder partners and neonatal intensive care unit (NICU) members, has shaped the course of its development.
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Affiliation(s)
- Jeffrey B. Gould
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94305, USA;
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
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18
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Demtse AG, Pfister RE, Nigussie AK, McClure EM, Ferede YG, Tazu Bonger Z, Mekasha A, Demisse AG, Gidi NW, Metaferia G, Worku B, Goldenberg RL, Muhe LM. Hypothermia in Preterm Newborns: Impact on Survival. Glob Pediatr Health 2020; 7:2333794X20957655. [PMID: 32974416 PMCID: PMC7493265 DOI: 10.1177/2333794x20957655] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 01/21/2023] Open
Abstract
Background. Globally, prematurity is the leading cause of neonatal mortality, and hypothermia is one of its contributing factors. The goal of this study was to determine the association between hypothermia and mortality. Methods. A prospective, multi-center, descriptive clinical study was conducted in 5 hospitals in Ethiopia. Axillary temperatures were taken at the time of admission to the newborn intensive care units (NICU) and followed during the NICU stay. Results. A total of 3852 premature neonates (<37 weeks) were admitted to the NICUs from July 2016 to May 2018. Of these infants, 1109 (28.8%) died and 2991 (79.6%) had hypothermia. Hypothermia was associated with perinatal asphyxia (89.5%), RDS (86.2%), and resuscitation at birth (82.7%). Admission temperatures in preterm newborns were inversely associated with mortality and morbidity. Conclusion. Hypothermia at admission is associated with neonatal mortality in premature neonates in Ethiopia. RDS and perinatal asphyxia were the main factors associated with hypothermia. The very high prevalence and association with mortality warrants quality improvement interventions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gesit Metaferia
- St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Bogale Worku
- Ethiopian Pediatric Society, Addis Ababa, Ethiopia
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19
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Bhatt DR, Reddy N, Ruiz R, Bustos DV, Peacock T, Dizon RA, Weerasinghe S, Braun DX, Ramanathan R. Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years. J Investig Med 2020; 68:1256-1260. [PMID: 32690596 PMCID: PMC7525784 DOI: 10.1136/jim-2020-001334] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2020] [Indexed: 11/11/2022]
Abstract
Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity and mortality, decreased length of stay and hospital costs. We designed a thermoregulation bundle to decrease hypothermia (<36.5°C) in ELBW infants with a multidisciplinary perinatal quality improvement initiative that included the following key interventions: dedicated delivery room (DR)/operating room (OR) for all preterm deliveries of ≤32 weeks with DR/OR temperature set 24/7 at 74°F by the hospital engineering staff, use of exothermic mattress, preheated radiant warmer set at 100% for heat prior to delivery, servo-controlled mode after the neonate is placed on the warmer, and use of plastic wrap, head cap and warm towels. A total of 200 ELBW infants were admitted to our NICU between January 1, 2014 and December 31, 2019. Hypothermia (<36.5°C) occurred in 2.5% of infants, normothermia (36.5°C–37.5°C) in 91% of infants and transitional hyperthermia (>37.5°C) in 6.5% of ELBW infants. No case of moderate hypothermia (32°C–36°C) was seen in our infants. Our target rate of less than 10% hypothermia was reached in ELBW infants over the last 2 years with no cases of moderate hypothermia in 6 years. Eliminating hypothermia among ELBW remains a challenge and requires team effort and continuous quality improvement efforts.
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Affiliation(s)
- Dilip R Bhatt
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Nirupa Reddy
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Reynaldo Ruiz
- Obstetrics, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Darla V Bustos
- Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Torria Peacock
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Roman-Angelo Dizon
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | | | - David X Braun
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Rangasamy Ramanathan
- Pediatrics/Division of Neonatology, LAC USC Medical Center, Los Angeles, California, USA
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20
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Lee HC, Liu J, Profit J, Hintz SR, Gould JB. Survival Without Major Morbidity Among Very Low Birth Weight Infants in California. Pediatrics 2020; 146:e20193865. [PMID: 32554813 PMCID: PMC7329260 DOI: 10.1542/peds.2019-3865] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine trends in survival without major morbidity and its individual components among very low birth weight infants across California and assess remaining gaps that may be opportune targets for improvement efforts. METHODS The study population included infants born between 2008 and 2017 with birth weights of 401 to 1500 g or a gestational age of 22 to 29 weeks. Risk-adjusted trends of survival without major morbidity and its individual components were analyzed. Survival without major morbidity was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. Variations in adjusted rates and/or interquartile ranges were examined. To assess opportunities for additional improvement, all hospitals were reassigned to perform as if in the top quartile, and recalculation of predicted numbers were used to estimate potential benefit. RESULTS In this cohort of 49 333 infants across 142 hospitals, survival without major morbidity consistently increased from 62.2% to 66.9% from 2008 to 2017. Network variation decreased, with interquartile ranges decreasing from 21.1% to 19.2%. The largest improvements were seen for necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. Over the final 3 years, if all hospitals performed as well as the top quartile, an additional 621 infants per year would have survived without major morbidity, accounting for an additional 6.6% annual improvement. CONCLUSIONS Although trends are promising, bronchopulmonary dysplasia remains a common and persistent major morbidity, remaining a target for continued quality-improvement efforts.
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Affiliation(s)
- Henry C Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Jessica Liu
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Susan R Hintz
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Jeffrey B Gould
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
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21
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Gupta A, Lee HC. Revisiting the Latest NRP Guidelines for Meconium: Searching for Clarity in a Murky Situation. Hosp Pediatr 2020; 10:300-302. [PMID: 32094238 DOI: 10.1542/hpeds.2020-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Arun Gupta
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Henry Chong Lee
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
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22
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Lapcharoensap W, Bennett MV, Xu X, Lee HC, Dukhovny D. Hospitalization costs associated with bronchopulmonary dysplasia in the first year of life. J Perinatol 2020; 40:130-137. [PMID: 31700090 PMCID: PMC6920537 DOI: 10.1038/s41372-019-0548-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/01/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine costs of hospitalization associated with bronchopulmonary dysplasia (BPD) during the first year in very low birth weight infants. STUDY DESIGN Retrospective cohort study of California births from 2008 to 2011 linking birth certificate, discharge records, and clinical data from California Perinatal Quality Care Collaborative. Inclusion: birth weight 401-1500 g, gestational age < 30 weeks, inborn or transferred within 2 days, alive at 36 weeks corrected, and without major congenital anomalies. Outcomes included cost and length of stay of initial hospitalization and rehospitalizations. RESULT Out of 7998 eligible infants, 2696 (33.7%) developed BPD. Median hospitalization cost in the first year was $377,871 per infant with BPD compared with $175,836 per infant without BPD (adjusted cost ratio 1.54, 95% confidence interval (CI) 1.49-1.59). Infants with BPD also had longer length of stay and a higher likelihood of rehospitalization. CONCLUSION BPD is associated with substantial resource utilization. Prevention strategies could help conserve healthcare resources.
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Affiliation(s)
| | - Mihoko V Bennett
- Pediatrics, Stanford University, Stanford, CA, 94305, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, 94305, USA
| | - Xiao Xu
- Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT, 06520, USA
| | - Henry C Lee
- Pediatrics, Stanford University, Stanford, CA, 94305, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, 94305, USA
| | - Dmitry Dukhovny
- Pediatrics, Oregon Health and Science University, Portland, OR, 97239, USA
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23
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Boghossian NS, Geraci M, Lorch SA, Phibbs CS, Edwards EM, Horbar JD. Racial and Ethnic Differences Over Time in Outcomes of Infants Born Less Than 30 Weeks' Gestation. Pediatrics 2019; 144:peds.2019-1106. [PMID: 31405887 PMCID: PMC6813804 DOI: 10.1542/peds.2019-1106] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers. METHODS Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models. RESULTS Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants. CONCLUSIONS Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Marco Geraci
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Scott A. Lorch
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;,Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ciaran S. Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California;,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont;,Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont; and,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont;,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
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Terao M, Hoffman JM, Brilli RJ, Finch A, Walsh KE, Coffey M. Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts. ACTA ACUST UNITED AC 2019; 5:111-130. [PMID: 32789105 DOI: 10.1007/s40746-019-00155-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose of review Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives. Recent Findings Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care. Summary Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.
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Affiliation(s)
- Michael Terao
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Office of Quality and Patient Care and Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Richard J Brilli
- Nationwide Children's Hospital; Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Amanda Finch
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
| | - Kathleen E Walsh
- MD, MS, James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Maitreya Coffey
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
- The Hospital for Sick Children, Toronto, Ontario, Canada
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Kakkilaya V, Jubran I, Mashruwala V, Ramon E, Simcik VN, Marshall M, Brown LS, Jaleel MA, Kapadia VS. Quality Improvement Project to Decrease Delivery Room Intubations in Preterm Infants. Pediatrics 2019; 143:peds.2018-0201. [PMID: 30602545 PMCID: PMC6361361 DOI: 10.1542/peds.2018-0201] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks' gestation. METHODS Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO2 detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre-quality improvement cohort (QIC) (January 2014-September 2015) were compared with post-QIC (October 2015-December 2016). RESULTS Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders. CONCLUSIONS Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.
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Affiliation(s)
| | - Ihab Jubran
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | | | - Emma Ramon
- Parkland Hospital and Health Systems, Dallas, Texas
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Survey of preterm neuro-centric care practices in California neonatal intensive care units. J Perinatol 2019; 39:256-262. [PMID: 30518797 PMCID: PMC6351217 DOI: 10.1038/s41372-018-0283-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/05/2018] [Accepted: 11/08/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Examine the adoption and presence of preterm, neuro-centric care practices across neonatal intensive care units (NICUs). STUDY DESIGN Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives. RESULT Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold, whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice. CONCLUSION Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.
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Eliminating Risk of Intubation in Very Preterm Infants with Noninvasive Cardiorespiratory Support in the Delivery Room and Neonatal Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5984305. [PMID: 30733962 PMCID: PMC6348842 DOI: 10.1155/2019/5984305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/09/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022]
Abstract
Introduction Avoiding intubation and promoting noninvasive modes of ventilator support including continuous positive airway pressure (CPAP) in preterm infants minimizes lung injury and optimizes neonatal outcomes. Discharge home on oxygen is an expensive morbidity in very preterm infants (VPI) with lung disease. In 2007 a standardized bundle was introduced for VPI admitted to the neonatal care unit (NICU) which included delayed cord clamping (DCC) at birth and noninvasive ventilation as first-line cardiorespiratory support in the delivery room (DR), followed by bubble CPAP upon NICU admission. Objective Our goal was to evaluate the risk of (1) intubation and (2) discharge home on oxygen after adopting this standardized DR bundle in VPI born at a regional perinatal center and treated in the NICU over a ten-year period (2008-2017). Materials and Methods We compared maternal and neonatal demographics, respiratory care processes and outcomes, as well as neonatal mortality and morbidity in VPI (< 33 weeks gestation) and extremely low birth weight (ELBW, < 1000 g) subgroup for three consecutive epochs: 2008-2010, 2011-2013, and 2014-2017. Results Of 640 consecutive inborn VPI, 55% were < 1500 g at birth and 23% were ELBW. Constant through all three epochs, DCC occurred in 83% of VPI at birth. There was progressive increase in maternal magnesium during the three epochs and decrease in maternal antibiotics during the last epoch. Over the three epochs, VPI had less risk of DR intubation (23% versus 15% versus 5%), NICU intubation (39% versus 31% versus 18%), and invasive ventilation (37% versus 30% versus 17%), as did ELBW infants. Decrease in postnatal steroid use, antibiotic exposure, and increase in early colostrum exposure occurred over the three epochs both in VPI and in ELBW infants. There was a sustained decrease in surfactant use in the second and third epochs. There was no significant change in mortality or any morbidity in VPI; however, there was a significant decrease in pneumothorax (17% versus 0%) and increase in survival without major morbidity (15% versus 41%) in ELBW infants between 2008-2010 and 2014-2017. Benchmarked risk-adjusted rate for oxygen at discharge in a subgroup of inborn VPI (401-1500 g or 22-31 weeks of gestation) is 2.5% (2013-2017) in our NICU compared with > 8% in all California NICUs and > 10% in all California regional NICUs (2014-2016). Conclusion Noninvasive strategies in DR and NICU minimize risk of intubation in VPI without adversely affecting other neonatal or respiratory outcomes. Risk-adjusted rates for discharge home on oxygen remained significantly lower for inborn VPI compared with rates at regional NICUs in California. Reducing intubation risk in ELBW infants may confer an advantage for survival without major morbidity. Prenatal magnesium may reduce intubation risk in ELBW infants.
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Abstract
A high incidence of postnatal hypothermia has been reported in high-as well low-resource countries and it remains an independent predictor of neonatal morbidity and mortality, especially in very preterm infants in all settings. The temperature of newly born infants should be maintained between 36.5 and 37.5 °C after birth through admission and stabilization. Interventions to achieve this may include environmental temperature 23-25 °C, use of radiant warmers, exothermic mattresses, woollen or plastic caps, plastic wraps, humidified and heated gases. Skin-to-skin contact has been used, especially in low-resource settings. The combinations of these interventions applied to quality improvement initiatives, including staff training, use of checklists, and continuous feedback with the staff involved in the management of the neonate, are key factors to prevent heat loss from delivery room to admission to the neonatal intensive care unit. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.
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Affiliation(s)
- Daniele Trevisanuto
- Department of Women's and Children's Health, Azienda Ospedaliera di Padova, University of Padua, Padua, Italy.
| | - Daniela Testoni
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
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Incidence Trends and Risk Factor Variation in Severe Intraventricular Hemorrhage across a Population Based Cohort. J Pediatr 2018; 200:24-29.e3. [PMID: 29754865 PMCID: PMC6109595 DOI: 10.1016/j.jpeds.2018.04.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/16/2018] [Accepted: 04/10/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To quantify the current burden of severe intraventricular hemorrhage (IVH), describe time trends in severe IVH, identify IVH-associated risk factors, and determine the contribution of mediating factors. STUDY DESIGN The retrospective cohort included infants 220/7-316/7 weeks of gestation without severe congenital anomalies, born at hospitals in the California Perinatal Quality Care Collaborative between 2005 and 2015. The primary study outcome was severe (grade III or IV) IVH. RESULTS Of 44 028 infants, 3371 (7.7%) had severe IVH. The incidence of severe IVH decreased significantly across California from 9.7% in 2005 to 5.9% in 2015. After stratification by gestational age, antenatal steroid exposure was the only factor associated with a decreased odds of severe IVH for all gestational age subgroups. Other factors, including delivery room intubation, were associated with an increased odds of severe IVH, though significance varied by gestational age. Factors analyzed in the mediation analysis accounted for 45.6% (95% CI 38.7%-71.8%) of the reduction in severe IVH, with increased antenatal steroid administration and decreased delivery room intubation mediating a significant proportion of this decrease, 19.4% (95% CI 13.9%-27.5%) and 27.3% (95% CI 20.3%-39.2%), respectively. The unaccounted proportion varied by gestational age. CONCLUSIONS The incidence of severe IVH decreased across California, associated with changes in antenatal steroid exposure and delivery room intubation. Maternal, patient, and delivery room factors accounted for less than one-half of the decrease in severe IVH. Study of other factors, specifically neonatal intensive care unit and hospital-level factors, may provide new insights into policies to reduce severe IVH.
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Pinheiro JMB. Preventing hypothermia in preterm newborns - simple principles for a complicated task. J Pediatr (Rio J) 2018; 94:337-339. [PMID: 29100745 DOI: 10.1016/j.jped.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Joaquim M B Pinheiro
- Albany Medical Center, Department of Pediatrics/Neonatology, Albany, United States.
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Lee HC, Bennett MV, Crockett M, Crowe R, Gwiazdowski SG, Keller H, Kurtin P, Kuzniewicz M, Mazzeo AM, Schulman J, Nisbet CC, Sharek PJ. Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay. Pediatrics 2018; 142:peds.2017-1395. [PMID: 29899043 DOI: 10.1542/peds.2017-1395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS. METHODS Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and <32 weeks' gestational age by 3 days. A secondary outcome was "early discharge," the proportion of infants discharged from the hospital before 36 + 5 weeks' PMA. The balancing measure of readmissions within 72 hours was tracked for the collaborative group. RESULTS From 2013 to 2015, 8917 infants were cared for in 20 collaborative NICUs, 19 individual project NICUs, and 71 nonparticipants. In the collaborative group, the PMA at discharge decreased from 37.8 to 37.5 weeks (P = .02), and early discharge increased from 31.6% to 41.9% (P = .006). The individual project group had no significant change. Nonparticipants had a decrease in PMA from 37.5 to 37.3 weeks (P = .01) but no significant change in early discharge (39.8% to 43.6%; P = .24). There was no significant change in readmissions over time in the collaborative group. CONCLUSIONS A structured collaborative project that was focused on optimizing LOS led to a 3-day decrease in LOS and was more effective than individualized quality improvement efforts.
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Affiliation(s)
- Henry C Lee
- Department of Pediatrics, Stanford University, Stanford, California; .,California Perinatal Quality Care Collaborative, Stanford, California
| | - Mihoko V Bennett
- Department of Pediatrics, Stanford University, Stanford, California.,California Perinatal Quality Care Collaborative, Stanford, California
| | | | - Ruth Crowe
- UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Heather Keller
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Paul Kurtin
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Michael Kuzniewicz
- Perinatal Research Unit, Kaiser Permanente Northern California, Oakland, California
| | | | - Joseph Schulman
- California Children's Services, California Department of Health Care Services, Sacramento, California
| | - Courtney C Nisbet
- Department of Pediatrics, Stanford University, Stanford, California.,California Perinatal Quality Care Collaborative, Stanford, California
| | - Paul J Sharek
- Department of Pediatrics, Stanford University, Stanford, California.,California Perinatal Quality Care Collaborative, Stanford, California
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Pinheiro JM. Preventing hypothermia in preterm newborns – simple principles for a complicated task. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.
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Schardosim JM, Rodrigues NLDA, Rattner D. Parâmetros utilizados na avaliação de bem-estar do bebê no nascimento. AVANCES EN ENFERMERÍA 2018. [DOI: 10.15446/av.enferm.v36n2.67809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objectivo: identificar parâmetros que se utilizan para evaluar el bienestar del recién nacido.Síntesis del contenido: revisión integrativa de la literatura, realizada en las bases PubMed y Biblioteca Virtual de Salud (bvs), que utilizó los descriptores “apgar score”, “neonatal outcomes”, “fetal vitality” y “health services evaluation”. El recorte temporal fue de enero del 2011 a diciembre del 2016. Se importaron los resúmenes para el software Endnote Web®, para la remoción de duplicados y los remanentes exportados para el software Covidence®, lo que permitió la selección de la muestra final por dos investigadoras, de forma independiente. La muestra final incluyó 17 estudios. Los parámetros más utilizados fueron admisión del neonato en Unidad de Cuidados Intensivos en las primeras 24 a 48 horas de vida y el índice de Apgar, pero hubo variaciones en la mensuración de esos parámetros entre los estudios. Otros parámetros fueron: peso al nacer, temperatura corporal, natimortalidad y mortalidad neonatal. El Apgar, a pesar de utilizado mundialmente, posibilita subjetividad en la evaluación de algunas variables; este puede evaluar la respuesta del bebé a las maniobras empleadas en el atendimiento en sala de parto, pero no debe ser un parámetro decisorio para instituir o no maniobras de reanimación.Conclusión: algunos parámetros fueron comunes entre los estudios, sin embargo pueden agregarse otros parâmetros al abordar patologías específicas. Se considera importante entrenar enfermeiros en la medición del Apgar, pues son professionales responsables por el cuidado de la madre y el bebé 24 horas del día y, en muchos servicios, por la primera atención del recién nacido.
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Carns J, Kawaza K, Quinn MK, Miao Y, Guerra R, Molyneux E, Oden M, Richards-Kortum R. Impact of hypothermia on implementation of CPAP for neonatal respiratory distress syndrome in a low-resource setting. PLoS One 2018; 13:e0194144. [PMID: 29543861 PMCID: PMC5854332 DOI: 10.1371/journal.pone.0194144] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/26/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Neonatal hypothermia is widely associated with increased risks of morbidity and mortality, but remains a pervasive global problem. No studies have examined the impact of hypothermia on outcomes for preterm infants treated with CPAP for respiratory distress syndrome (RDS). METHODS This retrospective analysis assessed the impact of hypothermia on outcomes of 65 neonates diagnosed with RDS and treated with either nasal oxygen (N = 17) or CPAP (N = 48) in a low-resource setting. A classification tree approach was used to develop a model predicting survival for subjects diagnosed with RDS. FINDINGS Survival to discharge was accurately predicted based on three variables: mean temperature, treatment modality, and mean respiratory rate. None of the 23 neonates with a mean temperature during treatment below 35.8°C survived to discharge, regardless of treatment modality. Among neonates with a mean temperature exceeding 35.8°C, the survival rate was 100% for the 31 neonates treated with CPAP and 36.4% for the 11 neonates treated with nasal oxygen (p<0.001). For neonates treated with CPAP, outcomes were poor if more than 50% of measured temperatures indicated hypothermia (5.6% survival). In contrast, all 30 neonates treated with CPAP and with more than 50% of temperature measurements above 35.8°C survived to discharge, regardless of initial temperature. CONCLUSION The results of our study suggest that successful implementation of CPAP to treat RDS in low-resource settings will require aggressive action to prevent persistent hypothermia. However, our results show that even babies who are initially cold can do well on CPAP with proper management of hypothermia.
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Affiliation(s)
- Jennifer Carns
- Department of Bioengineering, Rice University, Houston, Texas, United States of America
| | - Kondwani Kawaza
- Department of Pediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - MK Quinn
- Department of Bioengineering, Rice University, Houston, Texas, United States of America
| | - Yinsen Miao
- Department of Statistics, Rice University, Houston, Texas, United States of America
| | - Rudy Guerra
- Department of Statistics, Rice University, Houston, Texas, United States of America
| | - Elizabeth Molyneux
- Department of Pediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Maria Oden
- Department of Bioengineering, Rice University, Houston, Texas, United States of America
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Vamos CA, Cantor A, Thompson EL, Detman LA, Bronson EA, Phelps A, Louis JM, Gregg AR, Curran JS, Sappenfield WM. The Obstetric Hemorrhage Initiative (OHI) in Florida: The Role of Intervention Characteristics in Influencing Implementation Experiences among Multidisciplinary Hospital Staff. Matern Child Health J 2017; 20:2003-11. [PMID: 27178428 DOI: 10.1007/s10995-016-2020-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objectives Obstetric hemorrhage is one of the leading causes of maternal mortality. The Florida Perinatal Quality Collaborative coordinates a state-wide Obstetric Hemorrhage Initiative (OHI) to assist hospitals in implementing best practices related to this preventable condition. This study examined intervention characteristics that influenced the OHI implementation experiences among Florida hospitals. Methods Purposive sampling was employed to recruit diverse hospitals and multidisciplinary staff members. A semi-structured interview guide was developed based on the following constructs from the intervention characteristics domain of the Consolidated Framework for Implementation Research: evidence strength; complexity; adaptability; and packaging. Interviews were audio-recorded, transcribed and analyzed using Atlas.ti. Results Participants (n = 50) across 12 hospitals agreed that OHI is evidence-based and supported by various information sources (scientific literature, experience, and other epidemiologic or quality improvement data). Participants believed the OHI was 'average' in complexity, with variation depending on participant's role and intervention component. Participants discussed how the OHI is flexible and can be easily adapted and integrated into different hospital settings, policies and resources. The packaging was also found to be valuable in providing materials and supports (e.g., toolkit; webinars; forms; technical assistance) that assisted implementation across activities. Conclusions for Practice Participants reflected positively with regards to the evidence strength, adaptability, and packaging of the OHI. However, the complexity of the initiative adversely affected implementation experiences and required additional efforts to maximize the initiative effectiveness. Findings will inform future efforts to facilitate implementation experiences of evidence-based practices for hemorrhage prevention, ultimately decreasing maternal morbidity and mortality.
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Affiliation(s)
- Cheryl A Vamos
- Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL, 33612, USA. .,The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.
| | - Allison Cantor
- Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL, 33612, USA
| | - Erika L Thompson
- Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL, 33612, USA.,The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA
| | - Linda A Detman
- Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL, 33612, USA.,The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.,Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA
| | - Emily A Bronson
- The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.,Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA
| | - Annette Phelps
- Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA
| | - Judette M Louis
- Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.,Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, STC, 6th Floor, Tampa, FL, 33606, USA
| | - Anthony R Gregg
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida, P.O Box 100294, Gainesville, FL, 32610, USA
| | - John S Curran
- Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.,Faculty and Academic Affairs, USF Health, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - William M Sappenfield
- Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL, 33612, USA.,The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA.,Florida Perinatal Quality Collaborative, The Chiles Center, College of Public Health, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL, 33613, USA
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Wells S, Tamir O, Gray J, Naidoo D, Bekhit M, Goldmann D. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf 2017; 27:226-240. [DOI: 10.1136/bmjqs-2017-006926] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/09/2017] [Accepted: 10/07/2017] [Indexed: 12/16/2022]
Abstract
BackgroundQuality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.MethodWe searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.ResultsOf the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.ConclusionsQICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.
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Abstract
Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.
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Affiliation(s)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305,California Perinatal Quality Care Collaborative, Stanford, CA 94305
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Profit J, Gould JB, Bennett M, Goldstein BA, Draper D, Phibbs CS, Lee HC. Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics 2017; 140:e20170918. [PMID: 28847984 PMCID: PMC5574732 DOI: 10.1542/peds.2017-0918] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking. METHODS Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs. RESULTS We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents. CONCLUSIONS Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California;
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Jeffrey B Gould
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Mihoko Bennett
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, and Center for Predictive Medicine, Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - David Draper
- Department of Applied Mathematics and Statistics, Baskin School of Engineering, University of California, Santa Cruz, Santa Cruz, California; and
| | - Ciaran S Phibbs
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- Health Economics Resource Center and the Center for Innovation to Implementation Veteran's Affairs, Palo Alto Health Care System, Palo Alto, California
| | - Henry C Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
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Balakrishnan M, Falk-Smith N, Detman LA, Miladinovic B, Sappenfield WM, Curran JS, Ashmeade TL. Promoting teamwork may improve infant care processes during delivery room management: Florida perinatal quality collaborative's approach. J Perinatol 2017; 37:886-892. [PMID: 28406486 DOI: 10.1038/jp.2017.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND LOCAL PROBLEM: Inadequate understanding of compliance with standardized evidence-based DR management. INTERVENTIONS Promote inter-professional teamwork and a bundle of interventions focusing on resuscitation team roles, equipment check, and debriefing using QI methodology. Optimize delivery room (DR) management to achieve 10-min SPO2 targets, delayed-cord clamping (DCC), team role assignment and debriefings in >50% of deliveries, and achieve normothermia in >75% of infants. METHODS Over 15 months (Epoch 1 to 5), nine Florida hospitals implemented a DR management plan for infants <31 weeks gestational age or <1500 g (N=814) using quality improvement methodology. RESULTS There was increased compliance of DCC (36 to 66%), role assignment (53 to 98%), debriefing rates (33 to 76%) and having all seven pre-delivery preparedness components fulfilled (34 to 75%). There were no significant improvements in admission temperatures or SPO2 targeting. When 7 vs 0 items of pre-delivery preparedness were completed, we saw improvements in thermoregulation (57% vs 72%), SPO2 targeting (60% vs 78%) and DCC compliance (43 to 67%). CONCLUSION Promoting teamwork by increasing pre-delivery preparedness is associated with improvement of thermoregulation, SPO2 targeting and DCC compliance.
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Affiliation(s)
- M Balakrishnan
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - N Falk-Smith
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - L A Detman
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - B Miladinovic
- Center for Comparative Effectiveness Research, Division of Evidence-Based Medicine, Department of Internal Medicine, University of South Florida Health, Tampa, FL, USA
| | - W M Sappenfield
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - J S Curran
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - T L Ashmeade
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
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Ozawa M, Yokoo K, Funaba Y, Fukushima S, Fukuhara R, Uchida M, Aiba S, Doi M, Nishimura A, Hayakawa M, Nishimura Y, Oohira M. A Quality Improvement Collaborative Program for Neonatal Pain Management in Japan. Adv Neonatal Care 2017; 17:184-191. [PMID: 28114148 PMCID: PMC5457813 DOI: 10.1097/anc.0000000000000382] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neonatal pain management guidelines have been released; however, there is insufficient systematic institutional support for the adoption of evidence-based pain management in Japan. PURPOSE To evaluate the impact of a collaborative quality improvement program on the implementation of pain management improvements in Japanese neonatal intensive care units (NICUs). METHODS Seven Japanese level III NICUs participated in a neonatal pain management quality improvement program based on an Institute for Healthcare Improvement collaborative model. The NICUs developed evidence-based practice points for pain management and implemented these over a 12-month period. Changes were introduced through a series of Plan-Do-Study-Act cycles, and throughout the process, pain management quality indicators were tracked as performance measures. Jonckheere's trend test and the Cochran-Armitage test for trend were used to examine the changes in quality indicator implementations over time (baseline, 3 months, 6 months, and 12 months). FINDINGS Baseline pain management data from the 7 sites revealed substantial opportunities for improvement of pain management, and testing changes in the NICU setting resulted in measurable improvements in pain management. During the intervention phase, all participating sites introduced new pain assessment tools, and all sites developed electronic medical record forms to capture pain score, interventions, and infant responses to interventions. IMPLICATIONS FOR PRACTICE The use of collaborative quality improvement techniques played a key role in improving pain management in the NICUs. IMPLICATIONS FOR RESEARCH Collaborative improvement programs provide an attractive strategy for solving evidence-practice gaps in the NICU setting.
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Lapcharoensap W, Bennett MV, Powers RJ, Finer NN, Halamek LP, Gould JB, Sharek PJ, Lee HC. Effects of delivery room quality improvement on premature infant outcomes. J Perinatol 2017; 37:349-354. [PMID: 28005062 DOI: 10.1038/jp.2016.237] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 09/21/2016] [Accepted: 11/14/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality. STUDY DESIGN This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group. RESULTS Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death. CONCLUSION Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.
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Affiliation(s)
- W Lapcharoensap
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
| | - M V Bennett
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
| | - R J Powers
- Pediatrix Medical Group, San Jose, CA, USA
| | - N N Finer
- University of California San Diego, San Diego, CA, USA
| | - L P Halamek
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Center for Advanced Pediatric and Perinatal Education, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - J B Gould
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
| | - P J Sharek
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - H C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
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Gupta M, Donovan EF, Henderson Z. State-based perinatal quality collaboratives: Pursuing improvements in perinatal health outcomes for all mothers and newborns. Semin Perinatol 2017; 41:195-203. [PMID: 28646987 PMCID: PMC11009783 DOI: 10.1053/j.semperi.2017.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
State-based perinatal quality collaboratives (SPQC) have become increasingly widespread in the United States. Whereas the first was launched in 1997, today over 40 states have SPQCs that are actively working or are in development. Despite great variability in the structure and function of SPQCs among states, many have seen their efforts lead to significant improvements in the care of mothers and newborns. Clinical topics targeted by SPQCs have included nosocomial infection in newborns, human milk use, neonatal abstinence syndrome, early term deliveries without a medical indication, maternal hemorrhage, and maternal hypertension, among others. While each SPQC uses approaches suited to its own context, several themes are common to the goals of all SPQCs, including developing obstetric and neonatal partnerships; including families as partners; striving for participation by all providers; utilizing rigorous quality improvement science; maintaining close partnerships with public health departments; and seeking population-level improvements in health outcomes.
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Affiliation(s)
- Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215.
| | - Edward F Donovan
- Executive Committee, Colorado Perinatal Care Quality Collaborative, Denver, CO
| | - Zsakeba Henderson
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Thematic analysis of barriers and facilitators to implementation of neonatal resuscitation guideline changes. J Perinatol 2017; 37:249-253. [PMID: 27906192 PMCID: PMC5334207 DOI: 10.1038/jp.2016.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/20/2016] [Accepted: 10/10/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project. STUDY DESIGN Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general. RESULTS Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation. CONCLUSION Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.
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Bennett SC, Finer N, Halamek LP, Mickas N, Bennett MV, Nisbet CC, Sharek PJ. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Improvement Collaborative. Jt Comm J Qual Patient Saf 2017; 42:369-76. [PMID: 27456419 DOI: 10.1016/s1553-7250(16)42052-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative. METHODS The RB consisted of (1) a checklist for high-risk neonatal resuscitations and (2) briefings and debriefings to improve teamwork and communication in the delivery room (DR). Implementation of the RB was encouraged, compliance with the RB was tracked monthly up through 6 months after the completion of the collaborative, and satisfaction with the RB was evaluated. RESULTS Twenty-four neonatal intensive care units (NICUs) participated in the CPQCCDR collaborative. Before the initiation of the collaborative, the elements of the RB were complied with in 0 of 740 reported deliveries (0%). During the 12-month collaborative, compliance with the RB improved to a median of 71%, which was surpassed in the 6-month period after the collaborative ended (80%). One-hundred percent of responding NICUs would recommend the RB to other NICUs working on improving DR management. CONCLUSIONS The RB was rapidly adopted, with compliance sustained for 6 months after completion of the collaborative. Inclusion of the RB in the next generation of the NRP guidelines is encouraged.
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Affiliation(s)
- Stacie C Bennett
- Division of Neonatology, Department of Pediatrics, John Muir Medical Center, Walnut Creek, California, USA
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Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Jt Comm J Qual Patient Saf 2016; 42:309-15. [DOI: 10.1016/s1553-7250(16)42042-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin JG. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S543-60. [PMID: 26473001 DOI: 10.1161/cir.0000000000000267] [Citation(s) in RCA: 467] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA; California Perinatal Quality Care Collaborative, Palo Alto, CA, USA.
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA; Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA
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Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin JG. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). Pediatrics 2015; 136 Suppl 2:S196-218. [PMID: 26471383 DOI: 10.1542/peds.2015-3373g] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics 2015; 136 Suppl 2:S120-66. [PMID: 26471381 DOI: 10.1542/peds.2015-3373d] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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