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Gray KD, Saha S, Battarbee AN, Cotten CM, Boghossian NS, Walsh MC, Greenberg RG. Outcomes of Moderately Preterm Infants of Insulin-Dependent Diabetic Mothers. Am J Perinatol 2024; 41:1212-1222. [PMID: 35299277 PMCID: PMC10369370 DOI: 10.1055/a-1801-3050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Little is known about the hospital outcomes of moderately preterm (MPT; 29 0/7-33 6/7 weeks gestational age) infants born to insulin-dependent diabetic mothers (IDDMs). We evaluated characteristics and outcomes of MPT infants born to IDDMs compared with those without IDDM (non-IDDM). STUDY DESIGN Cohort study of infants from 18 centers included in the MPT infant database from 2012 to 2013. We compared characteristics and outcomes of infants born to IDDMs and non-IDDMs. RESULTS Of 7,036 infants, 527 (7.5%) were born to IDDMs. Infants of IDDMs were larger at birth, more often received continuous positive pressure ventilation in the delivery room, and had higher risk of patent ductus arteriosus (adjusted relative risk or aRR: 1.49, 95% confidence interval [CI]: 1.20-1.85) and continued hospitalization at 40 weeks postmenstrual age (aRR: 1.55, 95% CI: 1.18-2.05). CONCLUSION MPT infants of IDDM received more respiratory support and prolonged hospitalizations, providing further evidence of the important neonatal health consequences of maternal diabetes. KEY POINTS · Little data are available on moderate preterm infants of IDDMs.. · MPT infants of IDDMs need more respiratory support.. · Longer neonatal intensive care unit stays among MPT infants of IDDMs..
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Affiliation(s)
- Keyaria D. Gray
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Shampa Saha
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Ashley N. Battarbee
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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Hughes CS, Schmitt S, Passarella M, Lorch SA, Phibbs CS. Who's in the NICU? A population-level analysis. J Perinatol 2024:10.1038/s41372-024-02039-6. [PMID: 38944662 DOI: 10.1038/s41372-024-02039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/29/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE To understand the characteristics of infants admitted to US NICUs. STUDY DESIGN 2006-2014 linked birth certificate and hospital discharge data for potentially viable deliveries in Pennsylvania and South Carolina were used. NICU admissions were identified using revenue codes. NICU-admitted infants were categorized by gestational age (GA), birthweight, and condition severity (for GA 35+ weeks). We also assessed total patient days and trends over time. RESULTS 12% of infants were admitted to a NICU; 13.6% were GA < 32 weeks (45.3% of total days); 36.1% were GA 32-36 weeks (31.2% of total days); and 50.4% were GA 37+ weeks (23.5% of total days). 20% of admissions were for infants with GA 35+ weeks and mild conditions. Admissions increased numerically from 11.2% (2006) to 13.0% (2014), with increases among infants 35+ weeks. CONCLUSION Most NICU admissions are for infants 35+ weeks GA, many with mild conditions who may be accommodated in well-baby units.
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Affiliation(s)
- Carolyn S Hughes
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Susan Schmitt
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Molly Passarella
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott A Lorch
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Ciaran S Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA.
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Sammour I, Karnati S, Othman H, Heis F, Peluso A, Aly H. Trends in Procedures in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e494-e500. [PMID: 35858651 DOI: 10.1055/a-1905-5245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aim of the study is to identify the rates and trends of various procedures performed on newborns. STUDY DESIGN The Healthcare Cost and Utilization Project (HCUP) database for the years 2002 to 2015 was queried for the number of livebirths, and various procedures using International Classification of Diseases, Ninth Revision (ICD-9) codes. These were adjusted to the rate of livebirths in each particular year. A hypothetical high-volume hospital based on data from the last 5 years was used to estimate the frequency of each procedure. RESULTS Over the study period, there was a decline in the rates of exchange transfusions and placement of arterial catheters. There was an increase in the rates of thoracentesis, abdominal paracentesis, placement of umbilical venous catheter (UVC) lines, and central lines with ultrasound or fluoroscopic guidance. No change was observed in the rates of unguided central lines, pericardiocentesis, bladder aspiration, intubations, and LP. Intubations were the most performed procedures. Placement of UVC, central venous lines (including PICCs), arterial catheters, and LP were relatively common, whereas others were rare such as pericardiocentesis and paracentesis. CONCLUSION Some potentially lifesaving procedures are extremely rare or decreasing in incidence. There has also been an increase in utilization of fluoroscopic/ultrasound guidance for the placement of central venous catheters. KEY POINTS · Advances in neonatal care have impacted the number of procedures performed in the NICU.. · It is unclear whether invasive procedures occur at rates sufficient for adequate training and maintenance of skills.. · Understanding the NICU procedural trends is important in designing simulation and competency-based medical education programs..
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Affiliation(s)
- Ibrahim Sammour
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Hasan Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, Michigan
| | - Farah Heis
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Allison Peluso
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
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Rysavy MA, Bennett MM, Ahmad KA, Patel RM, Shah ZS, Ellsbury DL, Clark RH, Tolia VN. Neonatal Intensive Care Unit Resource Use for Infants at 22 Weeks' Gestation in the US, 2008-2021. JAMA Netw Open 2024; 7:e240124. [PMID: 38381431 PMCID: PMC10882422 DOI: 10.1001/jamanetworkopen.2024.0124] [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: 02/22/2024] Open
Abstract
Importance During the past decade, clinical guidance about the provision of intensive care for infants born at 22 weeks' gestation has changed. The impact of these changes on neonatal intensive care unit (NICU) resource utilization is unknown. Objective To characterize recent trends in NICU resource utilization for infants born at 22 weeks' gestation compared with other extremely preterm infants (≤28 weeks' gestation) and other NICU-admitted infants. Design, Setting, and Participants This is a serial cross-sectional study of 137 continuously participating NICUs in 29 US states from January 1, 2008, through December 31, 2021. Participants included infants admitted to the NICU. Data analysis was performed from October 2022 to August 2023. Exposures Year and gestational age at birth. Main Outcomes and Measures Measures of resource utilization included NICU admissions, NICU bed-days, and ventilator-days. Results Of 825 112 infants admitted from 2008 to 2021, 60 944 were extremely preterm and 872 (466 [53.4%] male; 18 [2.1%] Asian; 318 [36.5%] Black non-Hispanic; 218 [25.0%] Hispanic; 232 [26.6%] White non-Hispanic; 86 [9.8%] other or unknown) were born at 22 weeks' gestation. NICU admissions at 22 weeks' gestation increased by 388%, from 5.7 per 1000 extremely preterm admissions in 2008 to 2009 to 27.8 per 1000 extremely preterm admissions in 2020 to 2021. The number of NICU admissions remained stable before the publication of updated clinical guidance in 2014 to 2016 and substantially increased thereafter. During the study period, bed-days for infants born at 22 weeks increased by 732%, from 2.5 per 1000 to 20.8 per 1000 extremely preterm NICU bed-days; ventilator-days increased by 946%, from 5.0 per 1000 to 52.3 per 1000 extremely preterm ventilator-days. The proportion of NICUs admitting infants born at 22 weeks increased from 22.6% to 45.3%. Increases in NICU resource utilization during the period were also observed for infants born at less than 22 and at 23 weeks but not for other gestational ages. In 2020 to 2021, infants born at less than or equal to 23 weeks' gestation comprised 1 in 117 NICU admissions, 1 in 34 of all NICU bed-days, and 1 in 6 of all ventilator-days. Conclusions and Relevance In this serial cross-sectional study of 137 US NICUs from 2008 to 2021, an increasing share of resources in US NICUs was allocated to infants born at 22 weeks' gestation, corresponding with changes in national clinical guidance.
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Affiliation(s)
- Matthew A Rysavy
- Department of Pediatrics, McGovern Medical School at UTHealth Houston, Houston, Texas
| | | | - Kaashif A Ahmad
- The Woman's Hospital of Texas, Houston, Texas
- Department of Clinical Sciences, University of Houston, Houston, Texas
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Ravi M Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Zubin S Shah
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
- Texas A&M Health Science Center School of Medicine, Dallas, Texas
| | - Dan L Ellsbury
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- MercyOne Children's Hospital, Des Moines, Iowa
| | - Reese H Clark
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Veeral N Tolia
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
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Goodman DC, Stuchlik P, Ganduglia-Cazaban C, Tyson JE, Leyenaar J, Avritscher EBC, Rysavy M, Gautham KS, Lynch D, Stukel TA. Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas. JAMA Netw Open 2024; 7:e2355982. [PMID: 38353952 PMCID: PMC10867701 DOI: 10.1001/jamanetworkopen.2023.55982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/20/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.
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Affiliation(s)
- David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Patrick Stuchlik
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Cecilia Ganduglia-Cazaban
- Center for Health Care Data and Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston
| | - Jon E. Tyson
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - JoAnna Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Elenir B. C. Avritscher
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Mathew Rysavy
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Kanekal S. Gautham
- Division of Neonatology, Department of Pediatrics, Nemours Children’s Health, Orlando, Florida
| | | | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
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Gamber RA, Blonsky H, McDowell M, Lakshminrusimha S. Declining birth rates, increasing maternal age and neonatal intensive care unit admissions. J Perinatol 2024; 44:203-208. [PMID: 38012436 DOI: 10.1038/s41372-023-01834-x] [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] [Received: 01/24/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE To describe the number of US births, maternal age at birth and NICU admissions by maternal age cohorts. Our study aims to measure NICU utilization by maternal age over time. STUDY DESIGN We queried the CDC WONDER Natality database for births, NICU admissions, and maternal age at delivery from 2016 to 2021. Births and NICU admissions were analyzed by maternal age. RESULTS Between 2016 and 2021, US births decreased by 7% (3,945,875 to 3,664,292/year). NICU admissions increased from 344,454 to 351,775 (+2%) and admit rate from 8.7% to 9.6%. The proportion of births by maternal age declined each year for ≤29 y but increased for ≥30 y. NICU admission rates were lowest at maternal age 20-29 y and increased with age ≥30 y. CONCLUSIONS US NICUs have demonstrated a 2% increase in admissions despite a 7% decrease in births. Higher rates of NICU admissions among infants born at maternal age ≥30 y warrants investigation.
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Motter B. An Evidence-Based Practice Project to Provide Standardized Education on Skin-to-Skin Contact and Neonatal Hypoglycemia. Nurs Womens Health 2024; 28:58-65. [PMID: 38065222 DOI: 10.1016/j.nwh.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/25/2023] [Accepted: 11/06/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVE To develop and examine the implications of formalized education with staff and familial caregivers on skin-to-skin in relation to neonatal hypoglycemia, including the impact on NICU admission rate, exclusive breastfeeding, and glucose gel administration. DESIGN Evidence-based practice (EBP) project with a comparison of data pre-/postintervention. SETTING/LOCAL PROBLEM Implemented at a large health system in the mid-Atlantic, including four hospitals with postpartum care units. The EBP implementation site had approximately 19,400 births in 2021. PARTICIPANTS Participants included 320 postpartum nurses in addition to the familial neonatal caregivers these nurses provided care for. INTERVENTION/MEASUREMENT All team members were provided with online education via the HealthStream learning platform, a microlearning introduction video, weekly huddle messages, and unit-specific champions who shared a champion information sheet that included information such as the hypoglycemia protocol, how to perform safe skin-to-skin care, and how to effectively administer glucose gel. Familial caregiver education included a handout given upon admission with an explanation from the postpartum nurse if the neonate met the criteria for the hospital system's neonatal hypoglycemia protocol. RESULTS We observed a 4% system-wide increase in exclusive breastfeeding rates, a decrease in NICU admissions by 17.3% at 1-month postimplementation at the smallest hospital site (Hospital A), and a 12.3% reduction in NICU admission rates at the largest hospital site (Hospital B). Two hospitals reported a decrease in the need for glucose gel administration to neonates after the educational intervention. CONCLUSION This nurse-led project detailed the process of a system-wide EBP project to implement consistent and standardized education regarding neonatal protocols. Although the benefits of skin-to-skin contact are widely known, this project demonstrated that focused, targeted education on skin-to-skin protocols for neonates at risk for neonatal hypoglycemia may be effective at improving outcomes.
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Martin JS, Botta CJ, Bowman S, Giliberti D. Pragmatic Expansion of a Neonatal Antibiotic Stewardship Program in a Community Health Care System. Pediatrics 2024; 153:e2022056356. [PMID: 38093660 DOI: 10.1542/peds.2022-056356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Previously published neonatal antibiotic stewardship efforts have been primarily implemented in single centers. Piedmont Athens Regional began work to decrease antibiotic use in the NICU with spread to the newborn nursery (NBN) and, subsequently, 13 other NICUs and NBNs throughout a health care system over a 4-year period. METHODS This quality improvement initiative was conducted in the context of a multicenter learning collaborative from 2016 to 2019. The primary aim was a 10% reduction in antibiotic days per 1000 patient days (antibiotic utilization rate [AUR]) among newborns in the NICU and NBN at each hospital by December 2018. Change ideas were implemented by using plan-do-study-act cycles. The primary outcome measure was AUR with a balancing measure of antibiotic restarts. RESULTS Piedmont Athens Regional decreased the NICU AUR by 46% and NBN AUR by 83%. Piedmont Healthcare decreased the NICU AUR by 40% and NBN AUR by 74%. Seven of 8 NICUs and 5 of 7 NBNs achieved a >10% reduction in AUR and 8 of 8 intervention hospitals showed a sustained drop in AUR in the NBN, NICU, or both during the 1.5-year postobservation period. Decreases in antibiotic initiation resulted in 335 fewer antibiotic courses in the NICU and 189 fewer infants started on antibiotics in the NBN in 2020 versus 2017. CONCLUSIONS This initiative achieved reductions in AUR across multiple hospitals in the network. The system-wide approach facilitated information technology (IT) and electronic health record modifications. Common drivers of NICU improvement were involvement for at least 2 years, multidisciplinary teams, and the highest baseline AUR. The common driver of nursery improvement was the implementation of a neonatal sepsis risk calculator.
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Affiliation(s)
- Julie S Martin
- Piedmont Athens Regional, Athens, Georgia
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | - Caleb J Botta
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | - Sarah Bowman
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
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Handley SC, Salazar EG, Kunz SN, Lorch SA, Edwards EM. Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation. Pediatrics 2024; 153:e2023063118. [PMID: 38268423 PMCID: PMC10827647 DOI: 10.1542/peds.2023-063118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.
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Affiliation(s)
- Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington, Vermont
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Ismail L, Markowsky A, Adusei-Baah C, Gallizzi G, Hall M, Kalburgi S, McQuistion K, Morgan J, Tamaskar N, Parikh K. Variation in Length of Stay by Level of Neonatal Care Among Moderate and Late Preterm Infants. Hosp Pediatr 2024; 14:37-44. [PMID: 38058236 DOI: 10.1542/hpeds.2023-007252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Moderate and late preterm infants are a growing subgroup of neonates with increased care needs after birth, yet standard protocols are lacking. We aim to describe variation in length of stay (LOS) by gestational age (GA) across hospitals within the same level of neonatal care and between different levels of neonatal care. METHODS Retrospective cohort study of hospitalizations for moderate (32-33 weeks GA) and late (34-36 weeks GA) preterm infants in 2019 Kid's Inpatient Database. We compared adjusted LOS in this cohort and evaluated variation within hospitals of the same level and across different levels of neonatal care. RESULTS This study includes 217 051 moderate (26.2%) and late (73.8%) preterm infants from level II (19.7%), III (66.3%), and IV (11.1%) hospitals. Patient-level (race and ethnicity, primary payor, delivery type, multiple gestation, birth weight) and hospital-level (birth region, level of neonatal care) factors were significantly associated with LOS. Adjusted mean LOS varied for hospitals within the same level of neonatal care with level II hospitals showing the greatest variability among 34- to 36- week GA infants when compared with level III and IV hospitals (P < .01). LOS also varied significantly between levels of neonatal care with the greatest variation (0.9 days) seen in 32-week GA between level III and level IV hospitals. CONCLUSIONS For moderate and late preterm infants, the level of neonatal care was associated with variation in LOS after adjusting for clinical severity. Hospitals providing level II neonatal care showed the greatest variation and may provide an opportunity to standardize care.
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Affiliation(s)
- Lana Ismail
- Children's National Hospital, Washington, District of Columbia
| | | | | | - Gina Gallizzi
- Children's National Hospital, Washington, District of Columbia
| | | | - Sonal Kalburgi
- Children's National Hospital, Washington, District of Columbia
| | | | - Joy Morgan
- Children's National Hospital, Washington, District of Columbia
| | - Nisha Tamaskar
- Children's National Hospital, Washington, District of Columbia
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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Pang EM, Liu J, Lu T, Joshi NS, Gould J, Lee HC. Evaluating Epidemiologic Trends and Variations in NICU Admissions in California, 2008 to 2018. Hosp Pediatr 2023; 13:976-983. [PMID: 37867440 PMCID: PMC10593864 DOI: 10.1542/hpeds.2023-007190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE Previous research suggests increasing numbers of and variation in NICU admissions. We explored whether these trends were reflected in California by examining NICU admissions and birth data in aggregate and among patient and hospital subpopulations more susceptible to variations in care. METHODS In this retrospective cohort study, we evaluated NICU utilization between 2008 and 2018 for all live births at hospitals that provide data to the California Perinatal Quality Care Collaborative. We compared hospital- and admission-level data across birth weight (BW), gestational age (GA), and illness acuity categories. Trends were analyzed by using linear regression models. RESULTS We identified 472 402 inborn NICU admissions and 3 960 441 live births across 144 hospitals. Yearly trends in NICU admissions remained stable among all births and higher acuity births (mean admission rates 11.9% and 4.1%, respectively). However, analysis of the higher acuity births revealed significant increases in NICU admission rates for neonates with higher BW and GA (BW ≥ 2500g: 1.8% in 2008, 2.1% in 2018; GA ≥ 37 weeks: 1.5% in 2010, 1.8% in 2018). Kaiser hospitals had a decreasing trend of NICU admissions compared to non-Kaiser hospitals (Kaiser: 13.9% in 2008, 10.1% in 2018; non-Kaiser: 11.3% in 2008, 12.3% in 2018). CONCLUSIONS Overall NICU admission rates in California were stable from 2008-2018. However, trends similar to national patterns emerged when stratified by infant GA, BW, and illness acuity as well as Kaiser or non-Kaiser hospitals, with increasing admission rates for infants born at higher BW and GA and within non-Kaiser hospitals.
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Affiliation(s)
- Emily M. Pang
- Stanford University School of Medicine, Stanford, California
| | - Jessica Liu
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Tianyao Lu
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Neha S. Joshi
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Jeffrey Gould
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Henry C. Lee
- California Perinatal Quality Care Collaborative (CPQCC)
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, California
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12
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Sarathy L, Roumiantsev S, Lerou PH. Who Needs the NICU? Trends and Opportunities for Improvement. Hosp Pediatr 2023; 13:e345-e347. [PMID: 37867434 DOI: 10.1542/hpeds.2023-007473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Affiliation(s)
- Leela Sarathy
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School/Mass General for Children, Boston, Massachusetts
| | - Sergei Roumiantsev
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School/Mass General for Children, Boston, Massachusetts
| | - Paul H Lerou
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School/Mass General for Children, Boston, Massachusetts
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13
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Lockyear C, Coe K, Greenberg RG, Clark RH, Aleem S. Trends in morbidities of late preterm infants in the neonatal intensive care unit. J Perinatol 2023; 43:1379-1384. [PMID: 37393396 DOI: 10.1038/s41372-023-01705-5] [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] [Received: 10/31/2022] [Revised: 05/20/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To characterize demographics and trends in length of stay (LOS), morbidities, and mortality in late preterm infants. STUDY DESIGN Cohort study of infants born between 34 0/7 and 36 6/7 weeks gestation between 1999 and 2018 without major congenital anomalies at Pediatrix Medical Group neonatal intensive care units (NICUs). RESULTS 307,967 infants from 410 NICUs met inclusion criteria. The median (25th-75th percentile) LOS was 11 (8-16) days in the entire period. Postmenstrual age (PMA) at discharge increased during the cohort for all gestational ages (p < 0.001). There was a decrease in invasive ventilation, receipt of phototherapy, and reflux medications observed (p < 0.001). CONCLUSION In this large cohort, given 20 years of time for medical advancement, there was no significant improvement in the LOS of late preterm infants. All infants had an increased PMA at discharge, despite multiple practice changes that were observed.
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Affiliation(s)
| | - Kristi Coe
- Duke School of Nursing, Duke University, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- Pediatrix Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | - Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA.
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14
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Jones RA, Elhindi J, Lowe G, Henry L, Maheshwari R, Culcer MR, Pasupathy D, Melov SJ. Investigating short-stay admission to a neonatal intensive care unit as a risk factor for reduced breast feeding at discharge in infants ≥36 weeks' gestation: a retrospective cohort study. BMJ Open 2023; 13:e075658. [PMID: 37857543 PMCID: PMC10603420 DOI: 10.1136/bmjopen-2023-075658] [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: 05/18/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE This study aims to determine the effect of infant-mother separation following a short-stay (≤72 hours) admission to a Level 5 neonatal unit versus no admission on infant-feeding outcomes at hospital discharge. DESIGN Retrospective cohort study. SETTING An Australian Level 5 neonatal unit within a tertiary referral hospital. PARTICIPANTS Mothers and their infants born between 1 January 2018 and 31 December 2020 had a short-stay admission to the neonatal unit or no admission. All participants met admission criteria to the postnatal ward and were discharged home at ≤72 hours (n=12 540). Postnatal ward admission criteria included ≥36 weeks' gestation and birth weight ≥2.2 kg. MAIN OUTCOME MEASURES Infant feeding at discharge from hospital. Multivariate logistic regression analysis was conducted, adjusting for confounders associated with known breastfeeding issues. These included age, ethnicity, parity, obesity, socioeconomic score, hypertensive disorders of pregnancy, diabetes, infant gestation and birthweight centile, caesarean section birth, postpartum haemorrhage and skin-to-skin contact. RESULTS Of the 12 540 live births meeting inclusion criteria, 1000 (8%) infants were admitted to the neonatal unit. The primary reasons for admission were suspicion of sepsis (24%), maternal diabetes (19%) and jaundice (16%). We found a reduction in full breast feeding at hospital discharge in cases of a short admission to the neonatal unit compared with no admission (aOR 0.40; 95% CI 0.34 to 0.47; p<0.001). We identified that women of different ethnicities had differing levels of risk for formula supplementation at hospital discharge. The ethnic grouping least likely to be fully breast feeding at discharge was Southeast Asian women (aOR 0.47; 95% CI 0.39 to 0.57; p<0.001). CONCLUSIONS Identifying mother-infant dyads at risk of non-exclusive breast feeding at hospital discharge will help target resources for practice improvement.
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Affiliation(s)
- Rachel Ann Jones
- Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
| | - James Elhindi
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Gemma Lowe
- Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
| | - Lynne Henry
- Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
| | - Rajesh Maheshwari
- Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Dharmintra Pasupathy
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sarah J Melov
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
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15
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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16
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De Bie FR, Kim SD, Bose SK, Nathanson P, Partridge EA, Flake AW, Feudtner C. Ethics Considerations Regarding Artificial Womb Technology for the Fetonate. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:67-78. [PMID: 35362359 DOI: 10.1080/15265161.2022.2048738] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Since the early 1980's, with the clinical advent of in vitro fertilization resulting in so-called "test tube babies," a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically improved method of neonatal care through AWT, but instead to the remote scenario of "complete ectogenesis" that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate.
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Affiliation(s)
| | | | - Sourav K Bose
- The Children's Hospital of Philadelphia
- Leonard Davis Institute of Health Economics
| | | | | | | | - Chris Feudtner
- The Children's Hospital of Philadelphia
- University of Pennsylvania
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17
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Lee RD, D’Angelo DV, Dieke A, Burley K. Recent Incarceration Exposure Among Parents of Live-Born Infants and Maternal and Child Health. Public Health Rep 2023; 138:292-301. [PMID: 35301904 PMCID: PMC10031842 DOI: 10.1177/00333549221081808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Women who have direct exposure to incarceration or indirect exposure through their partner are at high risk for poor health behaviors and outcomes, which may have lasting impacts on their children. The objectives of this study were to estimate the prevalence of recent incarceration exposure among women with a recent live birth and assess the relationship between incarceration exposure and maternal and child health. METHODS We used data from the Pregnancy Risk Assessment Monitoring System (36 states and New York City, 2012-2015; N = 146 329) to estimate the prevalence of women reporting that they or their husband/partner spent time in jail during the 12 months before giving birth. We used multivariable logistic regression to assess associations between incarceration exposure and maternal and infant health conditions. RESULTS The prevalence of incarceration exposure shortly before or during pregnancy was 3.7% (95% CI, 3.6%-3.9%). Women with incarceration exposure had increased odds of prepregnancy hypertension (adjusted odds ratio [aOR] = 1.51; 95% CI, 1.26-1.81), prepregnancy and postpartum depressive symptoms (aOR = 1.95 [95% CI, 1.73-2.19] and 1.49 [95% CI, 1.32-1.67], respectively), and having an infant admitted to the neonatal intensive care unit (aOR = 1.18; 95% CI, 1.04-1.33). CONCLUSION Because a parent's incarceration exposure is an adverse childhood experience with the potential to disrupt important developmental periods and have negative impacts on the socioemotional and health outcomes of children, it is critical for researchers and health care providers to better understand its impact on maternal and infant health. Prenatal and postnatal care may provide opportunities to address incarceration-related health risks.
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Affiliation(s)
- Rosalyn D. Lee
- Division of Violence Prevention,
National Center for Injury Prevention and Control, Centers for Disease Control and
Prevention, Atlanta, GA, USA
| | - Denise V. D’Angelo
- Division of Reproductive Health,
National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, GA, USA
| | - Ada Dieke
- Division of Reproductive Health,
National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, GA, USA
| | - Kim Burley
- Division of Reproductive Health,
National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, GA, USA
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18
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Salazar EG, Handley SC, Greenberg LT, Edwards EM, Lorch SA. Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants. JAMA Pediatr 2023; 177:278-285. [PMID: 36648939 PMCID: PMC9857785 DOI: 10.1001/jamapediatrics.2022.5213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023]
Abstract
Importance A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown. Objective To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants. Design, Setting, and Participants This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database. Exposures NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs). Main Outcomes and Measures The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type. Results Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score. Conclusions and Relevance In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.
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Affiliation(s)
- Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Lucy T. Greenberg
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington
- Department of Pediatrics, The Robert Larner, MD College of Medicine, The University of Vermont, Burlington
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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19
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Zupancic JAF, Hudak ML, Edwards EM, Horbar JD, Mao WY, Miedema D, Keels E, Pursley DM. Using the Neonatal Intensive Care Unit Wisely: A National Survey of Clinicians Regarding Practices for Lower-Acuity Care. J Pediatr 2023; 253:165-172.e1. [PMID: 36181871 DOI: 10.1016/j.jpeds.2022.09.036] [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: 05/19/2022] [Revised: 08/25/2022] [Accepted: 09/23/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity. STUDY DESIGN We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network. RESULTS Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios. CONCLUSIONS A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.
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Affiliation(s)
- John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Mark L Hudak
- Department of Pediatrics, University of Florida College of Medicine - Jacksonville, Jacksonville, FL
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT; Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, VT; Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT; Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Wen Yang Mao
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Miedema
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Erin Keels
- Nationwide Children's Hospital, Columbus, OH
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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20
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Coggins SA, Edwards EM, Flannery DD, Gerber JS, Horbar JD, Puopolo KM. Serratia Infection Epidemiology Among Very Preterm Infants in the Neonatal Intensive Care Unit. Pediatr Infect Dis J 2023; 42:152-158. [PMID: 36638403 PMCID: PMC9846441 DOI: 10.1097/inf.0000000000003736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Serratia spp. are opportunistic, multidrug resistant, Gram-negative pathogens, previously described among preterm infants in case reports or outbreaks of infection. We describe Serratia late-onset infection (LOI) in very preterm infants in a large, contemporary, nationally representative cohort. METHODS In this secondary analysis of prospectively collected data of preterm infants born 401-1500 grams and/or 22-29 weeks gestational age from 2018 to 2020 at 774 Vermont Oxford Network members, LOI was defined as culture-confirmed blood and/or cerebrospinal fluid infection > 3 days after birth. The primary outcome was incidence of Serratia LOI. Secondary outcomes compared rates of survival and discharge morbidities between infants with Serratia and non-Serratia LOI. RESULTS Among 119,565 infants, LOI occurred in 10,687 (8.9%). Serratia was isolated in 279 cases (2.6% of all LOI; 2.3 Serratia infections per 1000 infants). Of 774 hospitals, 161 (21%) reported at least one Serratia LOI; 170 of 271 (63%) cases occurred at hospitals reporting 1 or 2 Serratia infections, and 53 of 271 (20%) occurred at hospitals reporting ≥5 Serratia infections. Serratia LOI was associated with a lower rate of survival to discharge compared with those with non-Serratia LOI (adjusted relative risk 0.88, 95% CI: 0.82-0.95). Among survivors, infants with Serratia LOI had higher rates of tracheostomy, gastrostomy and home oxygen use compared with those with non-Serratia LOI. CONCLUSIONS The incidence of Serratia LOI was 2.3 infections per 1000 very preterm infants in this cohort. Lower survival and significant morbidity among Serratia LOI survivors highlight the need for recognition and targeted prevention strategies for this opportunistic nosocomial infection.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Erika M. Edwards
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Dustin D. Flannery
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S. Gerber
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey D. Horbar
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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21
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Measuring quality of care in moderate and late preterm infants. J Perinatol 2022; 42:1294-1300. [PMID: 35354940 PMCID: PMC9522891 DOI: 10.1038/s41372-022-01377-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/22/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine quality measures for moderate and late preterm (MLP) infants. STUDY DESIGN By prospectively analyzing Vermont Oxford Network's all NICU admissions database, we adapted Baby-MONITOR, a composite quality measure for extremely/very preterm infants, for MLP infants. We examined correlations between the adapted MLP quality measure (MLP-QM) in MLP infants and Baby-MONITOR in extremely and very preterm infants. RESULT We studied 376,219 MLP (30-36 weeks GA) and 57,595 extremely/very preterm (25-29 weeks GA) infants from 465 U.S. hospitals born from 2016 to 2020. MLP-QM summary scores in MLP infants had weak correlation with Baby-MONITOR scores in extremely and very preterm infants (r = 0.47). There was weak correlation among survival (r = 0.19), no pneumothorax (r = 0.35), and no infection after 3 days (r = 0.45), but strong correlation among human milk at discharge (r = 0.79) and no hypothermia (r = 0.76). CONCLUSION Modest correlation among hospital care measures in two preterm populations suggests the need for MLP-specific care measures.
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22
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Weimer KED, Bidegain M, Shaikh SK, Couchet P, Tanaka DT, Athavale K. Comparison of short-term outcomes of 35-weeks' gestation infants cared for in a level II NICU vs mother-baby, a retrospective study. J Neonatal Perinatal Med 2022; 15:643-651. [PMID: 35661024 DOI: 10.3233/npm-221015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Late preterm infants are at high risk for medical complications and represent a growing NICU population. While 34-weeks' gestation infants are generally admitted to the NICU and 36-weeks'gestation infants stay in mother-baby, there is wide practice variation for 35-weeks'gestation infants. The objective of this study was to compare short-term outcomes of 35-weeks' gestation infants born at two hospitals within the same health system (DUHS), where one (DRH) admits all 35-weeks' gestation infants to their level II NICU and the other (DUH) admits all 35-weeks' gestation infants to mother-baby, unless clinical concern. METHODS We conducted a retrospective cohort analysis of 35-weeks' gestation infants born at DUHS from 2014-2019. Infant specific data were collected for birth, demographics, medications, medical therapies, LOS, ED visits and readmissions. 35-weeks' gestation infants at each hospital (DRH vs DUH) that met inclusion criteria were compared, regardless of unit(s) of care. RESULTS 726 infants of 35-weeks' gestation were identified, 591 met our inclusion criteria (DUH -462, DRH -129). Infants discharged from DRH were more likely to receive medical therapies (caffeine, antibiotics, blood culture, phototherapy, NGT), had a 4 day longer LOS, but were more likely to feed exclusively MBM at discharge. There were no differences in ED visits; however, more infants from DUH were readmitted within 30 days of discharge. CONCLUSIONS Our findings suggest admitting 35-weeks' gestation infants directly to the NICU increases medical interventions and LOS, but might reduce hospital readmissions.
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Affiliation(s)
- K E D Weimer
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - M Bidegain
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - S K Shaikh
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - P Couchet
- Department of Pediatrics, Duke University, Durham, NC, USA.,Hospital de Clínicas, Departamento de Neonatología, UDELAR, Montevideo, Uruguay
| | - D T Tanaka
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - K Athavale
- Department of Pediatrics, Duke University, Durham, NC, USA
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23
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Cost comparison of using reusable versus disposable equipment for retinopathy of prematurity screening rounds. J AAPOS 2022; 26:82-84. [PMID: 35085757 DOI: 10.1016/j.jaapos.2021.10.006] [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] [Received: 08/12/2021] [Revised: 09/29/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
Abstract
Retinopathy of prematurity (ROP) screening rounds have been linked to pathogen transmission and serious adverse outcomes in neonatal intensive care units (NICUs). Using Monte Carlo simulations, we found that it is more likely less expensive to use reusable than disposable equipment in NICUs of all levels for maintaining sterile equipment on ROP screening rounds.
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24
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Murthy S, Haeusslein L, Bent S, Fitelson E, Franck LS, Mangurian C. Feasibility of universal screening for postpartum mood and anxiety disorders among caregivers of infants hospitalized in NICUs: a systematic review. J Perinatol 2021; 41:1811-1824. [PMID: 33692474 PMCID: PMC8349842 DOI: 10.1038/s41372-021-01005-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 01/16/2021] [Accepted: 02/09/2021] [Indexed: 01/31/2023]
Abstract
This systematic review evaluated the feasibility of implementing universal screening programs for postpartum mood and anxiety disorder (PMAD) among caregivers of infants hospitalized in the neonatal intensive care unit (NICU). Four moderate quality post-implementation cohort studies satisfied inclusion criteria (n = 2752 total participants). All studies included mothers; one study included fathers or partners. Screening included measures of depression and post-traumatic stress. Screening rates ranged from 48.5% to 96.2%. The incidence of depression in mothers ranged from 18% to 43.3% and was 9.5% in fathers. Common facilitators included engaging multidisciplinary staff in program development and implementation, partnering with program champions, and incorporating screening into routine clinical practice. Referral to mental health treatment was the most significant barrier. This systematic review suggests that universal PMAD screening in NICUs may be feasible. Further research comparing a wider range of PMAD screening tools and protocols is critical to address these prevalent conditions with significant consequences for parents and infants.
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Affiliation(s)
- Snehal Murthy
- School of Medicine, University of California, San Francisco, CA, USA
| | - Laurel Haeusslein
- Benioff Children's Hospital Oakland, University of California, San Francisco, CA, USA
| | - Stephen Bent
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Fitelson
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Linda S Franck
- School of Nursing, University of California, San Francisco, CA, USA
| | - Christina Mangurian
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
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25
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Higgins Joyce A, Sengupta A, Garfield CF, Myers P. When is My Baby Going Home? Moderate to Late Preterm Infants are Discharged at 36 Weeks Based on Admission Data. Am J Perinatol 2021; 38:773-778. [PMID: 31887744 DOI: 10.1055/s-0039-3401850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study evaluates the effect of admission characteristics of uncomplicated moderate to late preterm infants on timing of discharge. One of the first questions that families of infants admitted to the Neonatal Intensive Care Unit (NICU) ask is, "When is my baby going home?" Moderate to late preterm infants are the largest cohort of NICU patients but little data exist about their length of stay (LOS). STUDY DESIGN A retrospective electronic chart review was completed on 12,498 infants admitted to our NICU between January 1, 2009 and December 31, 2015. All inborn infants with a gestational age between 320/7 and 366/7 weeks were studied. RESULTS A total of 3,240 infants met our inclusion criteria. The mean postmenstrual age at discharge was 363/7 weeks. Infants who were small for gestational age were significantly more likely to have an increased LOS. Infants born between 34 and 366/7 weeks had a significantly increased LOS if they had respiratory distress syndrome. Admission diagnoses of neonatal abstinence syndrome, meconium aspiration syndrome, hydrops, hypoxic ischemic encephalopathy, biliary emesis, ABO incompatibly, and a genetic diagnosis all had increased LOS for all late preterm infants. CONCLUSION For uncomplicated moderate to late preterm infants, clinicians can counsel families that their infants will likely be discharged at 36 weeks of postmenstrual age. Small for gestational age infants and those with specific diagnoses may stay longer.
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Affiliation(s)
- Alanna Higgins Joyce
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Arnab Sengupta
- Department of Pediatrics, Mercy Hospital, Springfield, Miami
| | - Craig F Garfield
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick Myers
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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26
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Choi YH, An HY, Kim YS, Park JD. Outcomes of infants with severe bronchopulmonary dysplasia in the pediatric intensive care unit. Pediatr Int 2021; 63:529-535. [PMID: 33205548 PMCID: PMC8252616 DOI: 10.1111/ped.14546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Some infants with severe bronchopulmonary dysplasia (sBPD) are referred to higher-level centers for multidisciplinary care, including the pediatric intensive care unit (PICU). However, information regarding these infants is limited in PICUs. METHODS We investigated the characteristics and outcomes of preterm infants with sBPD referred to the PICU of a tertiary hospital. This retrospective cohort study included 14 preterm infants with sBPD who were transferred to the PICU beyond 40 weeks' postmenstrual age (PMA) because of weaning failure, from January 1, 2014, to September 30, 2018. RESULTS The median age at referral was 47.1 weeks (range, 43.6-55.9 weeks), and the median length of stay in the previous neonatal intensive care unit was 154 days (range, 105.8-202.3 days) after birth. After referral the following major comorbidities were found in the patients: large airway malacia, n = 7 (50.0%); significant upper airway obstruction, n = 3 (21.4%); and pulmonary arterial hypertension, n = 8 patients (57.1%). Finally, eight patients (57.1%) were successfully extubated without tracheostomy. Final respiratory support of the patients was determined at a median PMA of 56 weeks (range, 48-63 weeks). Age at referral (P = 0.023) and large airway obstruction (P = 0.028) were significantly related to a decrease in successful extubation. CONCLUSION Based on a timely and individualized multidisciplinary approach, some of the prolonged ventilator-dependent infants, even those beyond term age, could be successfully extubated.
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Affiliation(s)
- Yu Hyeon Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Yul An
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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27
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Braun D, Edwards EM, Schulman J, Profit J, Pursley DM, Goodman DC. Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care. Semin Perinatol 2021; 45:151395. [PMID: 33573773 DOI: 10.1016/j.semperi.2021.151395] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.
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Affiliation(s)
- David Braun
- Neonatal Medicine, Kaiser Permanente, Panorama City, CA, United States; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Erika M Edwards
- Dept of Pediatrics and Mathematics and Statistics, University of Vermont, Burlington, VT, United States; Vermont Oxford Network, Burlington, VT, United States
| | - Joseph Schulman
- California Department of Health Care Services, California Children's Services, Sacramento, CA, United States
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - David C Goodman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, NH, Lebanon
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28
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Predicting NICU admissions in near-term and term infants with low illness acuity. J Perinatol 2021; 41:478-485. [PMID: 32678315 PMCID: PMC7855290 DOI: 10.1038/s41372-020-0723-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/29/2020] [Accepted: 07/07/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Describe NICU admission rate variation among hospitals in infants with birthweight ≥2500 g and low illness acuity, and describe factors that predict NICU admission. STUDY DESIGN Retrospective study from the Vizient Clinical Data Base/Resource Manager®. Support vector machine methodology was used to develop statistical models using (1) patient characteristics (2) only the indicator for the inborn hospital and (3) patient characteristics plus indicator for the inborn hospital. RESULTS NICU admission rates of 427,449 infants from 154 hospitals ranged from 0 to 28.6%. C-statistics for the patient characteristics model: 0.64 (Confidence Interval (CI) 0.62-0.65), hospital only model: 0.81 (CI, 0.81-0.82), and patient characteristic plus hospital variable model: 0.84 (CI, 0.83-0.84). CONCLUSION/RELEVANCE There is wide variation in NICU admission rates in infants with low acuity diagnoses. In all cohorts, birth hospital better predicted NICU admission than patient characteristics alone.
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29
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Decreasing Admissions to the NICU: An Official Transition Bed for Neonates. Adv Neonatal Care 2021; 21:87-91. [PMID: 32384327 DOI: 10.1097/anc.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence supports the need to decrease healthcare costs. One approach may be minimizing use of low-value care by reducing the number of unnecessary neonatal intensive care unit (NICU) admissions through the use of official neonatal transition beds. PURPOSE To evaluate whether transition beds decrease unnecessary NICU admissions and estimate the cost savings of this practice change. METHODS This retrospective chart review examined the records of all neonates of 350/7 weeks' gestational age and greater with birth weights of 2000 g and more admitted to a neonatal transition bed from January 1, 2017, to December 31, 2017. Outcomes evaluated were number of neonates returned to their mothers and an estimate of dollars saved for a 1-year period. RESULTS A total of 194 neonates were admitted to transition beds, which resulted in 144 NICU admissions averted. Respiratory distress was the most common reason for admission to transition beds. There was a statistically significant difference in length of stay in transition beds between neonates admitted to the NICU and those returned to couplet care after admission to transition beds (135.92 minutes vs 159.27 minutes; P = .047). There was no difference in gestational age based on admission to NICU or returned to couplet care (37.9 weeks vs 38 weeks; P = .772). The estimated cost savings was $3000 per neonate returned to couplet care totaling $432,000 annually. IMPLICATIONS FOR PRACTICE The use of neonatal transition beds is a potential strategy to decrease unnecessary NICU admissions and reduce low value care. IMPLICATIONS FOR RESEARCH Research regarding potential benefits of transition beds including the effect on hospital resources and low-value care at other institutions is needed. Additional research regarding potential benefits to the family including parent satisfaction and the effect of transition beds on rates of breastfeeding and skin-to-skin care is important.
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30
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Hospital variation in admissions to neonatal intensive care units by diagnosis severity and category. J Perinatol 2021; 41:468-477. [PMID: 32801351 PMCID: PMC7427695 DOI: 10.1038/s41372-020-00775-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/17/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine interhospital variation in admissions to neonatal intensive care units (NICU) and reasons for the variation. STUDY DESIGN 2010-2012 linked birth certificate and hospital discharge data from 35 hospitals in California on live births at 35-42 weeks gestation and ≥1500 g birth weight were used. Hospital variation in NICU admission rates was assessed by coefficient of variation. Patient/hospital characteristics associated with NICU admissions were identified by multivariable regression. RESULTS Among 276,489 newborns, 6.3% were admitted to NICU with 34.5% of them having mild diagnoses. There was high interhospital variation in overall risk-adjusted rate of NICU admission (coefficient of variation = 26.2) and NICU admission rates for mild diagnoses (coefficient of variation: 46.4-74.0), but lower variation for moderate/severe diagnoses (coefficient of variation: 8.8-14.1). Births at hospitals with more NICU beds had a higher likelihood of NICU admission. CONCLUSION Interhospital variation in NICU admissions is mostly driven by admissions for mild diagnoses, suggesting potential overuse.
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31
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Reiss J, Upadhyayula PS, You H, Xu R, Stellwagen LM. Short-Term Outcomes following Standardized Admission of Late Preterm Infants to Family-Centered Care. Am J Perinatol 2021; 38:131-139. [PMID: 31430819 DOI: 10.1055/s-0039-1694981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The study compares the short-term outcomes of late preterm infants (LPI) at an academic center in San Diego, California after a change in protocol that eliminated a previously mandatory 12-hour neonatal intensive care unit (NICU) observation period after birth. STUDY DESIGN This is a retrospective observational study examining all LPI born with gestational age 35 to 366/7 weeks between October 1, 2016 and October 31, 2017. A total of 189 infants were included in the review. Short-term outcomes were analyzed before and after the protocol change. RESULTS Transfers to the NICU from family-centered care (FCC) were considerably higher (23.2%) following the protocol change, compared to before (8.2%). More infants were transferred to the NICU for failed car seat tests postprotocol compared to preprotocol. Length of stay before the protocol change was 5.13 days compared to 4.80 days after. CONCLUSION LPI are vulnerable to morbidities after delivery and through discharge. We found an increase in failed car seat tests in LPI cared for in FCC after elimination of a mandatory NICU observation after birth. The transitions of care from delivery to discharge are key checkpoints in minimizing complications.
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Affiliation(s)
- Jonathan Reiss
- Department of Pediatrics, University of California San Diego School of Medicine, San Diego, California
| | | | - Hyeri You
- University of California San Diego Altman Clinical and Translational Research Institute, Biostatistics Unit, La Jolla, California
| | - Ronghui Xu
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California.,Department of Mathematics, University of California San Diego, La Jolla, California
| | - Lisa M Stellwagen
- Division of Academic General Pediatrics, Department of Pediatrics, University of California San Diego, La Jolla, California
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32
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Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic. J Perinatol 2021; 41:961-969. [PMID: 33727700 PMCID: PMC7962434 DOI: 10.1038/s41372-021-01014-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic. STUDY DESIGN Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status. RESULT We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p = 0.027) and difficulty focusing on work (59% vs. 36%, p = 0.013). CONCLUSION Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.
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33
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House SA, Singh N, Wasserman JR, Kim Y, Ganduglia-Cazaban C, Goodman DC. Small-Area Variation in the Care of Low-Risk Neonates in Massachusetts and Texas. Hosp Pediatr 2020; 10:1059-1067. [PMID: 33214138 DOI: 10.1542/hpeds.2020-000687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The success of neonatal intensive care in improving outcomes for critically ill neonates led to rapid growth of NICU use in the United States, despite a relatively stable birth cohort. Less is known about NICU use among late-preterm and term infants, although recent studies have observed wide variation in their care patterns. In this study, we measure special care days (SCDs) (intermediate or intensive), length of stay, and readmission rates among low-risk neonates across regions within 2 states. METHODS In this retrospective cohort study, we analyzed data from Massachusetts (all payer claims) and Texas (BlueCross BlueShield) from 2009 to 2012. A low-risk cohort was defined by identifying newborns with diagnostic codes indicating a gestational age ≥35 weeks and birth weight ≥1500 g and excluding infants with diagnoses and procedures generally necessitating nonroutine care. Outcomes were measured across neonatal intensive care regions by diagnosis and payer type. RESULTS We identified 255 311 low-risk newborns. SCD use varied nearly sixfold across neonatal intensive care regions. Use was highest among commercially insured Texas infants (8.42 per 100), followed by Medicaid-insured Massachusetts infants (6.67 per 100) and commercially insured Massachusetts infants (5.15 per 100). Coefficients of variation indicated high variation within each payer-specific cohort and moderate to high variation across each condition. No consistent relationship between regional SCD use and 30-day readmissions was identified. CONCLUSIONS Use of NICU services varied widely across regions in this cohort of low-risk infants. Further investigation is needed to delineate outcomes associated with patterns of care received by this population.
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Affiliation(s)
- Samantha A House
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; .,Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Neetu Singh
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Jared R Wasserman
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Youngran Kim
- Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Cecilia Ganduglia-Cazaban
- Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - David C Goodman
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
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34
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Zupancic JAF, Kunz SN, Pursley DM. Quantifying the Where and How Long of Newborn Care. Pediatrics 2020; 146:peds.2020-006213. [PMID: 32699068 DOI: 10.1542/peds.2020-006213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusets and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah N Kunz
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusets and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusets and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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35
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Pursley DM, Zupancic JAF. Using Neonatal Intensive Care Units More Wisely for At-Risk Newborns and Their Families. JAMA Netw Open 2020; 3:e205693. [PMID: 32556253 DOI: 10.1001/jamanetworkopen.2020.5693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- DeWayne M Pursley
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John A F Zupancic
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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36
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Braun D, Braun E, Chiu V, Burgos AE, Gupta M, Volodarskiy M, Getahun D. Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System. JAMA Netw Open 2020; 3:e205239. [PMID: 32556257 PMCID: PMC7303809 DOI: 10.1001/jamanetworkopen.2020.5239] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
IMPORTANCE There are few population-based studies addressing trends in neonatal intensive care unit (NICU) admission and NICU patient-days, especially in the subpopulation that, by gestational age (GA) and birth weight (BW), might otherwise be able to stay in the room with their mothers. OBJECTIVE To describe population-based trends in NICU admissions, NICU patient-days, readmissions, and mortality in the birth population of a large integrated health care system. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data extracted from electronic medical records at Kaiser Permanente Southern California (KPSC) health care system. Participants included all women who gave birth at KPSC hospitals and their newborns from January 1, 2010, through December 31, 2018. Data extraction was limited to data entry fields whose contents were either numbers or fixed categorical choices. Rates of NICU admission, NICU patient-days, readmission rates, and mortality rates were measured in the total population, in newborns with GA 35 weeks or greater and BW 2000 g or more (high GA and BW group), and in the remaining newborns (low GA and BW group). Admissions to the NICU and NICU patient-days were risk adjusted with a machine learning model based on demographic and clinical characteristics before NICU admission. Changes in the trends were assessed with 2-sided correlated seasonal Mann-Kendall test. Data analysis was performed in August 2019. EXPOSURES Admission to the NICU and NICU patient-days among the birth cohort. MAIN OUTCOMES AND MEASURES The primary outcomes were NICU admission and NICU patient-days in the total neonatal population and GA and BW subgroups. The secondary outcomes were readmission and mortality rates. RESULTS Over the study period there were 320 340 births (mean [SD] age of mothers, 30.1 [5.7] years; mean [SD] gestational age, 38.6 [1.97] weeks; mean [SD] birth weight, 3302 [573] g). The risk-adjusted NICU admission rate decreased from a mean of 14.5% (95% CI, 14.2%-14.7%) to 10.9% (95% CI, 10.7%-11.7%) (P for trend = .002); 92% of the change was associated with changes in the care of newborns in the high GA and BW group. The number of risk-adjusted NICU patient-days per birth decreased from a mean of 1.50 patient-days (95% CI, 1.43-1.54 patient-days) to 1.40 patient-days (95% CI, 1.36-1.48 patient-days) (P for trend = .03); 70% of the change was associated with newborns in the high GA and BW group. The unadjusted 30-day readmission rates and mortality rates did not change. CONCLUSIONS AND RELEVANCE Admission rates to the NICU and numbers of NICU patient-days decreased over the study period without an increase in readmissions or mortality. The observed decrease was associated with the high GA and BW newborn population. How much of this decrease is attributable to intercurrent health care systemwide quality improvement initiatives would require further investigation. The remaining unexplained variation suggests that further changes are also possible.
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Affiliation(s)
- David Braun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
- Women’s and Children’s Health Care Leadership Team, Kaiser Permanente Southern California, Pasadena, California
- Department of Pediatrics, Kaiser Permanente Southern California, Panorama City, California
| | - Eric Braun
- Department of Consulting and Implementation, Kaiser Permanente Southern California, Pasadena, California
| | - Vicki Chiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Anthony E. Burgos
- Department of Pediatrics, Kaiser Permanente Downey Medical Center, Downey, California
- Department of Pediatrics, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Mandhir Gupta
- Department of Pediatrics, Kaiser Permanente Downey Medical Center, Downey, California
| | - Marianna Volodarskiy
- Women’s and Children’s Health Care Leadership Team, Kaiser Permanente Southern California, Pasadena, California
- Department of Patient Care Services, Kaiser Permanente Southern California, Pasadena, California
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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37
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Vervenioti A, Fouzas S, Tzifas S, Karatza AA, Dimitriou G. Work of Breathing in Mechanically Ventilated Preterm Neonates. Pediatr Crit Care Med 2020; 21:430-436. [PMID: 32365285 DOI: 10.1097/pcc.0000000000002277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare the imposed work of breathing by means of pressure-time product of the diaphragm in newborn infants receiving different modes of mechanical ventilation. DESIGN Prospective observational crossover study. SETTING Tertiary care neonatal unit. PATIENTS Forty preterm newborns (gestational age ≤ 37 wk) in the phase of weaning from mechanical ventilation. INTERVENTIONS Participants were ventilated in assist control, synchronized intermittent mandatory ventilation, and intermittent mandatory ventilation mode, in a crossover manner. The combination synchronized intermittent mandatory ventilation-pressure support (SIMV-PS) at 50% (SIMV-PS50) and 75% (SIMV-PS75) of the difference between peak inflating and positive end-expiratory pressure, was also applied in a subset of infants (n = 11). Each mode was maintained for 30 minutes. Transdiaphragmatic pressure was obtained by digital subtraction of esophageal from gastric pressure (both measured using a dual pressure-tipped catheter), and pressure-time product of the diaphragm was computed by integration of transdiaphragmatic pressure over inspiratory time. MEASUREMENTS AND MAIN RESULTS The pressure-time product of the diaphragm was 224.2 ± 112.8 in the intermittent mandatory ventilation mode, 165.8 ± 58.8 in the synchronized intermittent mandatory ventilation mode, and 125.5 ± 61.8 cm H2O × s × min in the assist control mode; all values were significantly different to each other (p < 0.0001). The pressure-time product of the diaphragm difference between assist control and intermittent mandatory ventilation, and assist control and synchronized intermittent mandatory ventilation was negatively related to postmenstrual age (regression coefficient, -0.365; p = 0.020 and -0.341; p = 0.031, respectively). In the SIMV-PS subcohort, the pressure-time product of the diaphragm was significantly higher in the intermittent mandatory ventilation mode as compared with assist control (p < 0.0001) or SIMV-PS75 (p = 0.0027), and in the synchronized intermittent mandatory ventilation mode as compared with assist control (p = 0.0301). CONCLUSIONS In preterm infants, patient-triggered ventilation modalities result in lower work of breathing than intermittent mandatory ventilation, while the assist control mode is also associated with lower pressure-time product of the diaphragm compared with synchronized intermittent mandatory ventilation. The difference in the imposed diaphragmatic workload between these ventilation modalities was inversely related to postmenstrual age, implying that less mature infants benefit more from assist control-based ventilation strategies.
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Affiliation(s)
- Aggeliki Vervenioti
- All authors: Neonatal Intensive Care Unit, Department of Pediatrics, University of Patras Medical School, Patras, Greece
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Flannery DD, Mukhopadhyay S, Jensen EA, Gerber JS, Passarella MR, Dysart K, Aghai ZH, Greenspan J, Puopolo KM. Influence of Patient Characteristics on Antibiotic Use Rates Among Preterm Infants. J Pediatric Infect Dis Soc 2020; 10:97-103. [PMID: 32170951 PMCID: PMC7996645 DOI: 10.1093/jpids/piaa022] [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: 11/13/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The antibiotic use rate (AUR) has emerged as a potential metric for neonatal antibiotic use, but reported center-level AURs are limited by differences in case mix. The objective of this study was to identify patient characteristics associated with AUR among a large cohort of preterm infants. METHODS Retrospective observational study using the Optum Neonatal Database, including infants born from January 1, 2010 through November 30, 2016 with gestational age 23-34 weeks admitted to neonatal units across the United States. Exposures were patient-level characteristics including length of stay, gestational age, sex, race/ethnicity, bacterial sepsis, necrotizing enterocolitis, and survival status. The primary outcome was AUR, defined as days with ≥ 1 systemic antibiotic administered divided by length of stay. Descriptive statistics, univariable comparative analyses, and generalized linear models were utilized. RESULTS Of 17 910 eligible infants, 17 836 infants (99.6%) from 1090 centers were included. Median gestation was 32.9 (interquartile range [IQR], 30.3-34) weeks. Median length of stay was 25 (IQR, 15-46) days and varied by gestation. Overall median AUR was 0.13 (IQR, 0-0.26) and decreased over time. Gestational age, sex, and race/ethnicity were independently associated with AUR (P < .01). AUR and gestational age had an unexpected inverse parabolic relationship, which persisted when only surviving infants without bacterial sepsis or necrotizing enterocolitis were analyzed. CONCLUSIONS Neonatal AURs are influenced by patient-level characteristics besides infection and survival status, including gestational age, sex, and race/ethnicity. Neonatal antibiotic use metrics that account for patient-level characteristics as well as morbidity case mix may allow for more accurate comparisons and better inform neonatal antibiotic stewardship efforts.
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Affiliation(s)
- Dustin D Flannery
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA,Corresponding Author: Dustin D. Flannery, DO, Children’s Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107. E-mail:
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Molly R Passarella
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Dysart
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jay Greenspan
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karen M Puopolo
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr Res 2020; 87:227-234. [PMID: 31357209 PMCID: PMC6960093 DOI: 10.1038/s41390-019-0513-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.
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Affiliation(s)
- Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT, USA.
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA.
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, USA.
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marie C McCormick
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Dukhovny D, Buus-Frank ME, Edwards EM, Ho T, Morrow KA, Srinivasan A, Pollock DA, Zupancic JAF, Pursley DM, Goldmann D, Puopolo KM, Soll RF, Horbar JD. A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns. Pediatrics 2019; 144:peds.2019-0589. [PMID: 31676682 DOI: 10.1542/peds.2019-0589] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns. METHODS From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit. RESULTS The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% (P for trend < .0013), a 34% relative risk reduction. CONCLUSIONS NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.
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Affiliation(s)
- Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon;
| | - Madge E Buus-Frank
- Vermont Oxford Network, Burlington, Vermont.,Children's Hospital at Darmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont.,Department of Pediatrics, The Robert Larner, MD, College of Medicine, and.,Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont
| | - Timmy Ho
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | | | | | - John A F Zupancic
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - DeWayne M Pursley
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Karen M Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Roger F Soll
- Vermont Oxford Network, Burlington, Vermont.,Department of Pediatrics, The Robert Larner, MD, College of Medicine, and
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont.,Department of Pediatrics, The Robert Larner, MD, College of Medicine, and
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Abstract
A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA.,Department of Mathematics and Statistics, College of Engineering and Health Sciences, University of Vermont, Burlington, VT, USA
| | - Danielle E Y Ehret
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
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