Vermont Oxford Network: a worldwide learning community

Necrotising enterocolitis in a middle-income country: Early onset and risk factors for mortality

AIM

There is limited literature available about necrotising enterocolitis (NEC) in low- and middle-income countries. This study sought to determine the proportion, pattern and risk factors for mortality among very low birth weight (VLBW) neonates with NEC in a middle-income setting.

METHODS

A retrospective observational cohort study was conducted on all infants with birth weights less than 1501 g admitted from 2018 to 2020 at Groote Schuur Hospital, Cape Town, South Africa. Data were obtained from the Vermont Oxford Network and hospital folders.

RESULTS

A total of 104/1582 (6.6%) neonates were diagnosed with NEC with a median onset of 8 days of life. The mortality rate was 39.0%, compared to the all-cause mortality rate of 18.7% for VLBW neonates. Thirty-two (32.0%) neonates with NEC were transferred for surgery of whom 10 (31.3%) died. Small for gestational age (p = 0.13), NEC stage 2B or above (p = 0,002), a positive blood culture (p = 0.018), a raised C-reactive protein (p = 0.013), hyponatraemia (p = 0.004), anaemia requiring blood transfusion (p = 0.003) and thrombocytopenia requiring platelet transfusion (p = 0.033) were associated with mortality. A positive blood culture was found in 37.0% with a predominance of Klebsiella pneumoniae isolates.

CONCLUSION

NEC has an early onset and a high mortality rate in our setting.

Association between type of feeding at hospital discharge and nutritional status of Brazilian very preterm infants: a multicenter study

OBJECTIVES

To examine trends over time in diet and size of very preterm infants, and associations of diet with size at hospital discharge/transfer.

METHODS

The authors studied 4062 surviving very preterm infants born < 32 weeks' gestational age and < 1500 g between January 2012 and December 2020 from 12 Brazilian Neonatal Intensive Care Units. Diet type at discharge/transfer was classified as exclusive human milk, exclusive formula, or mixed. Outcomes were weight and head circumference at hospital discharge and the change in each from birth to discharge. The authors used linear regression to estimate adjusted associations of diet type with infant size, overall, and stratified by fetal growth category (small vs. appropriate for gestational age). The authors also examined trends in diet and infant size at discharge over the years.

RESULTS

Infants' mean gestational age at birth was 29.3 weeks, and the mean birth weight was 1136 g. Diet at discharge/transfer was exclusive human milk for 22 %, mixed for 62 %, and exclusive formula for 16 %. Infant size in weight and head circumference were substantially below the growth chart reference for all diets. Infants fed human milk and mixed diets were lighter and had smaller heads at discharge/transfer than infants fed formula only (weight z: -2.0, -1.8, and -1.5; head z: -1.3, -1.2 and -1.1 for exclusive human milk, mixed and exclusive formula respectively).

CONCLUSION

Results suggest high human milk use but gaps in nutrient delivery among hospitalized Brazilian very preterm infants, with little evidence of improvement over time.

Transcatheter and Surgical Ductus Arteriosus Closure in Very Low Birth Weight Infants: 2018-2022

BACKGROUND AND OBJECTIVE

The optimal patent ductus arteriosus (PDA) closure method in very low birth weight (VLBW) infants is uncertain. In 2019, the first transcatheter occlusion device was approved in the United States for infants ≥700 g. We described survival and short-term outcomes among VLBW infants who underwent transcatheter or surgical PDA closure (2018-2022).

METHODS

Vermont Oxford Network members submitted data on infants born from 401 to 1500 g or 22 to 29 weeks' gestational age. Adjusted risk ratios (aRR) for survival, length of stay (LOS), prematurity complications, and discharge support were used to compare transcatheter versus surgical closure. Subgroup analyses were conducted for infants with birth weight ≥700 g and born in 2020-2022.

RESULTS

Overall, 6410 of 216 267 infants at 726 hospitals received invasive PDA treatment. Transcatheter closure increased from 29.8% in 2018 to 71.7% in 2022. VLBW infants undergoing transcatheter closure had higher survival (adjusted rate ratio [aRR] 1.03; 1.02-1.04) with similar LOS (aRR 1.00; 0.97-1.03), neonatal complications (aRR 1.00; 0.98-1.01), and receipt of discharge support (aRR 0.94; 0.89-1.01). In subgroup analyses, survival (aRR 1.02; 1.00-1.04) and discharge support (aRR 0.90; 0.81-1.01) were similar between groups, whereas selected neonatal complications (aRR 0.95; 0.93-0.98) and LOS (aRR 0.95; 0.90-0.99) were lower after transcatheter closure.

CONCLUSIONS

Transcatheter PDA closure in VLBW infants was increasingly used after 2018. Selected short-term outcomes for infants receiving transcatheter closure may be more favorable, compared with surgical, and warrants further clinical investigation.

The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks' Gestation Infants

OBJECTIVE

To compare estimated healthcare resources needed to care for 22 through 24 weeks' gestation infants.

STUDY DESIGN

This multicenter, retrospective cohort study included 1505 live in-born and out-born infants 22 through 24 weeks' gestational age at delivery from 6 pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi's posthoc test and Fisher's exact test.

RESULTS

Of the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants.

CONCLUSIONS

Compared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. Twenty-two-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.

Potentially Better Practices for Follow Through in Neonatal Intensive Care Units

OBJECTIVE

To ascertain how NICU teams are undertaking action to follow through, involving teams, families, and communities as partners to address health-related social needs of infants and families.

METHODS

Nineteen potentially better practices (PBPs) for follow through first published in 2020 were reported and analyzed as a sum, overall, and by safety-net hospital status, hospital ownership, and NICU type, among US NICUs that finalized Vermont Oxford Network data collection in 2023.

RESULTS

One hundred percent of 758 eligible hospitals completed the annual membership survey, of which 57.5% reported screening for social risks. Almost all NICUs offered social work, lactation support, and translation services, but only 16% included a lawyer or paralegal on the team. Overall, 90.2% helped families offset financial costs while their infants were in the hospital, either with direct services or vouchers. At discharge, 94.0% of NICUs connected families with appropriate community organizations and services, 52.9% provided telemedicine after discharge, and 11.7% conducted home visits. The median number of PBPs at each hospital was 10 (25th percentile: 8, 75th percentile: 12). The number of PBPs reported differed by hospital control or ownership and level of NICU care. There were no differences by safety-net hospital status.

CONCLUSIONS

Despite concerns about time and resources, a diverse set of US NICUs reported adopting potentially better practices for follow through. However, the marked variation among NICUs and the lower rates at for-profit and lower-level NICUs suggest there is substantial opportunity for improvement.

Predictors of Mortality in Very Low Birth Weight Neonates With Congenital Diaphragmatic Hernia

BACKGROUND

Limited data exists regarding the mortality of very low birth weight (VLBW) neonates with congenital diaphragmatic hernia (CDH). This study aims to quantify and determine predictors of mortality in VLBW neonates with CDH.

METHODS

This analysis of 829 U.S. NICUs included VLBW [birth weight ≤1500g] neonates, born 2011-2021 with and without CDH. The primary outcome was in-hospital mortality. A generalized estimating equation regression model determined the adjusted risk ratio (ARR) of mortality.

RESULTS

Of 426,140 VLBW neonates, 535 had CDH. In neonates with CDH, 48.4% had an additional congenital anomaly vs 5.5% without. In-hospital mortality for neonates with CDH was 70.4% vs 12.6% without. Of those with CDH, 73.3% died by day of life 3. Of VLBW neonates with CDH, 38% were repaired. A subgroup analysis was performed on 60% of VLBW neonates who underwent delivery room intubation or mechanical ventilation, as an indicator of active treatment. Mortality in this group was 62.7% for neonates with CDH vs 16.4% without. Higher Apgars at 1 min and repair of CDH were associated with lower mortality (ARR 0.91; 95%CI 0.87,0.96 and ARR 0.28; 0.21,0.39). The presence of additional congenital anomalies was associated with higher mortality (ARR 1.14; 1.01,1.30).

CONCLUSION

These benchmark data reveal that VLBW neonates with CDH have an extremely high mortality. Almost half of the cohort have an additional congenital anomaly which significantly increases the risk of death. This study may be utilized by providers and families to better understand the guarded prognosis of VLBW neonates with CDH.

TYPE OF STUDY

Level II.

LEVEL OF EVIDENCE

Level II.

Reporting interhospital neonatal intensive care transport: international five-step Delphi-based template

OBJECTIVE

To develop a general and internationally applicable template of data variables for reporting interhospital neonatal intensive care transports.

DESIGN

A five-step Delphi method.

SETTING

A group of experts was guided through a formal consensus process using email.

SUBJECTS

12 experts in neonatal intensive care transports from Canada, Denmark, Norway, the UK and the USA. Four women and eight men. The experts were neonatologists, anaesthesiologists, intensive care nurse, anaesthetic nurse, medical leaders, researchers and a parent representative.

MAIN OUTCOME MEASURES

37 data variables were included in the final template.

RESULTS

Consensus was achieved on a template of 37 data variables with definitions. 30 variables to be registered for each transport and 7 for annual registration of the system of the transport service. 11 data variables under the category structure, 20 under process and 6 under outcome.

CONCLUSIONS

We developed a template with a set of data variables to be registered for neonatal intensive care transports. To register the same data will enable larger datasets and comparing services.

Trends in Mortality and Morbidities for Infants Born 24 to 28 Weeks in the US: 1997-2021

BACKGROUND

Mortality and morbidity for very preterm infants in the United States decreased for years. The current study describes recent changes to assess whether the pace of improvement has changed.

METHODS

Vermont Oxford Network members contributed data on infants born at 24 to 28 weeks' gestation from 1997 to 2021. We modeled mortality, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity by year of birth using segmented relative risk regression, reporting risk-adjusted annual percentage changes with 95% confidence intervals overall and by gestational age week.

RESULTS

Analyses of data for 447 396 infants at 888 hospitals identified 3 time point segments for mortality, late onset sepsis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity, and 4 for necrotizing enterocolitis. Mortality decreased from 2005 to 2021, but more slowly since 2012. Late-onset sepsis decreased from 1997 to 2021, but more slowly since 2012. Severe retinopathy of prematurity decreased from 2002 to 2021, but more slowly since 2011. Necrotizing enterocolitis, severe intraventricular hemorrhage, and death or morbidity were stable since 2015. Chronic lung disease has increased since 2012. Trends by gestational age generally mirror those for the overall cohort.

CONCLUSIONS

Improvements in mortality and morbidity have slowed, stalled, or reversed in recent years. We propose a 3-part strategy to regain the pace of improvement: research; quality improvement; and follow through, practicing social as well as technical medicine to improve the health and well-being of infants and families.

Shift-to-shift handoffs in the NICU: lessons learned from a large scale audit

OBJECTIVE

Describe the frequency of best practice behaviors during NICU provider and nursing shift-to-shift handoffs and identify strengths and opportunities for improvement.

STUDY DESIGN

Observational study of handoff characteristics among 40 centers participating in a learning collaborative over a 10-month period. Data were gathered using a handoff audit tool that outlined best practices. Comparisons of behaviors between nurse-to-nurse and provider-to-provider handoffs were made where appropriate.

RESULTS

Overall, 946 audits of shift-to-shift handoffs were analyzed. While many behaviors were demonstrated reliably, differences between nurse-to-nurse vs provider-to-provider handoffs were noted. Families were present for 5.9% of handoffs and, among those who were present, 48.2% participated by contributing information, asking questions, and sharing goals.

CONCLUSIONS

Observation and measurement of handoff behaviors can be used to identify opportunities to improve handoff communication, family participation, and human factors that support handoff. Auditing handoffs is feasible and necessary to improve these critical transitions in infants' care.

Perinatal health effects of herbicides exposures in the United States: the Heartland Study, a Midwestern birth cohort study

BACKGROUND

The objective of the Heartland Study is to address major knowledge gaps concerning the health effects of herbicides on maternal and infant health. To achieve this goal, a two-phased, prospective longitudinal cohort study is being conducted. Phase 1 is designed to evaluate associations between biomarkers of herbicide concentration and pregnancy/childbirth outcomes. Phase 2 is designed to evaluate potential associations between herbicide biomarkers and early childhood neurological development.

METHODS

People (target enrollment of 2,000) who are seeking prenatal care, are ages 18 or older, and are ≤ 20 + 6 weeks gestation will be eligible for recruitment. The Heartland Study will utilize a combination of questionnaire data and biospecimen collections to meet the study objectives. One prenatal urine and buccal sample will be collected per trimester to assess the impact of herbicide concentration levels on pregnancy outcomes. Infant buccal specimens will be collected post-delivery. All questionnaires will be collected by trained study staff and clinic staff will remain blinded to all individual level research data. All data will be stored in a secure REDCap database. Hospitals in the agriculturally intensive states in the Midwestern region will be recruited as study sites. Currently participating clinical sites include Indiana University School of Medicine- affiliated Hospitals in Indianapolis, Indiana; Franciscan Health Center in Indianapolis, Indiana; Gundersen Lutheran Medical Center in La Crosse, Wisconsin, and University of Iowa in Iowa City, Iowa. An anticipated 30% of the total enrollment will be recruited from rural areas to evaluate herbicide concentrations among those pregnant people residing in the rural Midwest. Perinatal outcomes (e.g. birth outcomes, preterm birth, preeclampsia, etc.) will be extracted by trained study teams and analyzed for their relationship to herbicide concentration levels using appropriate multivariable models.

DISCUSSION

Though decades of study have shown that environmental chemicals may have important impacts on the health of parents and infants, there is a paucity of prospective longitudinal data on reproductive impacts of herbicides. The recent, rapid increases in herbicide use across agricultural regions of the United States necessitate further research into the human health effects of these chemicals, particularly in pregnant people. The Heartland Study provides an invaluable opportunity to evaluate health impacts of herbicides during pregnancy and beyond.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov, NCT05492708 with initial registration and release 05 August, 2022.

High inter-rater reliability between physicians and nurses utilising modified Downes' scores in preterm respiratory distress

AIM

To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress.

METHODS

We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4.

RESULTS

Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment.

CONCLUSION

Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.

Horizontally integrated health systems and neonatal intensive care unit (NICU) care for very preterm infants

Hospital care has consolidated rapidly into health systems in the United States. Infants born very preterm are among the most vulnerable pediatric populations, accounting for the majority of infant deaths each year. The pediatric health care delivery system for infants is unique as the birth hospitalization includes 2 patients, the mother and the infant. Further, regionalization goals for infants who are born preterm require care to be provided at neonatal intensive care units (NICUs) with the capacity to treat them. National patient-level data from the Vermont Oxford Network demonstrates that most very preterm infants were born in a horizontally integrated, multi-hospital system (84%), and they tended to remain in the system for their entire hospitalization, including for risk-appropriate NICU care. Half of the infants were cared for in large systems with more than 10 hospitals that were disproportionately cross-market systems. With high transfer rates between hospitals (21%) it will be important to determine the implications of consolidation for the quality of care and patient-centeredness for families. The care for very preterm infants is important from a policy perspective as hospitalized newborn infants account for 21% of hospitalizations in Medicaid each year and 10% of aggregate hospital costs.

Reducing Severe Intraventricular Hemorrhage in Preterm Infants With Improved Care Bundle Adherence

BACKGROUND AND OBJECTIVES

Intraventricular hemorrhage prevention bundles (IVHPBs) can decrease the incidence of intraventricular hemorrhage (IVH) in premature infants. Our center had a high rate of severe (grade III/IV) IVH (9.8%), and poor adherence (24%) to an IVHPB in neonates born ≤1250 g or ≤30 gestational weeks. Improvement initiatives were planned to decrease the incidence of severe IVH by 30% over 2 years.

METHODS

A multidisciplinary team undertook interventions including in-service training, prompt initiation of IVHPB, revision of guidelines, and process standardization. Baseline data were collected from May 2016 to June 2018, with interventions occurring from July 2018 to May 2020. Adherence to the IVHPB was the primary process measure, and incidence of severe IVH the primary outcome measure. Control charts were used to analyze the effect of interventions on outcome. Balancing measures included use of breast milk at discharge, use of mechanical ventilation after initial resuscitation, and bronchopulmonary dysplasia.

RESULTS

A total of 240 infants were assessed preintervention, and 185 during interventions. Adherence to the IVHPB improved from 24% to 88%. During this period, the incidence of severe IVH decreased from 9.8% to 2.4%, a 76% reduction from baseline. A higher adherence score was associated with reduced odds of IVH (odds ratio 0.30; 95% confidence interval 0.10-0.90, P = .03).

CONCLUSIONS

Interventions focused on enhancing adherence to an IVHPB were associated with a reduced rate of severe IVH in high-risk neonates, highlighting the importance of assessing adherence to clinical guidelines.

The Cystic Fibrosis Learning Network: A mixed methods evaluation of program goals, attributes, and impact

Introduction

The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact.

Methods

We performed semi-structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN.

Results

Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI.

Conclusions

Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF.

Lessons learned from linking two complementary databases: the Society of Thoracic Surgeons Congenital Heart Surgery Database and The Vermont Oxford Network Expanded Database

The Society of Thoracic Surgeons Congenital Heart Surgery Database and the Vermont Oxford Network Expanded Database are both large, international, well-established quality and outcomes databases with high penetration in their respective fields of congenital heart surgery and neonatology. Previous studies have shown the value of combining large databases for research purposes. Our aim was to examine the feasibility and value of combining these databases on a local level.We included patients from both databases, cared for at our centre and born from 2015-2020, who had cardiac surgery as neonates or during the birth hospitalisation. We examined the number of patients from each database and overlap between the two. We compared cardiac diagnoses, surgeries performed, pre-operative factors, mortality, and length of stay between databases.Of the 255 patients meeting criteria, 209 (81.9%) had records in both databases. The most common diagnoses in both were hypoplastic left heart syndrome, coarctation, and transposition of the great arteries. Surgical data were incompletely recorded in Vermont Oxford. Gestational age, birth weight, multiple gestation, mortality, and length of stay did not differ significantly between the databases, while the percentage of patients with an extracardiac malformation or genetic syndrome recorded was higher in the Society for Thoracic Surgeons group.Larger-scale matching and comparison studies using these databases are feasible and desirable; for some variables, a record with data from both databases may be more complete. Specific attention should be given to inclusion criteria, reconciling different schema of diagnoses, and formulating questions relying on each database's relative strengths.

Measuring Equity for Quality Improvement

Applying an equity lens to quality improvement (QI) by collecting, reviewing, and using data that measure health disparities helps identify whether QI interventions improve outcomes evenly and equally across the population or have a greater impact in an advantaged or disadvantaged group. Methodological issues inherent in measuring disparities include appropriately selecting data sources; ensuring reliability and validity of equity data; choosing a suitable comparison group; and understanding between-group variation. The integration and utilization of QI techniques to promote equity is dependent on meaningful measurement to develop targeted interventions and provide a means of ongoing real-time assessment.

Texas Hospitals' Perspectives About NICU Performance Measures: A Mixed-Methods Study

BACKGROUND AND OBJECTIVES

This study was conducted to assess Texas hospital leaders' perspectives about neonatal intensive care (NICU) performance measures.

METHODS

We conducted an explanatory mixed-methods study. First, we sent a survey and a copy of the Dartmouth Atlas of Neonatal Intensive Care to clinical and administrative leaders of 150 NICUs in Texas. We asked respondents to review the chapter that reported Texas-specific results and respond to a variety of open and closed-ended questions about the overall usefulness of the report. Second, we conducted semistructured qualitative interviews with a subset of survey respondents to better understand their perspectives.

RESULTS

The survey had a 50% hospital response rate. Respondents generally found the report to be interesting and useful, and 87.7% of all respondents reported being in favor of receiving future reports with their own hospital's data benchmarked against anonymous peers. All of the specific measures in the Atlas were found to be of interest and valuable, with NICU admissions and special care days rating among the most interesting and useful. In the semistructured interviews, respondents expressed that a report with performance data would serve as a mechanism to drive change by identifying opportunities for improvement.

CONCLUSION

Texas hospital NICU leaders are interested in routinely receiving more information about their own NICU's performance anonymously benchmarked against their peers. This would facilitate a greater understanding of a unit's functionality, as well as accelerate clinically appropriate quality improvement initiatives, which together have the potential to deliver better newborn care at lower costs for all Texans.

Software development process of Neotree - a data capture and decision support system to improve newborn healthcare in low-resource settings

The global priority of improving neonatal survival could be tackled through the universal implementation of cost-effective maternal and newborn health interventions. Despite 90% of neonatal deaths occurring in low-resource settings, very few evidence-based digital health interventions exist to assist healthcare professionals in clinical decision-making in these settings. To bridge this gap, Neotree was co-developed through an iterative, user-centered design approach in collaboration with healthcare professionals in the UK, Bangladesh, Malawi, and Zimbabwe. It addresses a broad range of neonatal clinical diagnoses and healthcare indicators as opposed to being limited to specific conditions and follows national and international guidelines for newborn care. This digital health intervention includes a mobile application (app) which is designed to be used by healthcare professionals at the bedside. The app enables real-time data capture and provides education in newborn care and clinical decision support via integrated clinical management algorithms. Comprehensive routine patient data are prospectively collected regarding each newborn, as well as maternal data and blood test results, which are used to inform clinical decision making at the bedside. Data dashboards provide healthcare professionals and hospital management a near real-time overview of patient statistics that can be used for healthcare quality improvement purposes. To enable this workflow, the Neotree web editor allows fine-grained customization of the mobile app. The data pipeline manages data flow from the app to secure databases and then to the dashboard. Implemented in three hospitals in two countries so far, Neotree has captured routine data and supported the care of over 21,000 babies and has been used by over 450 healthcare professionals. All code and documentation are open source, allowing adoption and adaptation by clinicians, researchers, and developers.

Central apnea detection in premature infants using machine learning

BACKGROUND AND OBJECTIVE

Apnea of prematurity is one of the most common diagnosis in neonatal intensive care units. Apneas can be classified as central, obstructive or mixed. According to the current international standards, minimal fluctuations or absence of fluctuations in the chest impedance (CI) suggest a central apnea (CA). However, automatic detection of reduced CI fluctuations leads to a high number of central apnea-suspected events (CASEs), the majority being false alarms. We aim to improve automatic detection of CAs by using machine learning to optimize detection of CAs among CASEs.

METHODS

Using an optimized algorithm for automated detection, all CASEs were detected in a population of 10 premature infants developing late-onset sepsis and 10 age-matched control patients. CASEs were inspected by two clinical experts and annotated as CAs or rejections in two rounds of annotations. A total of 47 features were extracted from the ECG, CI and oxygen saturation signals considering four 30 s-long moving windows, from 30 s before to 15 s after the onset of each CASE, using a moving step size of 5 s. Consecutively, new CA detection models were developed based on logistic regression with elastic net penalty, random forest and support vector machines. Performance was evaluated using both leave-one-patient-out and 10-fold cross-validation considering the mean area under the receiver-operating-characteristic curve (AUROC).

RESULTS

The CA detection model based on logistic regression with elastic net penalty returned the highest mean AUROC when features extracted from all four time windows were included, both using leave-one-patient-out and 10-fold cross-validation (mean AUROC of 0.88 and 0.90, respectively). Feature relevance was found to be the highest for features derived from the CI. A threshold for the false positive rate in the mean receiver-operating-characteristic curve equal to 0.3 led to a high percentage of correct detections for all CAs (78.2%) and even higher for CAs followed by a bradycardia (93.4%) and CAs followed by both a bradycardia and a desaturation (95.2%), which are more critical for the well-being of premature infants.

CONCLUSIONS

Models based on machine learning can lead to improved CA detection with fewer false alarms.

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

Background: Unplanned extubations (UEs) occur frequently in the neonatal intensive care unit (NICU). These events can be associated with serious short-term and long-term morbidities and increased healthcare costs. Most quality improvement (QI) initiatives focused on UE prevention have concentrated efforts within individual NICUs. Methods: We formed a regional QI collaborative involving the four regional perinatal center (RPC) NICUs in upstate New York to reduce UEs. The collaborative promoted shared learning and targeted interventions specific to UE classification at each center. Results: There were 1167 UEs overall during the four-year project. Following implementation of one or more PDSA cycles, the combined UE rate decreased by 32% from 3.7 to 2.5 per 100 ventilator days across the collaborative. A special cause variation was observed for the subtype of UEs involving removed endotracheal tubes (rETTs), but not for dislodged endotracheal tubes (dETTs). The center-specific UE rates varied; only two centers observed significant improvement. Conclusions: A collaborative approach promoted knowledge sharing and fostered an overall improvement, although the individual centers’ successes varied. Frequent communication and shared learning experiences benefited all the participants, but local care practices and varying degrees of QI experience affected each center’s ability to successfully implement potentially better practices to prevent UEs.

Epidemiology and trends in neonatal early onset sepsis in California, 2010-2017

OBJECTIVE

This study evaluated patterns of neonatal early onset sepsis (EOS) disease burden to guide approaches to EOS management.

STUDY DESIGN

Retrospective cohort.

RESULT

A total of 1535 EOS cases were identified amongst 2,872,964 neonates born between 2010 and 2017 at 136 NICUs within the California Perinatal Quality Care Collaborative. EOS incidence was 7.4 per 1000 (E coli: 4.3, GBS: 1.1) in preterm, 0.76 per 1000 (E coli: 0.29, GBS: 0.22) in late preterm, and 0.31 per 1000 (E coli: 0.07, GBS 0.13) in term neonates. There was no significant change in overall incidence, though an increase in E coli (p < 0.001) and decrease in GBS (p = 0.04) incidence were noted. After adjusting for gestational age, there was no difference in the odds of death by pathogen (p > 0.2).

CONCLUSION

The overall EOS incidence remained steady in California NICUs from 2010-2017, though an increase in E coli and decrease in GBS EOS incidence was noted.

The Recipient Epidemiology and Donor Evaluation Study-IV-Pediatric (REDS-IV-P): A research program striving to improve blood donor safety and optimize transfusion outcomes across the lifespan

BACKGROUND

The Recipient Epidemiology and Donor Evaluation Study-IV-Pediatric (REDS-IV-P) is a new iteration of prior National Heart, Lung, and Blood Institute (NHLBI) REDS programs that focus on improving transfusion recipient outcomes across the lifespan as well as the safety and availability of the blood supply.

STUDY DESIGN AND METHODS

The US program includes blood centers and hospitals (22 including 6 free-standing Children's hospitals) in four geographic regions. The Brazilian program has 5 participating hemocenters. A Center for Transfusion Laboratory Studies (CTLS) and a Data Coordinating Center (DCC) support synergistic studies and activities over the 7-year REDS-IV-P program.

RESULTS

The US is building a centralized, vein-to-vein (V2V) database, linking information collected from blood donors, their donations, the resulting manufactured components, and data extracts from hospital electronic medical records of transfused and non-transfused patients. Simultaneously, the Brazilian program is building a donor, donation, and component database. The databases will serve as the backbone for retrospective and prospective observational studies in transfusion epidemiology, transfusion recipient outcomes, blood component quality, and emerging blood safety issues. Special focus will be on preterm infants, patients with sickle cell disease, thalassemia or cancer, and the effect of donor biologic variability and component manufacturing on recipient outcomes. A rapid response capability to emerging safety threats has resulted in timely studies related to Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2).

CONCLUSIONS

The REDS-IV-P program endeavors to improve donor-recipient-linked research with a focus on children and special populations while also maintaining the flexibility to address emerging blood safety issues.

Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa

Background

Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality.

Methods

We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions.

Results

Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109).

Conclusion

This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.

Morbidity and mortality in small for gestational age very preterm infants in a middle-income country

OBJECTIVE

To evaluate the impact of small for gestational age (SGA) on outcomes of very preterm infants at Groote Schuur Hospital (GSH), Cape Town, South Africa.

STUDY DESIGN

Data were obtained from the Vermont Oxford Network (VON) GSH database from 2012 to 2018. The study is a secondary analysis of prospectively collected observational data. Fenton growth charts were used to define SGA as birth weight < 10th centile for gestational age.

RESULTS

Mortality [28.9% vs. 18.5%, adjusted risk ratio (aRR) 2.1, 95% confidence interval (CI) 1.6-2.7], bronchopulmonary dysplasia (BPD; 14% vs. 4.5%, aRR 3.7, 95% CI 2.3-6.1), and late-onset sepsis (LOS; 16.7% vs. 9.6%, aRR 2.3, 95% CI 1.6-3.3) were higher in the SGA than in the non-SGA group.

CONCLUSION

Small for gestational age infants have a higher risk of mortality and morbidity among very preterm infants at GSH. This may be useful for counseling and perinatal management.

Global Health Education and Best Practices for Neonatal-Perinatal Medicine Trainees

Neonatal-perinatal medicine (NPM) trainees are expressing an increased interest in global health. NPM fellowship programs are tasked with ensuring that interested fellows receive appropriate training and mentorship to participate in the global health arena. Global health engagement during fellowship varies based on a trainee's experience level, career goals, and academic interests. Some trainees may seek active learning opportunities through clinical rotations abroad whereas others may desire engagement through research or quality improvement partnerships. To accommodate these varying interests, NPM fellows and training programs may choose to explore institutional partnerships, opportunities through national organizations with global collaborators, or domestic opportunities with high-risk populations. During any global health project, the NPM trainee needs robust mentorship from professionals at both their home institution and their partner international site. Trainees intending to use their global health project to fulfill the American Board of Pediatrics (ABP) scholarly activity requirement must also pay particular attention to selecting a project that is feasible during fellowship and also meets ABP criteria for board eligibility. Above all, NPM fellows and training programs should strive to ensure equitable, sustainable, and mutually beneficial collaborations.

The role of co-production in Learning Health Systems

Background

Co-production of health is defined as ‘the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations’. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services.

Objective

We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications.

Method

First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development.

Result

Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization.

Conclusions

The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.

Trends in Retinopathy of Prematurity Screening and Treatment: 2008-2018

BACKGROUND AND OBJECTIVES

Retinopathy of prematurity (ROP) is the leading avoidable and treatable cause of childhood blindness in the United States. The objective of this study was to evaluate trends of ROP screening, incidence, and treatment in US NICUs over the last 11 years.

METHODS

Using standardized data submitted by NICUs from US Vermont Oxford Network member hospitals from 2008 to 2018 on very low birth weight infants hospitalized at the recommended age for ROP screening, we assessed trends in the proportion of eligible infants who received ROP screening, incidence, and treatment of ROP using logistic regression models.

RESULTS

This study included 381 065 very low birth weight infants at 819 US NICUs participating in Vermont Oxford Network. Over time, more eligible infants received ROP screening (89% in 2008 to 91% in 2018, trend P < .001). Among those screened, overall ROP (stages 1-5, 37% in 2008 to 32% in 2018), severe ROP (stages 3-5, 8% in 2008 to 6% in 2018), and retinal ablation (6% in 2008 to 2% in 2018) declined and anti-vascular endothelial growth factor injections (1% in 2012 to 2% in 2018) increased (all trend P < .001).

CONCLUSIONS

Among US hospitals from 2008 to 2018, the proportion of ROP screening among infants hospitalized at the recommended age increased, less overall and severe ROP were reported, less retinal ablation was performed, and more anti-vascular endothelial growth factor treatment was used. Despite increased ROP screening over time, 10% of infants were not screened, representing an opportunity for improvement in health care delivery.

Population Improvement Bias Observed in Estimates of the Impact of Antenatal Steroids to Outcomes in Preterm Birth

OBJECTIVE

To examine the hypothesis that increasing rates and differential uptake of antenatal steroids would bias estimation of impact of antenatal steroids on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH).

STUDY DESIGN

The study population included infants born between 24 and 28 weeks of gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of antenatal steroid exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period.

RESULTS

The study cohort included 28 252 infants. Antenatal steroid exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to antenatal steroids (12.5%-8.6% for IVH, 11.5%-8.8% for death) but not in those not exposed (20.7%-19.1% and 16.6%-15.5%, respectively). Women not receiving antenatal steroids had greater risk profile (such as no prenatal care) and greater predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without antenatal steroids. In contrast, in women receiving antenatal steroids, observed and adjusted rates for both outcomes decreased (P < .0001).

CONCLUSIONS

As the population's proportion of antenatal steroid use increased, the observed positive effect of antenatal steroids also increased. This apparent increase may be designated as the "population improvement bias."

Quality improvement for NICU graduates: Feasible, relevant, impactful

Continuous quality improvement (CQI) has become a vital component of newborn medicine. Applying core principles - robust measurement, repeated small tests of change, collaborative learning through data sharing - have led to improvements in care quality, safety, and outcomes in the Neonatal Intensive Care Unit (NICU). High-risk infant follow-up programs (HRIF) have historically aided such quality improvement efforts by providing outcomes data about NICU interventions. Though as a discipline, HRIF has not universally embraced CQI for its own practice. In this review, we summarize the history of CQI in neonatology and applications of improvement science in healthcare and describe examples of CQI in HRIF. We identify the need for consensus on what defines 'high-risk' and constitutes meaningful outcomes. Last, we outline four areas for future investment: establishing evidence-based care delivery systems, standardizing outcomes and their measures, embracing a family-centered approach prioritizing parent goals, and developing professional standards of care for HRIF.

Necrotizing Enterocolitis in Neonates With Hyperinsulinemic Hypoglycemia Treated With Diazoxide

The most common cause of persistent hypoglycemia in the neonatal period is hyperinsulinism. Severe, refractory hypoglycemia resulting from hyperinsulinism can lead to significant brain injury and permanent cognitive disability. Diazoxide is the first-line and only US Food and Drug Administration-approved, pharmacologic treatment for refractory hyperinsulinism. In recent years, the use of diazoxide in neonates with persistent hyperinsulinemic hypoglycemia has increased in the United States. Known adverse effects of diazoxide include fluid retention, hypertrichosis, neutropenia, thrombocytopenia, and more recently, pulmonary hypertension. It is currently unknown if diazoxide exposure is associated with an increased risk of necrotizing enterocolitis (NEC) in neonates. We reviewed the cases of 24 patients in a level IV NICU at Massachusetts General Hospital who received diazoxide over 12 years (April 2006-April 2018). All 24 patients received enteral diazoxide for refractory hyperinsulinemic hypoglycemia. A total of 5 patients developed NEC after initiation of diazoxide based on clinical and radiographic findings, corresponding to 20% of infants exposed to diazoxide. This is above our baseline incidence of NEC (1% for all inborn infants and 6% for all inborn very low birth weight infants). More research and monitoring are necessary to characterize the potential risk of NEC associated with the use of diazoxide in the neonatal period.

The unfinished work of neonatal very low birthweight infants quality improvement: Improving outcomes at a continental level in South America

Neonatal mortality rate varies between 4.2 and 18.6 per thousand by country in South America. There is little information regarding the outcomes of very low birth weight infants in the region and mortality rates are extremely variable ranging from 6% to over 50%. This group may represent up to 50-70% of the neonatal mortality and approximately 25-30% of infant mortality. Some initiatives, like the NEOCOSUR Network, have systematically collected and analyzed epidemiological information on VLBW infants' outcomes in the region. Over a 16-year period, survival without major morbidity improved from 37 to 44%. However, mortality has remained almost unchanged at approximately 27%, despite an increase in the implementation of the best available evidence in perinatal practices over time. Implementing quality improvement initiatives in the continent is particularly challenging but represents a great opportunity considering that there is a wide margin for progress in both care and outcomes.

Multilevel social factors and NICU quality of care in California

OBJECTIVE

Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequities via development of a health equity dashboard.

STUDY DESIGN

We examined bivariate associations between NICU patient pool and NICU catchment area characteristics and NICU quality of care with data from a cohort of 15,901 infants from 119 NICUs in California, born 2008-2011.

RESULT

NICUs with higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. NICUs with catchment areas of lower SES, higher composition of minority residents, and more household crowding had lower quality scores.

CONCLUSION

Multilevel social factors impact quality of care in the NICU. Their incorporation into a health equity dashboard can inform providers of their patients' potential resource needs.

Small-Area Variation in the Care of Low-Risk Neonates in Massachusetts and Texas

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.

Evaluating preterm care across Europe using the eNewborn European Network database

BACKGROUND

The inefficiency of recording data repeatedly limits the number of studies conducted. Here we illustrate the wider use of data captured as part of the European eNewborn benchmarking programme.

METHODS

We extracted data on 39,529 live-births from 22 weeks 0 days to 31 weeks 6 days gestational age (GA) or ≤1500 g birth weight. We explored relationships between delivery room care and Apgar scores on mortality and bronchopulmonary dysplasia (BPD) and calculated the time needed for each country to detect a clinically relevant change in these outcomes following a hypothetical intervention.

RESULTS

Early neonatal, neonatal, and in-hospital mortality were 3.90% (95% CI 3.71, 4.09), 6.00% (5.77, 6.24) and 7.57% (7.31, 7.83), respectively. The odds of death were greater with decreasing GA, lower Apgar scores, growth restriction, male sex, multiple birth and no antenatal steroids. Relationships for BPD were similar. The time required for participating countries to achieve 80% power to detect a relevant change in outcomes following a hypothetical intervention in 23-25 weeks' GA infants ranged from 12 years for neonatal mortality and 22 years for BPD compared to 1 year for the whole network.

CONCLUSIONS

The eNewborn platform offers opportunity to drive efficiencies in benchmarking, quality control and research.

Trends, risk factors and outcomes of healthcare-associated infections in a neonatal intensive care unit in Italy during 2013-2017

Background

Healthcare-associated infections (HAIs) occur frequently in intensive care units (NICUs). The aim of this study was to analyze the results of surveillance of HAIs in a III level NICU in Naples, Italy during 2013–2017 and to compare with those obtained during 2006–2010.

Methods

The surveillance included 1265 neonates of all birth weight (BW) classes with > 2 days NICU stay. Infections were defined using standard Centers for Disease Control and Prevention definitions adapted to neonatal pathology.

Results

A total of 125 HAIs were registered during 2013–2017 with a frequency of 9.9% and an incidence density of 3.2 per 1000 patient days. HAIs occurred in all BW classes with a decreasing trend from the lowest to the highest BW classes (p = < 0.001). Central line-associated blood stream infection (CLABSI) was the most frequent infection (69.6%), followed by ventilator associated pneumonia (VAP) (20%), urinary tract infection (UTI) (8.8%) and necrotizing enterocolitis (NEC) (1.6%). Also, CLABSI and VAP incidence density decreased from lower to highest BW classes showing a significant trend (p = 0.007). Most frequent pathogens responsible for CLABSI were: Coagulase-negative staphylococci (CONS) (25.3%), Candida parapsilosis (21.8%), Pseudomonas aeruginosa (5.7), Escherichia coli and Klebsiella pneumoniae (6.8%). No microbiological diagnosis was achieved for 20.7% of CLABSI. Pseudomonas aeruginosa (28%), Stenotrophomonas maltophilia (20%), and CONS (20%) were the most frequent pathogens responsible for VAP. CLABSI incidence density showed no differences between 2006 and 2010 and 2013–2017, while VAP incidence density for the 751–100 g BW class was higher during 2006–2010 than during 2013–2017 (p = 0.006). A higher incidence of the CLABSI caused by Gram positive bacteria (p = 0.002) or by undetermined etiology (p = 0.01) was observed during 2013–2017 than during 2006–2010, while a significant lower incidence of VAP caused by Gram-negative bacteria was found during 2013–2017 than during 2006–2010 (p = 0.007).

Conclusion

HAIs in the NICU developed in all BW classes with a decreasing trend from the lowest to the highest BW classes in both study periods. Differences in the aetiology of CLABSI and VAP were found between the two study periods. This reinforces the importance of HAIs surveillance protocol in the NICU, which monitors microbiological isolates and use of medical devices for all BW classes of neonates.

Variability in the systems of care supporting critical neonatal intensive care unit transitions

OBJECTIVE

Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization.

STUDY DESIGN

Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status.

RESULTS

Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35-65%) for communication, 67% (IQR 33-83%) for teamwork, 50% (IQR 33-61%) for family integration, and 70% (IQR 56-85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit.

CONCLUSIONS

We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.