Variation in management of in-hospital newborn falls: a single-center experience

In-Hospital Newborn Falls and Near Miss Events: A Need to Report

OBJECTIVE

This study aimed to evaluate the clinical characteristics of the neonates who fell in the maternity ward and identify the incidence of near miss events during the immediate postpartum period.

STUDY DESIGN

The study consisted of two steps. The retrospective part included the evaluation of admissions due to the in-hospital newborn fall for 6 years. The prospective part included the assessment of the near miss events (any probability of falling of the newborn; either cosleeping or an incident with a possible consequence of falling of the newborn) in the postpartum clinic (<72 hours after delivery) for a period of 4 weeks. The details of the events and clinical outcomes were recorded. A questionnaire about fatigue was administered to mothers who experienced near miss event.

RESULTS

Seventeen in-hospital newborn falls were recorded: 1.8 to 2.4/10,000 live births. The median age of the neonates when the fall occurred was 22 (16-34) postnatal hours. Fourteen events (82%) occurred between 10 p.m. and 6 a.m. All neonates who experienced a fall were discharged without any known adverse outcomes. Twelve mothers (71%) had experienced a near miss event before. In the prospective arm of the study, 67 out of 804 mothers (8.3%) were found to experience a near miss event (44/1,000 days of postpartum hospitalization). Thirty-two events (49%) occurred in the first postpartum day. Fifty-two events (78%) occurred between 10 p.m. and 6 a.m. Fifty-eight mothers (86%) had no companion. Sixty-three percent of the mothers expressed intense fatigue after delivery.

CONCLUSION

In-hospital newborn fall may occur in the postpartum period, and near miss events should warn clinicians for a probable fall event. The nighttime shift requires more attention regarding the prevention of both the fall and the near miss events. Immediate postpartum mothers are needed to be observed carefully.

KEY POINTS

· In-hospital newborn falls occurred mainly during the night shift.. · Nearly two-third of the mothers whose newborn was fallen experienced a previous near miss event.. · Any near miss event in the hospital was detected in 8.3% of mothers..

Implementing a Maternal Rest Bundle to Prevent Newborn Falls

OBJECTIVE

The specific aims of this quality improvement project were to (a) examine the demographics of newborns who fell and their mothers, (b) implement a maternal rest bundle, and (c) decrease the total number of newborn falls to zero events within 3 months.

DESIGN

We used a quality improvement project with a pre-/postintervention design.

SETTING/LOCAL PROBLEM

Nine newborn falls occurred over 3.5 years on a 40-bed mother-baby inpatient unit at an urban, safety-net, teaching hospital. One fall resulted in a major injury that required an escalation of care and extended length of stay.

PATIENTS

A convenience sample of nine inpatient newborns who fell and their mothers.

INTERVENTION/MEASUREMENTS

We completed a retrospective review of medical records for the sample. We implemented a maternal rest bundle including staff and patient education, a safe sleep pledge contract signed by the woman, an official quiet time, and signage in the unit and each room. We tracked improvement with the outcome measure of the number of newborn falls, process measure of a staff evaluation survey, and balancing measure of a patient experience interview.

RESULTS

No newborn falls have occurred for 2 years (October 2018 to December 2020) since implementing the maternal rest bundle. Staff evaluated that the time of shift for quiet time should stay the same (53.33% [24/45]) and most frequently listed daily tasks as barriers to quiet time. Women reported they found quiet time beneficial (95% [912/960]).

CONCLUSION

The elimination of newborn falls in the hospital unit occurred after we implemented the maternal rest bundle. Sustainability can be attributed to staff support and engagement.

What a Catch: Safety Intervention to Reframe Newborn Falls and Drops

BACKGROUND

Parental fatigue rates after childbirth are high and may be associated with newborn drops that cause injury. Newborn drops and near-misses are potentially underreported due to parental embarrassment, shame, fear of reprisal, or guilt. Although newborn drops are rare, the leaders of mother-baby units need to enhance transparency of risk to assure a culture of safety.

PURPOSE

To describe components and outcomes of the What A Catch program, aimed at preventing newborn drops and addressing near-misses.

METHODS

The What A Catch program was implemented in two hospital mother-baby units. The five components of the program included maintaining a respite nursery, using visual management, positively framing situational communication and actions after a near-miss, safe and appropriate staffing, and celebrating and transparently displaying program successes. Data were collected on near-miss event rates and caregivers and families provided postevent comments.

RESULTS

The perinatal team embraced the program at both sites. Of 9,578 live births over 1 year, 202 near-misses or good catches were documented. Program leaders revise display the board multiple times per week.

CLINICAL IMPLICATIONS

Replication of this program is needed to determine if all five components are necessary to optimize a culture of safety. Future research may determine the scope of risk factors associated with newborn drops and near-misses, so that anticipated risk factors can be mitigated.

An evaluation of the differences in paediatric skeletal trauma between fatal simple short falls and physical abuse blunt impact loads: An international multicentre pilot study

In cases where a deceased child exhibits trauma as a result of a physical abuse blunt impact load, a parent/caregiver may provide a simple short fall (SSF) as the justification for that trauma. The skeletal fractures remain difficult to differentiate between a SSF and physical abuse however, as both are the result of a blunt impact load, and are therefore biomechanically alike, and the rare nature of these fatalities means only anecdotal research has been available to validate such claims. The aim of this pilot study was to investigate if there may be differences in the skeletal fracture patterns and types resulting from SSFs compared with those resulting from physical abuse blunt impacts. Paediatric (<10 years) cases of fatal SSFs (≤1.5 m) and physical abuse were collected from the Victorian Institute of Forensic Medicine (Australia), Institut Médico-Légal de Paris (France), University of Pretoria (South Africa) and Great Ormond Street Hospital (England). For each case the intrinsic and extrinsic variables were recorded from medico-legal reports and skeletal trauma was documented using post-mortem computed tomography scans and/or skeletal surveys. Three SSFs and 18 physical abuse cases were identified. Of the SSF cases, two exhibited fractures; both of which were simple linear neurocranial fractures. Comparatively, 12 of the physical abuse cases exhibited fractures and these were distributed across the skeleton; 58% located only in the skull, 17% only in the post-cranial and 25% located in both. Skull fracture types were single linear, multiple linear and comminuted. This pilot study suggests, anecdotally, there may be differences in the fracture patterns and types between blunt impact loads resulting from a SSF and physical abuse. This data will form the foundation of the Registry of Paediatric Fatal Fractures (RPFF) which, with further multicentre contributions, would allow this finding to be validated.

Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures

AIM

Specific birth-related fractures have been studied; underestimates might be a problem. We aimed to assess all fractures diagnosed as birth-related as well as other neonatal fractures.

METHODS

A population-based study on all infants born in Sweden 1997-2014; data were retrieved from the Swedish Health Registers (10th version of International Classification of Diseases. Outcome measures were birth-related fractures (ICD-10 P-codes) and other neonatal fractures (ICD-10 S-codes).

RESULTS

The overall fracture incidence was 2.9 per 1000 live birth (N = 5336); 92.6% had P-codes and 7.4% (S-codes). Some birth-related fractures were diagnosed beyond the neonatal period. Other neonatal fractures could have been birth-related. Clavicle fracture (88.8%) was associated with adverse maternal and infant anthropometrics and birth complications. The few neonates with rib fractures all had concomitant clavicle fracture. For skull fractures, a minor part was birth-related and most were associated with accidents. Half of the long bone fractures were associated with accidents. Birth-related femur fractures were associated with bone fragility risk factors. Five infants with abuse diagnoses had fractures: skull (4), long bone (2) and rib (1).

CONCLUSION

Birth-related and other neonatal fractures are rarely diagnosed. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures.

Does every newborn need an imaging study after a fall? Case series and literature review

Objective: This study examines the clinical and radiographic information from neonates who sustained a newborn fall (NF) to identify risk factors for the NF and the presence of skull fracture and intracranial bleed. In addition, published articles will be reviewed to provide data to assist in the evidence-based management of mothers after delivery and neonates after NF.Study design: This is a retrospective chart review of neonates who sustained a NF in a level 4 NICU between 2016 and 2019. Results of imaging reports, maternal and neonatal clinical information, physical examination after fall, mode of delivery, time of day of fall, time between delivery and fall, feeding regimen, and maternal in hospital opioid use were recorded. Published reports containing imaging results and the incidence of skull fracture after NF were obtained by searching Pub Med from 2000 to 2019.Main outcome measures: The main outcome of this study is to determine the presence and location of fractures and intracranial hemorrhage after a NF. Secondary outcome includes identification of clinical factors associated with the NF and presence of fractures. Student's t-test was used for statistical comparisons.Results: Twenty-one neonates sustained a NF and 83% were imaged by cranial CT. Skull fractures were identified by CT in 53% of neonates and ∼1/3 of infants had small intracranial hemorrhage. All infants were clinically stable and no neonate required neurosurgical intervention. Most NFs (73%) occurred between midnight and 8 AM and were associated with maternal sleeping while holding the infant.Conclusions: Mothers should have increased monitoring and support especially the days after delivery from 11 PM to 9 AM to assess for maternal exhaustion and to prevent NFs regardless of opioid use. When indicated, low-dose rapid sequence CT scan rather than X-ray is preferred for evaluation of the neonate after a fall.

Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study

AIM

To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury.

METHODS

Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days).

RESULTS

Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died.

CONCLUSIONS

Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.

Newborn Falls in Pennsylvania

Despite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may necessitate additional health care services and cause stress to all involved parties. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 318 events specifically related to newborn falls in the hospital following birth. An increase in the number and rate of serious newborn fall events reported to PA-PSRS was observed compared with a previous analysis by Wallace. Newborn falls were most commonly associated with a caregiver falling asleep (168 events, or 52.8%) and with newborn feeding (72 events, or 22.6%). Strategies to prevent newborn falls in the hospital include focusing efforts on providing support for exhausted parents during the critical time following the birth, offering periods of rest for new parents whenever they are tired, increasing the frequency of rounding when new mothers are breastfeeding, and promoting a midday break in visiting hours.

In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding

In-hospital neonatal falls are increasingly recognized as a postpartum safety risk, with maternal fatigue contributing to these events. Recommendations to support rooming-in may increase success with breastfeeding; however, this practice may also be associated with maternal fatigue. We report a cluster of in-hospital neonatal falls associated with a hospital program to improve breastfeeding, which included rooming-in practices. Metrics related to breastfeeding were prospectively collected by chart audit or patient survey while ongoing efforts to improve breastfeeding occurred (September 2015-August 2017). Falls were identified through the hospital adverse event reporting system from January 2011 to February 2018. Medical records were reviewed to determine factors associated with the falls, including time of event, pain medication administration, hours of life at fall, method of delivery, or other notable factors that may have contributed to the fall event. Three fall events occurred within 1 year of commencing improvement efforts as process and outcome metrics associated with breastfeeding improved. All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am Falls occurred from 38.0 to 75.7 hours after birth. No sedating pain medications were administered within 4 hours of any event. In 2 of 3 cases, mothers experienced notable ongoing social stressors. Rooming-in was the most significant change involved in our health care delivery during the programmatic effort to improve breastfeeding. Monitoring for in-hospital neonatal falls may be needed during projects aimed at improving breastfeeding, particularly if rooming-in practices are involved.

Consensus statement on abusive head trauma in infants and young children

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.