Post-discharge outcomes of failed car seat tolerance screens: A case-control and follow-up study

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm.

STUDY DESIGN

Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS. The primary outcome was a composite rate of death, 911 call-triggered transports, or readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening event, or brief resolved unexplained events within 30 days of discharge. Outcomes of infants born in the periods of CSTS and after discontinuation were compared.

RESULTS

Twelve of 14 hospitals initially utilized CSTS and contributed patients to the CSTS period; 71.4% of neonatal intensive care unit (NICU) patients and 26.9% of non-NICU infants were screened. All hospitals participated in the discontinuation period; 0.1% was screened. Rates of the unadjusted primary outcome were 1.02% in infants in the CSTS period (n = 21 122) and 1.06% after discontinuation (n = 20 142) (P = .76). The aOR (95% CI) was 0.95 (0.75, 1.19). Statistically insignificant differences between periods were observed in components of the primary outcome, gestational age strata, NICU admission status groups, and other secondary analyses.

CONCLUSIONS

Discontinuation of CSTS in a large integrated health care network was not associated with a change in 30-day postdischarge adverse outcomes. CSTS's value as a standard predischarge assessment deserves further evaluation.

The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns.

METHODS

This observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail.

RESULTS

Of 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51).

CONCLUSIONS

Hospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.

Getting Babies Safely Home: A Retrospective Chart Review of Car Safety Seat Tolerance Screening Outcomes

BACKGROUND

The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born <37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology.

DESIGN/METHODS

We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes.

RESULTS

Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS.

CONCLUSION

We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure and define practical criteria for CSTS recommendations.

A National Survey of Car Seat Tolerance Screening Protocols in Neonatal Intensive Care Units

OBJECTIVE

A predischarge car seat tolerance screen (CSTS) is currently recommended for all infants born prematurely in the United States to monitor for adverse cardiorespiratory events while in the semi-upright car seat. However, specific guidelines for failure criteria, timing of testing, and follow-up of failed CSTS do not exist. Our objective was to perform a national survey of neonatal intensive care units (NICUs) in order to identify common features and variation in CSTS protocols.

METHODS

We surveyed Level II-IV NICUs representing all 50 states to determine whether each performed CSTS, inclusion and failure criteria, timing of CSTS prior to discharge and in relation to feeds, follow-up of initial and subsequent CSTS failures, use of car beds, and outpatient referrals after failed CSTS.

RESULTS

Of the 199 NICUs surveyed, 96.5% perform a CSTS. The most common failure saturation cutoff was <90%, but values ranged from <80% to <92%. The most common failure bradycardia definition was <80 bpm but ranged from <70 bpm to <100 bpm. After an initial failed CSTS, 86.5% will perform a repeat CSTS after a period of observation that ranged from <12 hours to 3 or more days. When discharging in a car bed, 20% do not routinely perform a car bed test, and >70% refer only to the primary care physician for car bed follow-up.

CONCLUSIONS

Despite widespread implementation, significant variation exists in CSTS protocols and follow-up after NICU discharge. A stronger evidence base is needed to define appropriate testing parameters and inform more explicit guidelines.