Improving Outcomes through a Neonatal Abstinence Syndrome Collaborative in Maryland

OBJECTIVES

 A statewide Maryland Perinatal Neonatal Quality Collaborative, facilitated by the Maryland Patient Safety Center (MPSC), identified the three specific, measurable, attainable, relevant, and time-limited (SMART) aims to improve outcomes of neonatal abstinence syndrome (NAS) care as follows: (1) to reduce hospital length of stay (LOS), (2) to reduce interhospital transfers, and (3) to reduce 30-day readmission rates of infants with NAS.

STUDY DESIGN

 The Maryland collaborative developed a bundle of best practices for care of infants with NAS. MPSC partnered with Vermont Oxford Network (VON) to utilize the VON NAS toolkit and provided its standardized NAS educational curriculum to address the three objectives for participating birthing hospitals. Efforts began in quarter 4 (Q4) of 2016 and continued for 2 years. Thirty-one of Maryland's 32 delivery hospitals (97%) participated in the 2-year collaborative. Additionally, one specialty pediatric hospital with an NAS unit participated in the group learnings. Participating facilities implemented components of the MPSC NAS bundle and provided their staff caring for infants with NAS and their mothers access to the VON standardized educational curriculum. MPSC partnered with VON to conduct two audits of implementation of policies and procedures in Q1 of 2016 and Q3 of 2018. The Maryland Department of Health supplied quarterly aggregate hospital information on LOS, interhospital transfers, and 30-day readmissions of infants with a discharge diagnosis of the International Classification of Disease, 10th Revision (ICD-10), P96.1.

RESULTS

 Among term infants with NAS with total hospital stay greater than 5 days, we observed a nonsignificant reduction in both mean and median LOS of 1.5 days. In this same group, the rate of interhospital transfers fell significantly from 20.1% in 2016 to 13.8 and 11.0% in 2017 and 2018, respectively.

CONCLUSION

 The best practice bundle created by the Maryland collaborative was associated with a reduction in the percentage of infants with NAS who required interhospital transfer, thereby reducing family disruption.

KEY POINTS

· A state NAS collaborative engaged 97% of delivery hospitals in education and standardization of care.. · The collaborative witnessed a 1.5-day decrease in length of stay, similar to that observed in other state collaboratives.. · The unique outcome of our collaborative was a 50% decrease in the rate of interhospital transfer..

Spreading routine serious illness conversations at a single cancer center using a multidisciplinary and patient-family advisory approach

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Background: ASCO Guidelines recommend oncologists conduct serious illness conservations (SIC) for all patients with advanced cancer. We describe the spreading of a multidisciplinary and patient-family advisor (PFA) quality improvement (QI) initiative to conduct routine SIC at a NCI-designated comprehensive cancer center. Methods: This single center study describes the second phase of a learning health system initiative to conduct routine SIC for all seriously ill patients with cancer. Prior work completed included defining patient eligibility (e.g. two-year surprise question), and deploying a SIC template in the electronic health record (EHR) to capture SIC in a centralized location. Phase II can be categorized into three steps: a) increasing communication coach and PFA capacity; b) refining EHR tools to automate tracking and reporting of outcomes; and c) adoption of the Model for Improvement as the QI methodology to guide testing and implementation. For the first three months, each team engaged in preparatory work including: process mapping, key driver diagram development, and SIC Guide training. In the last six months, each team met weekly to set their own team goals, conducted iterative PDSAs, and reviewed run charts of their performance. Patient-level data on SIC documentation was collected through automated EHR tools and provided to the teams on a weekly basis. Results: Over nine months (3/1/2021 to 12/31/21), four teams screened 510 patients with cancer, identified 272 (53%) patients as eligible for SIC, and 178 (65%) of those eligible had a documented SIC from a baseline of 0%. The breakdown of this combined SIC patient count by clinician author is as follows: team A 40 (22%); team B 45 (25%); team C 9 (5%); team D 14 (8%) and specialty palliative care 70 (39%). Each team set modest, initial SIC documentation goals (range 5-15%), and attainment of first SIC documentation goal varied (range 2 to 4 months). We retained all clinician team members during the study period, but 2 out of 3 PFAs left by study period end. Noted challenges with PFA recruitment and retention included: lengthy recruitment, integration into clinical teams, and resistance to change by teams. Conclusions: The multidisciplinary approach, inclusive of specialty palliative care, increased SIC documentation. PFA involvement, as implemented, met with challenges and yielded mixed results. Additional follow-up will be required to assess if gains can be sustained and/or increased.

Interdisciplinary Approach and Patient/Family Partners to Improve Serious Illness Conversations in Outpatient Oncology

PURPOSE:

We aimed to increase Serious Illness Conversations (SIC) from a baseline of, at or near, zero to 25% of eligible patients by December 31, 2020.

METHODS:

We assembled an interdisciplinary team inclusive of a family partner and used the Model for Improvement as our quality improvement framework. The team developed a SMART Aim, key driver diagram, and SIC workflow. Standardized screening for SIC eligibility was implemented using the 2-year surprise question. Team members were trained in SIC communication skills by a trained facilitator and received ongoing coaching in quality improvement. We performed Plan-Do-Study-Act cycles and used audit-feedback data in weekly team meetings to inform iterative Plan-Do-Study-Act cycles. The primary outcome was the percent of eligible patients with documented SIC.

RESULTS:

Over 18 months, three clinics identified 63 eligible patients; of these, 32 (51%) were diagnosed with head and neck cancer and 31 (49%) with sarcoma. The SIC increased from a baseline near zero to 43 of 63 (70%) patients demonstrating three shifts in the median (95% CI). Conversations were interdisciplinary with 25 (57%) by oncology MD, six (14%) by advanced practice registered nurse, and 13 (30%) by specialty palliative care. We targeted four key drivers: (1) standardized work, (2) engaged interdisciplinary team, (3) engaged patients and families, and (4) system-level support.

CONCLUSION:

Our approach was successful in its documentation of end points and required resource investment (training and time) to embed into team workflows. Future work will evaluate scaling the approach across multiple clinics, the patient experience, and outcomes of care associated with oncology clinician–led SIC.

Prioritizing Measures that Matter Within a Person-Centered Oncology Learning Health System

Background

Despite progress in developing learning health systems (LHS) and associated metrics of success, a gap remains in identifying measures to guide the implementation and assessment of the impact of an oncology LHS. Our aim was to identify a balanced set of measures to guide a person-centered oncology LHS.

Methods

A modified Delphi process and clinical value compass framework were used to prioritize measures for tracking LHS performance. A multidisciplinary group of 77 stakeholders, including people with cancer and family members, participated in 3 rounds of online voting followed by 50-minute discussions. Participants rated metrics on perceived importance to the LHS and discussed priorities.

Results

Voting was completed by 94% of participants and prioritized 22 measures within 8 domains. Patient and caregiver factors included clinical health (Eastern Cooperative Oncology Group Performance Status, survival by cancer type and stage), functional health and quality of life (Patient Reported Outcomes Measurement Information System [PROMIS] Global-10, Distress Thermometer, Modified Caregiver Strain Index), experience of care (advance care planning, collaboRATE, PROMIS Self-Efficacy Scale, access to care, experience of care, end-of-life quality measures), and cost and resource use (avoidance and delay in accessing care and medications, financial hardship, total cost of care). Contextual factors included team well-being (Well-being Index; voluntary staff turnover); learning culture (Improvement Readiness, compliance with Commission on Cancer quality of care measures); scholarly engagement and productivity (institutional commitment and support for research, academic productivity index); and diversity, equity, inclusion, and belonging (screening and follow-up for social determinants of health, inclusivity of staff and patients).

Conclusions

The person-centered LHS value compass provides a balanced set of measures that oncology practices can use to monitor and evaluate improvement across multiple domains.

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice.

OBJECTIVES

To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials.

SELECTION CRITERIA

We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication.

MAIN RESULTS

We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.

Using NHSN's Antimicrobial Use Option to Monitor and Improve Antibiotic Stewardship in Neonates

BACKGROUND

The Antimicrobial Use (AU) Option of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) is a surveillance resource that can provide actionable data for antibiotic stewardship programs. Such data are used to enable measurements of AU across hospitals and before, during, and after stewardship interventions.

METHODS

We used monthly AU data and annual facility survey data submitted to the NHSN to describe hospitals and neonatal patient care locations reporting to the AU Option in 2017, examine frequencies of most commonly reported agents, and analyze variability in AU rates across hospitals and levels of care. We used results from these analyses in a collaborative project with Vermont Oxford Network to develop neonatal-specific Standardized Antimicrobial Administration Ratio (SAAR) agent categories and neonatal-specific NHSN Annual Hospital Survey questions.

RESULTS

As of April 1, 2018, 351 US hospitals had submitted data to the AU Option from at least 1 neonatal unit. In 2017, ampicillin and gentamicin were the most frequently reported antimicrobial agents. On average, total rates of AU were highest in level III NICUs, followed by special care nurseries, level II-III NICUs, and well newborn nurseries. Seven antimicrobial categories for neonatal SAARs were created, and 6 annual hospital survey questions were developed.

CONCLUSIONS

A small but growing percentage of US hospitals have submitted AU data from neonatal patient care locations to NHSN, enabling the use of AU data aggregated by NHSN as benchmarks for neonatal antimicrobial stewardship programs and further development of the SAAR summary measure for neonatal AU.

A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns

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.

Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations

: media-1vid110.1542/5839992664001PEDS-VA_2017-4322Video Abstract BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs), while the Choosing Wisely for Newborn Medicine Top 5 list identified antibiotic therapy as an area of overuse. We identify the baseline prevalence and makeup of newborn-specific ASPs and assess the variability of NICU antibiotic use rates (AURs).

METHODS

Data were collected using a cross-sectional audit of Vermont Oxford Network members in February 2016. Unit measures were derived from the 7 domains of the CDC's Core Elements of Hospital ASPs, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Patient-level measures included patient demographics, indications, and reasons for therapy. An AUR, defined as the number of infants who are on antibiotic therapy divided by the census that day, was calculated for each unit.

RESULTS

Overall, 143 centers completed structured self-assessments. No center addressed all 7 core elements. Of the 7, only accountability (55%) and drug expertise (62%) had compliance >50%. Centers audited 4127 infants for current antibiotic exposure. There were 725 infants who received antibiotics, for a hospital median AUR of 17% (interquartile range 10%-26%). Of the 412 patients on >48 hours of antibiotics, only 26% (107 out of 412) had positive culture results.

CONCLUSIONS

Significant gaps exist between CDC recommendations to improve antibiotic use and antibiotic practices during the newborn period. There is wide variation in point prevalence AURs. Three-quarters of infants who received antibiotics for >48 hours did not have infections proven by using cultures.

Variation in Performance of Neonatal Intensive Care Units in the United States

IMPORTANCE

Hospitals use rates from the best quartile or decile as benchmarks for quality improvement aims, but to what extent these aims are achievable is uncertain.

OBJECTIVE

To determine the proportion of neonatal intensive care units (NICUs) in 2014 that achieved rates for death and major morbidities as low as the shrunken adjusted rates from the best quartile and decile in 2005 and the time it took to achieve those rates.

DESIGN, SETTING, AND PARTICIPANTS

A total of 408 164 infants with a birth weight of 501 to 1500 g born from January 1, 2005, to December 31, 2014, and cared for at 756 Vermont Oxford Network member NICUs in the United States were evaluated. Logistic regression models with empirical Bayes factors were used to estimate standardized morbidity ratios for each NICU. Each ratio was multiplied by the overall network rate to calculate the 10th, 25th, 50th, 75th, and 90th percentiles of the shrunken adjusted rates for each year. The proportion in 2014 that achieved the 10th and 25th percentile rates from 2005 and the number of years it took for 75% of NICUs to achieve the 2005 rates from the best quartile were estimated.

MAIN OUTCOMES AND MEASURES

Death prior to hospital discharge, infection more than 3 days after birth, severe retinopathy of prematurity, severe intraventricular hemorrhage, necrotizing enterocolitis, and chronic lung disease among infants less than 33 weeks' gestational age at birth.

RESULTS

Of the 756 hospitals, 695 provided data for 2014. The mean unadjusted infant-level rate of death before hospital discharge decreased from 14.0% in 2005 to 10.9% in 2014. In 2014, 689 of 695 NICUs (99.1%; 95% CI, 97.4%-100.0%) achieved the 2005 shrunken adjusted rates from the best quartile for death prior to discharge, 678 of 695 (97.6%; 95% CI, 95.8%-99.6%) for late-onset infection, 558 of 681 (81.9%; 95% CI, 77.2%-86.6%) for severe retinopathy of prematurity, 611 of 693 (88.2%; 95% CI, 81.7%-97.0%) for severe intraventricular hemorrhage, 529 of 696 (76.0%; 95% CI, 71.8%-81.2%) for necrotizing enterocolitis, and 286 of 693 (41.3%; 95% CI, 36.1%-45.6%) for chronic lung disease. It took 3 years before 445 NICUs (75.0%) achieved the 2005 shrunken adjusted rate from the best quartile for death prior to discharge, 5 years to achieve the rate from the best quartile for late-onset infection, 6 years to achieve the rate from the best quartile for severe retinopathy of prematurity and severe intraventricular hemorrhage, and 8 years to achieve the rate from the best quartile for necrotizing enterocolitis.

CONCLUSIONS AND RELEVANCE

From 2005 to 2014, rates of death prior to discharge and serious morbidities decreased among the NICUs in this study. Within 8 years, 75% of NICUs achieved rates of performance from the best quartile of the 2005 benchmark for all outcomes except chronic lung disease. These findings provide a novel way to quantify the magnitude and pace of improvement in neonatology.

Improving Care for Neonatal Abstinence Syndrome

BACKGROUND AND OBJECTIVE

Care for neonatal abstinence syndrome (NAS), a postnatal drug withdrawal syndrome, remains variable. We designed and implemented a multicenter quality improvement collaborative for infants with NAS. Our objective was to determine if the collaborative was effective in standardizing hospital policies and improving patient outcomes.

METHODS

From 2012 to 2014, data were collected through serial cross-sectional audits of participating centers. Hospitals assessed institutional policies and patient-level data for infants with NAS requiring pharmacotherapy, including length of pharmacologic treatment and length of hospital stay (LOS). Models were fit, clustered according to hospital, to evaluate changes in patient outcomes over time.

RESULTS

Among 199 participating centers, the mean number of NAS-focused guidelines increased from 3.7 to 5.1 of a possible 6 (P < .001), with improvements noted in all measured domains. Among infants cared for at participating centers, decreases occurred in median (interquartile range) length of pharmacologic treatment, from 16 days (10 to 27 days) to 15 days (10 to 24 days; P = .02), and LOS from 21 days (14 to 33 days) to 19 days (15 to 28 days; P = .002). In addition, there was a statistically significant decrease in the proportion of infants discharged on medication for NAS, from 39.7% to 26.5% (P = .02). After adjusting for potential confounders, standardized NAS scoring process was associated with shorter LOS (-3.3 days,95% confidence interval, -4.9 to -1.4).

CONCLUSIONS

Involvement in a multicenter, multistate quality improvement collaborative focused on infants requiring pharmacologic treatment for NAS was associated with increases in standardizing hospital patient care policies and decreases in health care utilization.

Completeness of main outcomes across randomized trials in entire discipline: survey of chronic lung disease outcomes in preterm infants

OBJECTIVE

To map the availability of information on a major clinical outcome--chronic lung disease--across the randomized controlled trials in systematic reviews of an entire specialty, specifically interventions in preterm infants.

DESIGN

Survey of systematic reviews.

DATA SOURCES

Cochrane Database of Systematic Reviews.

STUDY SELECTION AND METHODS

All Cochrane systematic reviews (as of November 2013) that had evaluated interventions in preterm infants. We identified how many of those systematic reviews had looked for information on chronic lung disease, how many reported on chronic lung disease, and how many of the randomized controlled trials included in the systematic reviews reported on chronic lung disease. We also randomly selected 10 systematic reviews that did not report on chronic lung disease and 10 that reported on any such outcomes and identified whether any information on chronic lung disease appeared in the primary reports of the randomized controlled trials but not in the systematic reviews.

MAIN OUTCOME MEASURES

Whether availability of chronic lung disease outcomes differed by type of population and intervention and whether additional non-extracted data might have been available in trial reports.

RESULTS

174 systematic reviews with 1041 trials exclusively concerned preterm infants. Of those, 105 reviews looked for chronic lung disease outcomes, and 79 reported on these outcomes. Of the 1041 included trials, 202 reported on chronic lung disease at 28 days and 200 at 36 weeks postmenstrual; 320 reported on chronic lung disease with any definition. The proportion of systematic reviews that looked for or reported on chronic lung disease and the proportion of trials that reported on chronic lung disease was larger in preterm infants with respiratory distress or support than others (P<0.001) and differed across interventions (P<0.001). Even for trials on children with ventilation interventions, only 56% (48/86) reported on chronic lung disease. In the random sample, 45 of 84 trials (54%) had no outcomes on chronic lung disease in the systematic reviews, and only 9/45 (20%) had such information in the primary trial reports.

CONCLUSIONS

Most trials included in systematic reviews of interventions on preterm infants are missing information on one of the most common serious outcomes in this population. Use of standardized clinical outcomes that would have to be collected and reported by default in all trials in a given specialty should be considered.

A survey of the current neonatal nurse practitioner workforce

OBJECTIVE

To assess the adequacy and characteristics of the US neonatal nurse practitioner (NNP) workforce.

STUDY DESIGN

Internet-based survey of 271 NNP conference participants. Data were analyzed using SPSS (version 14; Chicago, IL, USA); descriptive statistics, including chi(2)-tests of independence, were performed (alpha=0.05).

RESULT

Respondents were primarily masters-prepared females, working in level III newborn intensive care units. Unfilled NNP positions were common; time estimated to fill positions averaged 6-18 months. One-third of the respondents' practice settings had substituted other providers. The mean NNP salary was $86,700. Motivators for becoming an NNP included autonomy and increased knowledge; challenges identified were overload of responsibilities and the NNP shortage.

CONCLUSION

This study provides the first data about NNP education and workforce characteristics in the United States. The use of an internet-based data collection process facilitated the rapid response of a large sample of NNPs and demonstrated the effectiveness of this method of data collection. The results of this survey suggest a mismatch between the need for NNPs the available NNP workforce supply.

The AWHONN Near-Term Infant Initiative: A Conceptual Framework for Optimizing Health for Near-Term Infants

In June 2005, the Association of Women's Health, Obstetric and Neonatal Nurses launched a multiyear initiative to address the unique physiologic and developmental needs of near-term infants (NTIs) defined as those born between 34 and 37 weeks post-menstrual age. The Optimizing Care for the Near-Term Infant Conceptual Model integrates the concepts of neonatal physiologic functional status, nursing care practices, care environment, and the essential role of the family both in the hospital and beyond. The elements of the model will serve to guide program and resource development within the Near-Term Infant Initiative. Goals of the initiative are to raise awareness of the NTI population's unique needs, emphasize the need for research, encourage development and adoption of evidence-based guidelines to promote safe care, and provide resources that assist nurses and other health care professionals in risk-based assessment of NTIs.

Evaluation of the neonatal nurse practitioner role: the next frontier

The neonatal nurse practitioner (NNP) role at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, has been in place since 1989. As part of the professional growth and development of this NNP group, the necessity for a useful evaluation instrument emerged. This instrument needed to be congruent with the job description, practice philosophy, and strong commitment to peer review. The literature search and institutional survey failed to uncover an acceptable option, so an evaluation instrument was developed, tested, and refined. This instrument captures the diverse scope of NNP practice and incorporates a continuum of novice to expert competencies based on the work of Patricia Benner. This evaluation mechanism has had a profound effect on our group, encouraging the development of a shared vision of the NNP role and stimulating professional growth.