A Novel Mutation in Junctional Plakoglobin Causing Lethal Congenital Epidermolysis Bullosa.

We report a case of neonatal generalized erythema and epidermolysis resulting from a novel mutation in the junctional plakoglobin gene causing truncation of the plakoglobin protein. Expedited genetic testing enabled diagnosis while the patient was in the neonatal intensive care unit, providing valuable information for the clinicians and family.

Use of an airway bundle to reduce unplanned extubations in a neonatal intensive care unit.

BACKGROUND: Following the opening of an infant cardiac neonatal intensive care unit, our aim was to determine a baseline UE rate and implement initiatives to target a goal less than 0.5 UEs/100 ventilator days. METHODS: We utilized the Model for Improvement. Key stakeholders included neonatal providers, nurses, and respiratory therapists. We focused on the creation of an airway bundle that addressed securement methods, communication and education. RESULTS: From October 2017 to January 2018, our baseline UE rate was 0.92 UEs/100 ventilator days. Subsequent to the implementation of an airway bundle with high compliance, we observed a significant change in the centerline (0.45 to 0.02 UEs/100 ventilator days) during the spring of 2021, followed by a period of 480 days with no UEs. CONCLUSION: In a unit where UEs were infrequent events, high compliance with an airway bundle led to a significantly sustained decrease in our UE rates.

Measuring practice preference variation for quality improvement in neonatal respiratory care.

OBJECTIVES: The authors sought to measure and compare practice preference variation in neonatal respiratory care within and between neonatal intensive care units (NICUs) using the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool (NSIGHT). STUDY DESIGN: Eleven NICUs completed the NSIGHT between 2019 and 2021. Net preference was measured by mean response; agreement was ranked by standard distribution of response values. Heat maps showed comparisons between NICUs and disciplines. RESULTS: NICUs and individuals agreed most often on use of pressure support with mandatory ventilation and on use of non-invasive positive pressure ventilation for apnea. High preference variation surrounded decisions for invasive ventilation versus continuous positive airway pressure for extremely low birth weight infants. Preference difference was most frequent between neonatologists and nurses. CONCLUSIONS: Patterns of practice preference variation in neonatal respiratory care are specific to clinical scenario. Measuring preference variation may inform psychology of change and strengthen quality improvement efforts.

Next Steps for Health Care-Associated Infections in the Neonatal Intensive Care Unit.

We discuss the burden of health care-associated infections (HAIs) in the neonatal ICU and the role of quality improvement (QI) in infection prevention and control. We examine specific QI opportunities and approaches to prevent HAIs caused by Staphylococcus aureus , multidrug-resistant gram-negative pathogens, Candida species, and respiratory viruses, and to prevent central line-associated bloodstream infections (CLABSIs) and surgical site infections. We explore the emerging recognition that many hospital-onset bacteremia episodes are not CLABSIs. Finally, we describe the core tenets of QI, including engagement with multidisciplinary teams and families, data transparency, accountability, and the impact of larger collaborative efforts to reduce HAIs.

Improving Postpartum Depression Screening in the NICU: Partnering with Students to Improve Outreach.

Infants born to mothers with postpartum depression (PPD) are at risk for adverse developmental outcomes. Mothers of premature infants are 40% more likely to develop PPD when compared with the general population. Current published studies on implementing PPD screening in the Neonatal Intensive Care Unit (NICU) do not comply with the American Academy of Pediatrics (AAP) guideline, which recommends multiple screening points in the first year postpartum and includes partner screening. Our team implemented PPD screening that follows the AAP guideline and includes partner screening for all parents of infants admitted to our NICU beyond 2 weeks of age. Methods: The Institute For Healthcare Improvement Model for Improvement was the framework for this project. Our initial intervention bundle included provider education, standardized identification of parents to be screened, and bedside screening performed by the nurse with social work follow-up. This intervention transitioned to weekly screening by phone by health professional students and the use of the electronic medical record for notification of team members of screening results. Results: Under the current process, 53% of qualifying parents are screened appropriately. Of the parents screened, 23% had a positive Patient Health Questionnaire-9 requiring referral for mental health services. Conclusions: Implementing a PPD screening program that complies with the AAP standard is feasible within a Level 4 NICU. Partnering with health professional students greatly improved our ability to screen parents consistently. Given the high percentage of parents with PPD uncovered with appropriate screening, this type of program has a clear need within the NICU.

Epidemiology, risk factors, and applicability of CDC definitions for healthcare-associated bloodstream infections at a level IV neonatal ICU.

OBJECTIVES: We studied the epidemiology of primary bloodstream infections (BSIs), secondary BSIs, and central line-associated BSIs (CLABSIs) and applicability of CDC definitions for primary sources of infection causing secondary BSIs in patients in the neonatal ICU. STUDY DESIGN: We classified healthcare-associated BSIs (HABSIs) as primary BSIs, secondary BSIs, and CLABSIs using CDC surveillance definitions and determined their overall incidence and incidence among different gestational age strata. We assessed the applicability of CDC definitions for infection sources causing secondary BSIs. RESULTS: From 2010 to 2019, 141 (32.7%), 202 (46.9%), and 88 (20.4%) HABSIs were classified as primary BSIs, secondary BSIs, and CLABSIs, respectively; all declined during the study period (all p < 0.001). Gestational age <28 weeks was associated with increased incidence of all HABSI types. CDC criteria for site-specific primary sources were met in 137/202 (68%) secondary BSIs. CONCLUSIONS: Primary and secondary BSIs were more common than CLABSIs and should be prioritized for prevention.

Atretic Coronary Artery Ostia in a Full-Term Infant with Early Postnatal Demise.

Congenital coronary artery anomalies are extremely rare causes of early cardiac failure. Several cardiac lesions are associated with coronary anomalies such as pulmonary atresia with intact ventricular septum. Isolated coronary ostial atresia is extremely rare and described in only a few published case reports. To our knowledge, there were two reports of bilateral coronary ostial atresia in which the entire coronary arterial system originated from the right ventricle without other intracardiac defects. We present a case of a full-term infant who presented with severely depressed biventricular function secondary to bilateral coronary ostial atresia.

Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities.

Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.

Congenital Measles in a Premature 25-week Gestation Infant.

We describe a premature infant with congenital measles. Laboratory testing confirmed measles in the mother (polymerase chain reaction- and IgM-positive) and congenital measles in the infant (polymerase chain reaction-positive, culture-positive and IgM-positive). The infant never developed a rash, pneumonia, or neurologic complications. This case supports using compatible laboratory findings to diagnose congenital measles in infants without clinical manifestations of measles.

Improving Neonatal Follow-up: A Quality Improvement Study Analyzing In-hospital Interventions and Long-term Show Rates.

Neonatal follow-up (NFU) clinics play an essential role in the multidisciplinary care of preterm patients. Despite the inherent value of NFU clinics, many clinical programs report poor compliance with follow-up visits. Preterm infants followed with difficulty in the long-term have higher rates of disability and lower IQ scores, even after adjustment of significant perinatal and sociodemographic variables. This quality improvement study aimed to improve the show rate for preterm infants from 60% to 80% at the initial 6-month adjusted age visit by implementing a multilevel education bundle. METHODS: Participants included neonatal intensive care unit (NICU) physicians, physician extenders, registered nurses, and parents of preterm patients admitted to the NICU who qualified for NFU. Our 75-bed NICU is the regional perinatal center within an urban free-standing children's hospital. Our bundle included NICU provider education, discharge planning, and parent education. A tracking system was developed to identify qualifying patients to streamline workflow. RESULTS: The monthly first visit show rate improved from 60% to 76% during the intervention period. Seventy-five percent of families who received parent education presented for their initial visit, compared to 51% of families who did not receive parent education. In anonymous surveys of families who presented for their initial visits, 95% indicated that bedside education played the most important role in appointment attendance. Interdisciplinary rounds are crucial for reaching all families before discharge. CONCLUSION: Implementing a multidimensional in-hospital education bundle and tracking system is feasible and can improve NFU clinic show rates, but may require dedicated personnel for sustainability.