Decreasing hypothermia during delivery room stabilization of preterm neonates.

BACKGROUND AND OBJECTIVE: Hypothermia during delivery room stabilization of very low birth weight (VLBW) newborns is independently associated with mortality, yet it occurred frequently both in collaborative networks and at our institution. We aimed to attain admission temperatures in the target range of 36 °C to 38 °C in ≥ 90% of inborn VLBW neonates through implementation of a thermoregulation bundle. METHODS: This quality improvement project extended over 60 consecutive months, using sequential plan-do-check-act cycles. During the 14 baseline months, we standardized temperature measurements and developed the Operation Toasty Tot thermoregulation bundle (including consistent head and torso wrapping with plastic, warmed blankets, and a closed stabilization room). We introduced this bundle in month 15 and added servo-controlled, battery-powered radiant warmers for stabilization and transfer in month 21. We provided results and feedback to staff throughout, using simple graphics and control charts. RESULTS: There were 164 inborn VLBW babies before and 477 after bundle implementation. Introduction and optimization of the bundle decreased the incidence of hypothermia, with rates remaining in the target range for the last 13 study months. The incidence of temperatures >38 °C was ~ 2% both before and after bundle implementation. CONCLUSIONS: This thermoregulation bundle resulted in sustained improvement in normothermia rates during delivery room stabilization of VLBW newborns. Our benchmark goal of ≥ 90% admission temperatures above 36 °C was met without increasing hyperthermia rates. Because these results compare favorably with those of recently published research or improvement collaboratives, we aim to maintain our performance through routine surveillance of admission temperatures.

Use of chemical warming packs during delivery room resuscitation is associated with decreased rates of hypothermia in very low-birth-weight neonates.

BACKGROUND: : Hypothermia is an independent contributor to neonatal mortality. All very low-birth-weight (VLBW) newborns have the potential to undergo cold stress or frank hypothermia during delivery room stabilization. Thus, clinicians aiming to maintain normothermia in VLBW neonates are compelled to use multiple adjuncts of unknown efficacy or safety. OBJECTIVE: : To evaluate the effectiveness of thermoregulation procedures in maintaining normothermia during delivery room resuscitation and to assess the impact of an unanticipated change in equipment at our institution on the admission temperatures of VLBW newborns. DESIGN/METHODS: : Institutional review board-approved, retrospective analysis of quality assurance data submitted to the Vermont-Oxford Network (VON) for 24 consecutive months starting January 2006. We compared the rate of hypothermia (admission temperature < 36.5°C) in our NICU during 2006 with the aggregate rates reported by VON. We then compared the rates of hypothermia and mean admission temperatures in our NICU during period 1 (when chemical warming packs were used routinely, in addition to plastic wrapping and warm blankets) and period 2 (after packs were discontinued owing to an incident of focal skin injury). RESULTS: : In 2006, 42% of VLBW babies in our NICU had an admission temperature of less than 36.5°C compared with the VON rate of 61% (interquartile range 48%, 76%). During period 1, 39% of 183 VLBW neonates were hypothermic compared with 68% of 103 during period 2 (P < .001). Mean admission temperatures during periods 1 and 2 were 36.5°C and 36.1°C, respectively (P < .001). A control chart showed the shift in temperatures occurring as period 2 began. No change in practice other than discontinuation of the warming packs was instituted during period 2. The incidence of temperatures greater than 38°C (hyperthermia) was 1.6% during period 1 and 1.0% during period 2. CONCLUSIONS: : The results associated with this isolated change in practice at our institution suggest that chemical warming packs were a useful adjunct in achieving above-average rates of normothermia during delivery room resuscitation of VLBW newborns. Their potential adverse effects should be weighed against the increased risk of mortality associated with hypothermia in this population.

Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists.

OBJECTIVE: In 2008, all 18 regional referral NICUs in New York state adopted central-line insertion and maintenance bundles and agreed to use checklists to monitor maintenance-bundle adherence and report checklist use. We sought to confirm whether adopting standardized bundles and using central-line maintenance checklists reduced central-line-associated bloodstream infections (CLABSI). METHODS: This was a prospective cohort study that enrolled all neonates with a central line who were hospitalized in any of 18 NICUs. Each NICU reported CLABSI and central-line utilization data and checklist use. We used χ(2) to compare CLABSI rates in the preintervention (January to December 2007) versus the postintervention (March to December 2009) periods and Poisson regression to model adjusted CLABSI rates. RESULTS: Each study period included more than 55 000 central-line days and more than 200 000 patient-days. CLABSI rates decreased 67% statewide (risk ratio: 0.33 [95% confidence interval: 0.27-0.41]; P < .0005); after adjusting for the altered central-line-associated bloodstream infection definition in 2008, by 40% (risk ratio: 0.60 [95% confidence interval: 0.48-0.75]; P < .0005). A total of 13 of 18 NICUs reported using maintenance checklists for 10% to 100% of central-line days. The checklist-use rate was associated with the CLABSI rate (coefficient: -0.57, P = .04). A total of 10 of 18 NICUs were independent CLABSI rate predictors, ranging from 1 site with greatly reduced risk (incidence rate ratio: 0.04, P < .0005) to 1 site with greatly increased risk (incidence rate ratio: 2.87, P < .0005). CONCLUSIONS: Although standardizing central-line care elements led to a significant statewide decline in NICU CLABSIs, site of care remains an independent risk factor. Using maintenance checklists reduced CLABSIs.

A nurse's guide to early detection of umbilical venous catheter complications in infants.

The use of umbilical catheters in the care of critically ill neonates has become standard practice. Both arterial and venous umbilical catheters are a vital component of care, providing a stable route for fluid and medication administration, vascular pressure monitoring, and frequent blood sampling. Although commonplace, umbilical catheters are not without complications. Neonatal caregivers must be aware of and monitor carefully for associated complications. This article, Part 1 of a 2-part series, provides a systematic guide to the physical assessment of infants with umbilical venous catheters with an emphasis on early and ongoing recognition of complications related to this device. Part 2 will focus on umbilical arterial catheters, their use, and assessment of the infant to detect device-specific complications.

Recognizing the clinical features of Trisomy 13 syndrome.

Recognition of the clinical features of Trisomy 13 syndrome, a common autosomal trisomy, provides the basis for diagnostic testing and counseling of families. This article provides a systematic guide to physical assessment and photographs to enhance recognition of this genetic disorder. The principles of numerical chromosomal abnormalities as related to trisomies are reviewed. An abnormal development of the forebrain, holoprosencephaly, is the most common cranial abnormality in infants with Trisomy 13. The embryology and implications of holoprosencephaly are described. A discussion of antenatal diagnosis of Trisomy 13 and delivery room management is also provided. The diagnosis of Trisomy 13 is confirmed antenatally or after delivery with genetic testing. Prognosis of infants with Trisomy 13 and implications for the infants development are described.

Scalp hair characteristics in the newborn infant.

Scalp hair growth and patterning are closely associated with the development of the central nervous system. A number of genetic, metabolic, and neurologic disorders are associated with recognizable scalp hair abnormalities. For this reason, a systematic step-by-step assessment of the hair and scalp should be an integral part of every initial newborn physical assessment. This article reviews the clinically relevant embryology related to fetal scalp hair formation. Normal cycles of hair growth and loss are discussed. A systematic review of typical newborn scalp hair characteristics such as color, quantity, texture, direction of growth, hairlines, and hair whorls is provided. Conditions associated with abnormal hair color, quality, quantity, and distribution are presented in a series of clinical photographs, and their salient features are discussed. Abnormal hair often occurs as a constellation of findings; implications for clinical care and further investigation will be briefly described.

Assessment of the umbilical cord outside of the delivery room. Part 2.

The umbilical cord is crucial to the growth and development of the fetus. Careful inspection in the delivery room and throughout the newborn period is essential. Part 1 of this 2-part series, entitled "Look Before You Clamp: Delivery Room Examination of the Umbilical Cord" (Advances in Neonatal Care, Vol. 2, No. 1, pp 19-26), reviewed umbilical problems that present in the delivery room. A number of subtle but significant umbilical cord abnormalities present outside the delivery room. These abnormalities will be the focus of Part 2 of this series. A review of the embryologic development of the umbilical cord enhances the clinician's understanding of umbilical abnormalities that present in the newborn period. The process of umbilical cord separation is outlined. Conditions associated with delayed cord separation are discussed. A systematic approach to the physical examination of the umbilicus is offered, with an emphasis on early detection of abnormalities. Common and uncommon physical findings, such as omphalitis, periumbilical necrotizing fascitis, vitelline duct remnants, and urachal anomalies are presented along with select photographs. A brief discussion of the clinical implications for newborn care is provided for the practicing clinician.

Examination of the newborn foot: positional and structural abnormalities.

Newborn feet come in a variety of shapes and sizes. The foot is malleable, making it susceptible to compression and deformation from intrauterine positioning. Clinicians frequently question whether variations represent deformations, that is, an alteration in the shape and contour of a normally formed foot, as opposed to a true structural malformation. Distinguishing between a temporary positional deformity and a more serious structural foot malformation is challenging and requires a clear understanding of the anatomy of the foot, its complex embryologic development, and the impact of environmental and intrauterine factors. This installment of Focus on the Physical provides a systematic framework to identify normal, abnormal, and atypical foot deformities in the newborn period. The current theories of pathogenesis are provided, along with a step-by-step approach to the examination of the foot. A series of clinical photographs illustrate talipes equinovarus, metatarsus adductus, talipes calcaneovalgus, and congenital vertical talus. A discussion of the diagnostic studies used to differentiate these abnormalities is provided, along with a brief overview of treatment options. Early recognition and treatment are essential to ensure optimal long-term functional outcomes.

Look before you clamp: delivery room examination of the umbilical cord.

The umbilical cord is a critical connection between the embryo (and later, the fetus) and the placenta. The umbilical cord houses the blood vessels that are responsible for nourishing the fetus. Proper umbilical cord function is essential for growth and development before birth. A review of the embryologic origin of the umbilical cord aids in understanding abdominal wall and umbilical cord defects that can present in the newborn period. In the delivery room, inspection of the umbilical cord is an integral part of the first minutes of life. Any abnormality either within the cord structure or in the areas surrounding the base of the cord may necessitate a delay in shortening the cord. Surgical consultation may also be indicated. This issue of Focus on the Physical will provide a step-by-step guide to cord assessment in the delivery room setting. Pictures showing normal, atypical, and abnormal umbilical cords and common abdominal wall defects will be presented along with a brief discussion of the significance and clinical implications of each of these findings.