Optimizing clinical care and training in the neonatal intensive care unit: the relationship between front line providers and physician trainees.

Changes in neonatal intensive care unit (NICU) coverage models, restrictions in trainee work hours, and alterations to the training requirements of pediatric house staff have led to a rapid increase in utilization of front-line providers (FLPs) in the NICU. FLP describes a provider who cares for neonates and infants in the delivery room, nursery, and NICU, and includes nurse practitioners, physician assistants, and/or hospitalists. The increasing presence and responsibility of FLPs in the NICU have fundamentally changed the way patient care is provided as well as the learning environment for trainees. With these changes has come confusion over role clarity with resulting periodic conflict. While staffing changes have addressed a critical clinical gap, they have also highlighted areas for improvement amongst the teams of NICU providers. This paper describes the current landscape and summarizes improvement opportunities with a dynamic neonatal interprofessional provider team.

Using the Neonatal Intensive Care Unit Wisely: A National Survey of Clinicians Regarding Practices for Lower-Acuity Care.

OBJECTIVE: The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity. STUDY DESIGN: We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network. RESULTS: Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios. CONCLUSIONS: A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.

Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn.

The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.

Transition to a Safe Home Sleep Environment for the NICU Patient.

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient.

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Neonatal Provider Workforce.

This technical report reviews education, training, competency requirements, and scopes of practice of the different neonatal care providers who work to meet the special needs of neonatal patients and their families in the NICU. Additionally, this report examines the current workforce issues of NICU providers, offers suggestions for establishing and monitoring quality and safety of care, and suggests potential solutions to the NICU provider workforce shortages now and in the future.

A quality improvement project to reduce length of stay for neonatal abstinence syndrome.

BACKGROUND AND OBJECTIVE: Neonatal abstinence syndrome (NAS), a self-limiting condition, is associated with clinical symptoms that may require pharmacological intervention. Optimal treatment of NAS remains undetermined, but the hospital length of stay (LOS) for patients with NAS is partially dependent upon a standard treatment protocol used. Prolonged LOS for patients with NAS can lead to adverse patient harm, impaired maternal-infant attachment, and significant health care costs. Therefore, we conducted a quality improvement study to reduce the LOS for infants with NAS. METHODS: In 2009, a multidisciplinary NAS Taskforce was created to implement a standardized treatment protocol, discuss the strengths and weaknesses of the current medical and nursing management, and improve communication among staff. Infants with NAS that required pharmacological intervention were followed throughout their hospitalization. Readmission within 30 days of hospital discharge was tracked as a balancing measure. RESULTS: Ninety-two infants were eligible for the project including 23 infants from a baseline period (January 2007-August 2009). Reliable monitoring of symptoms and the administration of a standardized morphine protocol effectively reduced LOS from 36 days to 18 days by June 2012. This improvement was sustained through December 2012. No patients were readmitted for NAS treatment. CONCLUSIONS: The most effective interventions that impacted LOS for infants with NAS were the development of a staff NAS education program and the implementation of a standard treatment protocol. The formation of the NAS Taskforce was also essential because it facilitated communication and the dissemination of vital treatment information among all clinical staff.

Significant Reduction of Central-Line Associated Bloodstream Infections in a Network of Diverse Neonatal Nurseries.

OBJECTIVE: To describe a quality improvement (QI) initiative that was associated with a dramatic reduction in neonatal central-line associated bloodstream infection (CLABSI) rate in a diverse group of 8 intensive care nurseries (Neonatal Services). STUDY DESIGN: A quasi-experimental time series QI initiative using the model for improvement and evidenced-based interventions. RESULTS: The aggregate CLABSI rate for Nationwide Children's Hospital-associated Neonatal Services decreased from 6.0 CLABSI per 1000 catheter days to 1.43 CLABSI per 1000 catheter days in less than 2 years and has remained in control at 0.68 per 1000 catheter days for over 5 years. Each of 8 nurseries has had a 1 year or more CLABSI-free period, including the neonatal intensive care unit with the largest patient volume, acuity, and central line usage. Aggregate Neonatal Services has experienced 3 CLABSI-free quarters since 2007. Key success factors included: (1) engagement of senior executive leadership; (2) bedside "huddles" among clinical and epidemiology staffs conducted within 72 hours after a positive blood culture; (3) implementation of chlorhexidine antisepsis and the use of chlorhexidine-impregnated catheter site discs; and (4) and establishment of a dedicated team for percutaneously inserted central catheter insertion to serve units in which central lines are placed less frequently. CONCLUSIONS: Using the model for improvement and evidenced-based interventions, this QI project has been associated with reduction in the CLABSI rate by 89%, and over 430 CLABSIs likely have been avoided.