Building a NICU quality & safety infrastructure.

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.

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.

COVID-19 & differential effects in twins: Insights from Placenta Pathology.

INTRODUCTION: COVID-19 has been associated with several adverse pregnancy outcomes, including perinatal loss. Differential effects of COVID-19 in a twin pregnancy may provide unique insights into virus-placental interactions. We present a case of perinatal loss of a female fetus with survival of the male co-twin in a pregnancy complicated by COVID-19 and premature delivery. METHODS: Viral detection methods recommended by the NICHD task force were used to identify SARS-CoV-2 and its viral receptors in the placentas and fetal tissue (Antoun et al., 2020) [1] RESULTS: Compared with the surviving twin, we found a more severe intervillous necrosis and a relatively low detection of ACE2 membranous expression in the syncytiotrophoblasts of the female twin that succumbed. DISCUSSION: The interactions of SARS-CoV-2 and ACE2 at the maternal fetal interface within the placenta may play a significant role in perinatal loss, and the effects of fetal sex and gestational age at time of infection need to be explored further.

Improving the quality of quality metrics in neonatology.

This article examines approaches for improving the efficiency and effectiveness of quality metrics currently in use in neonatal care. Desirable characteristics of quality metrics are discussed, the criteria and process for their development are presented, and the uses and limitations of current neonatal outcome and process metrics are explored together with approaches for improving metric performance. Discussion includes enhancing quality metrics through optimizing improvement readiness, sustaining improvements once achieved, and use of improvement science methods to improve metric validity.

Reducing Alarm Fatigue in Two Neonatal Intensive Care Units through a Quality Improvement Collaboration.

OBJECTIVE: To reduce nonactionable oximeter alarms by 80% without increasing time infants were hypoxemic (oxygen saturation [SpO2] ≤ 80%) or hyperoxemic (SpO2 > 95% while on supplemental oxygen). STUDY DESIGN: In 2015, a multidisciplinary team at Connecticut Children's Medical Center initiated a quality improvement project to reduce nonactionable oximeter alarms in two referral neonatal intensive care units (NICUs). Changes made through improvement cycles included reduction of the low oximeter alarm limit for specific populations, increased low alarm delay, development of postmenstrual age-based alarm profiles, and updated bedside visual reminders. Manual alarm tallies and electronic SpO2 data were collected throughout the project. RESULTS: Alarm tallies were collected for 158 patient care hours with SpO2 data available for 138 of those hours. Mean number of total nonactionable alarms per patient per hour decreased from 9 to 2 (78% decrease) and the mean number of nonactionable low alarms per patient per hour decreased from 5 to 1 (80% decrease). No change was noted in the balancing measures of percentage time with SpO2 ≤ 80% (mean 4.3%) or SpO2 > 95% (mean 23.7%). CONCLUSION: Through small changes in oximeter alarm settings, including revision of alarm limits, alarm delays, and age-specific alarm profiles, our NICUs significantly reduced nonactionable alarms without increasing hypoxemia.

Alarm Safety and Alarm Fatigue.

Clinical alarm systems have received significant attention in recent years following warnings from hospital accrediting and health care technology organizations regarding patient harm caused by unsafe practices. Alarm desensitization or fatigue from frequent, false, or unnecessary alarms, has led to serious events and even patient deaths. Other concerns include settings inappropriate to patient population or condition, inadequate staff training, and improper use or disabling. Research on human factors in alarm response and of functionality of medical devices will help clinicians develop appropriate policies, practices, and device settings for clinical alarms in neonatal intensive care units.

Nurse:patient ratio and achievement of oxygen saturation goals in premature infants.

BACKGROUND: Premature newborns often experience oxygen saturations outside policy-specified targets, which may be associated with increased morbidity. Nurse workload may affect oxygen management. OBJECTIVE: To examine the relationship between number of patients assigned to neonatal intensive care unit (NICU) nurses and achievement of oxygen saturation goals in premature newborns. DESIGN: The authors linked nurse-patient assignment data with continuous oxygen saturation data for infants <29 weeks' gestation in a single NICU between January and June 2008. The proportion of time oxygen saturation was in policy-specified target range (85-92%) and proportion of time hyperoxaemic (98-100%) were determined for multiple 6 h monitoring periods. Each period was characterised by a single nurse, respiratory support mode and fraction of inspired oxygen (Fio(2)) level (0.22-0.49 or ≥0.5). The nurse:patient ratio for the infant's nurse for each monitoring period was determined. Factors associated with Spo(2) target achievement and hyperoxaemia were identified. RESULTS: The authors analysed 1019 monitoring periods from 14 infants with a mean (SD) birth weight of 860 (270) g and gestational age of 26.6 (1.6) weeks. The mean (range) postmenstrual age for all monitoring periods was 31.6 (24.1-40.7) weeks. Eighty-seven nurses provided care. In a multivariate cross-classified hierarchical regression, the nurse:patient ratio, postmenstrual age, respiratory support mode and Fio(2) were significantly associated with oxygen saturation outcomes. Fewer patients per nurse was significantly associated with a higher saturation target achievement among patients on high-frequency ventilation, and with reduced hyperoxaemia among patients on nasal cannula. CONCLUSIONS: Fewer patients per nurse may be associated with improved achievement of oxygen saturation goals and may be an important modifiable factor influencing oxygen-related outcomes in premature newborns. This effect may vary with mode of respiratory support.