Societal costs of untreated perinatal mood and anxiety disorders in Vermont.

PURPOSE: To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum. METHODS: We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum. RESULTS: We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child. CONCLUSION: Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.

Nurse Staffing in Neonatal Intensive Care Units in the United States.

The neonatal intensive care unit (NICU) is a setting with high nurse-to-patient ratios. Little is known about the factors that determine nurse workload and assignment. The goals of this study were to (1) develop a measure of NICU infant acuity; (2) describe the acuity distribution of NICU infants; (3) describe the nurse/infant ratio at each acuity level, and examine the factors other than acuity, including nurse qualifications and the availability of physicians and other providers, that determined staffing ratios; and (4) explore whether nurse qualifications were related to the acuity of assigned infants. In a two-stage cohort study, data were collected in 104 NICUs in 2008 by nurse survey (6,038 nurses and 15,191 infants assigned to them) and administrators reported on unit-level staffing of non-nurse providers; in a subset of 70 NICUs in 2009-2010, census data were collected on four selected shifts (3,871 nurses and 9,276 infants assigned to them). Most NICU infants (62%) were low-acuity (Levels 1 and 2); 12% of infants were high-acuity (Levels 4 and 5). The nurse-to-infant ratio ranged from 0.33 for the lowest-acuity infants to 0.95 for the highest-acuity infants. The staffing ratio was significantly related to the acuity of assigned infants but not to nurse education, experience, certification, or availability of other providers. There was a significant but small difference in the percentage of high-acuity (Levels 4 and 5) infants assigned to nurses with specialty certification (15% vs. 12% for nurses without certification). These staffing patterns may not optimize patient outcomes in this highly intensive pediatric care setting.

Is implementing a post-lunch nap beneficial on evening performance, following two nights partial sleep restriction?

We have investigated the effects that partial-sleep-restriction (PSR0, 4-h sleep retiring at 02:30 and waking at 06:30 h for two consecutive nights) have on 07:30 and 17:00 h cognitive and submaximal weightlifting; and whether this performance improves at 17:00 h following a 13:00 h powernap (0, 30 or 60-min). Fifteen resistance-trained males participated in this study. Prior to the experimental protocol, one repetition max (1RM) bench press and back squat, normative habitual sleep and food intake were recorded. Participants were familiarised with the testing protocol, then completed three experimental conditions: (i) PSR with no nap (PSR0); (ii) PSR with a 30-min nap (PSR30) and (iii) PSR with a 60-min nap (PSR60). Conditions were separated by 7 days with trial order counterbalanced. Intra-aural temperature, Profile of Mood Scores, word-colour interference, alertness and tiredness values were measured at 07:30, 11:00, 14:00, 17:00 h on the day of exercise protocol. Following final temperature measurements at 07:30 h and 17:00 h, participants completed a 5-min active warm-up before performing three repetitions of left and right-hand grip strength, followed by three repetitions at each incremental load (40, 60 and 80% of 1RM) for bench press and back squat, with a 5-min recovery between each repetition. A linear encoder was attached perpendicular to the bar used for the exercises. Average power (AP), average velocity (AV), peak velocity (PV), displacement (D) and time-to-peak velocity (tPV) were measured (MuscleLab software) during the concentric phase of the movements. Data were analysed using general linear models with repeated measures. The main findings were that implementing a nap at 13:00 h had no effect on measures of strength (grip, bench press or back squat). There was a main effect for time of day with greatest performance at 17:00 h for measures of strength. In addition to a significant effect for "load" on the bar for bench press and back squat where AP, AV, PV, D values were greatest at 40% (P < 0.05) and decreased with increased load, whereas tPV and RPE values increased with load; despite this no interaction of "load and condition" were present. A post lunch nap of 30- and 60-minute durations improved mood state, with feelings of alertness, vigour and happiness highest at 17:00 h, in contrast to confusion, tiredness and fatigue (P < 0.05), which were greater in the morning (07:30 h). The word-colour interference test, used as an indicator of cognitive function, reported significant main effect for condition, with the highest total test score in PSR60 condition (P = 0.015). In summary, unlike strength measures the implementation of a 30 or 60-minute nap improved cognitive function when in a partially sleep restricted state, compared to no nap.

The Vermont Oxford Neonatal Encephalopathy Registry: rationale, methods, and initial results.

BACKGROUND: In 2006, the Vermont Oxford Network (VON) established the Neonatal Encephalopathy Registry (NER) to characterize infants born with neonatal encephalopathy, describe evaluations and medical treatments, monitor hypothermic therapy (HT) dissemination, define clinical research questions, and identify opportunities for improved care. METHODS: Eligible infants were ≥ 36 weeks with seizures, altered consciousness (stupor, coma) during the first 72 hours of life, a 5 minute Apgar score of ≤ 3, or receiving HT. Infants with central nervous system birth defects were excluded. RESULTS: From 2006-2010, 95 centers registered 4232 infants. Of those, 59% suffered a seizure, 50% had a 5 minute Apgar score of ≤ 3, 38% received HT, and 18% had stupor/coma documented on neurologic exam. Some infants experienced more than one eligibility criterion. Only 53% had a cord gas obtained and only 63% had a blood gas obtained within 24 hours of birth, important components for determining HT eligibility. Sixty-four percent received ventilator support, 65% received anticonvulsants, 66% had a head MRI, 23% had a cranial CT, 67% had a full channel encephalogram (EEG) and 33% amplitude integrated EEG. Of all infants, 87% survived. CONCLUSIONS: The VON NER describes the heterogeneous population of infants with NE, the subset that received HT, their patterns of care, and outcomes. The optimal routine care of infants with neonatal encephalopathy is unknown. The registry method is well suited to identify opportunities for improvement in the care of infants affected by NE and study interventions such as HT as they are implemented in clinical practice.

Association between hospital recognition for nursing excellence and outcomes of very low-birth-weight infants.

CONTEXT: Infants born at very low birth weight (VLBW) require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known. OBJECTIVE: To examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes. DESIGN, SETTING, AND PATIENTS: Cohort study of 72,235 inborn VLBW infants weighing 501 to 1500 g born in 558 Vermont Oxford Network hospital neonatal intensive care units between January 1, 2007, and December 31, 2008. Hospital RNE was determined from the American Nurses Credentialing Center. The RNE designation is awarded when nursing care achieves exemplary practice or leadership in 5 areas. MAIN OUTCOME MEASURES: Seven-day, 28-day, and hospital stay mortality; nosocomial infection, defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage. RESULTS: Overall, the outcome rates were as follows: for 7-day mortality, 7.3% (5258/71,955); 28-day mortality, 10.4% (7450/71,953); hospital stay mortality, 12.9% (9278/71,936); severe intraventricular hemorrhage, 7.6% (4842/63,525); and infection, 17.9% (11,915/66,496). The 7-day mortality was 7.0% in RNE hospitals and 7.4% in non-RNE hospitals (adjusted odds ratio [OR], 0.87; 95% CI, 0.76-0.99; P = .04). The 28-day mortality was 10.0% in RNE hospitals and 10.5% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.80-1.01; P = .08). Hospital stay mortality was 12.4% in RNE hospitals and 13.1% in non-RNE hospitals (adjusted OR, 0.90; 95% CI, 0.81-1.01; P = .06). Severe intraventricular hemorrhage was 7.2% in RNE hospitals and 7.8% in non-RNE hospitals (adjusted OR, 0.88; 95% CI, 0.77-1.00; P = .045). Infection was 16.7% in RNE hospitals and 18.3% in non-RNE hospitals (adjusted OR, 0.86; 95% CI, 0.75-0.99; P = .04). Compared with RNE hospitals, the adjusted absolute decrease in risk of outcomes in RNE hospitals ranged from 0.9% to 2.1%. All 5 outcomes were jointly significant (P < .001). The mean effect across all 5 outcomes was OR, 0.88 (95% CI, 0.83-0.94; P < .001). In a subgroup of 68,253 infants with gestational age of 24 weeks or older, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant. CONCLUSION: Among VLBW infants born in RNE hospitals compared with non-RNE hospitals, there was a significantly lower risk-adjusted rate of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage but not of 28-day mortality or hospital stay mortality.

Intergovernmental Relations in the UK: Time for a Radical Overhaul?

Brexit and the coronavirus pandemic have put relationships between the UK government and its devolved counterparts under growing strain. Tensions generated by both of these developments have exposed the inadequacies of the existing, under-developed system for bringing governments together in the UK. The limitations of the current system include the ad hoc nature of intergovernmental meetings, and their consultative rather than decision-making character. Drawing upon an analysis of how intergovernmental relationships are structured in five other countries, the authors offer a number of suggestions for the reconfiguration of the UK model. They explore different ways of enabling joint decision making by its governments, and argue against the assumption that England can be represented adequately by the UK administration. Without a serious attempt to address this dysfunctional part of the UK's territorial constitution, there is every prospect that relations between these different governments will continue to deteriorate.

Factors associated with infant feeding of human milk at discharge from neonatal intensive care: Cross-sectional analysis of nurse survey and infant outcomes data.

CONTEXT: Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting. OBJECTIVES: To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge. DESIGN AND SETTING: Cross sectional analysis combining nurse survey data with infant discharge data. PARTICIPANTS: A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997). METHODS: Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support). RESULTS: The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001). CONCLUSIONS: Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge.

Disparities in perinatal quality outcomes for very low birth weight infants in neonatal intensive care.

OBJECTIVE: To determine if hospital-level disparities in very low birth weight (VLBW) infant outcomes are explained by poorer hospital nursing characteristics. DATA SOURCES: Nurse survey and VLBW infant registry data. STUDY DESIGN: Retrospective study of 8,252 VLBW infants in 98 Vermont Oxford Network hospital neonatal intensive care units (NICUs) nationally. NICUs were classified into three groups based on their percent of infants of black race. Two nurse-sensitive perinatal quality standards were studied: nosocomial infection and breast milk. DATA COLLECTION: Primary nurse survey (N = 5,773, 77 percent response rate). PRINCIPAL FINDINGS: VLBW infants born in high-black concentration hospitals had higher rates of infection and discharge without breast milk than VLBW infants born in low-black concentration hospitals. Nurse understaffing was higher and practice environments were worse in high-black as compared to low-black hospitals. NICU nursing features accounted for one-third to one-half of the hospital-level health disparities. CONCLUSIONS: Poorer nursing characteristics contribute to disparities in VLBW infant outcomes in two nurse-sensitive perinatal quality standards. Improvements in nursing have potential to improve the quality of care for seven out of ten black VLBW infants who are born in high-black hospitals in this country.

Serious congenital heart disease and necrotizing enterocolitis in very low birth weight neonates.

BACKGROUND: Infants with serious congenital heart disease (CHD) appear to be at increased risk for necrotizing enterocolitis (NEC). This study aimed to quantify the incidence and mortality of NEC among very low birth weight (VLBW) neonates with serious CHD, and identify specific CHD diagnoses at the highest risk for developing NEC. STUDY DESIGN: Data were prospectively collected on 257,794 VLBW (401 to 1,500 g) neonates born from 2006 to 2011 and admitted to 674 Vermont Oxford Network US centers. Entries were coded for specific CHD diagnoses and reviewed for completeness and consistency. Survival was defined as alive in-hospital at 1 year or discharge. RESULTS: Of eligible neonates, 1,931 had serious CHD. Of these, 253 (13%) developed NEC (vs 9% in infants without CHD, adjusted odds ratio [AOR] 1.80, p<0.0001). Mortality for neonates with CHD and no NEC was 34%, vs 55% for those with CHD and NEC (p<0.0001). Both groups of CHD patients had higher mortality than infants with NEC without CHD (28%, p<0.0001). Although NEC mortality overall decreases with higher birth weight, mortality for NEC and CHD together does not. CONCLUSIONS: The incidence of NEC is significantly higher in VLBW neonates when CHD is present. The mortality of CHD and NEC together is substantially higher than that with each disease alone. Infants with atrioventricular canal appear to have higher risk for developing NEC than other CHD diagnoses. In addition to providing benchmark incidence and mortality data, these findings may have utility in the further study of the pathophysiology of NEC.

Concordance of different measures of nicotine dependence: two pilot studies.

Two samples of adult daily smokers completed a structured interview to determine nicotine dependence according to generic (DSM-IV/ICD-10), Fagerström [Fagerström Tolerance Questionnaire (FTQ), Fagerström Test for Nicotine Dependence (FTND), Heavy Smoking Index (HSI), and time to first cigarette after awakening (TFC)], consumption [e.g., cigarettes/day (CPD)], and self-rating (e.g., "how addicted are you") measures. One sample was a population-based sample of 43 smokers from the Vermont site of the DSM-IV field trial for substance use disorders. The other sample consisted of 50 smokers evenly distributed across a wide range of CPD to study biochemical markers of smokers. In the first study, DSM/ICD criteria were only slightly correlated with Fagerström (r =.24-.35) and consumption (r =.06-0.33) criteria. Self-rating criteria were correlated moderately with most other criteria (r =.24-.60). In the second study, generic, Fagerström, and self-rating criteria increased with increasing CPD up to 30 CPD but not thereafter. One interpretation of these results is that generic, Fagerström, consumption, and self-rating criteria each tap different aspects of nicotine dependence.

Indirect vs direct hospital quality indicators for very low-birth-weight infants.

CONTEXT: Evidence-based selective referral strategies are being used by an increasing number of insurers to ensure that medical care is provided by high-quality providers. In the absence of direct-quality measures based on patient outcomes, the standards currently in place for many conditions rely on indirect-quality measures such as patient volume. OBJECTIVES: To assess the potential usefulness of volume as a quality indicator for very low-birth-weight (VLBW) infants and compare volume with other potential indicators based on readily available hospital characteristics and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of 94 110 VLBW infants weighing 501 to 1500 g born in 332 Vermont Oxford Network hospitals with neonatal intensive care units between January 1, 1995, and December 31, 2000. MAIN OUTCOME MEASURES: Mortality among VLBW infants prior to discharge home; detailed case-mix adjustment was performed by using patient characteristics available immediately after birth. RESULTS: In hospitals with less than 50 annual admissions of VLBW infants, an additional 10 admissions were associated with an 11% reduction in mortality (95% confidence interval [CI], 5%-16%; P<.001). The annual volume of admissions only explained 9% of the variation across hospitals in mortality rates, and other readily available hospital characteristics explained an additional 7%. Historical volume was not significantly related to mortality rates in 1999-2000, implying that volume cannot prospectively identify high-quality providers. In contrast, hospitals in the lowest mortality quintile between 1995 and 1998 were found to have significantly lower mortality rates in 1999-2000 (odds ratio [OR], 0.64; 95% CI, 0.55-0.76; P<.001) and hospitals in the highest mortality quintile between 1995 and 1998 had significantly higher mortality rates in 1999-2000 (OR, 1.37; 95% CI, 1.16-1.64; P<.001). The percentage of hospital-level variation in mortality in 1999-2000 that was forecasted by the highest and lowest quintiles based on patient mortality was 34% compared with only 1% for the highest and lowest quintiles of volume. CONCLUSIONS: Referral of VLBW infants based on indirect-quality indicators such as patient volume may be minimally effective. Direct measures based on patient outcomes are more useful quality indicators for the purposes of selective referral, as they are better predictors of future mortality rates among providers and could save more lives.

Mortality and management of surgical necrotizing enterocolitis in very low birth weight neonates: a prospective cohort study.

BACKGROUND: Necrotizing enterocolitis (NEC) is a leading cause of death in very low birth weight (VLBW) neonates. The overall mortality of NEC is well documented. However, those requiring surgery appear to have increased mortality compared with those managed medically. The objective of this study was to establish national birth-weight-based benchmarks for the mortality of surgical NEC and describe the use and mortality of laparotomy vs peritoneal drainage. STUDY DESIGN: There were 655 US centers that prospectively evaluated 188,703 VLBW neonates (401 to 1,500 g) between 2006 and 2010. Survival was defined as living in-hospital at 1-year or hospital discharge. RESULTS: There were 17,159 (9%) patients who had NEC, with mortality of 28%; 8,224 patients did not receive operations (medical NEC, mortality 21%) and 8,935 were operated on (mortality 35%). On multivariable regression, lower birth weight, laparotomy, and peritoneal drainage were independent predictors of mortality (p < 0.0001). In surgical NEC, a plateau mortality of around 30% persisted despite birth weights >750 g; medical NEC mortality fell consistently with increasing birth weight. For example, in neonates weighing 1,251 to 1,500 g, mortality was 27% in surgical vs 6% in medical NEC (odds ratio [OR] 6.10, 95% CI 4.58 to 8.12). Of those treated surgically, 6,131 (69%) underwent laparotomy only (mortality 31%), 1,283 received peritoneal drainage and a laparotomy (mortality 34%), and 1,521 had peritoneal drainage alone (mortality 50%). CONCLUSIONS: Fifty-two percent of VLBW neonates with NEC underwent surgery, which was accompanied by a substantial increase in mortality. Regardless of birth weight, surgical NEC showed a plateau in mortality at approximately 30%. Laparotomy was the more frequent method of treatment (69%) and of those managed by drainage, 46% also had a laparotomy. The laparotomy alone and drainage with laparotomy groups had similar mortalities, while the drainage alone treatment cohort was associated with the highest mortality.

Neuroimaging in the evaluation of neonatal encephalopathy.

BACKGROUND AND OBJECTIVE: Computed tomography (CT) is still used for neuroimaging of infants with known or suspected neurologic disorders. Alternative neuroimaging options that do not expose the immature brain to radiation include MRI and cranial ultrasound. We aim to characterize and compare the use and findings of neuroimaging modalities, especially CT, in infants with neonatal encephalopathy. METHODS: The Vermont Oxford Network Neonatal Encephalopathy Registry enrolled 4171 infants (≥36 weeks' gestation or treated with therapeutic hypothermia) between 2006 and 2010 who were diagnosed with encephalopathy in the first 3 days of life. Demographic, perinatal, and medical conditions were recorded, along with treatments, comorbidities, and outcomes. The modality, timing, and results of neuroimaging were also collected. RESULTS: CT scans were performed on 933 of 4107 (22.7%) infants, and 100 of 921 (10.9%) of those received multiple CT scans. Compared with MRI, CT provided less detailed evaluation of cerebral injury in areas of prognostic significance, but was more sensitive than cranial ultrasound for hemorrhage and deep brain structural abnormalities. CONCLUSIONS: CT is commonly used for neuroimaging in newborn infants with neonatal encephalopathy despite concerns over potential harm from radiation exposure. The diagnostic performance of CT is inferior to MRI in identifying neonatal brain injury. Our data suggest that using cranial ultrasound for screening, followed by MRI would be more appropriate than CT at any stage to evaluate infants with neonatal encephalopathy.

Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis.

BACKGROUND: Spontaneous intestinal perforation (SIP) has been recognized as a distinct disease entity. This study sought to quantify mortality associated with laparotomy-confirmed SIP and to compare it to mortality of laparotomy-confirmed necrotizing enterocolitis (NEC). METHODS: Data were prospectively collected on 177,618 very-low-birth-weight (VLBW, 401-1500g) neonates born between January 2006 and December 2010 admitted to US hospitals participating in the Vermont Oxford Network (VON). SIP was defined at laparotomy as a focal perforation of the intestine without features suggestive of NEC or other intestinal abnormalities. The primary outcome was in-hospital mortality. RESULTS: At laparotomy, 2036 (1.1%) neonates were diagnosed with SIP and 4076 (2.3%) with NEC. Neonates with laparotomy-confirmed SIP had higher mortality (19%) than infants without NEC or SIP (5%, P=0.003). However, laparotomy-confirmed SIP patients had significantly lower mortality than those with confirmed NEC (38%, P<0.0001). Mortality in both NEC and SIP groups decreased with increasing birth weight and mortality was significantly higher for NEC than SIP in each birth weight category. Indomethacin and steroid exposure were more frequent in the SIP cohort than the other two groups (P<0.001). CONCLUSIONS: In VLBW infants, the presence of laparotomy-confirmed SIP increases mortality significantly. However, laparotomy-confirmed NEC mortality was double that of SIP. This relationship is evident regardless of birth weight. The variant mortality of laparotomy-confirmed SIP versus laparotomy-confirmed NEC highlights the importance of differentiating between these two diseases both for clinical and research purposes.

Nurse staffing and NICU infection rates.

IMPORTANCE: There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. OBJECTIVE: To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes. DESIGN: Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). SETTING: Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs. PARTICIPANTS: All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments. EXPOSURES: We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. MAIN OUTCOMES AND MEASURES: An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. RESULTS: Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation-higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009. CONCLUSIONS AND RELEVANCE: Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009.

OBJECTIVE: To identify changes in clinical practices for infants with birth weights of 501 to 1500 g born from 2000 to 2009. METHODS: We used prospectively collected registry data for 355,806 infants born from 2000 to 2009 and cared for at 669 North American hospitals in the Vermont Oxford Network. Main outcome measures included obstetric and neonatal practices, including cesarean delivery, antenatal steroids, delivery room interventions, respiratory practices, neuroimaging, retinal exams, and feeding at discharge. RESULTS: Significant changes in many obstetric, delivery room, and neonatal practices occurred from 2000 to 2009. Use of surfactant treatment in the delivery room increased overall (adjusted difference [AD] 17.0%; 95% confidence interval [CI] 16.4% to 17.6%), as did less-invasive methods of respiratory support, such as nasal continuous positive airway pressure (AD 9.9%; 95% CI 9.1% to 10.6%). Use of any ventilation (AD -7.5%; 95% CI -8.0% to -6.9%) and steroids for chronic lung disease (AD -15.3%; 95% CI -15.8% to -14.8%) decreased significantly overall. Most of the changes in respiratory care were observed within each of 4 birth weight strata (501-750 g, 751-1000 g, 1001-1250 g, 1251-1500 g). CONCLUSIONS: Many obstetric and neonatal care practices used in the management of infants 501 to 1500 g changed between 2000 and 2009. In particular, less-invasive approaches to respiratory support increased.

Exploratory Analysis in Time-Varying Data Sets: a Healthcare Network Application.

We introduce a new method for exploratory analysis of large data sets with time-varying features, where the aim is to automatically discover novel relationships between features (over some time period) that are predictive of any of a number of time-varying outcomes (over some other time period). Using a genetic algorithm, we co-evolve (i) a subset of predictive features, (ii) which attribute will be predicted (iii) the time period over which to assess the predictive features, and (iv) the time period over which to assess the predicted attribute. After validating the method on 15 synthetic test problems, we used the approach for exploratory analysis of a large healthcare network data set. We discovered a strong association, with 100% sensitivity, between hospital participation in multi-institutional quality improvement collaboratives during or before 2002, and changes in the risk-adjusted rates of mortality and morbidity observed after a 1-2 year lag. The proposed approach is a potentially powerful and general tool for exploratory analysis of a wide range of time-series data sets.

Mortality and neonatal morbidity among infants 501 to 1500 grams from 2000 to 2009.

OBJECTIVE: To identify changes in mortality and neonatal morbidities for infants with birth weight 501 to 1500 g born from 2000 to 2009. METHODS: There were 355806 infants weighing 501 to 1500 g who were born in 2000-2009. Mortality during initial hospitalization and major neonatal morbidity in survivors (early and late infection, chronic lung disease, necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, and periventricular leukomalacia) were assessed by using data from 669 North American hospitals in the Vermont Oxford Network. RESULTS: From 2000 to 2009, mortality for infants weighing 501 to 1500 g decreased from 14.3% to 12.4% (difference, -1.9%; 95% confidence interval, -2.3% to -1.5%). Major morbidity in survivors decreased from 46.4% to 41.4% (difference, -4.9%; 95% confidence interval, -5.6% to -4.2%). In 2009, mortality ranged from 36.6% for infants 501 to 750 g to 3.5% for infants 1251 to 1500 g, whereas major morbidity in survivors ranged from 82.7% to 18.7%. In 2009, 49.2% of all very low birth weight infants and 89.2% of infants 501 to 750 g either died or survived with a major neonatal morbidity. CONCLUSIONS: Mortality and major neonatal morbidity in survivors decreased for infants with birth weight 501 to 1500 g between 2000 and 2009. However, at the end of the decade, a high proportion of these infants still either died or survived after experiencing ≥ 1 major neonatal morbidity known to be associated with both short- and long-term adverse consequences.

Antecedents of neonatal encephalopathy in the Vermont Oxford Network Encephalopathy Registry.

BACKGROUND: Neonatal encephalopathy (NE) is a major predictor of death and long-term neurologic disability, but there are few studies of antecedents of NE. OBJECTIVES: To identify antecedents in a large registry of infants who had NE. METHODS: This was a maternal and infant record review of 4165 singleton neonates, gestational age of ≥ 36 weeks, meeting criteria for inclusion in the Vermont Oxford Network Neonatal Encephalopathy Registry. RESULTS: Clinically recognized seizures were the most prevalent condition (60%); 49% had a 5-minute Apgar score of ≤ 3 and 18% had a reduced level of consciousness. An abnormal maternal or fetal condition predated labor in 46%; maternal hypertension (16%) or small for gestational age (16%) were the most frequent risk factors. In 8%, birth defects were identified. The most prevalent birth complication was elevated maternal temperature in labor of ≥ 37.5 °C in 27% of mothers with documented temperatures compared with 2% to 3.2% in controls in population-based studies. Clinical chorioamnionitis, prolonged membrane rupture, and maternal hypothyroidism exceeded rates in published controls. Acute asphyxial indicators were reported in 15% (in 35% if fetal bradycardia included) and inflammatory indicators in 24%. Almost one-half had neither asphyxial nor inflammatory indicators. Although most infants with NE were observably ill since the first minutes of life, only 54% of placentas were submitted for examination. CONCLUSIONS: Clinically recognized asphyxial birth events, indicators of intrauterine exposure to inflammation, fetal growth restriction, and birth defects were each observed in term infants with NE, but much of NE in this large registry remained unexplained.

Distribution of and mortality from serious congenital heart disease in very low birth weight infants.

OBJECTIVE: To characterize serious congenital heart disease in very low birth weight (VLBW) infants (born at <1500 g or a gestational age of 22-29 weeks) in a large, international database. PATIENTS AND METHODS: We analyzed a database of 99 786 VLBW infants born or treated at 703 NICUs between calendar years 2006 and 2007. We defined serious congenital heart disease as 1 of 14 specific lesions or any other structural congenital heart disease that required surgical or medical treatment by initial hospital discharge or by the age of 1 year. We reviewed records for all infants with cardiac diagnoses and other genetic syndromes and associations to determine which had serious congenital heart disease. We excluded nonstructural disease as well as isolated and untreated atrial or ventricular septal defects. We determined the frequency of serious congenital heart disease, compared overall mortality rates of those with and without serious congenital heart disease, and determined the distribution of specific lesions and mortality for each diagnosis. RESULTS: Of 99 786 VLBW infants studied, 893 had serious congenital heart disease (8.9 per 1000). The most common lesions were tetralogy of Fallot (n = 166 [18.6% of those with serious congenital heart disease]), aortic coarctation (n = 103 [11.5%]), complete atrioventricular canal (n = 81 [9.1%]), pulmonary atresia (n = 73 [8.2%]), and double-outlet right ventricle (n = 68 [7.6%]). The mortality rate of those with serious congenital heart disease was 44%, compared with 12.7% in those without serious congenital heart disease (P < .0001). CONCLUSIONS: Serious congenital heart disease is probably more frequent in VLBW infants treated in NICUs than in the general live-born population, and the distribution reflects lesions associated with extracardiac malformations. VLBW infants with serious congenital heart disease have higher a mortality rate than those without, independent of other risk factors.