How Do Obstetric and Neonatology Teams Communicate Prior to High-Risk Deliveries?

BACKGROUND: Improving communication in healthcare improves the quality of care and patient outcomes, but communication between obstetric and neonatal teams before and during a high-risk delivery is poorly studied. STUDY DESIGN: We developed a survey to study communication between obstetric and neonatal teams around the time of a high-risk delivery. We surveyed neonatologists from North America and asked them to answer questions about their institutions' communication practices. RESULTS: The survey answers revealed variations in communication practices between responders. Most institutions relied on nursing to communicate obstetric information to the neonatal team. Although a minority of institutions used a standardized communication process to summon neonatology team or to communicate in the delivery room, these reported higher rates of information sharing and greater satisfaction with communication between services. CONCLUSION: Standardized communication procedures are an underutilized method of communication and have the potential to improve communication around high-risk deliveries.

How We Got Smart: Improving Interdisciplinary Communication When Summoning Neonatology to High-Risk Deliveries.

Communication around high-risk deliveries is critical to ensure patient safety. A hospital-wide system change in paging the neonatal resuscitation team (NRT) to deliveries was implemented but disliked. An interdisciplinary team seized the opportunity to explore opportunities for an enhanced system to improve communication. The team designed a new screen to our smart panel (responder 5 staff terminal, Rauland, Mount Prospect, Illinois) to page NRT with the location and primary indication for which they were needed at delivery. Surveys assessed user satisfaction among labor and delivery and NRT. Before and after implementation of the smart panel, we assessed number of NRT pages, frequency of NRT being paged prior to the delivery, the time between page and delivery, and use of the code button to summon help. Labor and delivery and NRT user satisfaction greatly improved with the smart panel. Frequency of NRT being paged before birth increased with fewer code pages being used to summon NRT to deliveries. A touch screen-based notification system can enhance timely notification to summon NRT to deliveries while concurrently enhancing satisfaction of providers in both the delivery room and on the NRT.

A clinical pathway for guardianship at Dartmouth-Hitchcock Medical Center.

BACKGROUND: Guardianship may be necessary when inpatients lack medical decision-making capacity and are unwilling to go home to be cared for by interested proxy decision makers. Interventions, centered on a clinical pathway, were conducted at Dartmouth-Hitchcock Medical Center (DHMC; Lebanon, New Hampshire). Because guardianship occurs at the interface of clinical care and governmental bureaucracy, quality improvement efforts focused on "in-hospital" processes, while actions were taken to improve communication between clinical teams and the legal system. METHODS: A multidisciplinary quality improvement team mapped the DHMC guardianship process and analyzed the causes for delays before creating the clinical pathway. Specific interventions were designed and implemented to address the identified improvement areas. RESULTS: For the 26 guardianship patients during a two-year period (May 1, 2011-May 1, 2013), the charges incurred totaled approximately $4,000,000--for an average of more than $150,000 per patient. The medically unnecessary days of their length of hospital stay decreased from an average of 27.8 to 11.3, a statistically significant result as demonstrated by statistical process control analysis. The shorter hospitalizations of the last 13 patients amounted to 214.5 medically unnecessary hospital days saved and more than $1.2 million in charges reduced during the two-year period. CONCLUSIONS: Guardianship is a complex process that generates significant delays in appropriate care and increases in charges. The redesigned, standardized guardianship process, as defined in the clinical pathway, reduced associated medically unnecessary days of hospitalization.

Measuring patient safety in neonatology.

Measurement of patient safety serves to identify opportunities to improve safety within a neonatal intensive care unit (NICU), compare the safety of care provided by different NICUs, determine changes in response to safety interventions or programs, follow safety trends over time, and potentially deny payment for specific events. The ideal patient safety measures are rates of events derived from surveillance with valid and reliable detection of numerators (errors or adverse events) and denominators (the opportunities for errors or adverse events to occur). Methods used to identify these numerators and denominators include reporting, direct observation, videotaping, chart review, trigger tools, and automated methods. However, there are significant methodological and practical (feasibility) challenges to the accurate and reliable determination of rates of errors and adverse events. These include failure to detect and document such events, surveillance bias, lack of consistent definitions, frequent requirement for judgment in identifying and classifying challenges (which introduces interrater inconsistency), and need for significant additional resources.

Central line-associated bloodstream infections in neonatal intensive care: changing the mental model from inevitability to preventability.

Previously considered unavoidable complications of hospital care (reflecting an "entitlement" mental model), health care-associated infections are now considered as medical errors and cause significant preventable morbidity and mortality in neonates. Prevention of such infections, particularly central line-associated bloodstream infections (CLABSI), should be an important patient safety priority for all neonatal intensive care units (NICUs). An important first step is to promote a mental model of CLABSIs as preventable complications of care. Other general strategies are (1) promoting an organizational culture of safety and empowerment of staff; (2) hand hygiene; (3) avoiding overcrowding and understaffing; (4) using breast milk for enteral feedings; and (5) involving families in infection prevention efforts. Specific strategies to prevent CLABSI are (1) insertion practices: insertion of all central vascular catheters under strict sterile conditions with the aid of a checklist; (2) maintenance practices: ensuring that entries into the lumen of the vascular catheter always occur under aseptic conditions, minimizing catheter disconnections, and replacement of intravenous infusion sets at recommended intervals; (3) removal of all central lines as soon as possible. Participation in national or statewide quality improvement collaboratives is an emerging trend in neonatology that can enhance CLABSI prevention efforts by NICUs.

Mortality and morbidity in outborn extremely low birth weight neonates: a retrospective analysis.

OBJECTIVE: We aimed to identify differences in morbidity and mortality between inborn versus outborn extremely low birth weight (ELBW) infants admitted to the Texas Children's Hospital neonatal intensive care unit (NICU). STUDY DESIGN: Vermont Oxford Network data were analyzed between January 2014 and December 2017. Inborn versus outborn outcomes were compared. RESULT: Of 533 ELBW infants, 402 were inborn, and 131 were outborn. Gestational age and birth weight (BW) were similar. After adjusting outcomes to control for maternal steroids, maternal hypertension, maternal prenatal care, and temperature below 36 °C at admission, no outcomes were significantly different except inborn patients had decreased odds of late onset sepsis (adjusted odds ratio = 0.606, 95% confidence interval: 0.377-0.973, p = 0.038). CONCLUSION: In this study, outborn ELBW patients had increased odds of late onset sepsis compared with inborn ELBW patients after controlling for covariates that differed significantly between these two cohorts.

Identifying a quality improvement project.

An important step on the roadmap to a successful quality improvement (QI) project is careful selection of topics and aims to be addressed by QI projects. Using information from a variety of data monitoring systems as well as individual events and experiences, leaders of neonatal units and QI teams should first identify quality and safety gaps in their unit. They should then use an explicit, formal process for selecting the best projects to which their limited time and resources should be allocated. Priority should be given to projects that address a quality gap of high magnitude and impact, have a high likelihood of success, have a champion, fit with the unit's state of readiness for change, have organizational support and align with organizational priorities. The scope of the project should also match the experience and expertise of the QI team.

Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization.

Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.

Focused Evidence-Based Medicine Curriculum for Trainees in Neonatal-Perinatal Medicine.

Introduction: While evidence-based medicine (EBM) is an Accreditation Council for Graduate Medical Education core competency, EBM teaching in pediatric subspecialties is rarely reported. Therefore, we designed, implemented, and evaluated this focused EBM curriculum for trainees in neonatal-perinatal medicine. Methods: This EBM curriculum consists of seven weekly 1-hour sessions. Specific EBM skills taught in the sessions include formulating a structured clinical question, conducting an efficient literature search, critically appraising published literature in both intervention and diagnostic studies, and incorporating evidence into clinical decision-making. The course was evaluated by a neonatology-adapted Fresno test (NAFT) and neonatology case vignettes, which were administered to learners before and after the curriculum. This publication includes the needs assessment survey, PowerPoint slides for the seven sessions, the NAFT, and the scoring rubric for the test. Results: The NAFT was internally reliable, with a Cronbach's alpha of .74. The intraclass correlation coefficient of the three raters' variability in assessment of learners was excellent at .98. Mean test scores increased significantly (54 points, p < .001) in 14 learners after the EBM curriculum, indicating an increase in EBM-related knowledge and skills. Discussion: This focused EBM curriculum enhances trainees' knowledge and skills and fosters evidence-based practice. The curriculum can be easily adapted for learners in pediatrics, as well as family medicine, in order to enhance trainees' EBM skills and knowledge.

Ethical Issues in Pediatric Global Health.

Children are vulnerable to the priorities and decision-making of adults. Usually, parents/caregivers make the difficult healthcare decisions for their children based on the recommendations from the child's healthcare providers. In global health work, healthcare team members from different countries and cultures may guide healthcare decisions by parents and children, and as a result ethical assumptions may not be shared. As a result, ethical issues in pediatric global health are numerous and complex. Here we discuss critical ethical issues in global health at an individual and organizational level in hopes this supports optimized decision-making on behalf of children worldwide.

Overview of surfactant replacement trials.

Clinical trials have evaluated the overall efficacy of surfactant therapy, as well as the relative efficacy of different surfactant preparations, the optimal timing of administration and the optimal dosage. Surfactant therapy leads to significant clinical improvement in infants at risk for, or having, respiratory distress syndrome (RDS). Clinical trials that compared the effects of synthetic or animal-derived surfactant preparations to placebo or no therapy demonstrate that surfactant therapy lead to rapid improvement in oxygenation, decreased ventilator support, decreased risk of pneumothorax, and mortality. Earlier treatment, prophylactic treatment of infants at high risk of developing RDS, and selective re-treatment leads to improved clinical outcome as well. Currently available animal-derived surfactants are superior to non-protein-containing synthetic surfactants. Ongoing evaluation will determine if important differences in animal-derived products are noted. Future trials will evaluate third-generation surfactant products and further refine what constitutes optimal use of surfactant.

Lung surfactants for neonatal respiratory distress syndrome: animal-derived or synthetic agents?

Exogenous surfactant therapy is widely used in the management of neonatal respiratory distress syndrome. Two types of surfactants are available: synthetic surfactants, and those derived from animal sources ("natural" surfactants). Both of these surfactants have been shown to be effective. In this article, we review the evidence to compare the two types of surfactants in terms of their physical properties, physiologic effects, and clinical outcomes. Natural surfactants have been shown to have advantages over synthetic surfactants in their physical properties and physiologic effects in animals, as well as in humans. A systematic review of 11 randomized clinical trials comparing natural and synthetic surfactants demonstrated that the use of natural surfactant preparations results in greater clinical benefits compared with synthetic surfactants. These benefits include a more rapid improvement in oxygenation and lung compliance after surfactant therapy, a decrease in the risk of mortality (typical relative risk 0.87; typical risk difference -0.02), and a decrease in the risk of pneumothorax (typical relative risk 0.63; typical risk difference -0.04). Although the use of natural surfactants results in a slightly increased risk of intraventricular hemorrhage (typical relative risk 1.09; typical risk difference 0.03), there is no increase in the risk of grade 3 or 4 intraventricular hemorrhage. There are theoretical but unproven risks of natural surfactants, such as transmission of infectious agents, immunogenicity and impurities in composition. The use of natural surfactants is preferred in most situations. In addition, clinicians should determine the costs of different types of surfactants in their individual practice settings and use this information in decision-making.

Quality improvement in neonatal care - a new paradigm for developing countries.

Infrastructure for facility-based neonatal care has rapidly grown in India over last few years. Experience from developed countries indicates that different health facilities have varying clinical outcomes despite accounting for differences in illness severity of admitted neonates and random variation. Variation in quality of care provided at different neonatal units may account for variable clinical outcomes. Monitoring quality of care, comparing outcomes across different centers and conducting collaborative quality improvement projects can improve outcome of neonates in health facilities. Top priority should be given to establishing quality monitoring and improvement procedures at special care neonatal units and neonatal intensive care units of the country. This article presents an overview of methods of quality improvement. Literature reports of successful collaborative quality improvement projects in neonatal health are also reviewed.

Education in Quality Improvement for Pediatric Practice: an online program to teach clinicians QI.

BACKGROUND: Education in Quality Improvement for Pediatric Practice (EQIPP) is an online program designed to improve evidence-based care delivery by teaching front-line clinicians quality improvement (QI) skills. Our objective was to evaluate EQIPP data to characterize 1) participant enrollment, use patterns, and demographics; 2) changes in performance in clinical QI measures from baseline to follow-up measurement; and 3) participant experience. METHODS: We conducted an observational study of EQIPP participants utilizing 1 of 3 modules (asthma, immunizations, gastroesophageal reflux disease) from 2009 to 2013. Enrollment and use, demographic, and quality measure data were extracted directly from the EQIPP system; participant experience was assessed via an optional online survey. RESULTS: Study participants (n = 3501) were diverse in their gender, age, and race; most were board certified. Significant quality gaps were observed across many of the quality measures at baseline; sizable improvements were observed across most quality measures at follow-up. Participants were generally satisfied with their experience. The most influential module elements were collecting and analyzing data, creating and implementing aim statements and improvement plans, and completing "QI Basics." CONCLUSIONS: Online educational programs, such as EQIPP, hold promise for front-line clinicians to learn QI. The sustainability of the observed improvements in care processes and their linkage to improvements in health outcomes are unknown and are an essential topic for future study.

In the 'gray zone,' a doctor faces tough decisions on infant resuscitation.

A neonatologist must decide whether to revive a premature baby on the borderline of viability.

Identification and collection of quality indicators for perinatal care.

We describe the development of a database of quality indicators and outcomes for perinatal care as part of a multi-institutional collaborative quality improvement project, Neonatal Intensive Care Quality 2002. Important principles of developing such a database are also discussed including eligibility criteria that identify high-risk patients without burdening data collectors, clinically important and well-defined measures, development of systems within each hospital to ensure identification of all eligible patients, use of data collectors with knowledge of perinatal care, appropriate design of paper and electronic data-collection tools, multiple pilot tests, and periodic feedback of data to participating hospitals.