Implementation of a Nurse-Driven Eat-Sleep-Console (ESC) Treatment Pathway at a Community Hospital for Treatment of Neonatal Opioid Withdrawal Syndrome in an Effort to Improve Short-term Outcomes.

BACKGROUND: The Chandler Regional Medical Center (CRMC) neonatal intensive care unit (NICU) began a phased implementation of Eat-Sleep-Console (ESC) for the management of those at risk for neonatal opioid withdrawal syndrome (NOWS). PURPOSE: The purpose of this initiative is to track short-term outcomes as well as the program's effect on nursing workflow and job performance rating/satisfaction. METHODS: A retrospective review of the ESC implementation process at CRMC from the years 2018-2020. The study consisted of 3 epochs: (1) traditional pharmacologic management; (2) parent-led ESC management; and (3) parent/nurse-led ESC management. Length of stay (LOS), treatment pathway assignment, and proportion of infants treated with pharmacologic agents were compared between epochs. In addition, a survey of NICU nursing staff was distributed to measure nurses' perceptions and attitudes towards the ESC program and the management of infants with NOWS. RESULTS: The proportion of infants treated via ESC increased (0%, 53%, and 100%), with an associated decrease in LOS (18.4, 10.5, and 9.3 days) during each epoch of the study period. Thirty-seven nurses completed the survey, with 94% of nurses reporting being comfortable caring for ESC patients and 89% feeling supported in their ESC nursing assignments, with only 11% stating that caring for ESC patients significantly alters their other nursing care processes. IMPLICATIONS FOR PRACTICE AND RESEARCH: Implementation of an ESC treatment program for infants with NOWS significantly decreased LOS and the proportion of infants treated pharmacologically. This phased implementation process was not associated with self-reported negative nursing perceptions of the program and its treatment goals/outcomes.

Universal Electrocardiographic Screening for Long QT Syndrome in Hospitalized Neonates.

OBJECTIVE: Long QT syndrome (LQTS) is a known cause of unexpected death, leading some to recommend routine neonatal electrocardiographic (ECG) screening. We used continuous electronic heart rate corrected QT interval (QTc) monitoring to screen for interval prolongation in a cohort of hospitalized neonates to identify those at a risk of having LQTS. We hypothesized that this screening method would yield an acceptable positive predictive value (PPV). STUDY DESIGN: A cohort of 589 infants hospitalized in a level II neonatal intensive care unit were screened through continuous electronic QTc monitoring linked to an investigator-designed, computerized data sniffer. Screening was conducted from days-of-life 3 through 7 or until hospital discharge. The data sniffer alerted investigators for a 24-hour average QTc of ≥475 ms. Positively screened patients were further evaluated with 12-lead ECG. RESULTS: Positive screens were obtained in 5.6% of patients, all of whom had negative follow-up ECG testing (PPV = 0%). Furthermore, one-quarter of positively screened neonates underwent echocardiography based on ECG findings, none of which identified clinically relevant pathology. CONCLUSION: Electronic monitoring of QTc in hospitalized neonates during the first week of life was not an efficient way to identify those at a risk of having LQTS. Conversely, screening triggered unnecessary testing.

Does Red Blood Cell Transfusion-Related Acute Lung Injury Occur in Premature Infants? A Retrospective Cohort Analysis.

Objective The objective of this study was to determine whether packed red blood cell (pRBC) transfusions in extremely low birth weight (ELBW) infants were associated with acute respiratory decompensation (ARD). Study Design Retrospective chart review of ELBW infant pRBC transfusions analyzed for meeting ARD criteria during the 6 hours post-pRBC transfusion was compared with the pretransfusion baseline period. A control period subdivided into similar pre- and postintervals was also assessed for each infant. ARD was defined as ≥ 1 of the following: (1) ≥ 10% increase in fraction of inspired oxygen from highest baseline, (2) ≥ 2 cm H2O increase from highest baseline in mean airway pressure, or (3) escalation in mode of respiratory support. Results A total of 238 pRBC transfusions occurred in 36 ELBW infants during 2012. Complete data for both the transfusion and control time periods existed for 110 pRBC transfusions (25 infants) and were included for analysis. The frequency of ARD was 15.5 and 18.2% (odds ratio, 1.25; p = 0.70) in the control and transfusion time periods, respectively. Conclusion pRBC transfusions in ELBW neonates are not associated with statistically significant rates of ARD compared with nontransfusion control time periods.

Outcomes of a Quality Improvement Initiative to Prevent Unnecessary Packed Red Blood Cell Transfusions Among Extremely Low Birth-Weight Neonates.

BACKGROUND: Extremely low birth-weight (ELBW) infants frequently receive packed red blood cell (PRBC) transfusions. Recent studies have shown that more restrictive PRBC transfusion guidelines limit donor exposure and reduce transfusion-related costs without any increase in adverse clinical outcomes. PURPOSE: We developed and implemented an evidence-based PRBC transfusion guideline for ELBW infants treated in our unit and then measured provider adherence to this guideline. METHODS/SEARCH STRATEGY: We performed a retrospective review of all PRBC transfusions given to ELBW infants in 2012 (preguideline) and the first half of 2014 (postguideline). We identified the indication for each transfusion by reviewing physiological/laboratory data and the daily clinical note. We then determine whether each transfusion met criteria according to our new evidence-based guideline. FINDINGS/RESULTS: When extrapolating the newly developed protocol to 2012 data, less than 15% of transfusions among ELBW infants would have met the current evidence-based standard. Conversely, during the first 6 months of 2014, 61% of transfusions were administered in adherence to the guideline (P < 001). Using current cost estimates, this represents a projected cost savings of $31,000 in that 6-month period. IMPLICATIONS FOR PRACTICE: A multidisciplinary approach to improving PRBC transfusion practices results in potentially safer, more cost-effective care for ELBW infants. IMPLICATIONS FOR RESEARCH: Given the frequency, potential harms, and costs associated with PRBC transfusions in ELBW infants, it seems both feasible and important to pursue prospective clinical trials comparing permissive and restrictive approaches to transfusion in this vulnerable population.

Predictive Ability of Direct Antibody Testing in Infants Born to Mothers with Rh(D) and Other Minor Red Blood Cell Antibodies.

OBJECTIVE: Hemolytic disease of the newborn (HDN) most commonly occurs in neonates whose mothers carry nonpassively acquired antibodies directed against red blood cell (RBC) antigens. Because affected neonates may develop severe hyperbilirubinemia, early identification of at-risk neonates is critically important. We hypothesized that use of the direct antibody test (DAT) would be of high predictive value in identifying those neonates most likely to meet treatment criteria for hyperbilirubinemia. STUDY DESIGN: We performed a retrospective chart review of all mother-infant pairs in which RBC antibodies were detected on routine prenatal screening during the current pregnancy (2011-2013). We then compared DAT results of neonates who eventually met the treatment criteria for hyperbilirubinemia with those who did not. MAIN RESULTS: Fifty-sixty neonates were born to mothers with clinically significant antibodies. The sensitivity and specificity of a positive DAT result for meeting the treatment criteria were 87.5 and 93.3%, respectively. The positive and negative predictive values were 77.8 and 96.6%, respectively. CONCLUSION: The result of a DAT, obtained in neonates of mothers with clinically relevant alloantibodies, is a specific marker with good positive predictive value for identifying those who are most likely to meet the treatment criteria for hyperbilirubinemia.

Clinical data needs in the neonatal intensive care unit electronic medical record.

BACKGROUND: The amount of clinical information that providers encounter daily creates an environment for information overload and medical error. To create a more efficient EMR human-computer interface, we aimed to understand clinical information needs among NICU providers. METHODS: A web-based survey to evaluate 98 data items was created and distributed to NICU providers. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the NICU. RESULTS: There were 23 responses (92% - response rate) with participants distributed among four clinical roles. The top 5 items with the highest mean score were daily weight, pH, pCO2, FiO2, and blood culture results. When compared by clinical role groupings, supervisory physicians gave individual data item ratings at the extremes of the scale when compared to providers more responsible for the daily clinical care of NICU patients. CONCLUSION: NICU providers demonstrate a need for large amounts of EMR data to help guide clinical decision making with differences found when comparing by clinical role. When creating an EMR interface in the NICU there may be a need to offer options for varying degrees of viewable data densities depending on clinical role.

Heart-rate-corrected QT interval evolution in premature infants during the first week of life.

Automated monitoring of the QT interval is increasingly common in a variety of clinical settings. A better understanding of how the heart-rate-corrected QT interval (QTc) evolves in early postnatal life is needed before its clinical utility in neonates can be determined. This study aimed to use real-time bedside monitoring as a tool to describe the QTc evolution of premature neonates during the first week of life. All neonates born at a gestation age (GA) of 31 weeks or later and admitted to the level 2 intensive care nursery of the authors' institution between December 2012 and March 2013 were included in this study. The authors prospectively collected QTc values at 15-min intervals during the first week of life, then used two-way analysis of variance (ANOVA) to compare these data among three GA cohorts: 31 to <34 weeks (cohort A), 34 to <37 weeks (cohort B), and ≥37 weeks (cohort C). All the cohorts demonstrated a statistically significant decline in the 24-h average QTc during the first 3-4 days of life before reaching a stable baseline. No diurnal variation in the QTc was identified in any of the study patients. Marked variability and a progressive decline in the QTc of premature neonates occur during the first 3-4 days of life. Understanding this phenomenon is imperative when screening programs for the early detection of QT prolongation are considered.

Perceptions and practices of therapeutic hypothermia in American neonatal intensive care units.

OBJECTIVE: In 2005, therapeutic hypothermia (TH) was used in few American neonatal intensive care units (NICUs) with great variability in practices. We hypothesized that TH would be used with greater frequency and uniformity today. STUDY DESIGN: We surveyed directors of 797 NICUs queried in our prior study to determine attitudes toward and practices of TH. RESULTS: Of the 781 participants with valid addresses, we received completed surveys from 330 (42.3%). There was an increase in the number of respondents who believed that TH is effective (85% versus 31%, p < 0.0001). More NICUs used TH (50% versus 6%, p < 0.0001) and nearly all not offering TH transferred eligible neonates to centers that did (97% versus 29%, p < 0.0001). There has been increased standardization of TH practices with regard to enrollment criteria, duration, and methods of monitoring. CONCLUSION: TH has become standard of care for the treatment of HIE in the United States. Most NICUs that use TH adhere to protocols, but variation still exists in TH practices.

Association of Early Inhaled Nitric Oxide With the Survival of Preterm Neonates With Pulmonary Hypoplasia.

Importance: Pulmonary hypoplasia affects a very small percentage of preterm neonates, but its presence is associated with high rates of mortality. Objective: To determine whether treatment with inhaled nitric oxide during the first week of life was associated with improved in-hospital survival in a cohort of extremely preterm neonates with pulmonary hypoplasia. Design, Setting, and Participants: This cohort study used data from the Pediatrix Medical Group's Clinical Data Warehouse, a data set containing information from more than 350 neonatal intensive care units in 35 US states and Puerto Rico. Since inhaled nitric oxide was not randomly prescribed, we used 1-to-1 propensity score matching to reduce the imbalance of measured covariates between the 2 treatment groups. The initial, unmatched cohort included singleton neonates who were born between 22 and 29 weeks' gestation, had a birth weight of 400 g or more, were diagnosed with pulmonary hypoplasia as a cause of their respiratory distress, remained free of major anomalies, and were discharged between January 1, 2000, and December 31, 2014. We defined exposure as the initiation of inhaled nitric oxide on day t in days 0 to 7 of the life of a neonate. Each exposed neonate was matched 1-to-1 to a neonate who had not initiated inhaled nitric oxide on a given day. Main Outcomes and Measures: The primary outcome was mortality defined as death prior to transfer or discharge home. Secondary outcomes were any-stage necrotizing enterocolitis, retinopathy of prematurity requiring treatment, chronic lung disease, and periventricular leukomalacia. Results: Among 92 635 neonates in our study sample, we identified 767 (0.8%) with pulmonary hypoplasia who met all study inclusion criteria, of whom 185 (0.2%) were exposed to inhaled nitric oxide. Among 151 matched pairs of exposed and unexposed neonates, we did not identify a significant association between inhaled nitric oxide use and mortality (hazard ratio [HR], 0.79; 95% CI, 0.57-1.11). Subgroup analyses of neonates with and without persistent pulmonary hypertension (PPHN) likewise revealed no significant association between inhaled nitric oxide use and mortality (pulmonary hypoplasia with PPHN: HR, 0.67; 95% CI, 0.45-1.01; pulmonary hypoplasia without PPHN: HR, 1.11; 95% CI, 0.61-2.02), but these findings may have been influenced by ascertainment bias. Conclusions and Relevance: Early treatment with inhaled nitric oxide is not associated with improved survival among extremely preterm neonates with pulmonary hypoplasia. Clinical trials are warranted to clarify the matter.

An appraisal of published usability evaluations of electronic health records via systematic review.

OBJECTIVE: In this systematic review, we aimed to evaluate methodological and reporting trends present in the current literature by investigating published usability studies of electronic health records (EHRs). METHODS: A literature search was conducted for articles published through January 2015 using MEDLINE (Ovid), EMBASE, Scopus, and Web of Science, supplemented by citation and reference list reviews. Studies were included if they tested the usability of hospital and clinic EHR systems in the inpatient, outpatient, emergency department, or operating room setting. RESULTS: A total of 4848 references were identified for title and abstract screening. Full text screening was performed for 197 articles, with 120 meeting the criteria for study inclusion. CONCLUSION: A review of the literature demonstrates a paucity of quality published studies describing scientifically valid and reproducible usability evaluations at various stages of EHR system development. A lack of formal and standardized reporting of EHR usability evaluation results is a major contributor to this knowledge gap, and efforts to improve this deficiency will be one step of moving the field of usability engineering forward.

Off-label use of inhaled nitric oxide after release of NIH consensus statement.

BACKGROUND: Inhaled nitric oxide (iNO) therapy is an off-label medication in infants <34 weeks' gestational age. In 2011, the National Institutes of Health released a statement discouraging routine iNO use in premature infants. The objective of this study was to describe utilization patterns of iNO in American NICUs in the years surrounding the release of the National Institutes of Health statement. We hypothesized that iNO prescription rates in premature infants have remained unchanged since 2011. METHODS: The Pediatrix Medical Group Clinical Data Warehouse was queried for the years 2009-2013 to describe first exposure iNO use among all admitted neonates stratified by gestational age. RESULTS: Between 2009 and 2013, the rate of iNO utilization in 23- to 29-week neonates increased from 5.03% to 6.19%, a relative increase of 23% (confidence interval: 8%-40%; P = .003). Of all neonates who received iNO therapy in 2013, nearly half were <34 weeks' gestation, with these infants accounting for more than half of all first exposure iNO days each year of the study period. CONCLUSIONS: The rates of off-label iNO use in preterm infants continue to rise despite evidence revealing no clear benefit in this population. This pattern of iNO prescription is not benign and comes with economic consequences.

Emergent thrombectomy in a neonate with an upper extremity arterial thrombus.

Case This case report is of a 39 (4/7)weeks infant who presented at the time of birth with an immobile, cyanotic right upper extremity consistent with ischemia but without evidence of gangrene. Doppler examination identified pulses in the axillary but not the brachial or radial arteries. Extremity arterial ultrasound confirmed the diagnosis of an arterial thrombosis extending from the right axillary artery to the brachial artery bifurcation. An emergent balloon thrombectomy was performed successfully with immediate return of blood flow. Intraoperative ultrasound demonstrated patent axillary and brachial arteries with forward flow. A retroperitoneal ultrasound and limited hypercoagulable workup failed to identify a source of the arterial thrombus. The infant had normal return of function without residual limb effects. Conclusion Emergent balloon thrombectomy should be heavily considered in neonates with an extremity arterial thrombosis of undeterminable duration both for limb salvage, preserve function, and to prevent long-term growth discordance.

Acute liver failure secondary to niacin toxicity.

A 17-year-old male was transferred to the pediatric intensive care unit for evaluation of acute liver failure. He was recently released from an alcohol treatment center with acute onset of chest pain. Cardiac workup was negative but he was found to have abnormal coagulation studies and elevated liver transaminases. Other evaluations included a normal toxicology screen and negative acetaminophen level. Autoimmune and infectious workups were normal providing no identifiable cause of his acute liver failure. He initially denied any ingestions or illicit drug use but on further query he admitted taking niacin in an attempt to obscure the results of an upcoming drug test. Niacin has been touted on the Internet as an aid to help pass urine drug tests though there is no evidence to support this practice. Niacin toxicity has been associated with serious multisystem organ failure and fulminant hepatic failure requiring liver transplantation. Pediatric providers should be aware of the risks associated with niacin toxicity and other experimental medical therapies that may be described on the Internet or other nonreputable sources.

QTc interval prolongation and severe apneas associated with a change in infant positioning.

For more than a decade there has been considerable interest in the role of QT interval prolongation in the pathogenesis of sudden infant death syndrome. It has been proposed that the QT interval is a surrogate marker for autonomic instability and can be used to identify infants at risk for significant morbidity and mortality, including sudden infant death syndrome. We present the case of an infant that experienced a significant increase in his QTc, as detected by continuous QTc monitoring in the NICU after repositioning from a supine to prone position. This increase from a 413 ± 6 millisecond baseline average to 500 milliseconds was sustained for 2 hours and associated with clinically relevant apnea that ultimately required repositioning of the infant back to the supine position. Repositioning resulted in an immediate decrease of the QTc back to the previous baseline and termination of the apneic events. This case demonstrates an example of how the use of continuous QTc monitoring in the NICU setting may be used to detect QTc-accentuating factors in real time and identify situations that cause perturbations in an infant's autonomic nervous system.

Infant race affects application of clinical guidelines when screening for drugs of abuse in newborns.

BACKGROUND: Screening for illicit drugs in newborns has privacy, social, and legal risks for families of the infants. Established drug-screening criteria may be applied in a manner that considers nonproven risk factors such as race in addition to evidence-based factors. OBJECTIVE: The goal of this study was to determine if race was used as a criterion for screening infants for intrauterine cocaine exposure. We hypothesized that infants of black mothers would be more likely to be screened regardless of whether they met the standard criteria for screening of our institution's NICU. METHODS: We used the electronic medical records of newborn infants and their mothers to determine which mother-infant pairs had documented evidence of meeting the criteria for screening infants for prenatal exposure to illicit drugs set forth in the guidelines of our NICU. We then assessed the rates of drug screening to determine the strongest predictors of whether an infant would be screened. RESULTS: We assessed 2121 mother-infant pairs. Infants born to black mothers were more likely than those born to white mothers to have screening performed whether they met screening criteria (35.1% vs 12.9%; P < .001) or did not (5.3% vs 1.2%; P < .001). In a logistic regression analysis, black race remained independently associated (odds ratio: 2.17 [95% confidence interval: 1.25-3.79]) with drug screening even when we controlled for our standard screening criteria and income, insurance status, and maternal education. CONCLUSION: Providers seemed to have used race, in addition to recognized risk criteria, as a factor in deciding whether to screen an infant for maternal illicit drug use.