Growth Failure Prevalence in Neonates with Gastroschisis : A Statewide Cohort Study.

OBJECTIVES: To perform a multicenter study to assess growth failure in hospitalized infants with gastroschisis. STUDY DESIGN: This study included neonates with gastroschisis within sites in the University of California Fetal Consortium. The study's primary outcome was growth failure at hospital discharge, defined as a weight or length z score decrease >0.8 from birth. Regression analysis was performed to assess changes in z scores over time. RESULTS: Among 125 infants with gastroschisis, the median gestational age was 37 weeks (IQR 35-37). Length of stay was 32 days (23-60); 55% developed weight or length growth failure at discharge (28% had weight growth failure, 42% had length growth failure, and 15% had both weight and length growth failure). Weight and length z scores at 14 days, 30 days, and discharge were less than birth (P < .01 for all). Weight and length z scores declined from birth to 30 days (-0.10 and -0.11 z score units/week, respectively, P < .001). Length growth failure at discharge was associated with weight and length z score changes over time (P < .05 for both). Lower gestational age was associated with weight growth failure (OR 0.70 for each gestational age week, 95% CI 0.55-0.89, P = .004). CONCLUSIONS: Growth failure, in particular linear growth failure, is common in infants with gastroschisis. These data suggest the need to improve nutritional management in these infants.

Perioperative Quality Improvement in Children's Hospitals Neonatal Consortium NICUs.

Infants admitted to NICUs in children's hospitals represent a different population than those in a traditional birth hospital. The patients in a children's hospital NICU often have the most complex neonatal diagnoses and are cared for by various subspecialists. The Children's Hospitals Neonatal Consortium is a collaborative of more than 40 NICUs that collect data and perform quality improvement (QI) work across the United States and Canada. The collaborative's database provides an opportunity to benchmark clinical outcomes for this specialized population and to support the QI efforts. In this review, we summarize the success of individual collaborative QI projects focused on improving the care of the neonate in the perioperative period related to clinical team handoffs, postoperative hypothermia prevention, and improvement of postoperative pain management. The collaborative's experience can serve as a model for other national collaboratives seeking to support QI efforts.

Implementing Screening for Neonatal Delirium in the Neonatal Intensive Care Unit: A Quality Improvement Initiative.

Introduction: Delirium is not commonly diagnosed in neonatal intensive care units and can adversely impact patient outcomes in the ICU setting. Recognition of delirium in the NICU is a necessary first step to address the potential impact on neonatal outcomes. Methods: We conducted a quality improvement initiative implementing screening for neonatal delirium. We aimed to increase screening in NICU patients from 0% to 85% by March 2022. Interdisciplinary meetings were held with key stakeholders to develop a clinical algorithm. We used standardized tools for delirium screening. Our process measures included weekly nursing compliance with Richmond Agitation Sedation Scale/Cornell Assessment of Pediatric Delirium/ scoring documentation (Fig. 1) and patients referred to psychiatry. Outcome measures included the percentage of patients screened for delirium before discharge. We conducted Plan-Do-Study Act cycles to optimize the screening process in the electronic medical record (EMR). This included creating an order set, documentation flowsheets, and prompts in the EMR for patients. Results: After initial implementation, we achieved an average weekly screening compliance of 76% (Fig. 1). Inclusion criteria expansion resulted in a downward compliance shift to 59%. Subsequently, the addition of the EMR checklist resulted in a center-line shift to a sustained average weekly screening compliance of 77%. An average of 82% of all eligible NICU patients received delirium screening before discharge (Fig. 2). Conclusions: Using quality improvement methodology, there was increased screening and recognition of delirium in our NICU. Future research efforts could focus on assessing preventive measures and the impact of neonatal delirium on patient outcomes.

Association between consensus-based nutrition pathway and growth faltering in infants with gastroschisis: A retrospective cohort study.

BACKGROUND: The University of California Fetal Consortium published that 55% of infants with gastroschisis develop growth faltering by hospital discharge. To address this problem, we developed a nutrition pathway emphasizing (1) early provision of parenteral macronutrients, (2) use of human milk, and (3) growth faltering treatment. This study's goals were to assess adherence to and efficacy of this pathway in infants with gastroschisis across six California hospitals. METHODS: In 2015, the consortium standardized the care for infants with gastroschisis. To decrease growth faltering rates, between 2019 and 2020, nutrition guidelines were proposed, discussed, revised, and initiated. This study's primary outcome was weight or linear growth faltering (z score decline ≥0.8 in weight or length) at hospital discharge. Adherence measures were assessed. RESULTS: One hundred twenty-six infants with gastroschisis were born prepathway; 52 were born postpathway. Median gestational age was similar between cohorts. Adherence to components of the pathway ranged from 58% to 95%. The proportion of infants with weight or linear growth faltering at discharge was lower after pathway initiation (59.4% vs 36.2%, P = 0.0068). Adjusting for gestational age and fetal growth restriction, the pathway was associated with decreased weight or linear growth faltering (odds ratio [OR] 0.35 [0.16-0.75], P = 0.0060) and decreased linear growth faltering (OR 0.24 [0.096-0.56], P = 0.0062) at discharge. Hypertriglyceridemia, cholestasis, and days to full feeds were similar to published cohorts. CONCLUSION: Fewer infants with gastroschisis experienced weight or length growth faltering at hospital discharge following the implementation of a multicenter nutrition pathway.

High-stage Device-related Pressure Injury Reduction in a Neonatal Intensive Care Unit: A Quality Improvement Project.

Introduction: Pressure injuries are a common complication in neonatal intensive care settings, and neonates are at high risk for this hospital-acquired condition. Pressure injury rates in the neonatal intensive care unit (NICU) at Rady Children's Hospital were higher than reported national comparisons in 2018. Device-related high-stage hospital-acquired pressure injuries (HAPI) were the most common injury source. We aimed to reduce the rate of device-related high-stage HAPIs per 1,000 patient days by 30% within 12 months. Methods: We formed an interdisciplinary quality improvement (QI) task force to address device-related injury. The team identified opportunities and interventions and created care bundles using QI methodology. To engage staff, device-related HAPI data were shared at nursing and respiratory therapy meetings. The team and stakeholders chose metrics. Outcome, process, and balancing measures were analyzed and displayed on statistical process control charts. Results: Device-related HAPIs were reduced by 60% from 0.94 to 0.37 per 1,000 patient days. electroencephalography and CPAP-related events were decreased to 0 and sustained for 10 months. Conclusions: Interprofessional collaboration, and a strong reliance on data were keys to reducing high-stage pressure injuries. This approach can be replicated and implemented by other units experiencing similar challenges.

Initiative to Reduce Antibiotic Exposure of Asymptomatic Infants Born to Mothers with Intraamniotic Infection.

Infants born to mothers with intraamniotic infection (IAI) received antibiotic treatment per the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines in our neonatal intensive care unit (NICU) for early-onset bacterial sepsis evaluation. We conducted a quality improvement project to decrease antibiotic use and NICU admission in infants born to mothers with IAI. METHODS: We aimed to decrease the antibiotic exposure for asymptomatic infants born to mothers with IAI from 100% to 20% in 6 months. We obtained baseline data on these infants from January 2018 to January 2019, with the intervention starting in February 2019. A new standardized guideline to clinically monitor and follow laboratories on asymptomatic infants in couplet care was created with a multidisciplinary team's help and implemented after provider education. The team reviewed data monthly and used PDSA cycles to make necessary changes, including updating order sets, more educational handouts, and real-time coaching to both nurses and physicians. RESULTS: There was a dramatic decline (93%-0%) in antibiotic exposure and NICU admission after implementing this guideline. There was also a decrease in IAI diagnosis. There were no readmissions of infants for infection within 30 days of discharge, and there were no positive blood cultures. CONCLUSIONS: Implementing best antibiotic stewardship practices through a standardized guideline, testing, implementation of processes, and education by a multidisciplinary team limited the antibiotic exposure and NICU admissions for infants born to mothers with IAI with no known increase in readmissions.

Improving Accuracy of Handoff by Implementing an Electronic Health Record-generated Tool: An Improvement Project in an Academic Neonatal Intensive Care Unit.

BACKGROUND: Written patient handoffs are susceptible to errors or incompleteness. The accuracy is dependent on the person inputting the information. Thus, handoff printouts generated by electronic health records (EHR) with automation reduces the risk of transcription errors and improves consistency in format. This single-center quality improvement project aims to increase the accuracy of handoff printouts with an EHR-generated handoff tool. METHODS: This project used a plan-do-study-act methodology. Participants included registered nurses, neonatal nurse practitioners, neonatal hospitalists, pediatric residents, neonatal fellows, and neonatologists. The goals were to (1) increase accuracy of information to 80%, (2) reduce verbal handoff time by 20%, (3) reduce the frequency of incorrectly listed medications below 20%, and (4) improve user satisfaction by 1 point (on a 5-point Likert scale) over 6 months. Baseline assessment included a survey and a review of handoff reports 4 months before transitioning to the new handoff tool. We created a new handoff tool using EHR autogenerated phrases (Epic SmartPhrases) and autopopulated fields for pertinent Neonatal Intensive Care Unit patient data. RESULTS: After the unit-wide implementation of the new tool, the accuracy of 16 patient data points increased from 51% to 97%, while the frequency of patients with incorrectly listed medications decreased from 51% to 0%. Handoff time remained unchanged, while a 5-question user satisfaction survey showed an increase on the Likert scale. CONCLUSIONS: We demonstrated that handoff printouts generated by EHR have fewer inaccuracies than manually scripted versions and do not add to the time required to give verbal handoff.

Evaluation of two newborn resuscitation training strategies in regional hospitals in Ghana.

AIM: In Ghana, institutional delivery has been emphasized to improve maternal and newborn outcomes. The Making Every Baby Count Initiative, a large coordinated training effort, aimed to improve newborn outcomes through government engagement and provider training across four regions of Ghana. Two newborn resuscitation training and evaluation approaches are described for front line newborn care providers at five regional hospitals. METHODS: A modified newborn resuscitation program was taught at the Greater Accra Regional Hospital (GARH) and evaluated with real-time resuscitation observations. A programmatic shift, led to a different approach being utilized in Sunyani, Koforidua, Ho and Kumasi South Regional Hospitals. This included Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) training followed by objective structured clinical examinations (OSCE) with manikins at fixed intervals. Data was collected on training outcomes, fresh stillbirth and institutional newborn mortality rates. RESULTS: Training was conducted for 412 newborn care providers. For 120 staff trained at GARH, resuscitation observations and chart review found improvements in conducting positive pressure ventilation. For 292 providers that received HBB and ECEB training, OSCE pass rates exceeded 90%, but follow-up decreased from 98% to 84% over time. A decrease in fresh stillbirth and institutional newborn mortality occurred at GARH (p â€‹< â€‹0.05), but not in the other four regional hospitals. CONCLUSION: Newborn resuscitation training is warranted in low-resource settings; however, the optimal training, monitoring and evaluation approach remains unclear, particularly in referral hospitals. Although, mortality reductions were observed at GARH, this cannot be solely attributed to newborn resuscitation training.

A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems.

OBJECTIVE: Necrotizing enterocolitis (NEC) is a devastating intestinal disease in premature infants. Local rates of NEC were unacceptably high. We hypothesized that utilizing quality improvement methodology to standardize care and apply evidence-based practices would reduce our rate of NEC. STUDY DESIGN: A multidisciplinary team used the model for improvement to prioritize interventions. Three neonatal intensive care units (NICUs) developed a standardized feeding protocol for very low birth weight (VLBW) infants, and employed strategies to increase the use of human milk, maximize intestinal perfusion, and promote a healthy microbiome. RESULTS: The primary outcome measure, NEC in VLBW infants, decreased from 0.17 cases/100 VLBW patient days to 0.029, an 83% reduction, while the compliance with a standardized feeding protocol improved. CONCLUSION: Through reliable implementation of evidence-based practices, this project reduced the regional rate of NEC by 83%. A key outcome and primary driver of success was standardization across multiple NICUs, resulting in consistent application of best practices and reduction in variation.

Factors associated with readmission in late-preterm infants: a matched case-control study.

OBJECTIVE: The goal of this study was to evaluate risk factors for readmission among late-preterm (34-36 weeks' gestation) infants in clinical practice. METHODS: This was a retrospective, matched case-control study of late-preterm infants receiving care across 8 regional hospitals in 2009 in the United States. Those readmitted within 28 days of birth were matched to non-readmitted infants at a ratio of 1:3 according to birth hospital, birth month, and gestational age. Step-wise modeling with likelihood ratio tests were used to develop a multivariable logistic regression model. A subgroup analysis of hyperbilirubinemia readmissions was also performed. RESULTS: Of 1861 late-preterm infants delivered during the study period, 67 (3.6%) were readmitted within 28 days of birth. These were matched to 201 control infants, for a final sample of 268 infants. In multivariable regression, each additional day in length of stay was associated with a significantly reduced odds ratio (OR) for readmission (0.57, P = .004); however, for those infants delivered vaginally, there was no significant association between length of stay and readmission (adjusted OR: 1.08, P = .16). A stronger inverse relationship was observed in subgroup analysis for hyperbilirubinemia readmissions, with the adjusted OR associated with increased length of stay 0.40 (P = .002) for infants born by cesarean delivery but 1.14 (P = .27) for those delivered vaginally. CONCLUSIONS: Infants born via cesarean delivery with longer length of hospital stay have a decreased risk for readmission. As hospitals implement protocols to standardize length of stay, mode of delivery may be a useful factor to identify late-preterm infants at higher risk for readmission.