Cell Phones in the Neonatal Intensive Care Unit: How to Eliminate Unwanted Germs.

BACKGROUND: Infants admitted to the neonatal intensive care unit (NICU) are more susceptible to infections due to immature immune systems or invasive procedures that compromise protection from bacteria. These infants may stay in the NICU for extended periods of time, are exposed to many caregivers, and may be exposed to other infections. Cell phone use by both family and staff introduce unwanted bacteria into the NICU environment, thereby becoming a threat to this high-risk population. PURPOSE: A quality improvement initiative to evaluate and improve the cleanliness of cell phones used in the NICU. METHODS: A convenience sample of 18 NICU parents and staff. The participants' cell phones were sampled for bacteria pre- and postcleaning with disinfectant wipes and sent to the microbiology laboratory for a 2-day incubation period. In addition, each participant completed a survey on cell phone cleaning habits. RESULTS: Microbial surface contamination was evident on every phone tested before disinfecting. All phones were substantially less contaminated after disinfection. IMPLICATIONS FOR PRACTICE: A standardized cleaning process with a surface disinfectant reduced the amount of germs and potential transmission of nosocomial pathogens within the NICU. The simple exercise illustrated the importance of cell phone hygiene in a high-risk population. The implementation of a simple cleaning process has been an easy and effective way to rid unwanted organisms from this high-risk population. IMPLICATIONS FOR RESEARCH: Further research evaluating transmission of nosocomial infections from cell phones would enhance the evidence to establish hospital policies on cleaning devices.

The 5-minute Apgar score: survival and short-term outcomes in extremely low-birth-weight infants.

The Apgar score is a standardized tool for evaluating newborns in the delivery room. Despite its long history and widespread use, debate remains over its reliability of predicting neonatal outcomes, especially in extremely low-birth-weight premature infants. The aim of the study was to examine the relationship between the 5-minute Apgar score of extremely low-birth-weight infants, as it relates to survival and morbidities associated with prematurity and length of hospital stay. A retrospective query of the Alere neonatal database from 2001 to 2011 examined all infants less than 32 weeks' gestation and less than 1000-g birth weight. The 5-minute Apgar score was divided into 2 groups, score of 4 or greater or less than 4. The study compared results of the 5-minute Apgar score and associated morbidities in surviving infants. Statistical analyses included chi-square, Fisher exact test, t test, and multivariate regression. The sample consisted of 3898 infants with an 86.4% (n = 3366) survival rate. Controlling for gestational age and birth weight, surviving infants with a 5-minute Apgar score of less than 4 were more likely to demonstrate nonintact survival. Infants with a low 5-minute Apgar score have greater risk for mortality and morbidities associated with prematurity.

Do premature female infants really do better than their male counterparts?

We compared survival and outcomes in process of care in female versus male infants born ≤32 weeks gestational age (GA). Data were obtained from the Alere database for infants born ≤32 weeks GA. Females were compared with males for demographics, complications, and care processes. Univariate and multivariate analysis was conducted using chi-square analysis, analysis of variance, or logistic regression. Of the infants included, 6086 female and 6721 males were included. Mean GA did not differ, males were born larger than females, and females were more likely to be born SGA. Males received more surfactant, developed more CLD, received more steroids, and more often required oxygen at discharge. Females were more likely to develop a patent ductus arteriosus. After controlling for body weight, GA, and small-for-GA status, females were more likely to survive (95.4% versus 93.6%, odds ratio 1.63, P < 0.01). Male sex did not play a role in other processes of care except for weaning to a crib. Male infants born ≤32 weeks GA have a decreased rate of survival and an increased rate of respiratory morbidity in spite of higher birth weight distributions. Sex did not play a role in other processes of care.

Outcomes and milestone achievement differences for very low-birth-weight multiples compared with singleton infants.

We examined if very low-birth-weight (VLBW) infants of multiple gestation pregnancies experience more complications and take longer to achieve clinical milestones compared with similar singletons. We performed a retrospective analysis of all infants less than 1500 g at birth in a large neonatal database. Singletons were compared with twins and higher-order multiples for demographic, morbidities, and process milestones including feeding, respiratory, thermoregulation, and length of stay. Multivariable regression analyses were performed to control for potential confounding variables. A total of 5507 infants were included: 3792 singletons, 1391 twins, and 324 higher-order multiples. There were no differences in Apgar scores, small for gestational age status, and incidence of necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, sepsis, bronchopulmonary dysplasia, or the need for surgery. Multiples had higher rates of apnea and patent ductus arteriosus than singletons. VLBW multiples achieved milestones at similar rates in most areas compared with singletons except for the achievement of full oral feedings. Length of stay, after controlling for confounding variables, did not differ between the groups. Compared with singletons, VLBW multiples had similar morbidity and achieved most feeding and thermoregulation milestones at similar rates.

Practice variation in suspected neonatal sepsis: a costly problem in neonatal intensive care.

OBJECTIVE: The most common admission to intensive care nurseries is the infant with suspected neonatal sepsis. To determine the clinical practice of neonatologists with respect to this diagnosis, we examined a large neonatal database during a 2-year period of time. The goal of this study was to define whether there were optimal practice strategies that could identify a "benchmark" clinical approach for this diagnosis. DESIGN: The PROACT database of ParadigmHealth was examined for all term infants with an admitting ICD - 9 code for suspected neonatal sepsis between January 1, 2001 and December 31, 2002. Infants had to be asymptomatic by 24 hours of life with no significant respiratory signs and receiving oral feedings. All infants had negative blood cultures. Maternal risk factors were examined to determine if they influenced the duration of therapy. The impact of treatment upon subsequent length of stay was also evaluated. Several areas of the country were individually examined to see if possible regional variations existed with respect to treatment of suspected sepsis. RESULTS: There were no significant differences noted in the management when maternal risk factors for suspected sepsis were assessed. In general, neonates were treated for 3.3+/-1.8 to 3.5+/-2.1 days, regardless of the number of maternal risk factors present at birth (p=NS). Length of stay ranged from 4.2+/-2.1 to 4.4+/-1.9 days in these groups (p=NS). The duration of treatment ranged from 1 to 10 days, even though all infants were clinically well and feeding by 24 hours of life. A total of 170 infants (17.0%) were treated for 4 to 6 days and 116 (11.6%) neonates received antibiotics for 7 to 10 days, even with negative blood cultures. One region of the country appeared to treat infants for a longer period of time than the other four regions examined, increasing the mean length of stay by 1.8 days (p<0.05). CONCLUSIONS: Treatment of neonates with suspected sepsis appears to be influenced by considerations other than maternal risk factors or the infant's clinical condition beyond the first day of life. There appears to be a great deal of practice variation among neonatologists confronted by patients with suspected sepsis. Awareness of this unnecessary variation may be of great value in reducing the duration of antibiotic therapy in the NICU and shortening the length of stay.

Early caffeine therapy for prevention of bronchopulmonary dysplasia in preterm infants.

OBJECTIVE: To determine if an early commencement of caffeine is associated with improved survival without bronchopulmonary dysplasia (BPD) in preterm infants. METHODS: Retrospective data analysis from the Alere Neonatal Database for infants weighing ≤1250 g, and treated with caffeine within the first 10 days of life. The neonatal outcomes were compared between the infants who received early caffeine (0-2 days) with the infants who received delayed caffeine (3-10 days). RESULTS: A total of 2951 infants met the inclusion criteria (early caffeine 1986, late caffeine 965). The early use of caffeine was associated with reduction in BPD (OR 0.69, 95% CI 0.58-0.82, p < 0.001) and BPD or death (OR 0.77, 95% CI 0.63-0.94, p = 0.01). Other respiratory outcomes also improved with the early commencement of caffeine. The frequency of severe intraventricular hemorrhage and patent ductus arteriosus was lower and the length of hospitalization was shorter in infants receiving early caffeine therapy. However, early use of caffeine was associated with an increase in the risk of nectrotizing enterocolits (NEC) (OR 1.41, 95% CI 1.04-1.91, p = 0.027). CONCLUSION: Early commencement of caffeine was associated with improvement in survival without BPD in preterm infants. The risk of NEC with early caffeine use requires further investigation.

Are outcomes and care processes for preterm neonates influenced by health insurance status?

OBJECTIVE: The purpose of this work was to compare the processes of care and to evaluate outcomes of premature neonates delivered to women with Medicaid managed care versus private insurance. DESIGN/METHODS: All of the infants born at <37 weeks' gestation between January 2001 and August 2005 in the ParadigmHealth database were included in these analyses (n = 24151). Infants were categorized by maternal health insurance status as private insurance or Medicaid managed care and analyzed for differences in demographic data and length of stay. For survivors, differences in respiratory care, nutritional, and maturational milestones were assessed. In addition, age to wean to open crib, weight gain, home oxygen, and apnea monitor use were compared. Adverse outcomes, including necrotizing enterocolitis, sepsis, severe intraventricular hemorrhage, severe retinopathy of prematurity, bronchopulmonary dysplasia, apnea, and mortality, were compared. Statistical tests used were Students t test, chi(2), and Kruskall-Wallis test. Multiple logistic regression was performed after controlling for demographic variables. RESULTS: Of the 24151 infants studied, 19046 (78.9%) had private insurance, and 5105 (21.1%) had Medicaid managed care. There were no differences in gestational age at birth; however, Medicaid managed care infants had lower birth weight, lower Apgar score at 5 minutes, increased incidence of necrotizing enterocolitis and bacterial sepsis, and longer length of stay. Of the surviving infants, more neonates with private insurance went home on oxygen and apnea monitors despite no differences found in the incidences of apnea or bronchopulmonary dysplasia between the groups. There were no differences in processes of care for feeding and respiratory milestones, but infants with Medicaid managed care weaned to an open crib later and had greater overall weight gain compared with infants with private insurance. CONCLUSIONS: We speculate that, in addition to the known impact of insurance status on well-being at birth, Medicaid managed care is independently associated with adverse neonatal outcomes in preterm infants, as well as differences in neonatal intensive care discharge processes.

Changing use of surfactant over 6 years and its relationship to chronic lung disease.

OBJECTIVES: Our goals were to identify the trend of surfactant use over a 6-year period and to determine whether a relationship exists between the incidence of chronic lung disease in infants born weighing <1000 g who receive surfactant and those who do not. METHODOLOGY: Data regarding surfactant use, incidence of chronic lung disease, nasal continuous positive airway pressure use and duration, and demographic data were collected from the Alere (formerly ParadigmHealth) database from 2001 to 2006 (n = 3086). Groups were compared by using chi(2) test, analysis of variance, or Student's t test. RESULTS: Use of surfactant has decreased over time from 67% in 2001 to 59.9% in 2006. Infants who received surfactant were more likely to develop chronic lung disease. Those who received >1 dose of surfactant were more likely to develop chronic lung disease when compared with infants treated with only 1 dose. Chronic lung disease rates have risen over time from 47.8% in 2001 to 57.8% in 2006. There was no difference in survival between groups. CONCLUSIONS: Despite the findings that surfactant use decreased during the study period and the rate of chronic lung disease increased, the data do not support a connection. Infants who receive surfactant are more likely to develop chronic lung disease, and chronic lung disease rates are stable in those infants not treated with surfactant. It is concerning, however, that 60% of infants not receiving surfactant developed chronic lung disease.

Differences in short-term neonatal outcomes between discordant twins.

PURPOSE: To evaluate short-term outcomes associated with discordant twin pairs admitted to the NICU. DESIGN: A retrospective descriptive study comparing discordant twin pairs. SUBJECTS: Three hundred eighty-four discordant twin pairs were included. Mean gestational age of the twin pairs was 32.6 weeks (range, 24-39). METHODS: The ParadigmHealth database was queried for all twin admissions from January 2001 to June 2004 admitted to 453 NICUs across the United States. Discordance was calculated for each twin set as defined as greater than 20% difference in birth weight. Exclusion criteria were death of a twin, congenital anomalies, or extracorporeal life support. MAIN OUTCOME MEASURES: Demographics, respiratory needs, feeding characteristics, complications, and discharge needs. RESULTS: A total of 384 discordant twin pairs met inclusion criteria. The larger twins required more ventilation/continuous positive airway pressure (55% vs 44%, P < .01) and/or oxygen therapy (50% vs 41%, P = .02) compared with smaller twins. Smaller twins reached full oral (PO) feeds an average of 0.6 weeks later than larger twins (P < .0001) but had more weight gain per day. Smaller twins transitioned to an open crib at lower weights but at slightly greater age. No differences were noted with necrotizing enterocolitis or apnea. Smaller twins had increased nosocomial infections. Mean length of stay was shorter (P = .0036) in the larger twin group. Only 33% of the twin pairs were discharged on the same day. CONCLUSIONS: Larger twins had more acute respiratory issues but achieved certain milestones more rapidly with fewer complications, thus leading to earlier discharge compared with their smaller twin counterparts.

Clinical outcomes and cost of the moderately preterm infant.

PURPOSE: The purpose of this study is to define the incidence of admission and morbidities and the economic impact of moderately preterm infants in the neonatal intensive care unit (NICU). DESIGN: A retrospective descriptive study. SUBJECTS: All infants born between 32 to 34 weeks' gestational age (GA) (n=4932) followed by ParadigmHealth, a care management company, from January 2001 through June 2004 were evaluated. Infants with major congenital anomalies were excluded. This sample represented 453 NICUs in 24 states in the United States. METHODS: Retrospective data analysis. Infants born between 32 and 34 weeks' GA were studied (n=4932). This subset of patients in the NICU was compared to the entire population in the database (n=19,923) for incidence and cost comparison. Infants were followed for 2 weeks after hospital discharge. MAIN OUTCOME MEASURES: Demographics, feeding characteristics, respiratory needs, complications, discharge needs, and patient costs. RESULTS: The 4932 infants admitted to the NICU with gestational ages of 32 to 34 weeks represented 24.8% of the 19,923 admissions during this time period. This cohort experienced low mortality (0.5%) and had an average length of stay (LOS) of 17.6 days. The average cost per case was $31,000, representing 21.6% of total NICU costs. Fifty-four percent of infants experienced respiratory compromise, requiring ventilation, continuous positive airway pressure, or oxygen during their hospital course. Fifty-six percent required intravenous nutrition, and 19% of these patients were discharged home with ongoing medical needs and the use of durable medical equipment. CONCLUSIONS: Although morbidities with long-term consequences were rare, there is a significant burden on the infant, family, and healthcare team for patients 32 to 34 weeks' GA. It is important to understand the characteristics of this group of infants and explore ways of optimizing care to minimize this burden.