Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology.

OBJECTIVE: We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals. STUDY DESIGN: Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models. RESULTS: The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries. CONCLUSION: Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable. KEY POINTS: · Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

Modeling the Cost of Teleneonatology from the Health System Perspective.

Introduction: Teleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs. Objective: To evaluate the cost of TN from the perspective of the health care system. Methods: We constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted. Results: For neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual care <12% (base-case = 82%), TN reducing the odds of transfer by <8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient). Conclusions: Economic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.

Low Utilization of Synchronous Telemedicine in Pediatric Critical Care Interfacility Transport: Barriers and Lessons.

OBJECTIVE: The use of telemedicine has increased and may enhance the care of children during medical transport. We aimed to evaluate the feasibility of synchronous telemedicine connectivity before interfacility transport of critically ill children by a pediatric transport team. METHODS: We performed a prospective, observational feasibility study of the introduction of synchronous telemedicine into an established pediatric transport team from 2019 to 2020. The outcomes examined included connectivity, physician workload, transport team satisfaction, and patient care outcomes. RESULTS: Among 118 eligible transports, telemedicine was considered in 23 transports (19%), including 11 transports in which an attempt to connect was sought and 12 in which telemedicine activation was offered but not attempted. The median connection time was 2.9 minutes (interquartile range, 1.7-4.4 minutes), and clinical care was altered in 1 case. Connection failed in 2 cases (18.2%). In 50% of cases, concurrent medical control physician workload prevented activation. There were no perceived benefits in 41.7% of cases. Team members indicated the desire for future telemedicine use in only 54.6% of cases. CONCLUSIONS: We found low utilization of synchronous telemedicine in interfacility pediatric transport. The identified barriers included reliable connectivity, physician workload, and low perceived benefit. Lessons learned and future research suggestions are presented to mitigate these barriers.

A Mixed-Methods Study on the Barriers and Facilitators of Telemedicine for Newborn Resuscitation.

BACKGROUND: Teleneonatology may improve the quality of high-risk newborn resuscitations performed by general providers in community settings. Variables that affect teleneonatology utilization have not been identified. INTRODUCTION: The objective of our mixed-methods study was to understand the barriers and facilitators experienced by local care providers who receive teleneonatology services. MATERIALS AND METHODS: In October 2015, an electronic survey was sent to 349 teleneonatology participants at 6 community hospitals to assess user satisfaction, technology usability and acceptability, and impact on patient care. From December 2015 to June 2016, 49 participants were involved in focus groups and individual interviews to better understand barriers and facilitators of teleneonatology implementation. Qualitative data were analyzed using a thematic approach. RESULTS: Survey response rate was 31.8% (N = 111). Of 93 survey respondents, 88 (94.6%) agreed that teleneonatology was needed at their hospitals, and of 52 participants, 50 (96.2%) believed that teleneonatology consults were helpful. We identified multiple facilitators and barriers to program implementation in education and training, process and work flow, communication, and technology. DISCUSSION: Local care teams believed that teleneonatology was valuable for connection to a remote neonatologist. Successful program implementation may be facilitated by communicating the value of teleneonatology, engaging local stakeholders in program training and education, maintaining supportive professional relationships, and designing simple, highly reliable clinical work flows. CONCLUSIONS: Teleneonatology is viewed as an innovative, valuable service by local care teams. The identified barriers and facilitators to program use should be considered when implementing a teleneonatology program.

Developing a Newborn Resuscitation Telemedicine Program: A Comparison of Two Technologies.

BACKGROUND: Early work has demonstrated the feasibility and acceptance of newborn resuscitation telemedicine programs (NRTPs). The technology requirements for providing this type of emergency telemedicine service are unclear. INTRODUCTION: We hypothesized that during NRTP consults, a wired telemedicine cart would provide a more reliable and higher-quality user experience than a consumer-grade wireless tablet. MATERIALS AND METHODS: In this retrospective observational study, six spoke sites used consumer-grade wireless tablets during preintervention and wired coder/decoder (CODEC)-based telemedicine carts during postintervention. Both technologies used the same videoconferencing software. After the telemedicine consult, providers completed surveys assessing connection reliability, user satisfaction, and audio and video quality using a 1-5 Likert scale. RESULTS: Preintervention, users completed 99 consults and 95 surveys. Postintervention, users completed 73 consults and 192 surveys. Successful connection on first attempt was significantly improved with the wired cart compared with the wireless tablet (82.7% vs. 69.5%, p = 0.01), and the percentage of consults complicated by an unplanned disconnection was reduced (6.4% vs. 14.7%, p = 0.02). User satisfaction and video and audio quality ratings were significantly higher for the wired cart. DISCUSSION: The wired telemedicine cart increased connection reliability, which is important given the critical nature and long duration of NRTP consults. Audio-video quality was also improved, allowing for better visualization of the neonate and communication with the care team. CONCLUSIONS: Consumer-grade wireless tablets did not meet the program's technical requirements. Wired telemedicine carts improved reliability, user satisfaction, and audio-video quality. Wired carts may not fully meet NRTP requirements because of cart size and limited mobility.

Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: a case-controlled study.

BACKGROUND: Neonatal encephalopathy (NE) affects 2-4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE. METHODS: Hospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case. RESULTS: Twenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1-144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0-135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p < 0.001) were significantly associated with hypoxic ischemic encephalopathy. The presence of a category 3 fetal heart rate tracing in any of the four 15-min segments during the hour prior to delivery (28.0% versus 4.0%, p = 0.002) was more common among hypoxic ischemic encephalopathy cases. CONCLUSION: Prolonged second stage of labor and the presence of meconium-stained amniotic fluid are risk factors for the development of HIE. Close scrutiny should be paid to labors that develop these features especially in the presence of an abnormal fetal heart tracing. Acute events also account for a substantial number of HIE cases and health systems should develop programs that can optimize the response to these emergencies.

Congenital diaphragmatic hernia: outcomes of neonates treated at Mayo Clinic with and without extracorporeal membrane oxygenation.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long-term comorbid conditions. AIMS: Our aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution. METHODS: We performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow-up. RESULTS: Thirty-eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver-up vs liver-down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01-0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20-73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO. CONCLUSION: The overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

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.

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.

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.

Workflow to develop 3D designed personalized neonatal CPAP masks using iPhone structured light facial scanning.

BACKGROUND: Continuous positive airway pressure (CPAP) is a common mode of respiratory support used in neonatal intensive care units. In preterm infants, nasal CPAP (nCPAP) therapy is often delivered via soft, biocompatible nasal mask suitable for long-term direct skin contact and held firmly against the face. Limited sizes of nCPAP mask contribute to mal-fitting related complications and adverse outcomes in this fragile population. We hypothesized that custom-fit nCPAP masks will improve the fit with less skin pressure and strap tension improving efficacy and reducing complications associated with nCPAP therapy in neonates. METHODS: After IRB approval and informed consent, we evaluated several methods to develop 3D facial models to test custom 3D nCPAP masks. These methods included camera-based photogrammetry, laser scanning and structured light scanning using a Bellus3D Face Camera Pro and iPhone X running either Bellus3D FaceApp for iPhone, or Heges application. This data was used to provide accurate 3D neonatal facial models. Using CAD software nCPAP inserts were designed to be placed between proprietary nCPAP mask and the model infant's face. The resulted 3D designed nCPAP mask was form fitted to the model face. Subsequently, nCPAP masks were connected to a ventilator to provide CPAP and calibrated pressure sensors and co-linear tension sensors were placed to measures skin pressure and nCPAP mask strap tension. RESULTS: Photogrammetry and laser scanning were not suited to the neonatal face. However, structured light scanning techniques produced accurate 3D neonatal facial models. Individualized nCPAP mask inserts manufactured using 3D printed molds and silicon injection were effective at decreasing surface pressure and mask strap pressure in some cases by more than 50% compared to CPAP masks without inserts. CONCLUSIONS: We found that readily available structured light scanning devices such as the iPhone X are a low cost, safe, rapid, and accurate tool to develop accurate models of preterm infant facial topography. Structured light scanning developed 3D nCPAP inserts applied to commercially available CPAP masks significantly reduced skin pressure and strap tension at clinically relevant CPAP pressures when utilized on model neonatal faces. This workflow maybe useful at producing individualized nCPAP masks for neonates reducing complications due to misfit.

Assessment of Clinician Diagnostic Concordance With Video Telemedicine in the Integrated Multispecialty Practice at Mayo Clinic During the Beginning of COVID-19 Pandemic From March to June 2020.

Importance: There was a shift in patient volume from in-person to video telemedicine visits during the COVID-19 pandemic. Objective: To determine the concordance of provisional diagnoses established at a video telemedicine visit with diagnoses established at an in-person visit for patients presenting with a new clinical problem. Design, Setting, and Participants: This is a diagnostic study of patients who underwent a video telemedicine consultation followed by an in-person outpatient visit for the same clinical problem in the same specialty within a 90-day window. The provisional diagnosis made during the video telemedicine visit was compared with the reference standard diagnosis by 2 blinded, independent medical reviewers. A multivariate logistic regression model was used to determine factors significantly related to diagnostic concordance. The study was conducted at a large academic integrated multispecialty health care institution (Mayo Clinic locations in Rochester, Minnesota; Scottsdale and Phoenix, Arizona; and Jacksonville, Florida; and Mayo Clinic Health System locations in Iowa, Wisconsin, and Minnesota) between March 24 and June 24, 2020. Participants included Mayo Clinic patients residing in the US without age restriction. Data analysis was performed from December 2020 to June 2021. Exposures: New clinical problem assessed via video telemedicine visit to home using Zoom Care Anyplace integrated into Epic. Main Outcomes and Measures: Concordance of provisional diagnoses established over video telemedicine visits compared against a reference standard diagnosis. Results: There were 2393 participants in the analysis. The median (IQR) age of patients was 53 (37-64) years; 1381 (57.7%) identified as female, and 1012 (42.3%) identified as male. Overall, the provisional diagnosis established over video telemedicine visit was concordant with the in-person reference standard diagnosis in 2080 of 2393 cases (86.9%; 95% CI, 85.6%-88.3%). Diagnostic concordance by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision chapter ranged from 64.7% (95% CI, 42.0%-87.4%) for diseases of the ear and mastoid process to 96.8% (95% CI, 94.7%-98.8%) for neoplasms. Diagnostic concordance by medical specialty ranged from 77.3% (95% CI, 64.9%-89.7%) for otorhinolaryngology to 96.0% (92.1%-99.8%) for psychiatry. Specialty care was found to be significantly more likely than primary care to result in video telemedicine diagnoses concordant with a subsequent in-person visit (odds ratio, 1.69; 95% CI, 1.24-2.30; P < .001). Conclusions and Relevance: This diagnostic study of video telemedicine visits yielded a high degree of diagnostic concordance compared with in-person visits for most new clinical concerns. Some specific clinical circumstances over video telemedicine were associated with a lower diagnostic concordance, and these patients may benefit from timely in-person follow-up.

A Scalable Framework for Telehealth: The Mayo Clinic Center for Connected Care Response to the COVID-19 Pandemic.

Background: The Mayo Clinic Center for Connected Care has an established organizational framework for telehealth care delivery. It provides patients, consumers, care teams, and referring providers access to clinical knowledge through technologies and integrated practice models. Central to the framework are teams that support product management and operational functions. They work together across the asynchronous, synchronous video telemedicine, remote patient monitoring (RPM), and mobile core service lines. Methods: The organizational framework of the Center for Connected Care and Mayo Clinic telehealth response to the COVID-19 pandemic is described. Barriers to telehealth delivery that were addressed by the public health emergency are also reported. This report was deemed exempt from full review by the Mayo Clinic IRB. Results: After declaration of the COVID-19 pandemic, there was rapid growth in established telehealth offerings, including patient online services account creation, secure messaging, inpatient eConsults, express care online utilization, and video visits to home. Census for the RPM program for patients with chronic conditions remained stable; however, its framework was rapidly adapted to develop and implement a COVID-19 RPM service. In addition to this, other new telehealth and virtual care services were created to support the unique needs of patients with COVID-19 symptoms or disease and the health care workforce, including a digital COVID-19 self-assessment tool and video telemedicine solutions for ambulances, emergency departments, intensive care units, and designated medical-surgical units. Conclusion: Rapid growth, adoption, and sustainability of telehealth services through the COVID-19 pandemic were made possible by a scalable framework for telehealth and alignment of regulatory and reimbursement models.

In Utero Restoration of Hindbrain Herniation in Fetal Myelomeningocele as Part of Prenatal Regenerative Therapy Program at Mayo Clinic.

OBJECTIVE: To assess our initial experience with prenatal restoration of hindbrain herniation following in utero repair of myelomeningocele (MMC). PATIENTS AND METHODS: Three consecutive patients with prenatally diagnosed MMC (between January 1, 2018 and September 30, 2018) were managed with open in utero surgery. As per institutional review board approval and following a protocol designed at the Mayo Clinic Maternal & Fetal Center, fetal intervention was offered between 19 0/7 and 25 6/7 weeks of gestation. Prenatal improvement of hindbrain herniation was the declared restorative end point. Obstetrical and perinatal outcomes were also assessed. RESULTS: Diagnosis of MMC was confirmed upon referral between 20 and 21 weeks' gestation by using fetal ultrasound and magnetic resonance imaging. In all cases reported here, the spinal defect was lumbosacral with evidence of hindbrain herniation. Open in utero MMC repair was performed between 24 and 25 weeks' gestation with no notable perioperative complications. Postprocedure fetal magnetic resonance imaging performed 6 weeks after in utero repair documented improvement of hindbrain herniation. Deliveries were at 37 weeks by cesarean section without complications. Most recent postnatal follow-ups were unremarkable at both 11 months (baby 1) and 3 months of age (baby 2), with mild ventriculomegaly. Antenatal and postnatal follow-up of baby 3 at 1 month of age was also unremarkable. CONCLUSION: Our study highlights the prenatal restoration of hindbrain herniation following in utero MMC repair in all cases presented here as an example of a prenatal regenerative therapy program in our institution.

Medical management of extremely low-birth-weight infants in the first week of life: a survey of practices in the United States.

We sought to determine the current practices of neonatologists in their management of extremely low-birth-weight (< 1000 g) infants. We directly mailed an anonymous survey to the medical directors of 809 neonatal intensive care units in the United States. More than one-third of those surveyed responded, with a substantial majority from intensive care (level III) nurseries or extracorporeal membrane oxygenation centers. Academic centers and private practice environments were both well represented. Some traditional practices have changed, such as beginning resuscitation with 40% rather than 100% oxygen. Many practices vary based on whether neonates are cared for in private versus academic centers, including initial resuscitation method, type of ventilation used, use of intraventricular hemorrhage prophylaxis, and routine antibiotic therapy. Parenteral nutrition composition and the use of inhaled nitric oxide differ based on the responding center's participation in clinical trials. The number of years in practice as a neonatologist does not affect practice decisions. Among all our findings, the prevalence of one potentially harmful practice, the continued use of dexamethasone for corticosteroid therapy, was particularly noteworthy. In conclusion, the strength of evidence does not always predict whether practices are adopted or abandoned. Further research is necessary to clarify the optimal management for this high-risk patient population.

Extracorporeal membrane oxygenation for the treatment of neonatal respiratory failure.

This review discusses the use of extracorporeal membrane oxygenation (ECMO) for the treatment of respiratory failure in neonates. After briefly reviewing the early history of neonatal ECMO, the authors describe the respiratory diagnoses most often treated with ECMO and the manner in which affected neonates are deemed to have "failed" conventional therapies and thus require ECMO. After reviewing the most common indications for ECMO, factors that influence the timing of conversion to extracorporeal life support, as well as criteria that may exclude patients from receiving ECMO therapy, are described. At the conclusion of this article, the authors discuss the long-term outcomes of neonates whose respiratory disease was treated with ECMO and the costs associated with that care.

Improving Infant Vaccination Status in a Level IV Neonatal Intensive Care Unit.

BACKGROUND AND OBJECTIVES: Infants in NICUs are at risk for underimmunization. Adherence to the routine immunization schedule recommended by the Advisory Committee for Immunization Practices minimizes the risk of contracting vaccine-preventable illnesses in this vulnerable population. From January 2015 to June 2017, only 56% (419 of 754) of the infants in our Mayo Clinic level IV NICU were fully up to date for recommended immunizations at the time of discharge or hospital unit transfer. We aimed to increase this rate to 80% within 6 months. METHODS: Using the quality improvement methodology of Define, Measure, Analyze, Improve, Control, we analyzed baseline data, including provider and nursing surveys using a fishbone diagram, the 5 Whys, and a Pareto chart. We identified 3 major root causes of the quality gap: lack of provider knowledge of the routine immunization schedule, failure of providers to order vaccines when due, and hesitancy of parents toward vaccination. Using plan-do-study-act cycles, 5 improvement interventions were implemented. These included an intranet resource for NICU providers on the routine immunization schedule, an Excel-based checklist to track when immunizations were due, and provider education on parental vaccine hesitancy and vaccine safety. RESULTS: During the 19-month improve and control phases of the project, the fully immunized rate at the time of NICU discharge or transfer rose from a baseline of 56% (419 of 754) to 93% (453 of 488), with a P value <.001. CONCLUSIONS: Our NICU significantly improved infant immunization rates with a small number of interventions. These interventions may be generalizable to other NICUs with low infant immunization rates.

Health Care Professionals' Perspectives on Teleneonatology Through the Lens of Normalization Process Theory.

BACKGROUND AND AIMS: Little research has been done on tele-intensive care unit (ICU) implementation across different types of ICUs, and there exist few studies that have used qualitative research methods to analyze the human and organizational factors influencing optimization of telemedicine for newborn resuscitation. The objective of this study was to understand health care professionals' acceptance, utilization, and integration of video telemedicine for newborn resuscitation (termed teleneonatology) in community hospital settings. METHODS: Focus group and individual interviews were conducted with 49 health care professionals at six affiliated health system hospitals. Data were gathered from physicians (n = 18), nurses (n = 30), and a nurse practitioner. Data were inductively analyzed using a thematic approach, and then constructs from normalization process theory (NPT) were deductively applied. NPT rendered a general framework to describe and assess how care teams perceive the implementation of teleneonatology and how they interact with this telemedicine service in their local setting. RESULTS: Local health care professionals accepted teleneonatology as an important, helpful service, yet its implementation was perceived as both valuable and a threat to professional traditions. Utilization may depend on perceived benefit, mutual understanding of the guidelines, and expectations of use, and other relational, human, contextual, and system factors. Participants in this study agreed on the need for collective work to successfully integrate teleneonatology into the local practice. DISCUSSIONS: NPT uncovered that successful implementation of a teleneonatology program may be facilitated by strong interpersonal relationships among care teams, continuous programmatic training and education, and communicating the clinical value of teleneonatology, including its opportunities and benefits.

The impact of telemedicine on the quality of newborn resuscitation: A retrospective study.

OBJECTIVE: We hypothesized that telemedicine consults provided by neonatologists to local care teams (termed teleneonatology) would improve the quality of high-risk newborn resuscitations that occur in community hospitals. METHODS: This retrospective cohort study compared 47 newborns who received a teleneonatology consult during their resuscitation at a community hospital to 45 controls who did not. Controls were matched on gestational age, sex, admission diagnosis, and level of newborn care. A two-person expert panel blinded to the intervention reviewed demographic and resuscitation data for each patient and assigned a resuscitation quality rating using a 1-10 descriptive rating scale. Paired comparisons between groups were evaluated using the Wilcoxon signed rank test for continuous measures and the McNemar's test for dichotomous measures. RESULTS: The median resuscitation quality rating was 7 for the teleneonatology group and 4 for the control group, with a median difference of 1 between matched pairs (P = .002). Neonates who received a teleneonatology consult were more likely to undergo measurement of temperature, glucose, and blood gases. When analyzing the 35 matched pairs that had a consult within one hour of birth, the positive impact of teleneonatology was greater (median rating 8 vs 4, median difference 2, P = .003). Subgroup analysis demonstrated teleneonatology significantly improved the resuscitation of preterm neonates (median rating 8 vs 4, median difference 1.5, P = .004) CONCLUSION: Teleneonatology improves the quality of high-risk newborn resuscitations that occur in community hospitals and increases adherence to process metrics. Earlier teleneonatology consults appear to have greater positive impact.