Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates.

Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.

28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use.

OBJECTIVE: There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN: Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT: Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention. CONCLUSION: Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.

Blood culture procedures and practices in the neonatal intensive care unit: A survey of a large multicenter collaborative in California.

OBJECTIVE: To describe variation in blood culture practices in the neonatal intensive care unit (NICU). DESIGN: Survey of neonatal practitioners involved with blood culturing and NICU-level policy development. PARTICIPANTS: We included 28 NICUs in a large antimicrobial stewardship quality improvement program through the California Perinatal Quality Care Collaborative. METHODS: Web-based survey of bedside blood culture practices and NICU- and laboratory-level practices. We evaluated adherence to recommended practices. RESULTS: Most NICUs did not have a procedural competency (54%), did not document the sample volume (75%), did not receive a culture contamination report (57%), and/or did not require reporting to the provider if <1 mL blood was obtained (64%). The skin asepsis procedure varied across NICUs. Only 71% had a written procedure, but ≥86% changed the needle and disinfected the bottle top prior to inoculation. More than one-fifth of NICUs draw a culture from an intravascular device only (if present). Of 13 modifiable practices related to culture and contamination, NICUs with nurse practitioners more frequently adopted >50% of practices, compared to units without (92% vs 50% of units; P < .02). CONCLUSIONS: In the NICU setting, recommended practices for blood culturing were not routinely performed.

Sucrose analgesia: identifying potentially better practices.

OBJECTIVE: The objectives of this study were to review the use of oral sucrose for procedural pain management in NICUs, develop potentially better practice guidelines that are based on the best current evidence, and provide ideas for the implementation of these potentially better practices. METHODS: A collaboration of 12 centers of the Vermont Oxford Network worked together to review the strength of the evidence, clinical indications, dosage, administration, and contraindications and identify potential adverse effects for the use of sucrose analgesia as the basis of potentially better practices for sucrose analgesia guidelines. Several units implemented the guidelines. RESULTS: Through reviews and inputs from all centers of the evidence, consensus was reached and guidelines that included indication, dosage per painful procedure, age-related dosage over 24 hours, method of delivery, and contraindications were developed. CONCLUSIONS: Guidelines now are available from a consensus group, and suggestions for implementation of guidelines, based on implementation of other pain management strategies, were developed.

Moving toward safer practice: reducing medication errors in neonatal care.

Medication errors are a concern in all areas of health care, including neonatal units. In order to reduce errors and move toward safer practice, it is essential for clinicians to focus less on assigning blame to individuals and more on how these problems occurred. Only then will we fully understand the contributing factors and comprehensively address the reduction of medication errors. This article examines historical perspectives, contributing factors, and strategies for developing safer practice in neonatal care.