Development of a Novel Assessment Tool and Code Sepsis Checklist for Neonatal Late-Onset Sepsis.

BACKGROUND: Accurate diagnosis and timely management of neonatal late-onset sepsis (nLOS) have been less well-studied than those of early-onset sepsis. We noticed a delay in nLOS detection and management in our neonatal intensive care unit. PURPOSE: To develop an assessment tool to aid in the recognition and reporting of nLOS and to standardize the management process once sepsis is recognized. METHODS: The Plan-Do-Study-Act (PDSA) improvement model provided the framework for interventions for our antibiotic stewardship program, including the aims of this project. A literature review was performed to evaluate tools and other literature available to guide the evaluation and management of suspected sepsis. A quality improvement project was initiated to develop tools for the detection and management of nLOS. RESULTS: An nLOS assessment tool to help identify neonates at risk for nLOS and a Code Sepsis checklist to standardize the process of evaluation and management of nLOS were developed. The guiding principles of this tool development were empowerment of nurses to initiate the assessment process, clarification of team roles, and removal of barriers to appropriate antibiotic administration. IMPLICATIONS FOR PRACTICE: Useful and practical tools valued by nursing and the multidisciplinary team may facilitate timely identification and treatment of infants with nLOS. IMPLICATIONS FOR RESEARCH: Future directions include validation of the nLOS assessment tool and the Code Sepsis checklist as well as ensuring the reliability of the tool to improve detection of nLOS and to reduce time to administer antibiotics in cases of nLOS.

Reducing Antibiotic Use in a Level III and Two Level II Neonatal Intensive Care Units Targeting Prescribing Practices for Both Early and Late-onset Sepsis: A Quality Improvement Project.

Introduction: Variation in antibiotic (ATB) use exists between neonatal intensive care units (NICUs) without demonstrated benefit to outcomes tested. Studies show that early-onset sepsis occurs in up to 2% of NICU patients, yet antibiotics (ABX) were started in over 50% of neonates admitted to our NICUs. An internal audit identified variations in prescribing practices and excessive use of ABX. As a result, we introduced ATB stewardship to our NICUs in 2015 to reduce unnecessary usage of these medications. Methods: We used standard quality improvement methodology utilizing multiple iterative plan-do-study-act cycles during a 6-year project to test various interventions aimed at using ABX wisely. Specifically, our goals were to reduce ABX on admission (AA), percent of patients who continued on ABX beyond 72 hours of life (AC), and ATB utilization rate in our 3 NICUs by 28% for each metric. Interventions implemented included the development of an ATB stewardship program consisting of a multidisciplinary team that met regularly, creation of tools and guidelines for evaluations of sepsis and ATB use, universal use of the neonatal early-onset sepsis calculator for all newborns 34 weeks and older gestational age, education regarding noninitiation of ABX for maternal indications in clinically well newborns, and discontinuation within 48 hours for asymptomatic newborns with negative blood cultures. Results: AA, AC, and ATB utilization rate decreased by 34.1%, 45.3%, and 34.9%, respectively, in our 3 NICUs. Conclusions: By introducing ATB stewardship in our NICUs, we exceeded our predetermined goal of significantly reducing ATB usage.

Effect of Phenobarbital on Elevated Direct Bilirubin Concentrations in Neonates and Infants in the Neonatal Intensive Care Unit.

OBJECTIVE: Few studies have evaluated the effect of phenobarbital (PB) on elevated direct bilirubin (DB) plasma concentrations in neonates and infants, and none have compared its effect with a control group with matched study baseline DB values. The purpose of this study was to quantify changes in elevated DB plasma concentrations (≥2 mg/dL) in neonates and infants between a PB-treated and control group. METHODS: A retrospective, observational, matched, cohort study was performed comparing patients between a PB-treated group and a control group with similar study baseline plasma DB values ≥2 mg/dL over an 8-week period. The percent change in DB plasma concentrations from study baseline was compared for each week of the study period. RESULTS: During the 8-year study period, 310 patients had DB plasma concentrations ≥2 mg/dL, of which 26 remained in each group after exclusions. The PB group had increased DB concentrations and the control group had decreased DB concentrations when compared with their study baseline DB concentrations each week of the study period. By study end, the mean DB concentration increased by 11.2% in the PB group and decreased by 48.5% in the control group (p = 0.02). In multiple regression analysis, only birth weight (standardized coefficient = 0.44, p = 0.02), and gastrointestinal obstruction (standardized coefficient = -0.4, p = 0.03) were associated with significant percent change in DB concentrations. CONCLUSIONS: This study demonstrated PB does not improve cholestasis in neonates and infants.

Oral Versus Intravenous Medications for Treatment of Patent Ductus Arteriosus in Preterm Neonates: A Cost-Saving Initiative.

OBJECTIVE: The purpose of the study was to quantify cost savings after promoting oral pharmacotherapy for the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). METHODS: This was a retrospective before-and-after time series quality improvement study. Oral ibuprofen and acetaminophen use criteria were developed and recommended, rather than the more costly intravenous equivalents. There were 24-month medication use reports generated for both the pre-criteria (Era-1) and the post-criteria (Era-2) implementation phases to identify neonates prescribed hsPDA medications in order to assess cost differences. RESULTS: Era-1 had 190 treatment courses in 110 neonates for a total medication cost of $171,260.70. Era-2 had 210 courses in 109 patients for a total medication cost of $47,461.49, yielding savings of $123,799.21 ($61,899.61 annually) after criteria implementation. The reduction in intravenous ibuprofen use in Era-2 accounted for all the savings. CONCLUSION: Preferentially prescribing lower-cost oral medications to treat hsPDA led to significant cost savings.

A comparison of the glycemic effects of glucagon using two dose ranges in neonates and infants with hypoglycemia.

INTRODUCTION: Consensus regarding optimal glucagon dosing for management or diagnosis of neonatal/infant hypoglycemia has not been established. OBJECTIVE: To investigate glycemic effects of glucagon dosed ≤0.2 mg/kg (Gnlow) vs. >0.2 mg/kg (Gnhigh) in neonatal/infant hypoglycemia. STUDY DESIGN: Retrospective, observational, cohort study. RESULTS: Glucagon administration at any dose resulted in 75/77 (97.4%) samples meeting criteria for normoglycemia (plasma glucose >60 mg/dL), and plasma glucose increases of >30 mg/dL occurred in 74.2% vs. 63% (NS) of samples in the Gnlow and Gnhigh groups, respectively. Despite equivalent glucagon dosing, there was a trend toward smaller (<2500 g) patients achieving post-glucagon plasma glucose increases of >30 mg/dL less often than their bigger (≥2500 g) counterparts (60% vs. 74.1%, NS). CONCLUSIONS: Glucagon is highly effective in raising plasma glucose levels in neonatal/infant hypoglycemia. No differences in glycemic effects were noted between either dosing regimen. However, glycemic effects may be diminished in lower weight patients.

Delayed diagnosis of spontaneous intestinal perforation among very low birth weight neonates: A single center experience.

OBJECTIVE: To assess incidence and effect of delayed diagnosis of spontaneous intestinal perforation (SIP). STUDY DESIGN: Retrospective case series review of 58 VLBW neonates with SIP at our institution. RESULT: SIP was diagnosed in 6.1%, 10%, and 15.1% of VLBW, ELBW, and ≤750 g neonates, respectively. Abdominal distension (58.6%) and abdominal discoloration (53.4%) were the most common presenting signs/symptoms. Smaller (≤750 g) neonates were more likely to present with hypotension and higher FiO2, and larger (751-1500 g) neonates with increased abdominal girth and abdominal distension. All but one neonate had radiographic pneumoperitoneum, and 25.9% had pneumoperitoneum on an X-ray prior to the X-ray at SIP diagnosis. An education module reduced delay in SIP diagnosis. CONCLUSION: SIP presentation varies by birth weight and gestational age. Since SIP diagnosis is often first suggested on X-ray, all X-rays of VLBW neonates in the first 2 weeks of life should be scrutinized for pneumoperitoneum.

Variation in management of in-hospital newborn falls: a single-center experience.

OBJECTIVE There are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution. METHODS All NFs occurring within the authors' institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared. RESULTS There were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge. CONCLUSIONS There is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.

Acquired oral commissure defect: a complication of prolonged endotracheal intubation.

A number of complications during and following endotracheal intubation of infants are well described in the literature. We describe a rare case of an oral commissure defect acquired from prolonged endotracheal intubation in a ventilator-dependent preterm infant.

Inter-NICU variation in rates and management of thrombocytopenia among very low birth-weight infants.

OBJECTIVES: To investigate variation among neonatal intensive care units (NICUs) in prevalence and management of thrombocytopenia in infants <1500 g. STUDY DESIGN: In total 1283 infants &<1500 g admitted to six NICUs over 21 months were prospectively analyzed. Illness severity was measured by the Score for Neonatal Acute Physiology (SNAP). Platelet counts in the first 12 hours after birth and on day 3 of life were abstracted from the infants' medical records. Thrombocytopenia was determined from the lowest platelet count in each of these time periods. RESULTS: There was variability in rates of thrombocytopenia among NICUs, even after controlling for risk factors (e.g., SNAP, small for gestational (SGA) age and maternal hypertension). One site had a high prevalence of thrombocytopenia, but the lowest percentage of infants with thrombocytopenia who received platelet transfusions. After controlling for SNAP, GA, SGA, Apgar score and incidence of thrombocytopenia, the odds of receiving platelets at this site, relative to the site with the highest transfusion rate, was 0.10 (95% CI 0.02 to 0.43). CONCLUSIONS: This multicenter study finds a 10-fold variation among NICU in the administration of platelets to their thrombocytopenic infants that cannot be explained by presence of thrombocytopenia or illness severity.

Effects of flow amplitudes on intraprong pressures during bubble versus ventilator-generated nasal continuous positive airway pressure in premature infants.

OBJECTIVES: The goal were to characterize the flow dependence of bubble nasal continuous positive airway pressure delivery in a cohort of preterm infants and to compare the actual (delivered) intraprong continuous positive airway pressure with the intended (set) nasal continuous positive airway pressure for both ventilator-generated nasal continuous positive airway pressure and bubble nasal continuous positive airway pressure delivery. A range of set values and constant flow rates were studied in the same preterm infants. METHODS: For 12 premature infants of <1500 g (birth weight: 1140 +/- 267 g; gestational age: 28.5 +/- 1.9 weeks; study age: 12.9 +/- 8 days; all mean +/- SD), intraprong pressures were measured at 3 increasing flow settings, repeated for set nasal continuous positive airway pressures (or desired immersion depths) of 4 and 6 cm H(2)O. Next, intraprong pressures were measured at bubble nasal continuous positive airway pressure expiratory tubing submersion depths and ventilator-generated nasal continuous positive airway pressure set expiratory pressures of 2, 3, 4, 5, and 7 cm H(2)O while the flow rate was held constant. RESULTS: Actual (delivered) intraprong pressure during bubble nasal continuous positive airway pressure delivery was highly flow dependent and increased as the flow rate increased. During ventilator-generated nasal continuous positive airway pressure delivery, actual pressure at the nasal prongs closely approximated the pressure set at the ventilator. During bubble nasal continuous positive airway pressure delivery at constant flow rate, the average delivered prong pressure was 1.3 cm H(2)O (range: 0.5-2.2 cm H(2)O) higher than that set through submersion of the expiratory tubing, and the relative difference between the set and actual pressures increased at lesser immersion depths. CONCLUSIONS: Prong pressure during bubble nasal continuous positive airway pressure delivery is highly variable and depends on the interaction of submersion depth and flow amplitudes.

Unpredictability of delivered bubble nasal continuous positive airway pressure: role of bias flow magnitude and nares-prong air leaks.

Nasal continuous-positive-airway-pressure (NCPAP) is popular for infant respiratory support. We compared delivered to intended intra-prong, proximal-airway, and distal-airway pressures using ventilator (V-NCPAP) and bubble (B-NCPAP) devices. Measurements were repeated at five flows (4, 6, 8, 10, and 12 L/min) and three NCPAP (4, 6, and 8 cm H2O) under no, small, and large nares-prong interface leak conditions. With no-leak, delivered B-NCPAP was systematically greater than intended levels at all pressure sites. The corresponding V-NCPAP flow-dependence was none-to-minimal. Prong and intra-airway B-NCPAP overshoots were also observed with small-leak, while only prong B-NCPAP showed a flow-dependent overshoot for large-leak. Leaks did not affect intra-prong V-NCPAP but resulted in progressively lower than desired, flow-independent intra-airway V-NCPAP. We conclude that the self-adjusting capability of ventilators allows closely matched actual versus intended V-NCPAP. Alternatively, for the range of flows used clinically, intra-prong and intra-airway B-NCPAP are systematically higher at increasing flows than operator-intended levels, even when appreciable nares-prong leak is present. Additionally, the oscillations (noise) characterizing B-NCPAP are substantially attenuated between the proximal and distal airways; therefore, it is unlikely that B-NCPAP engenders ventilation or lung recruitment via this phenomenon. Tubing submersion depth for setting the level of B-NCPAP is highly inaccurate, and operators should instead rely on intra-prong pressure measurement.

Association of thrombocytopenia and delivery method with intraventricular hemorrhage among very-low-birth-weight infants.

OBJECTIVES: To investigate the significance of neonatal thrombocytopenia and delivery method on the incidence of intraventricular hemorrhage in infants weighing <1500 g. STUDY DESIGN: A total of 1283 infants weighing <1500 g who were admitted to six neonatal intensive care units over 21 months were analyzed prospectively. Illness severity was measured by the Score for Neonatal Acute Physiology (SNAP). RESULTS: Of the infants analyzed, 145 (11.3%) had thrombocytopenia (platelet count <100 x 10(9)/L). The incidence of intraventricular hemorrhage was greater among infants with thrombocytopenia than among those without (44.8% vs 23.9%, P <.0001). Non-thrombocytopenic infants who were delivered vaginally had a higher incidence of intraventricular hemorrhage than those delivered via cesarean section (35.8% vs 15.9%, P <.0001). Thrombocytopenic infants who were delivered vaginally had the highest incidence of intraventricular hemorrhage (63.4% vs 37.5% for cesarean section, P =.005). Vaginal delivery and platelets < 50 x 10(9)/L on day 1 were independent risk factors for intraventricular hemorrhage (OR 2.7, 95% CI 2.0-3.8 and OR 11.2, 95% CI 3.0-42.5, respectively). CONCLUSIONS: This multicenter study confirms that thrombocytopenia and intraventricular hemorrhage are not uncommon in neonates who weigh <1500 g, and that the incidence of intraventricular hemorrhage is higher in those thrombocytopenic infants delivered vaginally.