An initiative to reduce medication errors in neonatal care unit of a tertiary care hospital, Kolkata, West Bengal: a quality improvement report.

BACKGROUND: Medication errors are an emerging problem in various hospital settings, especially in neonates. A study conducted in the neonatal care unit of a tertiary institute in Kolkata as baseline over 3 months, revealed total error to be around 71.1/100 prescriptions (median medication error percentage: 63%). PURPOSE: To assess the occurrences of medication errors and determine efficacy of Point-of-Care Quality improvement (POCQI) model in reducing the same from baseline 63% to less than 10%, in the above setting within next 9 months. MATERIALS AND METHODS: This quality improvement initiative of quasi-experimental design comprised randomly selected prescriptions and monitoring sheets of neonates admitted in the neonatal care unit, obeying inclusion and exclusion criteria. Medication errors were assessed and categorised using a predesigned and pretested checklist. Interventions were planned after forming a quality improvement team in four plan-do-study-act (PDSA) cycles spanning over 6 weeks each (including training of doctors and nurses, signature and countersignatures of respective healthcare personnel, computer-generated prescriptions and newly designed software-generated prescriptions) as per POCQI model of the WHO and results in post-intervention phase (3 months) were compared. RESULTS: A total of 552 prescriptions and monitoring sheets of 124 neonates were studied. Median medication error percentages in first, second, third and fourth PDSA cycle were, respectively, 48%, 42%, 30% and 14%. Total error reduced to 10.4/100 prescriptions (p<0.005), with significant reduction in erred dosage, timing, interval, preparation and rate of infusion of drugs in prescriptions of the post-intervention phase. CONCLUSION: Implementation of change ideas via PDSA cycles, as per the POCQI model with technological aid, significantly decreased the percentage of medication errors in neonates, which was also sustained in the post-intervention phase and facilitated error-free prescriptions.

Clinical Profile and Short-Term Outcome of SARS-CoV-2-Infected Neonates from a Government Medical College in West Bengal, India.

INTRODUCTION: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has led to a terrifying global pandemic. The presentations in neonates are varied with less case severity compared to adults. AIM: To describe the clinical and laboratory features and outcomes of neonates admitted with SARS-CoV-2 infection during the second surge of COVID-19 pandemic in a Government Medical College, West Bengal, India. MATERIALS AND METHODS: It is a hospital-based observational cross-sectional study conducted in the newborn unit of Burdwan Medical College and Hospital between 1 April 2021 and 31 July 2021 including all SARS-CoV-2 Real time RT-PCR (Reverse transcriptase polymerase chain reaction) positive neonates. The demographic, clinical and laboratory characteristics of all the neonates and their outcomes were documented and analysed. RESULTS: Twenty-two neonates were found to be SARS-CoV-2 RT-PCR positive out of which 9 (40.9%) were found to be asymptomatic and 6 (27.27%) required neonatal intensive care unit admissions. Among the symptomatic neonates, most common presentations were respiratory distress (40.9%) and gastrointestinal manifestations (40.9%). Eight (36.36%) neonates required respiratory support. Three (13.6%) neonates had pneumonia of which one had right middle lobe collapse. Laboratory parameters were nonspecific except for the two (9%) cases of multisystem inflammatory syndrome in neonates. High-resolution computed tomography findings in two cases were suggestive of SARS-CoV-2 infection-induced changes. Two (9%) neonates died of which one was likely due to SARS-CoV-2 infection. CONCLUSION: Neonates with SARS-CoV-2 infection are mostly asymptomatic. However, clinicians must be vigilant as atypical presentations such as consolidation, collapse, meningitis or multisystem inflammatory syndrome may occur.

SARS-CoV-2 infection in neonates is rare with varied presentations ranging from asymptomatic neonates to a few presenting with multiorgan failure. The disease severity and case fatality are much less than in adults. We studied the clinical and laboratory features and outcomes of 22 neonates with SARS-CoV-2 infection during the second surge of COVID-19 pandemic. While nine (40.9%) neonates were asymptomatic, six (27.27%) required NICU admission. Pneumonia is a rare presentation in neonates but severe COVID-19 pneumonia resulting in consolidation and lobar collapse requiring positive pressure ventilation is a possibility. Multisystem inflammatory syndrome in neonates is also a clinical entity probably as a result of hyperinflammatory syndrome due to transplacental transfer of antibodies. They require rigorous treatment, close monitoring and regular follow-ups. Amniotic fluid, placental or cord blood testing is essential to ascertain the definite mode of transmission in these neonates.

A Novel Whole Spectrum-Based Non-Invasive Screening Device for Neonatal Hyperbilirubinemia.

OBJECTIVE: Careful screening of bilirubin level in newborns is mandatory as per American Academy of Pediatrics (2004), to reduce incidents of kernicterus and acute bilirubin encephalopathy. Although, invasive capillary collection of blood and subsequent biochemical test is considered a gold standard for jaundice detection in neonates, transcutaneous bilirubin measurement using various non-invasive instruments is also used sporadically across the globe. The major aim of this study was to develop a non-invasive spectrometry-based technique for measurement of neonatal bilirubin level as an alternative of total serum bilirubin (TSB) test without limitations of other available bilirubinometers. METHODS: The instrument comprises of a light source and a spectroscopic detector. A light beam from source incident on the neonatal nail plate through optical fibers. The retro reflected light is acquired using the detector. An indigenously developed software is used to acquire and analyze the optical signal and to calculate the bilirubin value. The instrument was calibrated and validated in reference to TSB on 1033 subjects. MAJOR RESULTS: The result (r = 0.95 and P < 0.001) indicates a strong correlation between the bilirubin value obtained from our method and TSB. Time variant analysis of the subjects undergoing phototherapy provided a good correlation (r = 0.98). The repeatability test result shows the mean coefficient of variation is less than 5.0%. CONCLUSIONS: The indigenously developed non-invasive technique successfully detects the bilirubin level in newborns under various physiological conditions with high accuracy and precision.

A Quality Improvement Initiative for Early Initiation of Emergency Management for Sick Neonates.

OBJECTIVE: To determine efficacy of Point-of-care Quality improvement (POCQI) in early initiation (within 30 minutes) of emergency treatment among sick neonates. DESIGN: Quality improvement project over a period of twenty weeks. SETTING: Special Newborn Care Unit (SNCU) of a tertiary care center of Eastern India. PARTICIPANTS: All consecutive sick neonates (≥ 28 wk gestation) who presented at triage during morning shift (8 am to 2 pm). INTERVENTION: We used a stepwise Plan-do-study-act (PDSA) approach to initiate treatment within 30 min of receiving sick newborns. After baseline phase of one month, a quality improvement (QI) team was formed and conducted three PDSA cycles (PDSA I , PDSA II and PDSA III) of 10 d each, followed by a post-intervention phase over 3 months. MAIN OUTCOME MEASURE(S): Percentage of sick babies getting early emergency management at SNCU triage. RESULTS: 309 neonates were enrolled in the study (56 in baseline phase, 88 in implementation phase and 212 in post- intervention phase). Demographic characteristics including birthweight and gestational age were comparable among baseline and post intervention cohorts. During implementation phase, successful early initiation of management was noted among 47%, 69% and 80% neonates following PDSA I, PDSA II and PDSA III, respectively. In comparison to baseline phase, the percentage of neonates receiving treatment within 30 minutes of arrival at triage increased from 20% to 76% (P<0.001) and the mean (SD) time of initiation of treatment decreased from 80.8 (21.0) to 19.8 (5.6) min (P<0.001) during post-implementation phase. Hospital mortality (33% vs 15%, P=0.004) and need for ventilator support (44% vs 18%, P<0.001) were also significantly lower among post intervention cohort in comparison to baseline cohort. CONCLUSION: Stepwise implementation of PDSA cycles significantly increased the percentage of sick newborns receiving early emergency management at the SNCU triage, thereby resulting in better survival.

Giant molluscum contagiosum: an unusual presenting complaint of paediatric HIV disease.

We report a widely disseminated, disfiguring facial molluscum contagiosum (MC) as a presenting complaint in an 11-year-old girl secondary to human immune-deficiency virus infection. A biopsy specimen demonstrated lobulated epidermal growth consisting of keratinocytes with large intracytoplasmic eosinophilic inclusion bodies. The patient was treated with highly active anti-retroviral therapy (HAART). The extent of MC in our patient was remarkable and subsequently improved dramatically after starting HAART. Normally MC does not similarly respond in patients with AIDS.

Assessment of normal portal vein diameter in children.

BACKGROUND AND AIM: The internal diameter of the portal vein varies with age and anthropometric parameters. The caliber of the normal portal vein in adults has been extensively studied but little is known about portal vein dimensions in the growing child. This study was conducted to establish standards of portal vein diameter by ultrasonography in healthy Indian children based on age, gender and anthropometric parameters. METHODS: Total 306 healthy children between the age of < 1 month and 12 years, visiting our outpatient departmentor accompanying their siblings were enrolled in the study. The children were distributed into ten age-groups. Each group was further divided in two sub-groups based on gender. Anthropometric parameters including weight, height and chest circumference were measured.Portal vein diameter was assessed by ultrasonography. RESULTS: The portal vein diameter increases with age, height, weight and chestcircumference. But the values are similar in boys and girls. Multiple logistic regression (adjusted R- square: 0.922) revealed age (p = 0.002), height/length (p < 0.0001), weight (p = 0.011), and chest circumference (p < 0.0001), as independent determinants of portal vein diameter. However, height/length emerged as the most consistent determinant (coefficient of regression: 1.536; p < 0.001; 95% confidence interval: 0.066-0.092). CONCLUSION: Our results provide a normal range of portal vein diameter according to age, gender and anthropometric parameters. We conclude that portal vein diameter strongly correlates with age and anthropometric variables like height, weight and chestcircumference,with height being the strongest determinant.

Successful outcome in a HIV infected child presenting with Pre-B Acute Lymphoblastic Leukemia.

The present case is a 5 y old child with Pre-B Acute Lymphoblastic Leukemia (ALL), presenting with fever, pallor, purpuric spots, hepato-splenomegaly and lymphadenopathy of 20 d duration. During re-induction chemotherapy, he developed atypical skin lesions diagnosed as Varicella Zoster infection. He and his parents tested positive for anti HIV antibody. He entered complete remission and Anti-retroviral therapy (ART) along with maintenance chemotherapy has been initiated 3 mon ago. Acute leukemia is rare in HIV and probably this is the first case of Pre-B Acute Leukemia in association with perinatally transmitted HIV.

Dengue infection with multi-organ involvement.

Fever, headache, body aches, retro-orbital pain, haemorrhage and shock are well known manifestations of dengue infection. We report the case of a 4-y-old child with dengue who presented with meningo-encephalitis and subsequently developed myelitis, hepatitis, glomerulonephritis and bone marrow suppression. Complete recovery occurred within 3 weeks.