Reducing MRSA Infection in a New NICU During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is prevalent in most NICUs, with a high rate of skin colonization and subsequent invasive infections among hospitalized neonates. The effectiveness of interventions designed to reduce MRSA infection in the NICU during the coronavirus disease 2019 (COVID-19) pandemic has not been characterized. METHODS: Using the Institute for Healthcare Improvement's Model for Improvement, we implemented several process-based infection prevention strategies to reduce invasive MRSA infections at our level IV NICU over 24 months. The outcome measure of invasive MRSA infections was tracked monthly utilizing control charts. Process measures focused on environmental disinfection and hospital personnel hygiene were also tracked monthly. The COVID-19 pandemic was an unexpected variable during the implementation of our project. The pandemic led to restricted visitation and heightened staff awareness of the importance of hand hygiene and proper use of personal protective equipment, as well as supply chain shortages, which may have influenced our outcome measure. RESULTS: Invasive MRSA infections were reduced from 0.131 to 0 per 1000 patient days during the initiative. This positive shift was sustained for 30 months, along with a delayed decrease in MRSA colonization rates. Several policy and practice changes regarding personnel hygiene and environmental cleaning likely contributed to this reduction. CONCLUSIONS: Implementation of a multidisciplinary quality improvement initiative aimed at infection prevention strategies led to a significant decrease in invasive MRSA infections in the setting of the COVID-19 pandemic.

An Initiative to Decrease Laboratory Testing in a NICU.

BACKGROUND AND OBJECTIVES: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period. METHODS: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time. RESULTS: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months. CONCLUSIONS: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.

A novel and accurate method for estimating umbilical arterial and venous catheter insertion length.

OBJECTIVE: To develop a novel, rapid, and more accurate model for estimating umbilical arterial (UAC) and venous catheter (UVC) insertion length. STUDY DESIGN: We evaluated UACs and UVCs from a retrospective cohort to determine the rate of correct initial positioning based on conventional birth weight-based equations utilized in our neonatal intensive care unit. We then derived new equations, developed the mobile application, UmbiCalc, to simplify implementation of the new equations, and validated their accuracy with prospective utilization. RESULTS: The conventional equations successfully predicted insertion length in 69% (364 of 524) of UACs and only 36% (194 of 544) of UVCs. Our new model was prospectively applied to 68 UAC and 80 UVC placements with successful initial positioning achieved in 90% [95% CI, 80.2-94.9] and 76% [95% CI, 65.9-84.2], respectively. CONCLUSIONS: Our novel approach more accurately estimates UAC and UVC insertion length.

Gastrointestinal Zygomycosis in a Preterm Neonate Associated With Contaminated Probiotics.

A neonate of 29 weeks' gestation who received probiotics developed clinical signs suggesting surgical necrotizing enterocolitis. A specimen of resected ileum revealed fungal forms within the bowel wall. Rhizopus oryzae was detected via DNA sequencing from probiotic powder and tissue specimens from the infant. To our knowledge, this is the first report linking gastrointestinal zygomycosis to the administration of contaminated probiotics.

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome.

OBJECTIVES: This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN: We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS: The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS: Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Current training in percutaneously inserted central catheter (PICC) placement and maintenance for neonatal-perinatal medicine fellows.

OBJECTIVE: To describe the current educational status of percutaneously inserted central catheter (PICC) insertion/ maintenance training for neonatal-perinatal medicine (NPM) fellows in the United States. STUDY DESIGN: A cross-sectional 34-question survey was electronically distributed to NPM fellowship training program directors (PDs) in the United States. RESULTS: The response rate was 81.8% (81/99 PD). Most PDs (68.5%) reported that their neonatal intensive care unit has a PICC team. Fellows were PICC team members in 72%. Only 52% of programs offer formal training in PICC placement to fellows; 61.5% of these utilize a standardized curriculum. Dedicated PICC team existence was negatively associated with formal training for PICC insertion and maintenance for fellows (42.0% with PICC team vs. 73.91% without, p = 0.01). CONCLUSIONS: Wide variation exists in fellow's exposure, education, and competency assessment in PICC-related activities nationally. Development of a standardized curriculum would be beneficial.

Umbilical catheter-associated complications in a level IV neonatal intensive care unit.

OBJECTIVE: To assess complication rates and risks associated with the use of umbilical catheters. STUDY DESIGN: An observational cohort study was conducted in a level IV neonatal intensive care unit over 11 years. Any neonate with an umbilical catheter placed during this period was included. Complication event rates over time were assessed via Poisson and Cox regressions. RESULTS: Fifty one of 2035 umbilical arterial catheters (2.5%) and 269 of 2017 umbilical venous catheters placed (13.3%) developed a complication. Positional issues comprised most umbilical venous catheter-associated complications (86.2%) and breaks/ruptures the majority in umbilical arterial catheters (41.2%). The cumulative incidence of a complication increased most notably after 10 days of umbilical arterial catheter use and 16 days of umbilical venous catheter use. CONCLUSIONS: Complications occurred in a relatively low percentage of umbilical catheters placed in our neonatal intensive care unit. Extended catheter dwell time remains a significant risk of developing a complication.

Shifting focus toward healthcare-associated bloodstream infections: The need for neonatal intensive care unit-specific NHSN definitions.

OBJECTIVE: Healthcare-associated bloodstream infections (HABSIs) are a significant cause of mortality and morbidity in the neonatal intensive care unit (NICU) population. Our objectives were to review the epidemiology of HABSIs in our NICU and to examine the applicability of National Healthcare Safety Network (NHSN) definitions to the NICU population. METHODS: We performed a retrospective review of all neonates admitted to the 54-bed, level IV NICU at Yale-New Haven Children's Hospital with a HABSI between January 1, 2013, and December 31, 2018. Clinical definitions per NICU team and NHSN site-specific definitions used for source identification were compared using the McNemar χ2 test. RESULTS: We identified 86 HABSIs with an incidence rate of 0.80 per 1,000 patient days. Only 13% of these were CLABSIs. Both CLABSIs and non-catheter-related bloodstream infections occurred primarily in preterm neonates, but the latter were associated with a significantly higher incidence of comorbidities and the need for respiratory support. The NHSN definitions were less likely to identify a source compared to the clinical definitions agreed upon by our NICU treating team (P < .001). Furthermore, 50% of patients without an identified source of infection by NHSN definitions were bacteremic with a mucosal barrier injury organism, likely from gut translocation. CONCLUSIONS: HABSIs occur primarily in premature infants with comorbidities, and CLABSIs account for a small proportion of these infections. With the increasing focus on HABSI prevention, there is a need for better NHSN site-specific definitions for the NICU population to prevent misclassification and direct prevention efforts.

Risk factors for tracheostomy requirement in extremely low birth weight infants.

AIM: To identify variables that affect the risk of tracheostomy in a population of extremely low birth weight (ELBW) infants. METHODS: A retrospective matched case-control study was conducted. ELBW infants with a tracheostomy were compared with controls without tracheostomy. Data collection included demographics, detailed information about each intubation and extubation attempt, the use of steroids and the presence of comorbidities. Statistical analyses include conditional logistic regression and Poisson regression for clustered observations. RESULTS: Twenty-eight ELBW infants with a tracheostomy were identified. Mean gestational age for both cases and controls was 25 weeks (22-29) and 67.9% were males. Tracheostomy was performed on average on day of life 118 (95%CI: 107-128) and weight at tracheostomy was 2877 g (95%CI: 2657-3098). In the final model, cumulative days with an endotracheal tube (ETT) and total number of intubation episodes were associated with a tracheostomy. For each additional day of intubation, odds of tracheostomy increased by 11% (OR = 1.11, 95%CI: 1.01, 1.23) and with each new intubation episode/failed extubation episode, odds of tracheostomy increased by 150% from the previous episode (OR = 2.5, 95%CI: 1.2, 5.2). CONCLUSIONS: Greater cumulative exposure to ETT ventilation and number of intubations is associated with having a tracheostomy.

Is Extracorporeal Membrane Oxygenation for a Neonate Ever Ethically Obligatory?

Certain interventions in the neonatal intensive care unit are considered ethically obligatory, and should be provided over parental objections. After reviewing a case, comparative outcome data, and relevant ethical principles, we propose that extracorporeal membrane oxygenation for meconium aspiration syndrome may, in some cases, be an ethically obligatory treatment.

Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit.

OBJECTIVE To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP). DESIGN Quasi-experimental, interrupted time-series study. SETTING A 54-bed, level IV NICU in a regional academic and tertiary referral center. PATIENTS AND PARTICIPANTS All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion. INTERVENTION Implementation of a NICU-specific ASP beginning July 2012. METHODS We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance. RESULTS Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time. CONCLUSIONS Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices. Infect Control Hosp Epidemiol 2017;38:1137-1143.

An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.

Central line-associated bloodstream infections in the NICU: Successes and controversies in the quest for zero.

Central line-associated bloodstream infections (CLABSI) are among the most common healthcare-acquired infections in the neonatal intensive care unit (NICU) population and are associated with an increased risk of morbidity and mortality, as well as increased healthcare costs, and duration of hospitalization. Over the past decade, numerous local, statewide, and national quality improvement initiatives have resulted in a significant reduction in CLABSI rates. The majority of successful initiatives have utilized similar strategies to implement and sustain their efforts, including education of NICU staff in the principles of quality improvement, creation and implementation of central line insertion and maintenance bundles and methods for assessing compliance, formation of dedicated central line insertion and maintenance teams, and utilization of reliable and effective methods for collecting, analyzing, and displaying data. Despite this progress, continued work toward discovery of better practices, such as the safest and most effective agent for cutaneous antisepsis or identification of optimal outcome and process measures, is required if further progress is to be made. Additionally, sustained progress in reducing the burden of neonatal infections may require a shift in focus away from CLABSI and toward the reporting, investigation, and prevention of all NICU-onset bacteremia.

Biochemical Screening for Pulmonary Hypertension in Preterm Infants with Bronchopulmonary Dysplasia.

BACKGROUND: Pulmonary hypertension (PH) in infants with bronchopulmonary dysplasia (BPD) is associated with increased morbidity and mortality. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and decreased levels of amino acid precursors of nitric oxide (NO) have been associated with PH, but have not been studied in infants with PH secondary to BPD. OBJECTIVE: The aim of this study was to identify a biochemical marker for PH in infants with BPD. METHODS: Twenty infants, born at <27 weeks' gestational age (GA) and/or with a birth weight (BW) ≤750 g, who met the criteria for BPD at 36 weeks' corrected GA (CGA) were enrolled in this cross-sectional pilot study. A screening echocardiogram was conducted at 36-38 weeks' CGA and plasma NT-proBNP and amino acid levels were obtained within 1 week of the screening echocardiogram. RESULTS: Five infants (25%) had echocardiographic evidence of PH. GA and BW were not significantly different between the 2 groups (a PH group and a No PH group). NT-proBNP was significantly elevated in the PH group (median 1,650 vs. 520 pg/ml; p = 0.001) but citrulline levels were significantly lower (median 21 vs. 36 µmol/l; p = 0.005). Arginine levels were not significantly different between the groups (median 78 vs. 79 µmol/l; p = 1). CONCLUSION: NT-proBNP and the NO precursor citrulline may be cost-effective biochemical markers for screening for the presence of PH in preterm infants who have BPD. If validated in a larger study, such biochemical markers may, in part, replace PH screening echocardiograms in these patients.