Reducing Noise in the NICU.

BACKGROUND: In the neonatal intensive care unit (NICU), elevated noise negatively impacts the neurodevelopmental environment, interrupts sleep, and can affect brain development in neonates. The American Academy of Pediatrics recommends that noise levels in the NICU should not exceed 45 dB. PURPOSE: The project aims were to: (1) decrease average noise level by 10% from baseline and (2) decrease exposure to severe noise (>65 dB) to <5% of the time. METHODS: This quality improvement project was conducted during 2021-2022 as a pre/post observational design in a Level IV NICU in New York City. We monitored sound levels for 20-24 h, 5 d/wk. Quality improvement interventions included: novel approaches to staff education, visual cues for when noise thresholds were exceeded, parent education, including access to personal decibel meters, technical improvements to vital sign monitors and entry doors, and defined quiet times (HUSH) for 2 h each 12-hour shift. RESULTS: Education efforts and technical improvements successfully reduced median noise levels within the stepdown unit ( P < .001), though not in the acute care NICU. In contrast, the implementation of 2-hour periods of enforced "quiet time" every 12 h effectively reduced both median noise levels and the incidence of severe noise (>65 dB) in both locations. IMPLICATIONS FOR PRACTICE AND RESEARCH: The HUSH strategy may be a sustainable way to decrease noise in the NICU. Future projects should prioritize education and dedicated quiet times to align with recommended standards, while research should explore the long-term developmental impacts of excessive noise levels on neonatal growth.

Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative.

OBJECTIVE: To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support. SETTING: Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA). STUDY POPULATION: Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration. RESULTS: LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation. CONCLUSIONS: Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Lung ultrasound assessment of pulmonary edema in neonates with chronic lung disease before and after diuretic therapy.

INTRODUCTION: Bronchopulmonary dysplasia (BPD) is characterized by lung injury with varying degrees of disrupted alveolarization, vascular remodeling, inflammatory cell proliferation, and pulmonary edema. Diuretics are often used to ameliorate the symptoms or progression of BPD. Our primary objective was to use lung ultrasound (LUS) to determine if diuretics decrease pulmonary edema in infants with BPD. The secondary objective was to assess changes in respiratory support during the first week after initiation of diuretics. METHODS: Premature infants requiring noninvasive respiratory support and starting diuretic therapy for evolving BPD were compared with a similar group of infants not receiving diuretics (control). For the diuretic group, LUS exams were performed before and on Days 1, 3, and 6 after initiation of treatment. For the control group, LUS was performed at equivalent time points. A composite pulmonary edema severity (PES) score of 0-5 was calculated based on the total number of B-lines in six scanned areas. Respiratory support parameters (FiO2 , nasal cannula flow, or CPAP) were also recorded. RESULTS: Infants in the diuretic (n = 28) and control (n = 23) groups were recruited at median corrected gestational ages of 34.2 (33.3-35.9) and 34.0 (33.4-36.3) weeks, respectively (p = 0.82). PES scores, FiO2 , and respiratory flow support decreased significantly from Days 0 to 6 (p < 0.0001, p = 0.001, and p = 0.01, respectively) in the diuretic group, but not in the control group. CONCLUSION: Diuretic use is associated with decreased pulmonary edema and improved oxygenation in infants with BPD during the first week of treatment.

Correlation between visual inspection/physical exam and point-of-care ultrasound exam in the evaluation of neonatal peripheral intravenous catheter site.

BACKGROUND: A peripheral intravenous catheter (PIVC) is used to administer IV fluids and medications. The most common PIVC complication is peripheral intravenous extravasation and infiltration (PIVE/I). Early visual inspection and physical exam (VI/PE) of the insertion site performed by a registered nurse (RN) are essential to prevent or limit tissue damage caused by displaced PIV catheters. Skin ultrasound (US) of the PIVC site provides rapid, real-time, high-resolution images of the anatomic structures at the point of care (POC). OBJECTIVES: To correlate the standard practice of clinical assessment (VI/PE) with POC-US exam to determine the location and function of PIVC suspicious for malfunctioning. DESIGN/METHODS: PIVC sites suspicious of malfunctioning were assessed by RN and findings were recorded in the electronic medical record. POC-US exam of the PIVC site was performed immediately after VI/PE. Sonographic exam included B-mode assessment of the PIVC site subcutaneous tissue characteristics and PIVC location as assessed by the Doppler flow tracing during RN's normal saline flush. RN's decision to continue or discontinue the PIVC was based solely on her/his VI/PE. RESULTS: Forty-four infants were studied. We found sufficient disagreement between the two methodologies (p = .0074), with discordance noted in 15 (34.1%) cases. In 29 (65.9%) cases there was concordance between VI/PE and POC-US, 18 to remove and 11 not to remove PIVC (Gwet AC1 correlation coefficient = 0.34). There was no significant correlation between VI/PE finding of tissue edema, the most common initial clinical evaluation sign, and POC-US finding of tissue edema or fluid pockets (p = .67, p = .21 respectively). RN's findings during the PIVC flush with normal saline (NS) were in perfect agreement with the findings of the Doppler signal on POC-US (Gwet's AC1 = 0.82) as well as with the final US-based decision to remove PIVC (p < .0001). CONCLUSION: We found only a fair correlation between RN's VI/PE of the suspicious PIVC site and the POC-US exam of the same site. However, our data suggest that in the evaluation of questionable PIVC, POC-US could be used in conjunction with VI/PE. This combination may improve the accuracy of decisions to remove or maintain PIVCs, which will result in a decreased number of PIVC placement attempts and complications.

Point-Of-Care Ultrasound as an Adjunct in the Diagnosis of Neonatal and Pediatric Superficial Soft Tissue Infection: A Report of Two Cases.

Considerable technological advances, good safety profile, and ease of use have converged to support the use of ultrasound (US) as an important adjunct in the evaluation of superficial soft tissue infections (SSTI) in general and the differential diagnosis of cellulitis and abscess in particular. However, its use in neonatal populations has not been described. Pediatric studies report clinical examination is not always a reliable method of distinguishing cellulitis from abscess. Two (2) case reports are presented to supplement the growing body of published data that describe US imaging of SSTIs. In both cases, the US exam included the affected area as well as contralateral or adjacent normal skin for comparison. Case 1 describes a preterm infant boy who required placement of a peripheral intravenous (PIV) line and subsequently developed warm, painful, erythematous, and indurated skin in the area of the insertion. Point-of-care US (POC-US) was used to diagnose cellulitis, which initiated treatment with intravenous antibiotics. Case 2 involves a 7-year-old boy with multiple comorbidities who developed a PIV extravasation-related injury that subsequently progressed to cellulitis, likely secondary to wound infection with methicillin-resistant Staphylococcus aureus. Both patients healed completely and without any complications. Because treatment of cellulitis is different from that of abscess, it is important to obtain real-time data supportive of an accurate diagnosis. In these cases, POC-US confirmed the clinical diagnosis of cellulitis and ruled out the presence of an abscess.