Prevalence and Predictors of Back-Transport Closer to Maternal Residence After Acute Neonatal Care in a Regional NICU.

Objectives To describe the demographics, clinical characteristics and referral patterns of premature infants to a regional level IV neonatal intensive care unit (NICU); to determine the prevalence and predictors of back-transport of infants ≤ 32 weeks gestational age in a level IV NICU; for infants not back-transported closer to maternal residence, determine the length of stay beyond attainment of clinical stability. Methods Data (2010-2014) from the Children's Hospital Neonatal Database and individual chart review for infants ≤ 32 weeks admitted to a level IV NICU whose maternal residence was outside the metro area were included. Bivariate associations of maternal and infant characteristics with back-transport were estimated using two-sample t tests and Fisher's exact test. Multivariable logistic regression was used to measure independent predictors of back-transport. Clinical stability was defined as the attainment of full volume enteral feedings and low flow nasal cannula. Results A total of 223 infants were eligible for analysis; of whom 26% were back-transported after acute care. In the adjusted analysis, insurance status, distance from maternal residence and gestational age were significantly associated with back-transport. For infants not back-transported closer to maternal residence, median length of stay in the level IV NICU beyond attainment of clinical stability was 28.5 days. Conclusion for Practice Predictors of back-transport include private insurance, greater distance of maternal residence from NICU and younger gestational age. Many preterm infants admitted to a regional NICU for acute care remained hospitalized in a level IV NICU after achieving clinical stability, for which care in a NICU closer to maternal residence may be appropriate.

A Quality Initiative for Optimal Therapeutic Hypothermia during Transport for Neonates with Neonatal Encephalopathy.

INTRODUCTION: Neuroprotection with therapeutic hypothermia (TH) is standard of care for neonatal encephalopathy (NE) and decreases death and neurodevelopmental disability. TH initiated shortly after birth insult results in greater neuroprotection compared with delayed initiation. METHODS: Quality improvement methodology was used to improve temperature control during transport to a level IV neonatal intensive care unit. We included neonates with NE transported to a single institution for TH from 2010 to 2016. The quality improvement interventions were 2-fold. Review of the Transport Body Cooling Protocol revealed a suboptimal temperature goal of 34-35°C; this protocol was revised to 33-34°C. The second intervention was the implementation of an active cooling protocol. Clinical characteristics were compared using 2-sample t tests for continuous variables and Fisher's exact tests for categorical variables; statistical process control chart was used to monitor admission temperatures. RESULTS: We obtained baseline data for 78 neonates admitted from 2010 to 2014. These data were compared with postintervention data for 26 patients admitted between 2015 and 2016. Distance transported, NE severity, and seizures were similar between the 2 groups. The use of active cooling increased from 8% preimplementation to 31% postimplementation (P < 0.01). After implementation of the 2 interventions, more infants were admitted within the goal temperature of 33-34°C, 58% versus 22% (P < 0.01), and the average neonatal intensive care unit admission temperature improved from 34.4 ± 0.8°C to 33.8 ± 0.8°C (P < 0.01). CONCLUSION: Increased utilization of active cooling during transport for TH improves the percentage of neonates admitted within the target temperature range. However, 42% of neonates remained outside the target temperature range, supporting the need for additional tools to improve admission temperatures.

Reliability of conventional and new pulse oximetry in neonatal patients.

OBJECTIVES: Pulse oximetry is widely used in the NICU, but clinicians often distrust the displayed values during patient motion, i.e., questionable oxygen saturation (SpO(2)) and pulse rate (PR) values. Masimo Corporation (Irvine, CA) has developed pulse oximetry with claims of resistance to sources of interference. To test this premise, we compared the performance of the Masimo SET pulse oximeter to a conventional device, Nellcor N-200, and then with three other new-generation pulse oximeters, Nellcor N-395, Novametrix MARS, and Philips Viridia 24C. STUDY DESIGN: We studied 26 nonsedated NICU infants who were on supplemental oxygen and/or mechanical ventilation. ECG heart rate (HR) from a bedside monitor and SpO(2) and PR from the two pulse oximeters were captured by a PC for a total of 156 hours. The ECG HR and pulse oximeter spectral waveform were analyzed at alarms for hypoxemia (SpO(2)< or = 85%) and/or bradycardia (HR< or = 80 bpm). We then compared the performance of the Masimo SET to three other new-generation pulse oximeters, Agilent Viridia 24C, Nellcor N-395, and Novametrix MARS, in a similar population of seven infants for a total of 28 hours. We added to the test criteria the ability of the various pulse oximeters to track acute changes in HR. RESULTS: Compared with Nellcor, Masimo SET had 86% fewer false alarms, which also were shorter in duration, resulting in 92% less total alarm time. Masimo SET also identified nearly all bradycardias versus 14% for the Nellcor. Compared with the new-generation pulse oximeters, false desaturations, data drop-outs, and false bradycardias were lowest for Masimo SET, as was the capture of true desaturations and bradycardias. Notably, the new-generation devices differed greatly in their ability to detect changes in HR (i.e., the frequency of frozen PR during times of ECG HR change was 0, 6, 11, and 46 for Masimo, Nellcor, Philips, and Novametrix, respectively). CONCLUSIONS: Masimo SET pulse oximetry recorded markedly fewer false SpO(2) and PR alarms and identified more true hypoxic and bradycardic events than either conventional or other new-generation pulse oximeters. Masimo SET also most closely reflected the ECG rate irrespective of accelerations or decelerations in HR. SPECULATION: Routine use of Masimo SET pulse oximetry in the NICU could improve clinician confidence in the parameter leading to more judicious titration of oxygen with possible reductions in hypoxic (e.g., pulmonary hypertension) and hyperoxic (e.g., retinopathy of prematurity) pathology. Additionally, a more trustworthy technology should equate with fewer confirmatory arterial blood gas analyses (less blood loss), and faster weaning from the mechanical ventilation (less chronic lung disease).