28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use.

OBJECTIVE: There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN: Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT: Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention. CONCLUSION: Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.

Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates.

BACKGROUND: Racial disparities in preterm neonatal mortality are long-standing. We aimed to assess how cohort selection influences mortality rates and racial disparity estimates. METHODS: With 2014-2018 California data, we compared neonatal mortality rates among Black and non-Hispanic White very low birth weight (VLBW, <1500 g) or very preterm infants (22-29 weeks gestational age). Relative risks were estimated by different cohort selection criteria. Blinder-Oaxaca decomposition quantified factors contributing to mortality differential. RESULTS: Depending upon standard selection criteria, mortality ranged from 6.2% (VLBW infants excluding first 12-h deaths) to 16.0% (22-29 weeks' gestation including all deaths). Black observed neonatal mortality was higher than White infants only for delivery room deaths in VLBW infants (5.6 vs 4.2%). With risk adjustment accounting for higher rate of low gestational age, low Apgar score and other factors, White infant mortality increased from 15.9 to 16.6%, while Black infant mortality decreased from 16.7 to 13.7% in the 22-29 weeks cohort. Across varying cohort selection, risk adjusted survival advantage among Black infants ranged from 0.70 (CL 0.61-0.80) to 0.84 (CL 0.76-0.93). CONCLUSIONS: Standard cohort selection can give markedly different mortality estimates. It is necessary to reduce prematurity rates and perinatal morbidity to improve outcomes for Black infants. IMPACT: In this population-based observational cohort study that encompassed very low birth weight infant hospitalizations in California, varying standard methods of cohort selection resulted in neonatal mortality ranges from 6.2 to 16.0%. Across all cohorts, the only significant observed Black-White disparity was for delivery room deaths in Very Low Birth Weight births (5.6 vs 4.2%). Across all cohorts, we found a 16-30% survival advantage for Black infants. Cohort selection can result in an almost three-fold difference in estimated mortality but did not have a meaningful impact on observed or adjusted differences in neonatal mortality outcomes by race and ethnicity.

Early childhood outcomes of NICU graduates with cytomegalovirus infection in California.

BACKGROUND: To assess demographics and outcomes up to 3 years of age among children with cytomegalovirus (CMV) infection in California neonatal intensive care units (NICUs) during 2010-2021. METHODS: The California Perinatal Quality Care Collaborative (CPQCC) collects data on all very low birth weight (VLBW, birth weight ≤ 1500 g) and acutely ill infants with birth weight > 1500 g across 92% of NICUs in California. VLBW infants and those with neurological conditions are referred to a statewide high-risk infant follow-up (HRIF) program. CMV infection was defined as a positive culture or PCR identified during the NICU hospitalization. RESULTS: During 2010-2021, CMV reporting rates averaged 3.5/1000 VLBW infants (n = 205) and 1.1/1000 infants >1500 g (n = 128). Among all 333 infants with CMV, 314 (94%) were discharged home alive, 271 (86%) were referred for HRIF and 205 (65%) had ≥1 visit. Whereas infants born to mothers <20 years of age had highest CMV reporting rates and those born to Hispanic mothers comprised 49% of all infected infants, they had the highest loss of follow-up. At the 12-month visit (n = 152), 19 (13%) infants with CMV had bilateral blindness and 18 (12%) had hearing loss. At the 24-month visit, 5 (5%) of 103 had severe cerebral palsy. CONCLUSIONS: Among infants admitted to the NICU, those with CMV diagnoses may over represent infants with more severe CMV disease and outcomes. The CPQCC and HRIF program findings may help inform implementation of surveillance for congenital CMV infection in other U.S. states and guide strategies to reduce disparities in access to services.

Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis.

BACKGROUND AND OBJECTIVES: There is widespread unwarranted antibiotic use and large individual provider variation in antibiotic use in NICUs. Vignette-based research methodology offers a unique method of studying variation in individual provider decisions. The objective with this study was to use a vignette-based survey to identify specific areas of provider antibiotic use variation in newborns being evaluated for early onset sepsis. METHODS: This study was undertaken as part of a statewide multicenter neonatal antibiotic stewardship quality improvement project led by a perinatal quality improvement collaborative. A web-based vignette survey was administered to identify variation in decisions to start and discontinue antibiotics in cases of early onset sepsis. RESULTS: The largest variation was noted in 3 of the 6 vignette cases. These cases highlighted variation in (1) decisions to start antibiotics in a case describing a well-appearing newborn with risk factors and an elevated C-reactive protein, (2) decisions to start antibiotics in the case of a newborn with risk factors plus mild respiratory signs at birth, and (3) decisions to stop antibiotics in the case of the newborn with a history of sepsis risk factors and mild clinical respiratory signs that resolved after 72 hours. CONCLUSIONS: Clinical vignette assessment identified specific areas of variation in individual provider antibiotic use decisions in cases of suspected early onset sepsis. Vignettes are a valuable method of describing individual provider variation and highlighting antibiotic stewardship improvement opportunities in NICUs.

Designing a bed-side system for predicting length of stay in a neonatal intensive care unit.

Increased length of stay (LOS) in intensive care units is directly associated with the financial burden, anxiety, and increased mortality risks. In the current study, we have incorporated the association of day-to-day nutrition and medication data of the patient during its stay in hospital with its predicted LOS. To demonstrate the same, we developed a model to predict the LOS using risk factors (a) perinatal and antenatal details, (b) deviation of nutrition and medication dosage from guidelines, and (c) clinical diagnoses encountered during NICU stay. Data of 836 patient records (12 months) from two NICU sites were used and validated on 211 patient records (4 months). A bedside user interface integrated with EMR has been designed to display the model performance results on the validation dataset. The study shows that each gestation age group of patients has unique and independent risk factors associated with the LOS. The gestation is a significant risk factor for neonates < 34 weeks, nutrition deviation for < 32 weeks, and clinical diagnosis (sepsis) for ≥ 32 weeks. Patients on medications had considerable extra LOS for ≥ 32 weeks' gestation. The presented LOS model is tailored for each patient, and deviations from the recommended nutrition and medication guidelines were significantly associated with the predicted LOS.

Population Improvement Bias Observed in Estimates of the Impact of Antenatal Steroids to Outcomes in Preterm Birth.

OBJECTIVE: To examine the hypothesis that increasing rates and differential uptake of antenatal steroids would bias estimation of impact of antenatal steroids on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH). STUDY DESIGN: The study population included infants born between 24 and 28 weeks of gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of antenatal steroid exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period. RESULTS: The study cohort included 28 252 infants. Antenatal steroid exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to antenatal steroids (12.5%-8.6% for IVH, 11.5%-8.8% for death) but not in those not exposed (20.7%-19.1% and 16.6%-15.5%, respectively). Women not receiving antenatal steroids had greater risk profile (such as no prenatal care) and greater predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without antenatal steroids. In contrast, in women receiving antenatal steroids, observed and adjusted rates for both outcomes decreased (P < .0001). CONCLUSIONS: As the population's proportion of antenatal steroid use increased, the observed positive effect of antenatal steroids also increased. This apparent increase may be designated as the "population improvement bias."

Maternal and Infant Adverse Outcomes Associated with Mild and Severe Preeclampsia during the First Year after Delivery in the United States.

OBJECTIVE: The burden of preeclampsia severity on the health of mothers and infants during the first year after delivery is unclear, given the lack of population-based longitudinal studies in the United States. STUDY DESIGN: We assessed maternal and infant adverse outcomes during the first year after delivery using population-based hospital discharge information merged with vital statistics and birth certificates of 2,021,013 linked maternal-infant births in California. We calculated sampling weights using the National Center for Health Statistics data to adjust for observed differences in maternal characteristics between California and the rest of the United States. Separately, we estimated the association between preeclampsia and gestational age and examined collider bias in models of preeclampsia and maternal and infant adverse outcomes. RESULTS: Compared with women without preeclampsia, women with mild and severe preeclampsia delivered 0.66 weeks (95% confidence interval [CI]: 0.64, 0.68) and 2.74 weeks (95% CI: 2.72, 2.77) earlier, respectively. Mild preeclampsia was associated with an increased risk of having any maternal adverse outcome (relative risk [RR] = 1.95; 95% CI: 1.93, 1.97), as was severe preeclampsia (RR = 2.80; 95% CI: 2.78, 2.82). The risk of an infant adverse outcome was increased for severe preeclampsia (RR = 2.15; 95% CI: 2.14, 2.17) but only marginally for mild preeclampsia (RR = 0.99; 95% CI: 0.98, 1). Collider bias produced an inverse association for mild preeclampsia and attenuated the association for severe preeclampsia in models for any infant adverse outcome. CONCLUSION: Using multiple datasets, we estimated that severe preeclampsia is associated with a higher risk of maternal and infant adverse outcomes compared with mild preeclampsia, including an earlier preterm delivery.

Cytomegalovirus Infection among Infants in Neonatal Intensive Care Units, California, 2005 to 2016.

AIM: The main purpose of this article is to assess trends in cytomegalovirus (CMV) infection reported among infants in California neonatal intensive care units (NICUs) during 2005 to 2016. STUDY DESIGN: The California Perinatal Quality Care Collaborative collects data on all very low birth weight (VLBW, birth weight ≤ 1,500 g) and acutely ill infants > 1,500 g, representing 92% of NICUs in California. We compared clinical characteristics and length of hospital stay among infants with and without reported CMV infection (CMV-positive viral culture or polymerase chain reaction). RESULTS: During 2005 to 2016, CMV infection was reported in 174 VLBW infants and 145 infants > 1,500 g, or 2.7 (range: 1.5-4.7) and 1.2 (range: 0.8-1.7) per 1,000 infants, respectively (no significant annual trend). Among infants > 1,500 g, 12 (8%) versus 4,928 (4%) of those reported with versus without CMV infection died (p < 0.05). The median hospital stay was significantly longer among infants reported with versus without CMV infection for both VLBW infants (98 vs. 46 days) and infants > 1,500 g (61 vs. 14 days) (p < 0.001). CONCLUSION: Reports of CMV infection remained stable over a 12-year period. Although we were not able to assess whether infection was congenital or postnatal, CMV infection among infants > 1,500 g was associated with increased mortality.

Hospitalization costs associated with bronchopulmonary dysplasia in the first year of life.

OBJECTIVE: To determine costs of hospitalization associated with bronchopulmonary dysplasia (BPD) during the first year in very low birth weight infants. STUDY DESIGN: Retrospective cohort study of California births from 2008 to 2011 linking birth certificate, discharge records, and clinical data from California Perinatal Quality Care Collaborative. Inclusion: birth weight 401-1500 g, gestational age < 30 weeks, inborn or transferred within 2 days, alive at 36 weeks corrected, and without major congenital anomalies. Outcomes included cost and length of stay of initial hospitalization and rehospitalizations. RESULT: Out of 7998 eligible infants, 2696 (33.7%) developed BPD. Median hospitalization cost in the first year was $377,871 per infant with BPD compared with $175,836 per infant without BPD (adjusted cost ratio 1.54, 95% confidence interval (CI) 1.49-1.59). Infants with BPD also had longer length of stay and a higher likelihood of rehospitalization. CONCLUSION: BPD is associated with substantial resource utilization. Prevention strategies could help conserve healthcare resources.

Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection.

OBJECTIVES: To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection. METHODS: We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates. RESULTS: The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure. CONCLUSIONS: The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

Factors Associated with Successful First High-Risk Infant Clinic Visit for Very Low Birth Weight Infants in California.

OBJECTIVES: To determine rates of at least 1 high-risk infant follow-up (HRIF) visit by 12 months corrected age, and factors associated with successful first visit among very low birth weight (VLBW) infants in a statewide population-based setting. STUDY DESIGN: We used the linked California Perinatal Quality of Care Collaborative and California Perinatal Quality of Care Collaborative-California Children's Services HRIF databases. Multivariable logistic regression examined independent associations of maternal, sociodemographic, neonatal clinical, and HRIF program factors with a successful first HRIF visit among VLBW infants born in 2010-2011. RESULTS: Among 6512 VLBW children referred to HRIF, 4938 (76%) attended a first visit. Higher odds for first HRIF visit attendance was associated with older maternal age (OR, 1.48; 95% CI, 1.27-1.72; 30-39 vs 20-29 years), lower birth weight (OR, 2.11; 95% CI, 1.69-2.65; ≤750 g vs 1251-1499 g), private insurance (OR, 1.65; 95% CI, 1.19-2.31), a history of severe intracranial hemorrhage (OR, 1.61; 95% CI, 1.12-2.30), 2 parents as primary caregivers (OR, 1.18, 95% CI 1.03-1.36), and higher HRIF program volume (OR, 2.62; 95% CI, 1.88-3.66; second vs lowest quartile); and lower odds with maternal race African American or black (OR, 0.65; 95% CI, 0.54-0.78), and greater distance to HRIF program (OR, 0.69; 95% CI, 0.57-0.83). Rates varied substantially across HRIF programs, which remained after risk adjustment. CONCLUSIONS: In a population-based California VLBW cohort, maternal, sociodemographic, and home- and program-level disparities were associated with HRIF non-attendance. These findings underscore the need to identify challenges in access and resource risk factors during hospitalization in the neonatal intensive care unit, provide enhanced education about the benefits of HRIF, and create comprehensive neonatal intensive care unit-to-home transition approaches.

Population-based trends and underlying risk factors for infant respiratory syncytial virus and bronchiolitis hospitalizations.

OBJECTIVE: Respiratory syncytial virus (RSV) is a common pathogen during infancy, with the potential to cause serious disease and mortality in high-risk groups. The objective of this study was to characterize trends of RSV and bronchiolitis hospitalizations in the first year in a population-based cohort and assess differences in trends according to risk status. METHODS: Using an observational retrospective cohort design, we examined a California population-based dataset of vital statistics linked to hospital discharge data for up to 1 year after birth from 1997-2011. Infants were categorized by medical condition and then by gestational age. Medical conditions of interest included chronic lung disease, certain congenital heart diseases, or others known to affect risk for developing severe bronchiolitis. The primary outcome was hospitalization due to RSV; secondary outcome was hospitalization for unspecified bronchiolitis (UB) not coded as RSV. Annual person-year rates were calculated for infants <12 months of age during January to December of each year. RESULTS: Of 7,298,401 infants born during the study period, 121,230 (1.7%) had a medical condition associated with risk; these infants experienced 6853 RSV and 6568 UB hospitalizations in the first year. In infants without medical conditions, 96,694 RSV and 69,886 UB hospitalizations occurred. All-cause infant hospitalizations declined over time from 12.2 to 9.3 per 100 person-years. RSV hospitalization rates for infants with medical conditions decreased from 7.6 to 3.4 per 100 person-years, with the largest relative decline in infants with chronic lung disease (12.0 to 5.0 per 100 person-years). For infants without medical conditions, RSV hospitalizations declined from 1.4 to 0.8 per 100 person-years, with greater decreases among preterm infants with earlier gestational age. UB hospitalization rates remained relatively stable across the study years, from 6.2 to 5.4 and 1.0 to 0.8 per 100 person-years for infants with and without medical conditions. CONCLUSIONS: Various interventions may have contributed to observed decreases in RSV hospitalizations from 1998-2011, which were greater in high-risk populations recommended for RSV immunoprophylaxis and not observed with UB. Further efforts to promote evidence-based practice and optimal targeting of appropriate interventions will ensure continued improvement in care for vulnerable infants.

Covariation of Neonatal Intensive Care Unit-Level Patent Ductus Arteriosus Management and In-Neonatal Intensive Care Unit Outcomes Following Preterm Birth.

OBJECTIVE: To test the hypothesis that neonatal intensive care unit (NICU)-specific changes in patent ductus arteriosus (PDA) management are associated with changes in local outcomes in preterm infants. STUDY DESIGN: This retrospective repeated-measures study of aggregated data included infants born 400-1499 g admitted within 2 days of delivery to NICUs participating in the California Perinatal Quality Care Collaborative. The period 2008-2015 was divided into four 2-year epochs. For each epoch and NICU, we calculated proportions of infants receiving cyclooxygenase inhibitor (COXI) or PDA ligation and determined NICU-specific changes in these therapies between consecutive epochs. Generalized estimating equations were used to examine adjusted relationships between NICU-specific changes in PDA management and contemporaneous changes in local outcomes. RESULTS: We included 642 observations of interepoch change at 119 hospitals summarizing 32 094 infants. NICU-specific changes in COXI use and ligation showed significant dose-response associations with contemporaneous changes in adjusted local outcomes. Each percentage point decrease in NICU-specific proportion treated with either COXI or ligation was associated with a 0.21 percentage point contemporaneous increase in adjusted local in-hospital mortality (95% CI 0.06, 0.33; P = .005) among infants born 400-749 g. In contrast, decreasing NICU-specific ligation rate among infants 1000-1499 g was associated with decreasing adjusted local bronchopulmonary dysplasia (P = .009) and death or bronchopulmonary dysplasia (P = .01). CONCLUSIONS: NICU-specific outcomes of preterm birth co-vary with local PDA management. Treatment for PDA closure may benefit some infants born 400-749 g. Decreasing NICU-specific rates of COXI use or ligation were not associated with increases in local adjusted rates of examined adverse outcomes in larger preterm infants.

Variations in Neonatal Antibiotic Use.

OBJECTIVES: We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens. METHODS: In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts. RESULTS: By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (ρ = 0.53; P = .01), mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%). CONCLUSIONS: Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay.

BACKGROUND: There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS. METHODS: Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and <32 weeks' gestational age by 3 days. A secondary outcome was "early discharge," the proportion of infants discharged from the hospital before 36 + 5 weeks' PMA. The balancing measure of readmissions within 72 hours was tracked for the collaborative group. RESULTS: From 2013 to 2015, 8917 infants were cared for in 20 collaborative NICUs, 19 individual project NICUs, and 71 nonparticipants. In the collaborative group, the PMA at discharge decreased from 37.8 to 37.5 weeks (P = .02), and early discharge increased from 31.6% to 41.9% (P = .006). The individual project group had no significant change. Nonparticipants had a decrease in PMA from 37.5 to 37.3 weeks (P = .01) but no significant change in early discharge (39.8% to 43.6%; P = .24). There was no significant change in readmissions over time in the collaborative group. CONCLUSIONS: A structured collaborative project that was focused on optimizing LOS led to a 3-day decrease in LOS and was more effective than individualized quality improvement efforts.

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity.

Importance: Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. Objectives: To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Design, Setting, and Participants: Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Exposures: Live birth at GA of 34 weeks or more. Main Outcomes and Measures: Inborn NICU admission rate. Results: Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41). Conclusions and Relevance: Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Improvement Collaborative.

BACKGROUND: The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative. METHODS: The RB consisted of (1) a checklist for high-risk neonatal resuscitations and (2) briefings and debriefings to improve teamwork and communication in the delivery room (DR). Implementation of the RB was encouraged, compliance with the RB was tracked monthly up through 6 months after the completion of the collaborative, and satisfaction with the RB was evaluated. RESULTS: Twenty-four neonatal intensive care units (NICUs) participated in the CPQCCDR collaborative. Before the initiation of the collaborative, the elements of the RB were complied with in 0 of 740 reported deliveries (0%). During the 12-month collaborative, compliance with the RB improved to a median of 71%, which was surpassed in the 6-month period after the collaborative ended (80%). One-hundred percent of responding NICUs would recommend the RB to other NICUs working on improving DR management. CONCLUSIONS: The RB was rapidly adopted, with compliance sustained for 6 months after completion of the collaborative. Inclusion of the RB in the next generation of the NRP guidelines is encouraged.

Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit.

Objective Develop length of stay prediction models for neonatal intensive care unit patients. Study Design We used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. Results Our sample included 23,551 patients. Median length of stay was 79 days when birth weight was < 1,000 g, 46 days for 1,000 to 1,500 g, 21 days for 1,500 to 2,500 g, and 8 days for ≥2,500 g. Risk factors for longer length of stay varied by weight. Units with shorter length of stay for one weight group had shorter lengths of stay for other groups. Conclusion Risk models for comparative assessments of length of stay need to appropriately account for weight, particularly considering the cutoff of 1,500 g. Refining prediction may benefit counseling of families and health care systems to efficiently allocate resources.

Neonatal intensive care unit antibiotic use.

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California.

OBJECTIVES: To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative. STUDY DESIGN: Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral. RESULTS: In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment. CONCLUSIONS: There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.