Disparities in the use of antenatal corticosteroids among women with hypertension in North Carolina.

OBJECTIVE: To evaluate antenatal corticosteroids (ANS) use in pregnant women with hypertension. STUDY DESIGN: Retrospective analysis of ANS use in the Perinatal Quality Collaborative of North Carolina between 2015 and 2017. RESULTS: Twenty-five centers participated, with 9% (1580/17,692) of mothers delivering at <34 weeks; of these, 81% (1286/1580) received a full course of ANS, which was not different between phases (p = 0.32), or between Level III/IV neonatal intensive care units (NICUs; 82%), and I/II NICUs (76%) (p = 0.05). In Level III/IV NICUs, White mothers were more likely to receive ANS (87%) than African Americans (77%) or other race/ethnicity (80%) (including Hispanics) (p = 0.001). ANS use did not differ among mothers with different payers (p = 0.94). CONCLUSION: The rates of full ANS courses did not significantly increase from 2015-2017 and disparities persisted. Targeted efforts to improve ANS exposures among hypertensive African American and Hispanic mothers, as well as in community hospital settings are needed.

Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants.

BACKGROUND AND OBJECTIVE: Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI. METHODS: Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type. RESULTS: Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1. CONCLUSIONS: Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

The perinatal quality collaborative of North Carolina's 39 weeks project: a quality improvement program to decrease elective deliveries before 39 weeks of gestation.

BACKGROUND: Despite long-standing guidelines from the American College of Obstetricians and Gynecologists that call for avoiding elective births prior to 39 weeks of gestation, elective deliveries make up almost one-third of US births occurring in weeks 36-38. Poor outcomes are more likely for infants born electively before 39 weeks than for those born at 39 weeks. The Perinatal Quality Collaborative of North Carolina (PQCNC) undertook the 39 Weeks Project in 2009-2010 with the aim of reducing the number of early-term elective deliveries in North Carolina hospitals. METHODS: Participating hospitals (N = 33) provided retrospective data on all early-term deliveries and created new policies, or amended or enforced existing policies, to accomplish the project's goals. Project activities included in-person learning sessions, regional meetings, webinars, electronic newsletters, a secure extranet Web site where participating hospitals could share relevant materials, and individual leadership consultations with hospital teams. Hospitals submitted monthly data to PQCNC, which provided ongoing training and data analysis. RESULTS: Elective deliveries before 39 weeks of gestation decreased 45% over the project period, from 2% to 1.1% of all deliveries. The proportion of elective deliveries among all scheduled early-term deliveries also decreased, from 23.63% to 16.19%. There was an increase in the proportion of patients with documented evidence of medical indications for early delivery, from 62.4% to 88.2%. LIMITATIONS: No data were collected to determine whether outcomes changed for patients whose deliveries were deferred. The project also depended on each hospital to code its own data. CONCLUSION: The PQCNC's 39 Weeks Project successfully decreased the rate of early-term elective deliveries in participating hospitals.

Reducing central line-associated bloodstream infections in North Carolina NICUs.

OBJECTIVE: Central lines in NICUs have long dwell times. Success in reducing central line-associated bloodstream infections (CLABSIs) requires a multidisciplinary team approach to line maintenance and insertion. The Perinatal Quality Collaborative of North Carolina (PQCNC) CLABSI project supported the development of NICU teams including parents, the implementation of an action plan with unique bundle elements and a rigorous reporting schedule. The goal was to reduce CLABSI rates by 75%. METHODS: Thirteen NICUs participated in an initiative developed over 3 months and deployed over 9 months. Teams participated in monthly webinars and quarterly face-to-face learning sessions. NICUs reported on bundle compliance and National Health Surveillance Network infection rates at baseline, during the intervention, and 3 and 12 months after the intervention. Process and outcome indicators were analyzed using statistical process control methods (SPC). RESULTS: Near-daily maintenance observations were requested for all lines with a 68% response rate. SPC analysis revealed a trend to an increase in bundle compliance. We also report significant adoption of a new maintenance bundle element, central line removal when enteral feedings reached 120 ml/kg per day. The PQCNC CLABSI rate decreased 71%, from 3.94 infections per 1000 line days to 1.16 infections per 1000 line days with sustainment 1 year later (P = .01). CONCLUSIONS: A collaborative structure targeting team development, family partnership, unique bundle elements and strict reporting on line care produced the largest reduction in CLABSI rates for any multiinstitutional NICU collaborative.