Evaluation of a Modified SBAR Report to Physician Tool to Standardize Communication on Neonatal Transport.

OBJECTIVE: SBAR (situation, background, assessment and recommendation) is a structured format for the effective communication of critically relevant information. This tool was developed as a generic template to provide structure to the communication of clinical information between health care providers. Neonatal transport often presents clinically stressful circumstances where concise and accurate information is required to be shared clearly between multidisciplinary health care providers. A modified SBAR communication tool was designed to facilitate structured communication between nonphysician bedside care providers operating from remote sites and physicians providing decision-making support at receiving care facilities. Prospective interventional study was designed to evaluate the reliability of a "SBAR report to physician tool" in sharing clinically relevant information between multidisciplinary care providers on neonatal transport. STUDY DESIGN: The study was conducted between 2011 and 2014 by a dedicated neonatal transport service based at McMaster Children's Hospital which provides care for approximately 500 infants in Southern Ontario annually. In the preintervention phase, 50 calls were randomly selected for the evaluation and 115 consecutively recorded transport calls following adoption of the reporting tool. The quality of calls prior to and after the intervention was assessed by reviewers independently. Inter-rater agreement was also assessed for both periods. RESULTS: Inter-rater agreement between raters was moderate to perfect in most components of the SBAR "report to the physician tool" except for the assessment component, which showed fair agreement during both preintervention and postintervention periods. There was an improvement in global score (primary outcome) with a mean difference of 0.95 (95% confidence interval [CI]: 0.77-1.14; p < 0.001) and in cumulative score with a mean difference of 8.55 (95% CI: 7.26-9.84; p < 0.001) in postintervention period. CONCLUSION: The use of the SBAR report to physician tool improved the quality of clinical information shared between nonphysician members of the neonatal transport team and neonatal transport physicians. KEY POINTS: · Long-Accurate and concise information sharing is crucial for decision-making in neonatal transport.. · Information sharing between multidisciplinary teams can be enhanced by using a commonly understood information sharing template.. · The SBAR report to physician tool improves the quality of information shared between multidisciplinary team members in neonatal transport..

Association of Low Umbilical Cord pH and Hypoglycemia in Healthy Term Newborns: Should it Be a Part of Postnatal Screening?

Hypoglycemia may lead to neurological impairment; therefore, high-risk newborns are screened postnatally. However, hypoglycemia monitoring protocols often do not include cord blood acidosis as a risk factor. The study aimed to find an association between asymptomatic cord blood acidosis and hypoglycemia. All healthy term infants born at McMaster Children Hospital, Hamilton, Canada, between October 2013 and September 2014, who had umbilical cord blood pH <7.0 or base excess <12 mmol/L were studied. Infants with evidence of hypoxic-ischemic encephalopathy, birth weights outside of 10th to 95th percentiles for gestation, mothers with preeclampsia, diabetes or taking a -blockers at the time of the birth were excluded. Hypoglycemia was defined as blood glucose <2.6 mmol/L in the first two hours of life. One hundred sixtysix infants met the cord blood gas criteria, but only 16 had hypoglycemia. Although infants with mild perinatal depression are at risk for hypoglycemia, a significant association could not be proved.

Individualized Postnatal Growth Trajectories for Preterm Infants.

BACKGROUND: Growth of preterm infants is monitored using fetal charts despite individual trajectories being downshifted postnatally by adaptational processes. The study aims to compare different approaches to create individualized postnatal trajectories. METHODS: Three approaches to achieve growth similar to healthy term infants at 42+0/7 weeks postmenstrual age (PMA) on World Health Organization growth standards (WHOGS) (target weight) were tested by comparing trajectories obtained by: 1) following birth percentiles (Birth-Weight-Percentile Approach); 2) following percentiles achieved at day of life 21 (Postnatal-Percentile Approach); 3) using day-specific fetal median growth velocities starting at day of life 21 (Fetal-Median-Growth Approach [FMGA]). The primary outcome was delta weight (ΔW), defined as difference between target weight (WHOGS) at 42+0/7 weeks and weight predicted by trajectories. The secondary outcome was ΔW vs %fat mass in a cohort of 20 disease-free surviving very low-birth-weight infants. RESULTS: Birth-Weight-Percentile and Postnatal-Percentile Approach showed high ΔW; FMGA alone reduced ΔW. Introducing a factor to FMGA to reflect the transition to extrauterine conditions (Growth-Velocity Approach [GVA]) minimized ΔW. GVA merged with target and best normalized for body composition related to ΔW. CONCLUSIONS: GVA provides an evidence-based approach for individualized growth trajectories. GVA is based on physiologic data and that healthy preterm infants adjust their postnatal trajectory below their birth percentile. GVA may reflect a biologic principle because it matches consistently with WHOGS at 42+0/7 weeks for all preterm infants from 24 to 34 weeks. This concept could become a bedside tool to aid clinicians in monitoring growth, guiding nutrition, and minimizing chronic adult disease risks as a consequence of unguided, inappropriate growth.

Introduction of microsystems in a level 3 neonatal intensive care unit-an interprofessional approach.

BACKGROUND: Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care. METHODS/DESIGN: The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model. DISCUSSION: In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns. TRIAL REGISTRATION: ClinicalTrial.gov, NCT02912780 . Retrospectively registered on 22 September 2016.

Length Normalized Indices for Fat Mass and Fat-Free Mass in Preterm and Term Infants during the First Six Months of Life.

OBJECTIVE: Postnatal tissue accretion in preterm infants differs from those in utero, affecting body composition (BC) and lifelong morbidity. Length normalized BC data allows infants with different body lengths to be compared and followed longitudinally. This study aims to analyze BC of preterm and term infants during the first six months of life. METHODS: The BC data, measured using dual energy X-ray absorptiometry, of 389 preterm and 132 term infants from four longitudinal studies were combined. Fat-mass/length² (FMI) and fat-free mass/length² (FFMI) for postmenstrual age were calculated after reaching full enteral feeding, at term and two further time points up to six months corrected age. RESULTS: Median FMI (preterm) increased from 0.4 kg/m² at 30 weeks to 2.5, 4.3, and 4.8 kg/m² compared to 1.7, 4.7, and 6 kg/m² in term infants at 40, 52, and 64 weeks, respectively. Median FFMI (preterm) increased from 8.5 kg/m² (30 weeks) to 11.4 kg/m² (45 weeks) and remained constant thereafter, whereas term FFMI remained constant at 11 kg/m² throughout the tested time points. CONCLUSION: The study provides a large dataset of length normalized BC indices. Followed longitudinally, term and preterm infants differ considerably during early infancy in the pattern of change in FMI and FFMI for age.

Implementation of an Interprofessional Team Review of Adverse Events in Obstetrics Using a Standardized Computer Tool: A Mixed Methods Study.

OBJECTIVE: As part of a larger study, an interprofessional team piloted a computer tool called Standardized Clinical Outcome Review (SCOR) to review adverse obstetric events that occurred at a tertiary care hospital over a 12-month period. We sought to understand whether the SCOR tool offered a feasible, acceptable, and appropriate strategy for improving patient safety through improved review of incidents. METHODS: We designed a mixed methods implementation study. Following completion of the 12-month pilot period, team members completed a questionnaire and participated in a focus group. Quantitative data analysis was performed using descriptive statistics, and qualitative data were analyzed using grounded theory to generate themes. RESULTS: The SCOR tool was easy to implement with an interprofessional team. Despite technical challenges with the software, the tool was quicker and more efficient than traditional case review methods. The content was appropriate for an obstetric unit and provided objective identification of factors contributing to adverse events. Team members were positive about the use of the tool in their institution and in wider contexts and believed that it was a valuable tool for raising awareness and addressing patient safety at their unit. CONCLUSIONS: SCOR was an acceptable and appropriate tool for the interprofessional team review of adverse outcomes, and its use represents a significant advance in the quality assurance process for formal peer review of incidents.

Learning from Adverse Events in Obstetrics: Is a Standardized Computer Tool an Effective Strategy for Root Cause Analysis?

OBJECTIVE: Adverse events occur in up to 10% of obstetric cases, and up to one half of these could be prevented. Case reviews and root cause analysis using a structured tool may help health care providers to learn from adverse events and to identify trends and recurring systems issues. We sought to establish the reliability of a root cause analysis computer application called Standardized Clinical Outcome Review (SCOR). METHODS: We designed a mixed methods study to evaluate the effectiveness of the tool. We conducted qualitative content analysis of five charts reviewed by both the traditional obstetric quality assurance methods and the SCOR tool. We also determined inter-rater reliability by having four health care providers review the same five cases using the SCOR tool. RESULTS: The comparative qualitative review revealed that the traditional quality assurance case review process used inconsistent language and made serious, personalized recommendations for those involved in the case. In contrast, the SCOR review provided a consistent format for recommendations, a list of action points, and highlighted systems issues. The mean percentage agreement between the four reviewers for the five cases was 75%. The different health care providers completed data entry and assessment of the case in a similar way. Missing data from the chart and poor wording of questions were identified as issues affecting percentage agreement. CONCLUSION: The SCOR tool provides a standardized, objective, obstetric-specific tool for root cause analysis that may improve identification of risk factors and dissemination of action plans to prevent future events.

Objectif : Des événements indésirables se manifestent dans jusqu'à 10 % des cas obstétricaux et jusqu'à la moitié de ces événements sont évitables. Les analyses de cas et l'analyse des causes fondamentales au moyen d'un outil structuré pourraient aider les fournisseurs de soins à tirer des leçons des événements indésirables et à identifier les tendances et les problèmes systémiques récurrents. Nous avons cherché à établir la fiabilité d'un logiciel d'analyse des causes fondamentales connu sous le nom de Standardized Clinical Outcome Review (SCOR). Méthodes : Nous avons conçu une étude faisant appel à des méthodes mixtes pour évaluer l'efficacité de l'outil. Nous avons mené une analyse qualitative du contenu de cinq dossiers ayant été analysés tant au moyen des méthodes traditionnelles d'assurance de la qualité en obstétrique qu'au moyen de l'outil SCOR. Nous avons également déterminé la fidélité interévaluateurs en demandant à quatre fournisseurs de soins d'analyser les cinq mêmes dossiers au moyen de l'outil SCOR. Résultats : L'analyse qualitative comparative a révélé que le processus traditionnel d'assurance de la qualité dans le cadre de l'analyse des cas utilisait un langage hétérogène et formulait de sérieuses recommandations personnalisées à l'endroit des intervenants du dossier. En revanche, l'analyse au moyen de l'outil SCOR fournissait un format uniforme pour les recommandations et une liste de points de décision, en plus de faire ressortir les problèmes systémiques. Le taux moyen d'entente (en pourcentage) entre les quatre évaluateurs pour les cinq dossiers en question était de 75 %. Les autres fournisseurs de soins ont procédé à la saisie des données et à l'évaluation des dossiers de façon semblable. L'absence de certaines données dans les dossiers et la mauvaise formulation des questions ont été identifiées comme étant des problèmes affectant le taux d'entente. Conclusion : L'outil SCOR permet la tenue d'une analyse des causes fondamentales de façon standardisée, objective et centrée sur l'obstétrique, ce qui pourrait améliorer l'identification des facteurs de risque et la dissémination des plans d'action pour la prévention de futurs événements.

Incidence and complications of multiple gestation in Canada: proceedings of an expert meeting.

This paper reports the proceedings of a consensus meeting on the incidence and complications of multiple gestation in Canada. In addition to background presentations about current and possible future practice in Canada, the expert panel also developed a set of consensus points. The need for infertility to be understood, and funded, as a healthcare problem was emphasized, along with recognition of the emotional impact of infertility. It was agreed that the goal of assisted reproduction treatment is the delivery of a single healthy infant and that even though many positive outcomes have resulted from twin or even triplet pregnancies, the potential risks associated with multiple pregnancy require that every effort be made to achieve this goal. The evidence shows that treatments other than IVF (such as superovulation and clomiphene citrate) contribute significantly to the incidence of multiple pregnancy. There is an urgent need for studies to understand better the usage and application of these other fertility technologies within Canada, as well as the non-financial barriers to treatment. The final consensus of the expert panel was that with adequate funding and good access to treatment, it will be possible to achieve the goal of reducing IVF-related multiple pregnancy rates in Canada by 50%.

Morphine for elective endotracheal intubation in neonates: a randomized trial [ISRCTN43546373].

BACKGROUND: Elective endotracheal intubations are still commonly performed without premedication in many institutions. The hypothesis tested in this study was that morphine given prior to elective intubations in neonates would decrease fluctuations in vital signs, shorten the duration of intubation and reduce the number of attempts. METHODS: From December 1999 to September 2000, infants of all gestations admitted to a level III neonatal intensive care unit and requiring an elective endotracheal intubation were randomly assigned to receive morphine 0.2 mg/kg IV or placebo 5 minutes before intubation. Duration of severe hypoxemia (HR< 90/min and Sp02<85%), duration of procedure, duration of hypoxemia (Sp02<85%), number of attempts and change in mean blood pressure were compared between groups. RESULTS: 34 infants (median 989 g and 28 weeks gestation) were included. The duration of severe hypoxemia was similar between groups. Duration of procedure, duration of hypoxemia, number of attempts and increases in mean blood pressure were also similar between groups. 94% of infants experienced bradycardia during the procedure. CONCLUSION: We failed to demonstrate the effectiveness of morphine in reducing the physiological instability or time needed to perform elective intubations. Alternatives, perhaps with more rapid onset of action, should be considered.