Quality improvement initiative: implementing and redefining video review of real-time neonatal procedures using action research.

Video review (VR) of procedures in the medical environment can be used to drive quality improvement. However, first it has to be implemented in a safe and effective way. Our primary objective was to (re)define a guideline for implementing interprofessional VR in a neonatal intensive care unit (NICU). Our secondary objective was to determine the rate of acceptance by providers attending VR. For 9 months, VR sessions were evaluated with a study group, consisting of different stakeholders. A questionnaire was embedded at the end of each session to obtain feedback from providers on the session and on the safe learning environment. In consensus meetings, success factors and preconditions were identified and divided into different factors that influenced the rate of adoption of VR. The number of providers who recorded procedures and attended VR sessions was determined. A total of 18 VR sessions could be organised, with an equal distribution of medical and nursing staff. After the 9-month period, 101/125 (81%) of all providers working on the NICU attended at least 1 session and 80/125 (64%) of all providers recorded their performance of a procedure at least 1 time. In total, 179/297 (61%) providers completed the questionnaire. Almost all providers (99%) reported to have a positive opinion about the review sessions. Preconditions and success factors related to implementation were identified and addressed, including improving the pathway for obtaining consent, preparation of VR, defining the role of the chair during the session and building a safe learning environment. Different strategies were developed to ensure findings from sessions were used for quality improvement. VR was successfully implemented on our NICU and we redefined our guideline with various preconditions and success factors. The adjusted guideline can be helpful for implementation of VR in emergency care settings.

Using the providers' perspective on video review of neonatal procedures to create a roadmap: a qualitative study.

OBJECTIVE: To examine the providers' perceptions and experiences on implementation of video review (VR) of procedures in the neonatal intensive care unit (NICU). DESIGN: Qualitative study using semi-structured interviews with neonatal care providers about their experiences with VR. Interviews were audio-recorded, transcribed and thematically analysed using the data analysis software Atlas.ti V.22.2. SETTING: Providers working in the NICU of the Leiden University Medical Center were interviewed during implementation of VR. RESULTS: In total, 28 NICU staff members were interviewed. The interviewed providers appreciated VR and valued the focus on a safe learning environment. Five overarching themes were identified: (1) added value: providers reported that VR is a powerful tool for reflection on daily practice and serves as a magnifying glass on practice, provides a helicopter view and VR with nursing and medical staff together led to new insights and was seen as highly valuable; (2) preconditions and considerations: the existing culture of trust on the NICU positively influenced providers' perception; (3) adjustment: it was recommended to first let providers attend a VR session, before being recorded; (4) experiences with VR: suggestions were made by the providers regarding the preparation and organisation of VR and the role of the chair; (5) embedding VR: providers considered how to embed VR on the long-term while maintaining a safe learning environment and provided suggestions for expanding. CONCLUSION: Neonatal care providers appreciated the use of VR and provided viewpoints on how to implement VR successfully, which were used to develop a roadmap with recommendations.

Record, reflect and refine: using video review as an initiative to improve neonatal care.

BACKGROUND: The goal of every medical team is to provide optimal care for their patients. We aimed to use video review (VR) sessions to identify and address areas for improvement in neonatal care. METHODS: For nine months, neonatal procedures (stabilization at birth, intubations and sterile line insertions) were video recorded and reviewed with the neonatal care providers. Action research was used to identify and address areas for improvement which were categorized as (1) protocol/equipment adjustments, (2) input for research, (3) aspects of variety, or (4) development of educational material or training programs. RESULTS: Eighteen VR sessions were organized with a mean(SD) of 17(5) staff members participating. In total, 120 areas for improvement were identified and addressed, of which 84/120 (70%) were categorized as aspects of variety, 20/120 (17%) as development of educational material or training programs, 10/120 (8%) as protocol/equipment adjustments, and 6/120 (5%) as input for research. The areas for improvement were grouped in themes per category, including sterility, technique, equipment, communication, teamwork, parents' perspective and ventilation. CONCLUSION: Our study showed that regularly organized VR empowered healthcare providers to identify and address a large variety of areas for improvement, contributing to continuous learning and improvement processes. IMPACT: Video review empowered healthcare providers to identify areas for improvement in neonatal care Video review gave providers the opportunity to address identified areas for improvement, either by enhancing the application of external evidence (i.e. guidelines), learning from individual clinical expertise or strengthening resilience and teamwork Embedding regularly organized video review sessions allowed for continuous monitoring of care by providers, which can be beneficial for creating ongoing learning and improvement processes The structured pathways, supporting implementation of changes that were proposed based on the video review sessions, could help other centers make use of the potential video review has to offer.

Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation.

AIM: The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation. METHODS: The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019. RESULTS: The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial. CONCLUSION: Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.

Video recording emergency care and video-reflection to improve patient care; a narrative review and case-study of a neonatal intensive care unit.

As the complexity of emergency care increases, current research methods to improve care are often unable to capture all aspects of everyday clinical practice. Video recordings can visualize clinical care in an objective way. They can be used as a tool to assess care and to reflect on care with the caregivers themselves. Although the use of video recordings to reflect on medical interventions (video-reflection) has increased over the years, it is still not used on a regular basis. However, video-reflection proved to be of educational value and can improve teams' management and performance. It has a positive effect on guideline adherence, documentation, clinical care and teamwork. Recordings can also be used for video-reflexivity. Here, caregivers review recordings together to reflect on their everyday practice from new perspectives with regard to context and conduct in general. Although video-reflection in emergency care has proven to be valuable, certain preconditions have to be met and obstacles need to be overcome. These include gaining trust of the caregivers, having a proper consent-procedure, maintaining confidentiality and adequate use of technical equipment. To implement the lessons learned from video-reflection in a sustainable way and to continuously improve care, it should be integrated in regular simulation training or education. This narrative review will describe the development of video recording in emergency care and how video-reflection can improve patient care and safety in new ways. On our own department, the NICU at the LUMC, video-reflection has already been implemented and we want to further expand this. We will describe the use of video-reflection in our own unit. Based on the results of this narrative review we will propose options for future research to increase the value of video-reflection.

Consent for Delivery Room Studies: What Can Be Learned from Perceptions of Parents.

BACKGROUND: Obtaining ethically valid consent to participate in delivery room (DR) studies from parents facing an imminent premature birth can be challenging. This study aims to provide insight into parental experiences with and perceptions of consent for DR studies. METHODS: Semistructured interviews were conducted with parents of very and extreme preterm infants. Interviews were audio-recorded, transcribed, and analyzed using the qualitative data analysis software Atlas. ti V.8.4. RESULTS: Twenty-five parents were interviewed. Despite being in an emotional and stressful situation, most parents considered being approached for DR studies as valuable. According to parents, this was mostly due to appropriate timing and communication, compassion, and investigators not being obtrusive. Interviewed parents generally decided to accept or decline study participation based on perceived risk. Parents differed widely in how risk of specific study interventions was perceived, but agreed on the fact that parental consent is needed for DR studies that involve risk. There was no consensus among parents on deferred consent for DR studies running at our NICU. However, parents considered deferred consent appropriate for observational studies. Furthermore, it became clear that parental misunderstanding of various aspects of DR studies, including aims, the concept of randomization, and risk associated with specific interventions, was common. CONCLUSIONS: Insight into parental perceptions of consent for DR studies allowed us to determine areas where the validity of parental consent can be improved. Further research on parental perspectives for consent for DR studies will allow us to establish consent procedures that are considered both valid and valuable.

A multi-centre randomised controlled trial of respiratory function monitoring during stabilisation of very preterm infants at birth.

AIM: To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range. METHODS: Unmasked, randomised clinical trial conducted October 2013 - May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes. RESULTS: Among 288 infants randomised (median (IQR) gestational age 26+2 (25+3-27+1) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no differences in other respiratory function measurements, oxygen saturation, heart rate or FiO2. There were no differences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028). CONCLUSION: In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range. TRIAL REGISTRATION: Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.

Improving Guideline Compliance and Documentation Through Auditing Neonatal Resuscitation.

Objective: Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Study design: Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. Results: A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median (IQR) gestational age of 30 (27-35) weeks vs. 30 (29-33) weeks (p = 0.64) and birth weight of 1368 (998-1780) grams vs. 1420 (1097-1871) grams (p = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; p < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO2), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% (p < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Conclusion: Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.

Sedation during minimal invasive surfactant therapy: a randomised controlled trial.

BACKGROUND AND AIMS: Although sedation for endotracheal intubation of infants is widely adopted, there is no consensus whether sedation should be used for minimal invasive surfactant therapy (MIST). We compared, in a randomised controlled setting, the level of stress and comfort of preterm infants during MIST with and without receiving low-dose sedation. METHODS: Infants between 26 and 36 weeks gestational age were randomised to receive either low-dose sedation (1 mg/kg propofol intravenous) or no premedication during MIST procedure. Standard comfort care was given in both groups, which consisted of administering sucrose in the cheek pouch of the infant and containment. Primary end point was the percentage of infants assessed to be comfortable during the procedure (COMFORTneo-score <14). Secondary parameters included complications of both the MIST procedure and low-dose sedation administration. RESULTS: In total, 78 infants were randomised and analysed, with a median (IQR) gestational age of 29+0 (28+0-32+0) weeks. The percentage of infants with a COMFORTneo score <14 during MIST was significantly higher in the sedated group (32/42 (76%) vs 8/36 (22%), p<0.001). The incidence of desaturation (SpO2 <85%) during the procedure was significantly higher in the sedated group (38/42 (91%) vs 25/36 (69%), p=0.023), and infants needed more often nasal intermittent mandatory ventilation during the procedure (39/42 (93%) vs 17/36 (47%), p<0.001). There were no differences in incidence of hypotension, bradycardia, intubation or pneumothoraxes. CONCLUSION: Low-dose sedation increased comfort during MIST procedure in preterm infants, but the need for transient non-invasive ventilation was increased. TRIAL REGISTRATION NUMBER: NTR5010, pre-results.

Optimal Target Range of Closed-Loop Inspired Oxygen Support in Preterm Infants: A Randomized Cross-Over Study.

OBJECTIVE: To investigate the effect of different pulse oximetry (SpO2) target range settings during automated fraction of inspired oxygen control (A-FiO2) on time spent within a clinically set SpO2 alarm range in oxygen-dependent infants on noninvasive respiratory support. STUDY DESIGN: Forty-one preterm infants (gestational age [median] 26 weeks, age [median] 21 days) on FiO2 >0.21 receiving noninvasive respiratory support were subjected to A-FiO2 using 3 SpO2 target ranges (86%-94%, 88%-92%, or 89%-91%) in random order for 24 hours each. Before switching to the next target range, SpO2 was manually controlled for 24 hours (washout period). The primary outcome was the time spent within the clinically set alarm limits of 86%-94%. RESULTS: The percent time within the 86%-94% SpO2 alarm range was similar for all 3 A-FiO2 target ranges (74%). Time spent in hyperoxemia was not significantly different between target ranges. However, the time spent in severe hypoxemia (SpO2 <80%) was significantly reduced during the narrowed target ranges of A-FiO2 (88%-92%; 1.9%, 89%-91%; 1.7%) compared with the wide target range (86%-94%; 3.4%, P < .001). There were no differences between the 88%-92% and 89-91% target range. CONCLUSIONS: Narrowing the target range of A-FiO2 to the desired median ±2% is effective in reducing the time spent in hypoxemia, without increasing the risk of hyperoxemia. TRIAL REGISTRATION: www.trialregister.nl: NTR4368.

Tactile Stimulation to Stimulate Spontaneous Breathing during Stabilization of Preterm Infants at Birth: A Retrospective Analysis.

BACKGROUND AND AIMS: Tactile maneuvers to stimulate breathing in preterm infants are recommended during the initial assessment at birth, but it is not known how often and how this is applied. We evaluated the occurrence and patterns of tactile stimulation during stabilization of preterm infants at birth. METHODS: Recordings of physiological parameters and videos of infants <32 weeks gestational age were retrospectively analyzed. Details of tactile stimulation during the first 7 min after birth (timing, duration, type, and indication) were noted. RESULTS: Stimulation was performed in 164/245 (67%) infants. The median (IQR) GA was 28 6/7 (27 2/7-30 1/7) weeks, birth weight 1,153 (880-1,385) g, Apgar score at 5 min was 8 (7-9), 140/245 (57%) infants were born after cesarean section, and 134/245 (55%) were male. There were no significant differences between the stimulated and the non-stimulated infants with regard to basic characteristics. In the stimulated infants, the first episode of stimulation was given at a median (IQR) of 114 (73-182) s after birth. Stimulation was repeated 3 (1-5) times, with a median (IQR) duration of 8 (4-16) s and a total duration of 32 (15-64) s. Modes of stimulation were: rubbing (68%) or flicking (2%) the soles of the feet, rubbing the back (12%), a combination (9%), or other (8%). In 67% of the stimulation episodes, a clear indication was noted (25% bradycardia, 57% apnea, 48% hypoxemia, 43% combination) and an effect was observed in 18% of these indicated stimulation episodes. A total effect of all stimulation episodes per infant remains unclear, but infants who did not receive stimulation were more often intubated in the delivery room (14/79 (18%) vs 12/164 (7%), p < 0.05). CONCLUSION: There was a large variation in the use of tactile stimulation in preterm infants during stabilization at birth. In most cases, there was an indication for stimulation, but only in a small proportion an effect could be observed.

Improving manual oxygen titration in preterm infants by training and guideline implementation.

To study oxygen saturation (SpO2) targeting before and after training and guideline implementation of manual oxygen titration, two cohorts of preterm infants <30 weeks of gestation needing respiratory support and oxygen therapy were compared. The percentage of the time spent with SpO2 within the target range (85-95%) was calculated (%SpO2-wtr). SpO2 was collected every minute when oxygen is >21%. ABCs where oxygen therapy was given were identified and analyzed. After training and guideline implementation the %SpO2-wtr increased (median interquartile range (IQR)) 48.0 (19.6-63.9) % vs 61.9 (48.5-72.3) %; p < 0.005, with a decrease in the %SpO2 > 95% (44.0 (27.8-66.2) % vs 30.8 (22.6-44.5) %; p < 0.05). There was no effect on the %SpO2 < 85% (5.9 (2.8-7.9) % vs 6.2 (2.5-8) %; ns) and %SpO2 < 80% (1.9 (1.0-3.0) % vs 1.7 (0.8-2.6) %; ns). In total, 186 ABCs with oxygen therapy before and 168 ABCs after training and guideline implementation occurred. The duration of SpO2 < 80% reduced (2 (1-2) vs 1 (1-2) minutes; p < 0.05), the occurrence of SpO2 > 95% did not decrease (73% vs 64%; ns) but lasted shorter (2 (0-7) vs 1 (1-3) minute; p < 0.004). CONCLUSION: Training and guideline implementation in manual oxygen titration improved SpO2 targeting in preterm infants with more time spent within the target range and less frequent hyperoxaemia. The durations of hypoxaemia and hyperoxaemia during ABCs were shorter. What is Known: • Oxygen saturation targeting in preterm infants can be challenging and the compliance is low when oxygen is titrated manually. • Hyperoxaemia often occurs after oxygen therapy for oxygen desaturation during apnoeas. What is New: • Training and implementing guidelines improved oxygen saturation targeting and reduced hyperoxaemia. • Training and implementing guidelines improved manual oxygen titration during ABC.

Hypothermia in Preterm Infants in the First Hours after Birth: Occurrence, Course and Risk Factors.

BACKGROUND: Hypothermia is associated with increased morbidity and mortality rates. Preterm infants frequently have hypothermia when they are admitted to the NICU, but there is no data on the occurrence of hypothermia during the first hours after admission. OBJECTIVE: To investigate the occurrence of hypothermia in preterm infants in the first three hours of admission and to identify risk factors. METHODS: Infants < 32 weeks of gestation included in a randomized trial with admission temperature as primary outcome were retrospectively analyzed for the occurrence of hypothermia (< 36.5°C) in the first three hours after admission. Risk factors were identified using linear regression analysis and logistic regression. RESULTS: In total 80 infants were included with a median (IQR) gestational age at birth of 29 (27-30) weeks. In 93% of the infants hypothermia occurred in the first three hours after admission. The median (IQR) duration of hypothermia was 101 (34-162) minutes, of which 24 (7-52) minutes the hypothermia was mild, 45 (4-111) minutes moderate, severe hypothermia hardly occurred. Gestational age and the occurrence of hypothermia at birth were independent risk factors for the occurrence of moderate and severe hypothermia and significantly correlated with duration of hypothermia. CONCLUSIONS: Hypothermia occurred often and for a long period in preterm infants in the first three hours of life, low gestational age and admission temperature were independent risk factors.

Accuracy of currently available neonatal respiratory function monitors for neonatal resuscitation.

UNLABELLED: This study aimed to test the accuracy in volume measurements of three available respiratory function monitors (RFMs) for neonatal resuscitation and the effect of changing gas conditions. The Florian, New Life Box Neo-RSD (NLB Neo-RSD) and NICO RFM were tested on accuracy with volumes of 10 and 20 mL and on changes in volume measurements under changing gas conditions (oxygen level 21-100 % and from cold dry air (24 ± 2 °C) to heated humidified air (37 °C). Volume differences >10 % were considered clinically relevant. We found that the mean (SD) volume difference was clinically acceptable for all devices (10, 20 mL): Florian (+8.4 (1.2)%, +8.4 (0.5)%); NLB Neo-RSD (+5.8 (1.1)%, +4.3 (1.4)%); and NICO (-8.2 (0.9)%, -8.7 (0.8)%). Changing from cold dry to heated humidified air increased the volume difference using the Florian (cold dry air, heated humidified air (+5.2 (1.2)%, +12.2 (0.9)%) but not NLB Neo-RSD (+2.0(1.6)%, +3.4(2.8)%) and NICO (-2.3 % (0.8), +0.1 (0.6)%). Similarly, when using heated humidified air, increasing oxygen enlarged increased the volume difference using the Florian (oxygen 21 %, 100 %: +12.2(1.0)%, +19.8(1.1)%), but not NLB Neo-RSD (+0.2(1.9)%, +1.1(2.8)%) and NICO (-5.6(0.9)%, -3.7(0.9)%). Clinically relevant changes occurred when changing both gas conditions (Florian +25.7(1.7)%; NLB Neo-RSD +3.8(2.4)%; NICO -5.7(1.4)%). CONCLUSION: The available RFMs demonstrated clinically acceptable deviations in volume measurements, except for the Florian when changing gas conditions. WHAT IS KNOWN: •Respiratory function monitors (RFMs) are increasingly used for volume measurements during respiratory support of infants at birth. •During respiratory support at birth, gas conditions can change quickly, which can influence the volume measurements. What is new: •The available RFMs have clinically acceptable deviations when measuring the accuracy of volume measurements. •The RFM using a hot wire anemometer demonstrated clinically relevant deviations in volume measurements when changing the gas conditions. These deviations have to be taken into account when interpreting the volumes directly at birth.

Cardiorespiratory Monitoring during Neonatal Resuscitation for Direct Feedback and Audit.

Neonatal resuscitation is one of the most frequently performed procedures, and it is often successful if the ventilation applied is adequate. Over the last decade, interest in seeking objectivity in evaluating the infant's condition at birth or the adequacy and effect of the interventions applied has markedly increased. Clinical parameters such as heart rate, color, and chest excursions are difficult to interpret and can be very subjective and subtle. The use of ECG, pulse oximetry, capnography, and respiratory function monitoring can add objectivity to the clinical assessment. These physiological parameters, with or without the combination of video recordings, can not only be used directly to guide care but also be used later for audit and teaching purposes. Further studies are needed to investigate whether this will improve the quality of delivery room management. In this narrative review, we will give an update of the current developments in monitoring neonatal resuscitation.

Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in newborn infants.

BACKGROUND: Mechanical ventilation is a life-saving intervention for critically ill newborn infants with respiratory failure admitted to a neonatal intensive care unit (NICU). Ventilating newborn infants can be challenging due to small tidal volumes, high breathing frequencies, and the use of uncuffed endotracheal tubes. Mechanical ventilation has several short-term, as well as long-term complications. To prevent complications, weaning from the ventilator is started as soon as possible. Weaning aims to support the transfer from full mechanical ventilation support to spontaneous breathing activity. OBJECTIVES: To assess the efficacy of protocolized versus non-protocolized ventilator weaning for newborn infants in reducing the duration of invasive mechanical ventilation, the duration of weaning, and shortening the NICU and hospital length of stay. To determine efficacy in predefined subgroups including: gestational age and birth weight; type of protocol; and type of protocol delivery. To establish whether protocolized weaning is safe and clinically effective in reducing the duration of mechanical ventilation without increasing the risk of adverse events. SEARCH METHODS: We searched the Cochrane Central Register of Controlled trials (CENTRAL; the Cochrane Library; 2015, Issue 7); MEDLINE In-Process and other Non-Indexed Citations and OVID MEDLINE (1950 to 31 July 2015); CINAHL (1982 to 31 July 2015); EMBASE (1988 to 31 July 2015); and Web of Science (1990 to 15 July 2015). We did not restrict language of publication. We contacted authors of studies with a subgroup of newborn infants in their study, and experts in the field regarding this subject. In addition, we searched abstracts from conference proceedings, theses, dissertations, and reference lists of all identified studies for further relevant studies. SELECTION CRITERIA: Randomized, quasi-randomized or cluster-randomized controlled trials that compared protocolized with non-protocolized ventilator weaning practices in newborn infants with a gestational age of 24 weeks or more, who were enrolled in the study before the postnatal age of 28 completed days after the expected date of birth. DATA COLLECTION AND ANALYSIS: Four authors, in pairs, independently reviewed titles and abstracts identified by electronic searches. We retrieved full-text versions of potentially relevant studies. MAIN RESULTS: Our search yielded 1752 records. We removed duplicates (1062) and irrelevant studies (843). We did not find any randomized, quasi-randomized or cluster-randomized controlled trials conducted on weaning from mechanical ventilation in newborn infants. Two randomized controlled trials met the inclusion criteria on type of study and type of intervention, but only included a proportion of newborns. The study authors could not provide data needed for subgroup analysis; we excluded both studies. AUTHORS' CONCLUSIONS: Based on the results of this review, there is no evidence to support or refute the superiority or inferiority of weaning by protocol over non-protocol weaning on duration of invasive mechanical ventilation in newborn infants.

Compliance in oxygen saturation targeting in preterm infants: a systematic review.

During oxygen therapy in preterm infants, targeting oxygen saturation is important for avoiding hypoxaemia and hyperoxaemia, but this can be very difficult and challenging for neonatal nurses. We systematically reviewed the qualitative and quantitative studies investigating the compliance in targeting oxygen saturation in preterm infants and factors that influence this compliance. We searched PubMed, Embase, Web of Science, Cochrane, CINAHL and ScienceDirect from 2000 to January 2015. Sixteen studies were selected, which involved a total of 2935 nurses and 574 infants. The studies varied in methodology, and we have therefore used a narrative account to describe the data. The main finding is that there is a low compliance in oxygen targeting; the upper alarm limits are inappropriately set, and maintaining the saturation (SpO2) below the upper limit presented particular difficulties. Although there is little data available, the studies indicate that training, titration protocols and decreasing workload could improve awareness and compliance. Automated oxygen regulations have been shown to increase the time that SpO2 is within the target range. CONCLUSION: The compliance in targeting oxygen during oxygen therapy in preterm infants is low, especially in maintaining the SpO2 below the upper limit. WHAT IS KNOWN: • The use of oxygen in preterm infants is vital, but the optimal strategyremains controversial. • Targeting SpO2 during oxygen therapy in preterm infants has beenshown to reduce mortality and morbidity. WHAT IS NEW: • Review of the literature showed that the compliance in targeting SpO2and alarm settings is low. • Creating awareness of risks of oxygen therapy and benefits in targeting,decreasing nurse/patient ratio and automated oxygen therapy couldincrease compliance.