Decreasing delivery room intubations: A quality improvement project.

AIM: The delivery room intubation rate for babies born less than 32 weeks postmenstrual age (PMA) at the Mater Mothers' Hospital in 2017 was 51%. Delivery room intubation of preterm infants may be associated with an increased risk of developing bronchopulmonary dysplasia. This quality improvement project aimed to decrease the rate of delivery room intubation for infants born less than 32 weeks PMA. METHODS: A quality improvement process using the evidence-based practice for improving quality framework and Plan-Do-Study-Act cycles was undertaken from October 2018 to December 2019. Commencing bubble continuous positive airway pressure for initial resuscitation in the delivery room was the principal change idea. RESULTS: The delivery room intubation rate for infants born less than 32 weeks PMA before the commencement of this project was 48% (cohort 1, n = 221). There was a significant decrease in the rate to 37.2% while the project was being conducted (cohort 2, n = 277) and a further significant reduction to 28.2% after introducing bubble continuous positive airway pressure in the delivery room (cohort 3, n = 202). There was a significant improvement in admission temperatures and a significant decrease in mortality rate between cohort 1 and cohort 2 but not between cohort 2 and cohort 3. There was no change in the rate of discharge home on oxygen between cohorts. CONCLUSIONS: This quality improvement project led to a significantly decreased delivery room intubation rate in infants born less than 32 weeks PMA. There was no evidence of any adverse outcomes with this approach.

Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation.

PURPOSE: The provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these 'periviable' infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes. METHODS: A retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23+0 and 24+6 weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002-2017). RESULTS: A total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2-3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2-3 years and 29 of the 56 (51%) assessed had mild or no disability. CONCLUSIONS: In the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2-3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise. LEVEL OF EVIDENCE: Level III cohort study.

Time to peak velocity in the main pulmonary artery as a marker of persistent pulmonary hypertension in neonates.

PURPOSE: To assess right ventricular systolic time intervals, specifically, time to peak velocity (TPV) in the pulmonary artery as a marker of persistent pulmonary hypertension of the newborn (PPHTN). METHODS: This was a retrospective case-control study of 30 infants with pulmonary hypertension requiring intensive care management. Cardiac ultrasounds were re-analysed, comparing TPV measurements to a group of 31 controls who had cardiac ultrasounds performed for incidental murmurs with structurally normal hearts. RESULTS: Time to peak velocity was significantly shorter in the PPHTN group compared to controls, 47 vs. 95 ms, respectively. This was statistically significant with a P-value of <0.001. CONCLUSION: Time to peak velocity in the pulmonary artery is a useful marker of PPHTN in the first week of life. This measurement is especially useful if neither tricuspid regurgitation or a patent ductus are present for interrogation on ultrasound.

Butt lengths differ by area deprivation level: a field study to explore intensive smoking.

We collected cigarette butts in a range of residential areas, to assess differences in the length of unburnt tobacco in the butts, and in proportions of roll-your-own (RYO) cigarettes. Two high, two medium, and two low deprivation areas, as classified by deciles of the New Zealand Deprivation Index, were selected for the Wellington region. Collected butts were systematically classified and measured. A mixed model of analysis, treating location clusters nested within deprivation level areas as a random effect, was used to assess differences in mean length of unburnt tobacco in the butts. A total of 6,262 cigarette butts and separate filters were collected, of which 3,509 (56.0%) were measurable manufactured cigarette butts, 1,069 were unmeasurable manufactured butts, 1,450 were RYO butts, and 236 were RYO filters. The RYO butts were not measured because of the extent of their degradation. The unburnt tobacco lengths in manufactured cigarette butts were significantly shorter in the most deprived areas, relative to the least deprived areas (p = .035). Deformed manufactured cigarette butts (i.e., that potentially were stubbed out) showed the same pattern (p = .011 between the most and least deprived areas). We found no significant difference between deprivation areas in the proportion of RYO material found. The shorter mean unburnt tobacco length in the most deprived areas is consistent with more intensive smoking among smokers in those areas. This finding is consistent with other evidence of increased price sensitivity among poorer smokers, and with basic economic theory. Further evidence on observed smoking behavior in the field is necessary to better interpret these preliminary findings.