Survival of Ventilated Extremely Premature Neonates With Severe Intraventricular Hemorrhage.

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH-associated mortality are unknown. METHODS: We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks' gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score-matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score-matched subgroup analyses, comparing severe IVH-associated mortality among 4 geographic regions of the United States. RESULTS: In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49-3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47-2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS: The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH-associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.

Reducing Alarm Burden in a Level IV Neonatal Intensive Care Unit.

Introduction: Excessive alarm burden contributes to alarm fatigue, causing staff to ignore or delay response to clinically significant alarms. The objective of this quality improvement project was to reduce yellow self-resolving SpO2 alarms from a mean of 14 alarms/patient-hour (APH) to 7 APH (a 50% reduction) within a 6-month period, without significantly decreasing the amount of time spent in target SpO2 range (90%-95%). Methods: A multidisciplinary team used Define-Measure-Analyze-Improve-Control methodology to identify etiologies of alarm frequency and design improvement interventions to reduce alarm burden in a single-site Level IV NICU. Data-driven changes in alarm limit settings, alarm delay, and trial of a new pulse oximeter probe were used. Alarm data from the bedside monitor were analyzed following each improvement cycle. As a balancing measure, histograms monitored time spent in target SpO2 range. Results: SpO2 alarm data were collected for 4,320 patient-hours (180 patient-days) on 40 neonatal intensive care unit patients meeting inclusion criteria. Corresponding histograms were obtained for each patient day. Following 5 Plan-Do-Study-Act cycles, the mean number of yellow self-resolving SpO2 alarms decreased from 14 to 5 APH, a 64% decrease. There was no difference in time spent in target SpO2 range (50% versus 50%, P = 0.93). After achieving the project aim, 2 control phase measurements demonstrated sustained improvement (mean APH = 6). Conclusions: Yellow self-resolving SpO2 alarm frequency was reduced by 64% through the implementation of data-driven changes in alarm limit settings, alarm delays, and trial of a more sensitive oximeter probe without introducing harm to patients.

Developing a Newborn Resuscitation Telemedicine Program: A Follow-Up Study Comparing Two Technologies.

Background: Early work has demonstrated that newborn resuscitation telemedicine programs (NRTPs) are feasible and improve the quality of high-risk newborn resuscitations in community settings. Research evaluating the telemedicine technology requirements for NRTPs is limited. Objective: To compare the quality and reliability of two telemedicine technologies for providing NRTP consults. We hypothesized that the InTouch Lite Version 2 (ITH Lite) would provide a higher-quality user experience and superior reliability when compared with a wired telemedicine cart. Methods: From December 1, 2015 to August 31, 2017, providers completed electronic surveys assessing technology performance after each NRTP consult and incident reporting/resolution was monitored. Survey questions assessed the overall, audio, and video quality using a 1-5 Likert scale. Reliability was assessed based on the ability to connect on first-attempt, unplanned disconnections, and the frequency and impact of reported incidents. Results: During the study period, 118 NRTP consults were performed (n = 25 wired cart; n = 93 ITH Lite) and 155 surveys were completed (n = 26 wired cart; n = 129 ITH Lite). Overall and video quality were similar between the two technologies, but audio quality (mean ± standard deviation) was superior using the ITH Lite (4.61 ± 0.72 vs. 4.08 ± 1.13, p < 0.01). Ability to connect on first attempt was improved with the ITH Lite (96% vs. 73%, p < 0.01). Fewer incidents were reported per activation (0.5:1 vs. 0.9:1) and more incidents were proactively resolved using the ITH Lite (93% vs. 68%, p < 0.01).Conclusion: The ITH Lite demonstrated improved audio quality and reliability when compared with a wired cart. Organizations should consider connection reliability and audio/video quality when selecting a NRTP technology.

Implementation of a Clinical Prediction Model Using Daily Postnatal Weight Gain, Birth Weight, and Gestational Age to Risk Stratify ROP.

PURPOSE: To develop a simple prognostic model using postnatal weight gain, birth weight, and gestational age to identify infants at risk for developing severe retinopathy of prematurity (ROP). METHODS: Medical records from two tertiary referral centers with the diagnosis code "Retinopathy of Prematurity" were evaluated. Those with a birth weight of 1,500 g or less, gestational age of 30 weeks or younger, and unstable clinical courses were included. Multivariate regression analysis was applied to transform three independent variables into a growth rate algorithm. RESULTS: Seventeen of 191 neonates had severe ROP. Weight gain of at least 23 g/d was determined as a protective cut-off value against development of severe ROP. This value maintained 100% sensitivity with 62% specificity to ensure all neonates who require treatment would be captured. Overall, the Omaha (OMA)-ROP model calculated a 58% reduction in eye examinations within the cohort. CONCLUSIONS: Inclusion of postnatal growth rate in risk stratification will minimize the number of eye examinations performed without increasing adverse visual outcomes. The OMA-ROP model predicts neonates who gain less than 23 g/d are at higher risk for developing severe ROP. Although promising, larger cohort studies may be necessary to validate and implement new screening practices among preterm infants. [J Pediatr Ophthalmol Strabismus. 2018;55(5):326-334.].