Effect of Health Insurance Status and Visitation Restrictions on Virtual Visitation Technology in the Neonatal Intensive Care Unit.

OBJECTIVE: This study aimed to examine the relationship between virtual technology system utilization and insurance status or type of visitation restrictions in a single-center neonatal intensive care unit. STUDY DESIGN: Prospective cohort study with separate analyses performed based on insurance status (public vs. nonpublic) and "in effect" unit visitation restrictions. The three study epochs based on patient visitation restrictions were Epoch 1 (July to October 2019) with standard visitation restrictions, Epoch 2 (November 2019 to February 2020) with respiratory syncytial virus/influenza visitation restrictions, and Epoch 3 (March to June 2020) with coronavirus disease 2019 (COVID-19) visitation restrictions, respectively. RESULTS: Families of 357 infants used web-based cameras through most of the infant's hospitalization (median: 86.05%, Q3: 97.9%) with 165,795 total camera logins, indicating consistent utilization. There was a trend for fewer logins per infant and significantly longer time to consent (p = 0.03) in the Public Insurance group. Unit visitation restrictions impacted the time to consent, the shortest being in Epoch 3 during the COVID-19 pandemic (p = 0.03). CONCLUSION: Virtual visitation technology is well embraced by neonatal instensive care unit families; however, gaps in access and use among subgroups signals a form of social inequality that needs to be explored further. KEY POINTS: · Virtual visitation technology can bridge the distance gap for families of hospitalized infants.. · Utilization of virtual technology is affected by socioeconomic factors and seasonal unit visitation restrictions.. · Factors influencing disparities in access and utilization of virtual technology need to be investigated further..

A Standardized, 3-Tiered, Seizure Burden-Based Protocol for the Treatment of Neonatal Seizures.

OBJECTIVE: To evaluate use of a standardized, 3-tiered, seizure burden-based protocol for treatment of all electroencephalography (EEG)-confirmed seizures in a level IV neonatal intensive care unit (NICU). STUDY DESIGN: All infants admitted to the NICU with EEG-confirmed seizures over a 25-month period were enrolled in the study. We compared short-term outcomes before and after implementation of a standardized, 3-tiered protocol. RESULTS: A total of 107 infants were enrolled in the study. Use of midazolam infusions was reduced by 53.7% (p = 0.02). Midazolam infusion duration increased from 4 to 7.5 days (p = 0.003); however, when excluding 3 outliers, there was no significant difference between groups (-p = 0.67). Duration of EEG monitoring decreased from 5 to 3 days (p = 0.005). Hospital length of stay was unchanged. CONCLUSION: Implementation of a standardized, 3-tiered protocol for treatment of neonatal seizures improved short-term outcomes. Although not measured directly, reductions in EEG duration and midazolam use are promising indicators of overall seizure burden. More research is needed to evaluate impact on long-term neurodevelopmental outcomes.

Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital.

BACKGROUND: Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes. PURPOSE: To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital. METHODS: The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization. FINDINGS: NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention. IMPLICATIONS FOR PRACTICE: Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals. IMPLICATIONS FOR RESEARCH: Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

Very low birth weight infant care: adherence to a new nutrition protocol improves growth outcomes and reduces infectious risk.

BACKGROUND: Very low birth weight (VLBW) infants are at risk for postnatal growth restriction due to inadequate nutrient delivery and concomitant illness. Integrated clinical pathways or protocols can improve growth outcomes by decreasing practice variability. METHODS: A comprehensive nutrition bundle comprising standardized recommendations for initiating, advancing, and fortifying enteral feedings, and timely discontinuation of central lines was implemented in July 2012. Eligible were infants with a birth weight of <1500 g and <34 weeks gestation who were born over a 1-year period pre- and post-intervention, respectively. The primary aim was to determine if the intervention improved anthropometric parameter delta z scores at 36 weeks PMA. Secondary aims included time to first and full enteral feedings, central line-days, and rates of necrotizing enterocolitis (NEC) and sepsis/sepsis-like episodes. RESULTS: A total of 299 infants were included, of which 156 received the proposed intervention (Nutrition bundle group), and 143 received non-standardized nutrition practices (Conventional group). Median delta z scores for length (-1.2 versus -1.71; p=0.01) and head circumference (-0.73 versus -1.21; p=0.03) but not weight at 36 weeks PMA (-1.42 versus -1.58; p=0.74) were significantly higher in the Nutrition bundle group as compared to the Conventional group. Fewer infants in the intervention group had severe growth restriction. Time to first feed, full feeds, and central line duration were significantly shorter in the intervention period. The incidence of NEC and sepsis/sepsis-like episodes decreased with the intervention. CONCLUSIONS: A strategy using a comprehensive nutrition bundle improved linear and head circumference growth, reduced postnatal growth restriction, and decreased comorbidities in VLBW infants.