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2.
Arch Dis Child Fetal Neonatal Ed ; 105(6): 656-661, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32414815

RESUMO

OBJECTIVE: To characterise the association between weekend (Saturday and Sunday) deliveries of very low birthweight (VLBW) infants and delivery room outcomes in the 'golden hour' after birth. DESIGN AND SETTING: A retrospective cohort study using California Perinatal Quality Care Collaborative data from participating neonatal intensive care units. PATIENTS: The study population after exclusions was 26 515 VLBW infants born in California from 2010 to 2016. MAIN OUTCOME MEASURES: Delivery room outcomes assessed included: chest compressions, epinephrine, intubation prior to continuous positive airway pressure ventilation, 5 min Apgar <4, admission hypothermia and death within 12 hours. To adjust for potential confounders, we fit multivariate regression models controlling for two sets of infant, maternal and hospital characteristics. RESULTS: Infants delivered on weekends were less likely to have been prenatally diagnosed with intrauterine growth restriction but were otherwise not significantly different in gestational age, ethnicity, sex or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends, while vaginal deliveries were consistent across all days. After adjusting for sex and race, weekend delivery was associated with delivery room chest compressions (OR: 1.12, 95% CI 1.02 to 1.24) and lower 5 min Apgar (OR: 1.11, 95% CI 1.01 to 1.21). CONCLUSION: In this population-based study of VLBW infants, there was an increase in chest compressions for infants born on the weekend. More research is needed on the differences between populations born on weekdays versus weekends, and how these may contribute to observed associations.


Assuntos
Reanimação Cardiopulmonar , Recém-Nascido de muito Baixo Peso , Terapia Intensiva Neonatal/normas , Índice de Apgar , California , Cesárea , Epinefrina/administração & dosagem , Mortalidade Hospitalar , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Intubação Intratraqueal , Respiração com Pressão Positiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
4.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32409481
7.
Crit Care ; 24(1): 65, 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32093763

RESUMO

BACKGROUND: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.


Assuntos
Terapia Intensiva Neonatal , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Cuidados Críticos/métodos , Estado Terminal , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/métodos , Terapia Intensiva Neonatal/normas , Sistemas Automatizados de Assistência Junto ao Leito/normas , Revisões Sistemáticas como Assunto , Ultrassonografia/métodos , Ultrassonografia/normas
8.
Neoreviews ; 21(2): e109-e119, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32005721

RESUMO

The clinical goals of intravenous lipid emulsions (ILEs) have changed since their initial development. In the past, 100% soybean oil was used to provide energy and prevent an essential fatty acid deficiency. Now, different oil sources are used with the goal of improving nutritional status and preventing common neonatal comorbidities. We now have a better understanding of specific ILE constituents, namely, fatty acids, vitamin E, and phytosterols, and how these components contribute to complications such as intestinal failure-associated liver disease. This review addresses the development and composition of different ILEs and summarizes how individual ILE ingredients affect infant metabolism and health.


Assuntos
Emulsões Gordurosas Intravenosas/normas , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/normas , Emulsões Gordurosas Intravenosas/efeitos adversos , Emulsões Gordurosas Intravenosas/química , Emulsões Gordurosas Intravenosas/história , História do Século XX , História do Século XXI , Humanos , Recém-Nascido , Terapia Intensiva Neonatal/história , Terapia Intensiva Neonatal/métodos
9.
CMAJ ; 192(4): E81-E91, 2020 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-31988152

RESUMO

BACKGROUND: Preterm birth is the leading cause of morbidity and mortality in children younger than 5 years. We report the changes in neonatal outcomes and care practices among very preterm infants in Canada over 14 years within a national, collaborative, continuous quality-improvement program. METHODS: We retrospectively studied infants born at 23-32 weeks' gestation who were admitted to tertiary neonatal intensive care units that participated in the Evidence-based Practice for Improving Quality program in the Canadian Neonatal Network from 2004 to 2017. The primary outcome was survival without major morbidity during the initial hospital admission. We quantified changes using process-control charts in 6-month intervals to identify special-cause variations, adjusted regression models for yearly changes, and interrupted time series analyses. RESULTS: The final study population included 50 831 infants. As a result of practice changes, survival without major morbidity increased significantly (56.6% [669/1183] to 70.9% [1424/2009]; adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 1.06-1.10, per year) across all gestational ages. Survival of infants born at 23-25 weeks' gestation increased (70.8% [97/137] to 74.5% [219/294]; adjusted OR 1.03, 95% CI 1.02-1.05, per year). Changes in care practices included increased use of antenatal steroids (83.6% [904/1081] to 88.1% [1747/1983]), increased rates of normothermia at admission (44.8% [520/1160] to 67.5% [1316/1951]) and reduced use of pulmonary surfactant (52.8% [625/1183] to 42.7% [857/2009]). INTERPRETATION: Network-wide quality-improvement activities that include better implementation of optimal care practices can yield sustained improvement in survival without morbidity in very preterm infants.


Assuntos
Terapia Intensiva Neonatal/métodos , Terapia Intensiva Neonatal/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Melhoria de Qualidade , Canadá , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Avaliação de Programas e Projetos de Saúde , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Análise de Sobrevida
10.
Pediatrics ; 145(2)2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31941760

RESUMO

BACKGROUND: Premature infants have bradycardia and/or desaturation events due to apnea of prematurity that resolve as the infants mature. Despite American Academy of Pediatrics guidelines recommending a standard "event-free" period before discharge, length of observation in our Intensive Care Nursery was variable. By June 2018, for infants born <36 weeks' gestation in the Intensive Care Nursery, we aimed to standardize time to discharge after the last documented event at 5 days, when the baseline mean was 3.6 days (range 0-6 days). METHODS: A quality-improvement team used the Model for Improvement. Plan-do-study-act cycles improved nursing documentation of events and standardized discharge criteria after consensus on operational definitions. The outcome measure was days to discharge after last documented event. Process measures included percentage of events documented completely and correctly in the electronic medical record. Balancing measure was length of stay after 36 weeks' corrected gestational age. We used statistical process control. RESULTS: The baseline event watch ranged from 0 to 6 days. After defining significant events, documentation expectations, and consensus on a 5-day "watch" before discharge, the event watch range narrowed with a mean that shifted from 3.6 to 4.8 days on X-bar S statistical process control chart. Completeness of documentation increased from 38% to 63%, and documentation of significant events increased from 38% to 88%. Length of stay after 36 weeks' corrected gestational age was unchanged, and nursing satisfaction improved. CONCLUSIONS: We found decreasing variation in the management of apnea of prematurity while simultaneously improving staff satisfaction. Next steps include revising electronic medical record flowsheets and spread to network NICUs.


Assuntos
Apneia/terapia , Documentação/normas , Terapia Intensiva Neonatal/normas , Tempo de Internação , Alta do Paciente/normas , Melhoria de Qualidade , Consenso , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Avaliação de Resultados em Cuidados de Saúde , Fatores de Tempo , Sinais Vitais
11.
Adv Neonatal Care ; 20(2): 109-117, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31990696

RESUMO

BACKGROUND: Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE: To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY: Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS: Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE: Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH: As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.


Assuntos
Terapia Intensiva Neonatal/normas , Cuidados Paliativos/psicologia , Cuidados Paliativos/normas , Pais/psicologia , Guias de Prática Clínica como Assunto , Assistência Terminal/psicologia , Assistência Terminal/normas , Adaptação Psicológica , Adulto , Tomada de Decisões , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pesquisa Qualitativa , Estresse Psicológico
12.
BMJ Open Qual ; 9(1)2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31986114

RESUMO

BACKGROUND: Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents. METHODS: Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a 'Blood Month' awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents' knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers). RESULTS: Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during 'Blood Month' was well-received by staff. Parents' feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice. CONCLUSION: PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.


Assuntos
Transfusão de Sangue/normas , Prática Clínica Baseada em Evidências/normas , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/normas , Austrália , Pessoal de Saúde/educação , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Consentimento Livre e Esclarecido/normas , Pais/educação , Inquéritos e Questionários
14.
Dev Neurorehabil ; 23(2): 113-120, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31431098

RESUMO

Purpose: Identify parent-focused transition practices for parents of children born preterm/acutely ill when transitioning from Neonatal Follow-Up Programs (NFUP) to Children's Treatment Centers or Networks (CTCN).Methods: NFUP and CTCN health-care providers participated in an online survey and qualitative interviews. Quantitative data were analyzed using descriptive statistics and qualitative data underwent conventional content analysis.Results: 60 participants (17 sites) from diverse health disciplines completed the survey, and 14 (from 11 of 17 sites) participated in a follow-up interview. Enablers to transition included knowledgeable practitioners, shared services, and family engagement; although not present across all sites. Barriers commonly reported were a lack of time, understanding of roles, and parent engagement.Conclusion: Research study findings highlight the need to improve and bridge NFUP to CTCN parent-focused transition practices. Recommendations for next actions steps include improved cross-sector communication, bridging sectors through enhanced service provision, and moving from information provision to family engagement.


Assuntos
Assistência ao Convalescente/métodos , Terapia Intensiva Neonatal/métodos , Pais , Transferência de Pacientes/métodos , Assistência ao Convalescente/normas , Criança , Feminino , Pessoal de Saúde/normas , Humanos , Recém-Nascido , Recém-Nascido Prematuro/crescimento & desenvolvimento , Terapia Intensiva Neonatal/normas , Masculino , Transferência de Pacientes/normas , Guias de Prática Clínica como Assunto , Inquéritos e Questionários
15.
Adv Neonatal Care ; 19(6): 500-508, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31567313

RESUMO

BACKGROUND: Parents of neonates are integral components of patient safety in the neonatal intensive care unit (NICU), yet their views are often not considered. By understanding how parents perceive patient safety in the NICU, clinicians can identify appropriate parent-centered strategies to involve them in promoting safe care for their infants. PURPOSE: To determine how parents of neonates conceptualize patient safety in the NICU. METHODS: We conducted qualitative interviews with 22 English-speaking parents of neonates from the NICU and observations of various parent interactions within the NICU over several months. Data were analyzed using thematic content analysis. Findings were critically reviewed through peer debriefing. FINDINGS: Parents perceived safe care through their observations of clinicians being present, intentional, and respectful when adhering to safety practices, interacting with their infant, and communicating with parents in the NICU. They described partnering with clinicians to promote safe care for their infants and factors impacting that partnership. We cultivated a conceptual model highlighting how parent-clinician partnerships can be a core element to promoting NICU patient safety. IMPLICATIONS FOR PRACTICE: Parents' observations of clinician behavior affect their perceptions of safe care for their infants. Assessing what parents observe can be essential to building a partnership of trust between clinicians and parents and promoting safer care in the NICU. IMPLICATIONS FOR RESEARCH: Uncertainty remains about how to measure parent perceptions of safe care, the level at which the clinician-parent partnership affects patient safety, and whether parents' presence and involvement with their infants in the NICU improve patient safety.


Assuntos
Comportamento do Consumidor , Terapia Intensiva Neonatal , Pais/psicologia , Segurança do Paciente , Gestão da Segurança , Adulto , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/organização & administração , Terapia Intensiva Neonatal/métodos , Terapia Intensiva Neonatal/psicologia , Terapia Intensiva Neonatal/normas , Masculino , Relações Profissional-Família , Pesquisa Qualitativa , Gestão da Segurança/métodos , Gestão da Segurança/normas , Percepção Social
17.
Pediatr Phys Ther ; 31(4): 308-314, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31568371

RESUMO

Knowledge translation is the process by which we take new information that is evidence based and incorporate it into our practice. While we can each incorporate evidence into our practice, the collaboration between a researcher and a clinician can advance the implementation of evidence-based practice. We highlight the use of the Plan-Do-Study-Act cycle that includes a researcher and clinical partner on a journey of research question development, knowledge generation, clinical implementation, and policy change that advances the care to infants in the neonatal intensive care unit and in a developmental follow-up clinic. The team provides examples of implementation and highlights the clinical care differences following a decade of collaboration. Pediatric physical therapists have a responsibility to embrace and support knowledge translation to advance our profession and the care of infants, children, and families.


Assuntos
Prática Clínica Baseada em Evidências/normas , Conhecimentos, Atitudes e Prática em Saúde , Terapia Intensiva Neonatal/normas , Pesquisa Médica Translacional/normas , Humanos , Recém-Nascido
18.
PLoS Med ; 16(9): e1002900, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31498784

RESUMO

BACKGROUND: Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. METHODS AND FINDINGS: We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. CONCLUSION: These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care. TRIAL REGISTRATION: ISRCTN30829654.


Assuntos
Mortalidade Hospitalar , Mortalidade Infantil , Terapia Intensiva Neonatal , Parto , Morte Perinatal/prevenção & controle , Ressuscitação , Natimorto , Adulto , Feminino , Hospitais Públicos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/normas , Nepal , Morte Perinatal/etiologia , Gravidez , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Ressuscitação/efeitos adversos , Ressuscitação/mortalidade , Ressuscitação/normas , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Early Hum Dev ; 138: 104847, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31488312

RESUMO

Point-of-care, or clinician-performed ultrasound (CPU), is increasingly utilised within neonatology as a valuable adjunct to clinical examination. The ability to perform and interpret rapid, real-time, serial assessment of patient physiology at the bedside has seen the potential uses of CPU expand, with an evolving list of clinical and research applications. Benefits of functional assessment of neonatal haemodynamics in particular have been described across a range of gestational ages and disease states. Devising suitable curricula for trainees and ensuring robust processes for the training and credentialing of clinicians performing CPU is essential. Challenges to universal implementation of CPU in the neonatal intensive care setting exist, and regional differences in training and accreditation are well described. Appropriate integration into clinical decision-making and ensuring competency-based locally appropriate training programs, which build on an expanding evidence base, are key priorities in ensuring newborns receive optimal benefit from the modality.


Assuntos
Doenças do Recém-Nascido/diagnóstico por imagem , Terapia Intensiva Neonatal/métodos , Testes Imediatos/normas , Ultrassonografia/métodos , Humanos , Recém-Nascido , Terapia Intensiva Neonatal/normas , Neonatologistas/educação , Ultrassonografia/normas
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