Biochemical surveillance versus clinical observation of term infants born after prolonged rupture of membranes - A quality assurance initiative.

AIM: To examine whether biochemical surveillance vs clinical observation of term infants with prolonged rupture of membranes as a risk factor for early-onset sepsis is associated with differences in patient trajectories in maternity and neonatal intensive care units. METHODS: A retrospective study of live-born infants with gestational age ≥ 37 + 0 weeks born after prolonged rupture of membranes (≥24 h) in four Norwegian hospitals 2017-2019. Two hospitals used biochemical surveillance, and two used predominantly clinical observation to identify early-onset sepsis cases. RESULTS: The biochemical surveillance hospitals had more C-reactive protein measurements (p < 0.001), neonatal intensive care unit admissions (p < 0.001) and antibiotic treatment (p < 0.001). Hospitals using predominantly clinical observation initiated antibiotic treatment earlier in infants with suspected early-onset sepsis (p = 0.04) but not in infants fulfilling early-onset sepsis diagnostic criteria (p = 0.09). There was no difference in antibiotic treatment duration (p = 0.59), fraction of infants fulfilling early-onset sepsis diagnostic criteria (p = 0.49) or length of hospitalisation (p = 0.30), and no early-onset sepsis-related adverse outcomes. CONCLUSION: The biochemical surveillance hospitals had more C-reactive protein measurements, but there was no difference in antibiotic treatment duration, early-onset sepsis cases, length of hospitalisation or adverse outcomes. Personnel resources needed for clinical surveillance should be weighed against the limitation of potentially painful procedures.

A cross-sectional study of neonatal intensive care unit overcrowding and understaffing associated with bacterial outbreaks.

AIM: To study whether overcrowding and/or nurse understaffing preceded four bacterial outbreaks during a 5-year period in a Norwegian university hospital neonatal intensive care unit (NICU). METHODS: A repeated cross-sectional study based on prospectively collected data from the Norwegian neonatal network's (NNN) web-based electronic database, digital work schedules and information about the outbreaks from logs, reports and publications. Number of admitted patients, category 4-5 patients (i.e., with the highest nurse to patient ratio), rostered nursing staff and nurse specialists were analysed in relation to periods (1) >28 days before individual outbreaks, (2) ≤28 days before, (3) during and (4) after outbreaks. Overcrowding and understaffing were compared between the four periods with Chi-square test and post hoc analysis with Bonferroni correction. RESULTS: When all outbreaks were analysed together, overcrowding was more frequent in the periods within 28 days of outbreaks compared to the other periods (p < 0.001). For understaffing, the periods within 28 days of outbreaks were only different from the periods >28 days before outbreaks (p < 0.001). The trends regarding individual outbreaks were less consistent, but there were more category 4-5 patients before and during the outbreaks. CONCLUSION: Bacterial outbreaks in a 5-year period were weakly associated with overcrowding and understaffing.

Sepsis treatment options identified by 10-year study of microbial isolates and antibiotic susceptibility in a level-four neonatal intensive care unit.

AIM: This observational study investigated the microbiology of blood culture-positive sepsis episodes and susceptibility to empiric antibiotics in early-onset sepsis (EOS) and late-onset sepsis (LOS) in a level-four neonatal intensive care unit (NICU) from 2010 to 2019. METHODS: It was based on patient records and data that Oslo University Hospital, Norway, routinely submitted to the Norwegian Neonatal Network database. Clinical data were merged with blood culture results, including antibiotic susceptibility. RESULTS: We studied 5249 infants admitted to the NICU 6321 times and identified 324 positive blood cultures from 287 infants, with 30 EOS and 305 LOS episodes. Frequent causative agents for EOS were group B streptococci (33.3%), Escherichia coli (20.0%) and Staphylococcus aureus (16.7%). All were susceptible to empiric ampicillin and gentamicin. LOS was most frequently caused by coagulase-negative staphylococci (CONS) (73.8%), Staphylococcus aureus (15.7%) and Enterococci (6.9%). CONS, Staphylococcus aureus, Enterococci, Escherichia coli, Klebsiella and Enterobacter represented 91.9% of LOS episodes and were susceptible to vancomycin and cefotaxime (96.1%), vancomycin and gentamicin (97.0%) and cloxacillin and gentamicin (38.1%). CONCLUSION: Empiric treatment with ampicillin and gentamicin was adequate for EOS. Combining vancomycin and gentamicin may be a safer alternative to cefotaxime for LOS, as this reduces exposure to broad-spectrum antibiotics.

But what do we mean by "health"? A critical perspective on the concept of health in the adolescent transition program of a Norwegian university hospital.

BACKGROUND: To understand better what influences the practice of our transition program, we wanted to explore the underlying theory of health. METHODS: We performed a qualitative content analysis of the written material that guides the program, comprising a quality system guideline, two checklists, a guide to health professionals and managers, and three patient brochures. RESULTS: The analysis resulted in the formulation of three themes; "Being on top of medical management", "Ability to promote own health" and "Awareness of own goals and expectations". CONCLUSION: Our analysis indicates that the program content revolves mainly around medical management and that other dimensions of health are not emphasised. We question what the goals of the program are and if these goals are explicit and shared among the program stakeholders. An explicit program theory is vital and needs to be evident in material supporting transition programs.

A critical appraisal of tools for delivery room assessment of the newborn infant.

Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.

Adolescent and young adult patients as co-researchers: A scoping review.

BACKGROUND: As part of a research project aimed at evaluating a hospital-based adolescent transition programme, we asked ourselves what is known about the ethical and methodological challenges of research involving adolescent patients as co-researchers. The aim of our review was to summarize empirical evidence and identify knowledge gaps about the involvement of young patients as co-researchers. METHODS: We conducted a scoping review through searches in MEDLINE, EMBASE, PsychINFO, AMED. RESULTS: We found reports of young patients being actively engaged as co-researchers in any stage of a research project, although commonly they were not involved in every stage. Including young patients as co-researchers is resource demanding and time-consuming. Involving young patients as co-researchers contributes to the fulfilment of their right to participation and may improve the relevance of research. Benefits for the young co-researcher include empowerment, skills building and raised self-esteem. Few authors go into detail about ethical considerations when involving young co-researchers. None of the included articles discuss legal considerations. DISCUSSION AND CONCLUSION: No lists of recommendations are given, but recommendations can be deduced from the articles. There is need for time, funding and flexibility when including young patients as co-researchers. Knowledge gaps concern legal and ethical dilemmas of including a vulnerable group as co-researchers. More reflection is needed about what meaningful participation is and what it entails in this context. PATIENT OR PUBLIC CONTRIBUTION: This review is part of a research project where the hospital youth council has been involved in discussions of focus area and methods.

Active antibiotic discontinuation in suspected but not confirmed early-onset neonatal sepsis-A quality improvement initiative.

AIM: To study whether a simple targeted intervention could reduce unwarranted antibiotic treatment in near-term and term neonates with suspected, but not confirmed early-onset sepsis. METHODS: A quality improvement initiative in three Norwegian neonatal intensive care units. The intervention included an inter-hospital clinical practice guideline for discontinuing antibiotics after 36-48 hours if sepsis was no longer suspected and blood cultures were negative in neonates ≥ 34+0 weeks of gestation. Two units used procalcitonin in decision-making. We compared data 12-14 months before and after guideline implementation. The results are presented as median with interquartile ranges. RESULTS: A total of 284 infants (2.5% of all births ≥ 34+0 weeks of gestation) received antibiotics before and 195 (1.8%) after guideline implementation (P = .0018). The two units that used procalcitonin discontinued antibiotics earlier after guideline implementation than the unit without procalcitonin. Neonates not diagnosed with sepsis were treated 49 (31-84) hours before and 48 (36-72) hours after guideline implementation (P = .68). In all infants, including those diagnosed with sepsis, antibiotic treatment duration was reduced from 108 (60-144) to 96 (48-120) hours (P = .013). CONCLUSION: Antibiotic treatment duration for suspected, but not confirmed early-onset sepsis did not change. However, treatment duration for all infants and the proportion of infants commenced on antibiotics were reduced.

Optimal Conventional Mechanical Ventilation in Full-Term Newborns: A Systematic Review.

BACKGROUND: Most studies examining the best mechanical ventilation strategies in newborn infants have been performed in premature infants with respiratory distress syndrome. PURPOSE: To identify and synthesize the evidence regarding optimal mechanical ventilation strategies in full-term newborns. METHODS: Systematic review carried out according to the methods described in the PRISMA statement. SEARCH STRATEGY: Searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library in March 2017, with an updated search and hand searches of reference lists of relevant articles in August 2017. STUDY SELECTION: Studies were included if they were published between 1996 and 2017, involved newborns with gestational age of 37 to 42 weeks, were randomized controlled trials, intervention or crossover studies, and addressed outcomes affecting oxygenation and/or ventilation, and/or short-term outcomes including duration of mechanical ventilation. Because of the large heterogeneity between the studies, it was not possible to synthesize the results in meta-analyses. The results are presented according to thematic analysis. RESULTS: No individual study reported research exclusively in newborns 37 to 42 weeks of gestation. Eight studies fulfilled the inclusion criteria, but the population in all these studies included both premature and term newborns. Evidence about mechanical ventilation tailored exclusively to full-term newborns is scarce. IMPLICATION FOR PRACTICE: Synchronized intermittent mandatory ventilation with a 6 mL/kg tidal volume and a positive end-expiratory pressure of 8 cm H2O may be advantageous in full-term newborns. IMPLICATION FOR RESEARCH: There is an urgent need for high-quality studies, preferably randomized controlled trials, in full-term newborns requiring mechanical ventilation to optimize oxygenation, ventilation, and short-term outcomes, potentially stratified according to the underlying pathology.

Hope in Parents of Very-Low Birth Weight Infants and its Association with Parenting Stress and Quality of Life.

PURPOSE: Being a parent of a very-low-birth-weight (VLBW) infant can be stressful. We aimed to describe parental hope 42months after the birth of a VLBW infant and determine whether there is an association between hope and parenting stress with quality of life (QoL), respectively. DESIGN AND METHODS: Fifty-nine parents of VLBW infants completed questionnaires about hope, parenting stress and QoL. Pearson correlation coefficients (r) and linear regression models were used to examine the relationship between the selected variables. To compare groups, t-test was used and Cohen's d for effect size was calculated. RESULTS: Parents of VLBW infants were more hopeful than the general population (p<0.001). Parenting stress and hope were both independently associated with QoL (p<0.001). The subgroup of parents of infants with birth weight <1000g had less hope (p=0.041) and higher parenting stress (p=0.041) than parents of infants with birth weight 1000-1500g. CONCLUSIONS: Hope and parenting stress were both independent determinants of QoL. Parents of the presumably sickest infants had less hope and higher parenting stress than parents of VLBW infants with a birth weight over 1000g. Hope should be further explored as a coping mechanism in parents of VLBW infants. PRACTICE IMPLICATIONS: The clinical implications of the strong association between hope, parenting stress and QoL remain to be determined, but reducing stress and strengthening hope seem to be important. This should be taken into account both at hospital discharge and at follow-up, especially for lower-birth-weight infants.

Outcomes following neonatal cardiopulmonary resuscitation. / Utfallet etter hjerte-lunge-redning av nyfødte.

BAKGRUNN: Hjerte-lunge-redning av et kritisk sykt barn ved fødsel kan føre til overlevelse eller død. De som overlever kan utvikle komplikasjoner direkte etter fødsel eller senere i småbarns- og skolealder. Hypoksisk iskemisk encefalopati er en tilstand med nevrologiske symptomer hos den nyfødte etter hypoksi ved fødsel. Tilstanden klassifiseres som mild, moderat eller alvorlig. Vi ønsket å gi en oversikt over kort- og langtidsutfall etter hjerte-lunge-redning ved fødsel. KUNNSKAPSGRUNNLAG: Vi søkte i databasen Medline for utfall etter hjerte-lunge-redning ved fødsel. RESULTATER: Vi identifiserte 15 indekserte, fagfellevurderte originalartikler og to metaanalyser om utfall etter hjerte-lunge-redning ved fødsel eller fødselsasfyksi. Hypoksisk iskemisk encefalopati rammer generelt 38 % av pasientene i mild til moderat grad og 23 % i alvorlig grad. Dødeligheten varierte fra 10 % i høy- til 28 % i lavinntektsland. Overlevende utvikler ofte motoriske, kognitive og sensoriske utviklingshemninger. I noen tilfeller blir det først avdekket ved skolestart når mer komplekse ferdigheter kreves. FORTOLKNING: Funksjonshemning ved skolealder er sterkt korrelert til tilstanden i småbarnsalder. Endringer i algoritmene ved hjerte-lunge-redning og rutinebehandling med hypotermi har redusert risikoen for alvorlige følgetilstander etter hypoksisk iskemisk encefalopati.

Oxygen Saturation and Heart Rate Ranges in Very Preterm Infants Requiring Respiratory Support at Birth.

OBJECTIVE: To evaluate the changes in preductal oxygen saturation (SpO2) and heart rate in preterm infants receiving continuous positive airway pressure (CPAP) and/or positive-pressure ventilation (PPV) at birth. STUDY DESIGN: A prospective observational study at birth of infants aged <32 weeks separated into 2 gestational age (GA) groups: 230/7-276/7 weeks (group 1) and 280/7-316/7 weeks (group 2). Infants received delayed cord clamping (DCC) in accordance with institutional protocol. CPAP and/or PPV was applied at the clinical team's discretion. SpO2 and heart rate were recorded every minute for 10 minutes. Preductal SpO2 was targeted according to published nomograms. For heart rate, the goal was to maintain a stable heart rate >100 bpm. RESULTS: The study cohort comprised 96 group 1 infants (mean GA, 26 ± 1 weeks; mean birth weight, 818 ± 208 g) and 173 group 2 infants (mean GA, 30 ± 1 weeks; mean birth weight, 1438 ± 374 g). In general, infants requiring respiratory support reached target values for heart rate and SpO2 more slowly than the published nomograms for spontaneously breathing preterm infants without respiratory support. Infants receiving CPAP reached SpO2 and heart rate targets faster than infants receiving PPV. In group 1, but not group 2 infants, DCC resulted in higher SpO2 and heart rate. CONCLUSION: SpO2 and heart rate do not quickly and reliably reach the values achieved by spontaneously breathing preterm infants not requiring respiratory support.

Resuscitators who compared four simulated infant cardiopulmonary resuscitation methods favoured the three-to-one compression-to-ventilation ratio.

AIM: Suboptimal cardiopulmonary resuscitation (CPR) is associated with a poor outcome, and international guidelines state that resuscitators should optimise compression and ventilation techniques with as few interruptions as possible. We investigated compression and ventilation quality during simulated CPR with four compression-to-ventilation (C:V) methods. METHODS: In this crossover manikin study, 42 pairs of doctors, nurses, midwives and sixth-year medical students from two Norwegian hospitals provided two-minute resuscitation using the 3:1, 9:3 and 15:2 C:V methods and continuous chest compressions at 120 per minute with asynchronous ventilations (CCaV-120). We measured chest compression, ventilation mechanics and the resuscitators' preferences. RESULTS: C:V methods 3:1 and 9:3 provided comparable chest compressions and ventilation mechanics, whereas 15:2 produced fewer ventilations and lower minute volumes. The CCaV-120 method was significantly less effective than the 3:1 C:V ratio method: the chest compression depth was 1.9 mm lower, there were 25 fewer chest compressions and 21 fewer ventilations per minute, and the minute volume was 69 mL lower. The 3:1 C:V method also provided better coordination between resuscitators. CONCLUSION: Our comparison of four simulated infant cardiopulmonary resuscitation methods favoured the 3:1 C:V method, and the multidisciplinary group of participants felt it offered the best level of coordination between resuscitators.

Newborn manikin study shows that physicians often fail to detect correct lung compliance when using a self-inflating bag.

AIM: Recognising changes in lung compliance can help clinicians to adjust initial inflations during resuscitation at birth. We examined whether physicians sensed low and normal compliance with a self-inflating bag before and after an educational intervention that used a manikin connected to a newborn lung simulator. METHODS: We asked 43 physicians with neonatal duties to perform two low compliance ventilation attempts and two normal-compliance ventilation attempts in a randomised order at baseline and after the educational intervention, with 34 taking part in a retest three months later. RESULTS: The physicians correctly recognised low and normal compliance in 71% and 66% of the ventilations at baseline, 80% and 66% of the ventilations after the intervention and 74% and 81% at retest. Correct recognition of normal compliance improved from baseline to retest (p = 0.04). Ventilations in low- vs normal-compliance settings resulted in lower tidal volumes (4.4 vs 23.0 mL, p < 0.001), lower ventilation rates (42 vs 51, p < 0.001) and higher peak inflating pressure (35.2 vs 31.4 cmH2 O, p < 0.001). CONCLUSION: Around one in four physicians failed to recognise correct compliance levels when using a self-inflating bag and showed limited improvement after an educational intervention. Ventilations in a low-compliance setting resulted in suboptimal ventilation.