Association, among very-low-birthweight neonates, between red blood cell transfusions in the week after birth and severe intraventricular hemorrhage.

BACKGROUND: Previous reports describe a statistical association, among very-low-birthweight (VLBW, <1500 g) neonates, between red blood cell (RBC) transfusion in the first days after birth and development of severe intraventricular (brain) hemorrhage (IVH). STUDY DESIGN AND METHODS: We hypothesized that after we established a neonatal intensive care unit (NICU) transfusion management program in 2009, a decrease in early (first week after birth) RBC transfusion rate and a decrease in the incidence of severe IVH occurred concomitantly. RESULTS: During a 9-year period 2716 VLBW neonates were admitted to our NICUs. In 2004, 58% of VLBW neonates received one or more RBC transfusions during the first week. After a transfusion compliance program was established in 2009, this rate declined, reaching 25% by 2012. In parallel, the severe IVH rate also declined, from 17% in 2004 to 8% in 2012 (R(2) = 0.73). IVH occurred in 27% of those who received a RBC transfusion during the first week versus less than 2% of those with no early transfusion (p < 0.001). The decrease in IVH rate occurred exclusively among neonates born in an Intermountain Healthcare perinatal center and not among those initially cared for in an "outside" hospital and subsequently transported to an Intermountain NICU. CONCLUSIONS: It remains unclear whether transfusing VLBW neonates during the first days after birth is a proximate cause of IVH. However, the present report is consistent with previous studies showing that successful efforts to reduce early RBC transfusions is associated with a decrease in the incidence of severe IVH.

Unexplained extreme hyperbilirubinemia among neonates in a multihospital healthcare system.

We report a series of neonates who developed a total serum bilirubin (TSB) >20mg/dL during a recent ten-year period in a multihospital healthcare system. The incidence of a TSB >20mg/dL fell after instituting a pre-hospital discharge bilirubin screening program in 2003/2004 (91.3 cases/10,000 births before vs. 72.4/10,000 after), but the incidence has subsequently remained unchanged. No specific cause for the hyperbilirubinemia was identified in 66% of (n=32) cases with a TSB >30 mg/dL or in 76% of (n=112) cases with a TSB 25.0-29.9 mg/dL. We hypothesized that hemolysis was a common contributing mechanism, but our review of hospital records indicated that in most instances these infants were not evaluated sufficiently to test this hypothesis. Records review showed maternal and neonatal blood types and direct antiglobulin testing were performed in >95% cases, but rarely were other tests for hemolysis obtained. In the ten-year period reviewed there were zero instances where erythrocyte morphology from a blood film examination or Heinz body evaluation by a pediatric hematologist or pathologist were performed. In 3% of cases pyruvate kinase was tested, 3% were evaluated by hemoglobin electrophoresis, 3% had a haptoglobin measurement, and 16% were tested for G6PD deficiency. Thus, determining the cause for hyperbilirubinemia in neonates remains a problem at Intermountain Healthcare and, we submit, elsewhere. As a result, the majority of infants with a TSB >25mg/dL have no specific causation identified. We speculate that most of these cases involve hemolysis and that the etiology could be identified if searched for more systematically. With this in mind, we propose a "consistent approach" to evaluating the cause(s) of hyperbilirubinemia among neonates with a TSB >25mg/dL.

Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system.

BACKGROUND: We previously reported that in the year 2006, approximately 35% of the transfusions administered in the Intermountain Healthcare neonatal intensive care units (NICU) were noncompliant with our transfusion guidelines. In January 2009 we instituted an electronic NICU transfusion ordering and monitoring system as part of a new program to improve compliance with transfusion guidelines. STUDY DESIGN AND METHODS: In the four largest NICUs of Intermountain Healthcare, we performed a pre-post analysis of compliance with transfusion guidelines and transfusion usage. RESULTS: After beginning the new transfusion compliance program all four NICUs had an increase in compliance from 65% to 90%. Accompanying the improved compliance, all four NICUs had a reduction in transfusions administered. Specifically, compared with 2007 and 2008, there were 984 fewer NICU transfusions given in 2009. This included 554 fewer red blood cell (RBC) transfusions, 174 fewer platelet transfusions, and 256 fewer frozen plasma infusions. We calculate that in 2009, a total of 200 NICU patients who in previous years would have received one or more transfusions instead received none. Applying specific Intermountain Healthcare billing data to the observed transfusion reductions, this new program resulted in an annual decrease of $780,074 in blood bank charges (blood administration charges were not included). During the 3-year period, January 2007 through December 2009, we detected no change in NICU demographics, major morbidities, length of hospital stay, or mortality rate. CONCLUSION: Implementing a systemwide NICU program to improve compliance with already-established transfusion guidelines increased compliance from 65% to 90%. Improved compliance with transfusion guidelines was accompanied by a significant reduction in transfusions given, with no increase in NICU length of stay or mortality rate.

A low-sodium solution for airway care: results of a multicenter trial.

BACKGROUND: Normal saline is sometimes instilled into the endotracheal tube preparatory to airway suctioning, to assist in removing thick secretions. However, saline can damage the antimicrobial properties of airway secretions. We previously described a low-sodium physiologically based solution for airway care and reported a small (n = 60) randomized trial in neonates, which showed trends toward less ventilator-associated pneumonia (VAP) and less chronic lung disease with the new solution. We now report a multicenter trial of that solution. METHODS: We conducted a before-and-after study with a parallel control group, in 4 level-3 neonatal intensive care units (NICUs). During year 1, all 4 NICUs used saline for airway care. During year 2, one NICU used the test solution exclusively while the other NICUs used saline exclusively. The 2 study outcomes were VAP (cases/1,000 ventilator days) and chronic lung disease, defined 3 ways: supplemental oxygen at 28 days; supplemental oxygen at 36 weeks gestation; and supplemental oxygen on hospital discharge. RESULTS: During the study period 1,116 neonates had endotracheal intubation for respiratory management. Of those, 1,029 received the standard saline for airway suctioning, and the 87 in NICU 4 received the test solution. NICU 4 had a decrease in VAP rate, from 4.2 VAPs/1,000 ventilator days with saline, to 1.6 VAPs/1,000 ventilator days with the test solution (P = .04), and also had the lowest prevalence of chronic lung disease (P < .001 for each definition). CONCLUSIONS: The test solution significantly reduced the VAP and chronic lung disease rates.

Acute kernicterus in a neonate with O/B blood group incompatibility and a mutation in SLC4A1.

We cared for a term female newborn, who at 108 hours of age, with a total serum bilirubin of 15.4 mg/dL, was discharged from the hospital on home phototherapy. At a return appointment 44 hours later, her total serum bilirubin was 41.7 mg/dL and signs of acute kernicterus were present. Maternal/fetal blood group O/B incompatibility was identified, with a negative direct antiglobulin test, which was positive on retesting. She had abundant spherocytes on blood smear, and these persisted at follow-up, but neither parent had spherocytes identified. A heterozygous SLC4A1(E508K) mutation (gene encoding erythrocyte membrane protein band 3) was found, and in silico predicted to result in damaged erythrocyte cytoskeletal protein function. No mutations were identified in other red cell cytoskeleton genes (ANK1, SPTA1, SPTB, EPB41, EPB42) and the UGT1A1 promoter region was normal. Neurologic follow-up at 2 and 4 months showed developmental delays consistent with mild kernicterus.

Center differences in NEC within one health-care system may depend on feeding protocol.

We tabulated the incidence of necrotizing enterocolitis (NEC) during a recent 4-year period among three neonatal intensive care units (NICUs) within a single health-care system. We then sought associations to explain differences in NEC incidence between the centers. Between January 1, 2002, and December 31, 2005, 6787 neonates were admitted to the three NICUs. The incidence of NEC (Bell's stage II or higher) among these patients was correlated with birthweight, gestational age, maternal and neonatal demographics, and various events and practices. These events and practices included feeding practices, the management of patent ductus arteriosus, rates of systemic bacterial and fungal infection, transfers to the regional children's hospital for surgical treatment, and mortality rate. Bell's stage II or higher NEC was documented in 131 of 6787 NICU patients. The incidence was 7.4% among those with birthweights <750 g (16 of 217), 6.9% among those of birthweights 750 to 1250 g (36 of 519), and 1.3% (79 of 6051) among those with birthweights >1250 g. Center A had an incidence of NEC significantly higher than the other two, accounting for 72% of the total cases (94 of 131). Among patients <1250 g, Center A had a rate of NEC of 14.5%; Centers B (2.3%) and C (2.3%) had lower rates ( P<0.0001). After controlling for gestational age, birthweight, small for gestational age status, and Apgar scores, the overall odds ratio of developing NEC in Center A, compared with the other two, was 21.6 (95% confidence interval, 14.7 to 31.6). This difference could not be accounted for by differences in maternal or neonatal demographic characteristics, bed occupancy rates, or a higher incidence of culture-proven nosocomial bacterial or fungal infections. Although the incidence of NEC was significantly higher at Center A, the percentage of patients with NEC transferred to the children's hospital for surgical evaluation and treatment was similar. The mortality rate of patients who developed NEC was similar among the three hospitals. Centers B and C utilize standardized feeding guidelines. During each of the 4-year study periods, one of three NICUs within the same health-care system had a higher incidence of NEC than the other two. Once NEC developed, the outcome was similar in all three NICUs. The higher incidence in Center A could not be explained by differences in demographics, socioeconomics, or systemic nosocomial infections. Similarities in feeding practices between Centers B and C suggest to us that these may be responsible, at least in part, for the differences in the incidence of NEC. Changing the feeding practices at Center A to those at Centers B and C is planned to test this theory.

Neonatal bilirubin management as an implementation example of interdisciplinary continuum of care tools.

Management of newborn bilirubin spans the inpatient and outpatient continuum of care. Intermountain Healthcare has developed and implemented a web-based tool for managing bilirubin that follows newborn patients across care settings and providers with a consistent plan of care. The underlying model for the tool is derived from published guidelines. The model divides the time-sensitive data into risk zones and associates each zone with the appropriate order set for follow-up care. The tool integrates Intermountain's Help2 infrastructure for authoring terms, guidelines, and order sets, with alerts, results, and data entry within the context of the care model. Implementation of the bilirubin management tool is shown to improve communication, ease workflow, and improve guideline compliance. Lessons learned from the implementation include recommendations for handling point-of-care laboratory data and managing archival views, which are insightful to health networks managing longitudinal data.

The effect of instituting a prehospital-discharge newborn bilirubin screening program in an 18-hospital health system.

OBJECTIVE: Kernicterus is a rare but devastating condition. The prevention of bilirubin-induced brain injury is based on the detection of infants at risk for developing severe hyperbilirubinemia. In an 18-hospital health system, Intermountain Health Care (IHC), we initiated a program of predischarge bilirubin screening of all neonates and coupled this with a results assessment using a percentile-based nomogram. Data during 2 periods of time, before versus after initiating the program, were compared to assess the effect of the program on significant hyperbilirubinemia and rehospitalization. METHODS: We conducted a historic cohort study involving all neonates delivered at > or =35 weeks' gestation, within IHC's 18-hospital system, during 2 periods of time: March 1, 2001, to December 31, 2002, versus January 1, 2003, to December 31, 2004. A bilirubin screening program, instituted in December 2002, called for a total serum bilirubin (TSB) or transcutaneous bilirubin measurement to be performed on every neonate either at the recognition of clinical jaundice or before discharge regardless of whether jaundice was observed. For nonjaundiced neonates, the nursery staff was encouraged to obtain the screening TSB at the same time they obtained the state-mandated newborn screen for inborn errors of metabolism. Bilirubin values were plotted on an hour-specific nomogram and the corresponding percentile was used to guide evaluation, therapy, and follow-up. This study compared TSB data and readmission data for a 2-year period before versus a 2-year period after implementing the program. RESULTS: The study involved 101272 neonates: 48789 in period 1 and 52483 in period 2. Before the program, 1 in every 77 neonates born at an IHC hospital had 1 or more serum bilirubin levels >20 mg/dL. After initiating the program, the incidence fell to 1 in 142 and the number of neonates with a level >25 mg/dL fell from 1 in 1522 before to 1 in 4037 after. The rate of hospital readmission with a primary diagnosis of jaundice fell from 0.55% in period 1 to 0.43% in period 2. CONCLUSIONS: Initiating a program of bilirubin screening in a multihospital health system, coupled with evaluating the results using a percentile-based nomogram, reduced the proportion of neonates with significant hyperbilirubinemia and reduced the rate of hospital readmissions with jaundice.