Australian Neonatal Intensive Care Unit Research Articles

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in the neonatal intensive care unit (NICU): an Australian NICU experience

BackgroundPreterm infants often require non-invasive breathing support while their lungs and control of respiration are still developing. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is an emerging technology that allows infants to breathe spontaneously while receiving support breaths proportional to their effort. This study describes the first Australian Neonatal Intensive Care Unit (NICU) experience of NIV-NAVA.MethodsRetrospective cohort study of infants admitted to a major tertiary NICU between October 2017 and April 2021 supported with NIV-NAVA. Infants were divided into three groups based on the indication to initiate NIV-NAVA (post-extubation; apnoea; escalation). Successful application of NIV-NAVA was based on the need for re-intubation within 48 h of application.ResultsThere were 169 NIV-NAVA episodes in 122 infants (82 post-extubation; 21 apnoea; 66 escalation). The median (range) gestational age at birth was 25 + 5 weeks (23 + 1 to 43 + 3 weeks) and median (range) birthweight was 963 g (365–4320 g). At NIV-NAVA application, mean (SD) age was 17 days (18.2), and median (range) weight was 850 g (501–4310 g). Infants did not require intubation within 48 h in 145/169 (85.2%) episodes [72/82 (87.8%) extubation; 21/21 (100%) apnoea; 52/66 (78.8%) escalation).ConclusionNIV-NAVA was successfully integrated for the three main indications (escalation; post-extubation; apnoea). Prospective clinical trials are still required to establish its effectiveness versus other modes of non-invasive support.

Neonatal acuity tool-defined staffing ratios in a tertiary Australian neonatal intensive care unit.

There is well-established data linking the adequacy of nurse staffing to patient outcomes. Evidence-based standards for staffing are therefore critical to drive improvements in clinical care. One such evidence-based approach is the use of patient acuity-based tools. The objective of this study is to determine the performance of a neonatal acuity tool in an Australian tertiary neonatal health-care setting, focusing on the classification of patient acuity and nursing:patient staffing ratios compared to current practice. Acuity data were collected in a neonatal intensive care unit (NICU) and special care baby unit (SCBU) over a 10-week period in 2023. Patient data were scored in the 16 domains at two time points (prior to morning and evening nursing shift changeover) for all admitted newborns. For ventilated newborns nursed with a nurse:patient staffing ratio of 1:1, 78% of scores were within the L4-high acuity (score ≥ 26) band, with the remaining scores within the L3-high acuity (18-25) band. For newborns on non-invasive respiratory support in NICU staffed 1:1, the proportion scoring within the L4 acuity band was higher in the nasal high-flow group compared to the nasal continuous positive airway pressure group (P = 0.032), an effect not seen for those nursed 1:2 in NICU or for those on nasal high-flow nursed in SCBU either 1:2 or 1:3. This study of how a neonatal acuity classification system compares with current nurse:patient staffing allocations in an Australian tertiary NICU, suggests refinements in staffing ratios for specific patient groups on respiratory support are possible.

Implementation of a Web Camera System in an Australian Neonatal Intensive Care Unit: Pre- and Postevaluation of the Parent and Staff Experience.

Admission to a neonatal intensive care unit (NICU) for prematurity or illness is necessary for approximately 20% of newborns in Australia, resulting in parent-infant separation. Web cameras in the NICU provide a virtual link for parents to remain remotely connected to their infant during admission. Web camera use is increasing; however, there is limited evidence on the impact of web cameras on parents, infants, and neonatal staff. There were two objectives: (1) to determine the attitudes of parents and staff toward web cameras in the NICU and (2) to compare parental depression, anxiety, and stress levels using validated scales before and after web camera implementation in the NICU. A pre- and postevaluation survey was administered before and after implementation of the NICVIEW camera system in a tertiary NICU in Sydney, Australia. The NICVIEW camera system provides secure real-time viewing of infants and can be accessed from any device with an internet connection. Surveys were administered to parents of inpatients and staff, and included open- and closed-ended questions and Likert scales. Survey questions aimed to determine parent and staff attitudes and use of web cameras before and after implementation. In addition, pre- and postimplementation parental levels of depression, anxiety, and stress, as measured by the 21-item version of the Depression Anxiety Stress Scale (DASS-21) and Parental Stressor Scale: Neonatal Intensive Care Unit, were recorded. In total, 94 parents and 109 staff members completed the pre- and postimplementation surveys. Post implementation, 43 of 44 (98%) parents supported web cameras, and 40 of 42 (95%) parents stated that they used web cameras. The most common reasons for support from parents included web cameras making parents feel more at ease, facilitating parent-infant bonding, increasing parental confidence in staff, and allowing others to see infants. There was no significant difference between the parental groups for the depression, anxiety, or stress scales measured by DASS-21. Staff support for web cameras increased significantly from 34 of 42 (81%) participants before to 64 of 67 (96%) participants after implementation (P=.01). Following implementation, there was a resolution in staff concerns about web cameras having an adverse impact on staff roles and privacy and security concerns. Web camera use in a tertiary Australian NICU was strongly supported by parents and staff and may reduce parental stress, facilitate parent-infant bonding, and encourage positive parent-staff engagement. Web cameras are a feasible method of providing continuity of care for families and should be considered as a standard of care in similarly resourced settings.

Variation in hospital morbidities in an Australian neonatal intensive care unit network

ObjectiveThere is an expectation among the public and within the profession that the performance and outcome of neonatal intensive care units (NICUs) should be comparable between centres with a similar...

When can I hold my baby? An audit of time to first cuddle for preterm babies (

The audit examined time to first cuddle between preterm babies (born<32weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay. Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing. A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit. A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27+6weeks and 28-31+6weeks. SQUIRE checklist guided reporting of the audit. One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27+6weeks n=39 and 28-31+6weeks n=40) and 74 from 2018 (≤27+6weeks n=35 and 28-31+6weeks n=39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27+6weeks in 2018 were cuddled earlier (median=141h old) compared with those in 2015 (median=157h old). Median time to reach full feeds decreased and was significant in the ≤27+6-week group: 288h (12days) in 2015 to 207.5h (8.6days) in 2018. Length of stay was longer for the ≤27+6-week gestation 2018 group (median=64days) and 28-31+6-week gestation 2018 group (median=22days). Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge. Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.

Outcomes after Introduction of Minimally Invasive Surfactant Therapy in Two Australian Tertiary Neonatal Units

To assess the procedural and clinical outcomes associated with the introduction of minimally invasive surfactant therapy (MIST) into standard care at 2 tertiary Australian neonatal intensive care units. A prospective audit was designed before the introduction of MIST in 2018, with data collected over a period of 18months. Procedural data were completed by the clinical team performing MIST, including clinical observations, medication use, and adverse events. The audit team collected demographic data and subsequent clinical outcomes from medical records. There were 135 MIST procedures recorded in 122 infants. For the included infants, the median gestation was 302/7weeks (IQR, 276/7 to 322/7weeks) and birth weight was 1439g (IQR, 982-1958 g). During the MIST procedure, desaturation to a peripheral oxygen saturation of <80% was common, occurring in 75.2% of procedures. Other adverse events included need for positive pressure ventilation (10.6%) and bradycardia <100 beats per minute (13.3%). The use of atropine premedication was associated with a significantly lower incidence of bradycardia: 8.6% vs 52.9% (P<.01). Senior clinicians demonstrated higher rates of procedural success. The majority of infants (63.9%) treated with MIST did not require subsequent intubation and mechanical ventilation. MIST can be successfully introduced in neonatal units with limited experience of this technique. The use of atropine premedication decreases the incidence of bradycardia during the procedure. Success rates can be optimized by limiting MIST to clinicians with greater competence in endotracheal intubation.

Relationships between Neonatal Nutrition and Growth to 36 Weeks' Corrected Age in ELBW Babies-Secondary Cohort Analysis from the Provide Trial.

A key modifiable factor for improving neurodevelopment in extremely low birthweight (ELBW) babies may be improving growth, especially head growth, by optimising nutrition in the early neonatal period. We aimed to investigate relationships between nutrient intakes in the 4 weeks after birth, and growth from birth to 36 weeks’ corrected age (CA) in ELBW babies. We undertook a prospective cohort study of 434 participants enrolled in a randomised controlled trial (ProVIDe) in eight New Zealand and Australian neonatal intensive care units. Macronutrient intakes from birth to 4 weeks and weight, length and head circumference measurements from birth to 36 weeks’ CA were collected. From birth to 36 weeks’ CA, the median (IQR) z-score changes were: weight −0.48 (−1.09, 0.05); length −1.16 (−1.86, −0.43), and head circumference −0.82 (−1.51, −0.19). Changes in z-score to 4 weeks and 36 weeks’ CA were correlated with protein intake. Each 1 g·Kg−1·d−1 total protein intake in week 2 was associated with 0.26 z-score increase in head circumference at 36 weeks’ CA. Both nutritional intake and change in z-scores to 36 weeks’ CA differed widely amongst sites. Correlations between nutrition and growth, and differences in these amongst sites, indicate there may be potential to improve growth with enhanced nutrition practices.

Quality pharmaceutical care in the neonatal intensive care unit: identification of essential pharmacy services and key performance indicators for the Australian setting

AbstractBackgroundWhen considering subspecialties of clinical pharmacy practice such as the neonatal intensive care unit (NICU), no key performance indicators (KPIs) or practice standards have been published by national or international pharmacy organisations.AimThe aims of this study were to identify: (1) a list of essential pharmacist roles that should be performed in the NICU; and (2) a set of clinical pharmacy KPIs that can be used to benchmark the quality of pharmaceutical care provided to patients in Australian NICU settings.MethodsA modified Delphi technique was used to send 65 indicators and 30 proposed roles to an expert panel of doctors, pharmacists and nurses. The indicators and roles were compiled from a previously conducted literature review. An online survey sent in two consecutive Delphi rounds in August and September 2017 asked experts to rank the indicators and roles against specific criteria.ResultsFifteen healthcare professionals from Australia participated as expert panellists. Overall, 75% consensus was reached for 31 indicators and 23 roles by Australian panellists. Experts particularly valued the following roles: pharmacists being a source of medication information (100%; median = 1.00), assisting in off‐label prescribing (100%; median = 1.00), documenting medication errors (100%; median = 1.00), medication chart review (100%; median = 1.00) and writing medication protocols for the NICU (100%; median = 1.00).ConclusionFurther investigations are needed to formalise a set of NICU‐specific clinical pharmacy KPIs and a practice model to form the foundations of national and international standardised practice guidelines for this subspecialty.

Central and peripheral line-associated bloodstream infections in Australian neonatal and paediatric intensive care units: findings from a comprehensive Victorian surveillance network, 2008–2016

Healthcare-associated infections in neonatal and paediatric populations are associated with poorer outcomes and healthcare costs, and surveillance is a necessary component of prevention programmes. To evaluate burden of illness, aetiology, and time-trends for central and peripheral line-associated bloodstream infection (CLABSI and PLABSI) in Australian neonatal and paediatric intensive care units (ICUs) between July 1st, 2008 and December 31st, 2016. Using National Healthcare Safety Network methods, surveillance in neonatal and paediatric units was performed by hospitals participating in the Victorian Healthcare Associated Infection Surveillance System. Mixed effects Poisson regression was used to model infections over time. Overall, 82 paediatric CLABSI events were reported during 37,125 CVC-days (2.21 per 1000 CVC-days), 203 neonatal CLABSI events were reported during 92,169 CVC-days (2.20 per 1000 CVC-days), and 95 neonatal PLABSI events were reported during 142,240 peripheral line-days (0.67 per 1000 peripheral line-days). Over time, a significant decrease in quarterly risk for neonatal CLABSI events was observed (risk ratio (RR): 0.98; 95% confidence interval: 0.97-0.99; P=0.023) and this reduction was significant for the 751-1000 g birth weight cohort (RR: 0.97; P=0.015). Most frequently, coagulase-negative Staphylococcus spp. (24.2%) and Staphylococcus aureus (16.1%) were responsible for CLABSI events. A significant reduction in Gram-negative neonatal infections was observed (annual RR: 0.85; P<0.001). CLABSI rates in neonatal and paediatric ICUs in our region are low, and neonatal infections have significantly diminished over time. Evaluation of infection prevention programmes is required to determine whether specific strategies can be implemented to further reduce infection risk.

Variation in hospital mortality in an Australian neonatal intensive care unit network

BackgroundStudying centre-to-centre (CTC) variation in mortality rates is important because inferences about quality of care can be made permitting changes in practice to improve outcomes. However, comparisons between hospitals can...

Przetrwałe nadciśnienie płucne noworodków – wybrane aspekty opieki pielęgniarskiej w polskich i australijskich oddziałach intensywnej terapii noworodków

Przetrwałe nadciśnienie płucne noworodków – wybrane aspekty opieki pielęgniarskiej w polskich i australijskich oddziałach intensywnej terapii noworodków

The assessment of parental stress and support in the neonatal intensive care unit using the Parent Stress Scale - Neonatal Intensive Care Unit.

Parental stress in the neonatal intensive care unit (NICU) has been reported, however identifying modifiable stress factors and looking for demographic parent factors related to stress has not been well researched. This study aims to identify the most stressful elements for parents in the neonatal intensive care unit. Parents of babies in an Australian neonatal intensive care unit (N=73) completed both the Parent Stress Scale - Neonatal Intensive Care Unit and a survey of parent and baby demographic and support experience variables (Parent Survey) over an 18-month period. Older parental age, very premature birth and twin birth were significantly associated with a higher Parent Stress Scale - Neonatal Intensive Care Unit score. Having a high score in the Relationship and Parental Role scale was strongly associated with attendance at the parent support group. These results indicate the variables associated with stress and this knowledge can be used by teams within hospitals to provide better supportive emotional care for parents.

Nosocomial Pulmonary Tuberculosis Contact Investigation in a Neonatal Intensive Care Unit

The diagnosis of smear-positive pulmonary tuberculosis in a medical officer working in a metropolitan Australian neonatal intensive care unit led to a contact investigation involving 125 neonates, 165 relatives, and 122 healthcare workers with varying degrees of exposure. There was no evidence of nosocomial tuberculosis transmission from the index case.

Causes of death in infants admitted to Australian neonatal intensive care units between 1995 and 2006

To compare causes and rates of mortality among infants admitted to 10 Australian neonatal intensive care units (NICUs) between 1995 and 2006. De-identified perinatal data from the Neonatal Intensive Care Units' (NICUS) Data Collection for 24 131 infants were examined for causes and rates of death. The study period was divided into two epochs: I (1995-2000, n = 11 185 infants) and II (2001-2006, n = 12 946 infants). A total of 2224 (9.2%) infants died in hospital. Mortality decreased from 10.3% (1152/11 185) in epoch I to 8.3% (1072/12 946) in epoch II (p < 0.001) due to improved survival in term infants. Extreme prematurity also decreased as a primary cause of death (118 (10.2%) vs 76 (7.1%), p = 0.008). No infant >42-week gestation was admitted in epoch II. Congenital abnormalities were the most common cause of death (>20%) in both epochs, mostly in term rather than preterm infants (40.7% vs 13.9%, p < 0.001). Age of death was unchanged between the two epochs (median 4, 1st, 3rd quartiles: 1,16 days). Mortality rates have continued to decrease but improvement is predominantly due to improved survival of term infants and prevention of postdate deliveries. Congenital abnormalities continue to be the most common cause of death.

Breast milk banking: Current opinion and practice in Australian neonatal intensive care units

To find out the knowledge and attitudes of health-care professionals (HCPs) in Australian neonatal intensive care units (NICUs) towards breast milk banking (BMBg) and pasteurised donated breast milk (PDBM). Cross-sectional structured survey of HCPs in all 25 NICUs in Australia. Response rate was 43.4% (n= 358 of 825). Participants included nurses and midwives (291, 81.3%) and the remainder were neonatologists and neonatal trainees (67, 18.7%). A variable number of HCPs agreed that PDBM would decrease the risk of necrotising enterocolitis (81%) and allergies (48.9%), 8.4% thought PDBM will carry risk of infections and 78.8% agreed that PDBM is preferable over formula, but only 67.5% thought that establishing breast milk banks (BMBs) are justifiable. Significant differences were found between doctors and nurses/midwives, with 19.4% of doctors compared with 5.8% of nurses/midwives agreed that PDBM carried an increased risk of infection. Although, over 90% of nurses/midwives and 70% of doctors agreed that the donation of breast milk is important, only 71% of nurses/midwives and 52.2% of doctors thought that setting up a BMB was justifiable. The opinions about BMBg differ widely between HCPs; however, the majority support the practice. HCPs had different knowledge gaps in regard to BMBg. Nurses/midwives positively view the practice of BMBg more strongly compared with neonatologists.

Incorporating speech‐language pathology within Australian neonatal intensive care units

Working in neonatal intensive care units (NICU) is considered to be advanced practice for speech-language pathologists (SLPs) requiring post-graduate specialised education and ongoing clinical mentoring, not easily accessible within some countries such as Australia. This review investigated whether there was evidence to support SLPs as core NICU team members, rather than fleeting therapists. The review found that the roles and responsibilities of SLPs in NICUs included assessment and intervention of preterm infant communication, feeding and swallowing using a family-centred approach. This approach was respectful of the cultural and linguistic diversity of the parents and the particular expertise of other NICU team members. Whilst there has been a significant and promising increase in research with regard to SLP involvement with preterm infants (especially around feeding and swallowing assessment and specific treatments), the need for high-quality well-designed research is essential.

Mortality and Morbidities Among Very Premature Infants Admitted After Hours in an Australian Neonatal Intensive Care Unit Network

Mortality and Morbidities Among Very Premature Infants Admitted After Hours in an Australian Neonatal Intensive Care Unit Network

A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit

Background The World Health Organisation (WHO) and a substantial body of literature recommend breastfeeding from birth until at least 6 months of age. The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have been shown for term and preterm infants. Meeting the WHO recommendations for breastfeeding is problematic in the cohort of infants requiring hospitalisation in a neonatal intensive care unit (NICU) for management of complex medical and surgical conditions. Method A retrospective audit of medical records of all infants admitted to the neonatal unit of the Royal Children's Hospital, Melbourne, Australia between 2001 and 2003 was conducted. Results One thousand, one hundred and sixty-three babies were admitted during the audit period. Babies discharged directly home were of significantly greater gestational age, higher birthweight and had a shorter length of stay than those babies transferred to another facility ( P < 0.05). Fifty-six percent of the cohort was receiving breast milk on discharge from the neonatal unit. Babies exclusively breastfed on discharge were of greater gestational age and had a shorter length of stay in the NICU than those babies discharged on a combination of breast milk and formula, or formula alone ( P < 0.001). Babies transferred to another facility, rather than discharged directly home, were less likely to be breastfed and more likely to receive enteral nutrition via intragastric tube feeds or a combination of bottle and tube feeds. Conclusion Birthweight, gestational age, and length of stay in a neonatal intensive care unit are factors likely to influence breastfeeding in the cohort of babies requiring tertiary level care.

Mortality and Morbidities Among Very Premature Infants Admitted After Hours in an Australian Neonatal Intensive Care Unit Network

To assess risk-adjusted early (within 7 days) mortality and major morbidities of newborn infants at < 32 weeks' gestation who are admitted after office hours to a regional Australian network of NICUs where statewide caseload is coordinated and staffed by on-floor registrars working in shift rosters. We hypothesize that adverse sequelae are increased in these infants. We conducted a database review of the records of infants (n = 8654) at < 32 weeks' gestation admitted to a network of 10 tertiary NICUs in New South Wales and the Australian Capital Territory from 1992 to 2002. Multivariate logistic regression analysis was performed to adjust for case-mix and significant baseline characteristics. Sixty-five percent of infants were admitted to the NICUs after hours. These infants did not have an increase in early neonatal mortality or major neonatal sequelae compared with their office-hours counterparts. Admissions during late night hours after midnight or fatigue risk periods before the end of a medical 12-hour shift were not associated with higher early mortality. Risk factors significantly predictive of early neonatal death were lack of antenatal steroid treatment, Apgar score < 7 at 5 minutes, male gender, gestation age, and being small for gestation. Current staffing levels, specialization, and networking are associated with lower circadian variation in adverse outcomes and after-hours admission to this NICU network and have no significant impact on early neonatal mortality and morbidity.

Unlicensed and off-label drug use in an Australian neonatal intensive care unit.

To determine the extent of unlicensed and off-label drugs prescribed in the level 3 neonatal intensive care unit (NICU) at the Royal Women's Hospital, Melbourne, Australia. A prospective cohort study was conducted of all infants who were admitted to the NICU during a 10-week period. Each drug prescribed was evaluated in relation to the licensed approved uses to determine whether the drug was administered in a licensed manner or was unlicensed or used in an off-label manner. There were a total of 101 admissions involving 97 infants. A total of 1442 prescriptions were administered; 42% were licensed, 11% were unlicensed, and 47% were off-label. Twenty-one percent were off-label for 2 or more reasons. Eighty percent of infants received either an unlicensed or an off-label prescription or both; this proportion rose to 93% of extremely low birth weight infants. This is the largest study performed of unlicensed and off-label drug use in the NICU. This practice remains widespread despite clear recommendations to improve this undesirable situation. The attendant risks to infants and prescribers remain. It is time for legislation to be introduced to govern this area.