California Neonatal Intensive Care Units Research Articles

Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation

ObjectiveTo assess clinician perceptions towards the value and implementation of antibiotic stewardship (AS) in neonatal intensive care units (NICU).Study designWe performed a mixed-methods study of AS perceptions (prescribing appropriateness, importance, activity, capacity) using surveys and interviews in 30 California NICUs before and after a multicenter collaborative (Optimizing Antibiotic Use in California NICUs [OASCN]).ResultsPre-OASCN, 24% of respondents felt there was “a lot of” or “some” inappropriate prescribing, often driven by fear of a bad outcome or reluctance to change existing practice. Clinicians reported statistically significant increases in AS importance (71 v 79%), perceived AS activity (67 v 87%), and more openness to change after OASCN (59 v 70%). We identified other concerns that lessen AS effort.ConclusionOASCN increased perceived AS activity and openness to change in AS practices among NICU prescribers. Greater attention to subjective concerns should augment AS improvement.

Early childhood outcomes of NICU graduates with cytomegalovirus infection in California.

To assess demographics and outcomes up to 3 years of age among children with cytomegalovirus (CMV) infection in California neonatal intensive care units (NICUs) during 2010-2021. The California Perinatal Quality Care Collaborative (CPQCC) collects data on all very low birth weight (VLBW, birth weight ≤ 1500 g) and acutely ill infants with birth weight > 1500 g across 92% of NICUs in California. VLBW infants and those with neurological conditions are referred to a statewide high-risk infant follow-up (HRIF) program. CMV infection was defined as a positive culture or PCR identified during the NICU hospitalization. During 2010-2021, CMV reporting rates averaged 3.5/1000 VLBW infants (n = 205) and 1.1/1000 infants >1500 g (n = 128). Among all 333 infants with CMV, 314 (94%) were discharged home alive, 271 (86%) were referred for HRIF and 205 (65%) had ≥1 visit. Whereas infants born to mothers <20 years of age had highest CMV reporting rates and those born to Hispanic mothers comprised 49% of all infected infants, they had the highest loss of follow-up. At the 12-month visit (n = 152), 19 (13%) infants with CMV had bilateral blindness and 18 (12%) had hearing loss. At the 24-month visit, 5 (5%) of 103 had severe cerebral palsy. Among infants admitted to the NICU, those with CMV diagnoses may over represent infants with more severe CMV disease and outcomes. The CPQCC and HRIF program findings may help inform implementation of surveillance for congenital CMV infection in other U.S. states and guide strategies to reduce disparities in access to services.

Delayed Cord Clamping Uptake and Outcomes for Infants Born Very Preterm in California.

To investigate whether the purported benefits of DCC translate into a reduction in mortality and intraventricular hemorrhage (IVH) among preterm neonates in practice. This was a prospective cohort study of very preterm infants constructed from data from the California Perinatal Quality Collaborative for infants admitted into 130 California neonatal intensive care units (NICUs) within the first 28 days of life from 2016 through 2020. Individual-level analyses were conducted using log-binomial regression models controlling for confounders and allowing for correlation within hospitals to examine the relationship of DCC to the outcomes of mortality and IVH. Hospital-level analyses were conducted using Poisson regression models with robust variance controlling for confounders Results: Among 13,094 included very preterm infants (5,856 with DCC and 7,220 without), DCC was associated with a 44% lower risk of mortality (adjusted RR: 0.56, 95% CI: 0.47 - 0.66). Furthermore, every 10% increase in the hospital rate of DCC among preterm infants was associated with a 5% lower hospital mortality rate among preterm infants (aRR: 0.95, 95% CI: 0.92 - 0.98). DCC was associated with severe IVH at the individual-level, but not at the hospital-level. At the individual-level and hospital-level, the use of DCC was associated with lower mortality among preterm infants admitted to NICUs in California. These findings are consistent with clinical trial results, suggesting that the effects of DCC seen in clinical trials are translating to improved survival in practice.

Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives.

Variation in patient outcomes among institutions and within institutions is a major problem in healthcare. Some of this variation is due to differences in practice, termed practice variation. Some practice variation is expected due to appropriately personalized care for a given patient. However, some practice variation is due to the individual preference or style of the clinicians. Quality improvement collaboratives are commonly used to disseminate quality care on a wide scale. Practice variation is a notable barrier to any quality improvement effort. A detailed and accurate understanding of practice variation can help optimize the quality improvement efforts. The traditional survey methods do not capture the complex nuances of practice variation. Vignette methods have been shown to accurately measure the actual practice variation and quality of care delivered by clinicians. Vignette methods are cost-effective relative to other methods of measuring quality of care. This review describes our experience and lessons from implementing vignette research methods in quality improvement collaboratives in California neonatal intensive care units. Vignette methodology is an ideal tool to address practice variation in quality improvement collaboratives, actively engage a large number of participants, and support more evidence-based practice to improve outcomes.

Learning from Wildfire Disaster Experience in California NICUs.

Wildfires have been affecting California greatly, and vulnerable patients in neonatal intensive care units (NICUs) are not exempt. Our aim was to learn how personnel working in NICUs of California hospitals handled issues of neonatal transfer during wildfire disasters in recent years, with an ultimate goal to share lessons learned with healthcare teams on disaster preparedness. We identified California fires through newspaper articles and the CalFire.gov list. We determined which hospitals were affected and contacted members of the healthcare team through connections via the California Perinatal Quality Care Collaborative (CPQCC) database. We audio recorded interviews over phone or remote conferencing software or by written survey. We coded and analyzed transcripts and survey responses. While describing disaster preparedness, equipment (such as bassinets and backpacks), ambulance access/transport and documentation/charting were noted as important and essential. Teamwork, willingness to do other tasks that are not part of typical job descriptions, and unconventional strategies contribute to the success of keeping NICU babies safe when California wildfire strikes. Healthcare teams developed ingenious and surprising ways to evacuate NICU babies.

Former NICU Families Describe Gaps in Family-Centered Care.

Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families' experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.

Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit.

To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes. Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs). Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression. We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients. An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality. Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

Safety climate, safety climate strength, and length of stay in the NICU

BackgroundSafety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).MethodsObservational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU’s respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality.ResultsNICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes.ConclusionsSafety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

Delayed Cord Clamping and Umbilical Cord Milking among Infants in California Neonatal Intensive Care Units.

To assess the current practice of delayed cord clamping (DCC) and to determine patient and hospital factors that predict DCC. The California Perinatal Quality Care Collaborative (CPQCC) collects data on preterm and acutely ill infants. In 2016, 52 CPQCC neonatal intensive care units (NICUs) collected data on DCC. Hospital and patient characteristics were analyzed using multivariable logistic regression. Of 5,332 deliveries, 1,555 (29%) newborns received DCC. Hospital rates ranged from 0 to 74.5% and increased from 21 to 37% throughout 2016. Infants delivered at <32 weeks or with birth weight <1,500 g were more likely to receive DCC (odds ratio: 2.80; 95% confidence interval: 2.33, 3.36). Cesarean delivery was associated with less likelihood of DCC (odds ratio: 0.68; 95% confidence interval: 0.59, 0.79). After risk adjustment, 17 (33%) hospitals had higher than expected DCC rate. Hospitals with less than 50 NICU beds are more likely to practice DCC, whereas Level 3 American Academy of Pediatrics NICUs, nonprofit owned hospitals, and teaching institutions were less likely to practice DCC (p < 0.001). There are opportunities to implement quality improvement activities to increase DCC rates.

Cytomegalovirus Infection among Infants in Neonatal Intensive Care Units, California, 2005 to 2016.

The main purpose of this article is to assess trends in cytomegalovirus (CMV) infection reported among infants in California neonatal intensive care units (NICUs) during 2005 to 2016. The California Perinatal Quality Care Collaborative collects data on all very low birth weight (VLBW, birth weight ≤ 1,500 g) and acutely ill infants > 1,500 g, representing 92% of NICUs in California. We compared clinical characteristics and length of hospital stay among infants with and without reported CMV infection (CMV-positive viral culture or polymerase chain reaction). During 2005 to 2016, CMV infection was reported in 174 VLBW infants and 145 infants > 1,500 g, or 2.7 (range: 1.5-4.7) and 1.2 (range: 0.8-1.7) per 1,000 infants, respectively (no significant annual trend). Among infants > 1,500 g, 12 (8%) versus 4,928 (4%) of those reported with versus without CMV infection died (p < 0.05). The median hospital stay was significantly longer among infants reported with versus without CMV infection for both VLBW infants (98 vs. 46 days) and infants > 1,500 g (61 vs. 14 days) (p < 0.001). Reports of CMV infection remained stable over a 12-year period. Although we were not able to assess whether infection was congenital or postnatal, CMV infection among infants > 1,500 g was associated with increased mortality.

Survey of preterm neuro-centric care practices in California neonatal intensive care units.

Objective:Examine the adoption and presence of preterm, neuro-centric care practices across Neonatal Intensive Care Units (NICUs).Study Design:Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives.Result:Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice.Conclusion:Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.

Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units

Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP. Cross-sectional study. Setting: Four high-acuity neonatal intensive care units in California (40-84 beds). Total of 194 English- and Spanish-speaking parents of very low birth weight (<1500 grams) infants recruited from September 2013 to April 2015. We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status. Of the 194 participants, 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (vs English-proficient, literate). Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections

Objective:To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Study Design:Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.Results:We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=−0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04–1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Conclusion:Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.

Inhaled nitric oxide use in preterm infants in California neonatal intensive care units.

ObjectiveTo describe inhaled nitric oxide (iNO) exposure in preterm infants and variation in Neonatal Intensive Care Unit (NICU) use.Study DesignThis was a retrospective cohort study of infants, 22–33+6/7 weeks gestational age (GA), during 2005–2013. Analyses were stratified by GA and included population characteristics, iNO use over time and hospital variation.ResultOf 65 824 infants, 1 718 (2.61%) received iNO. Infants, 22–24+6/7 weeks GA, had the highest incidence of iNO exposure (6.54%). Community NICUs (n = 77, median hospital use rate 0.7%) used less iNO than regional NICUs (n = 23, median hospital use rate 5.8%). In 22–24+6/7 week GA infants the median rate in regional centers was 10.6% (hospital IQR 3.8%–22.6%).ConclusioniNO exposure varied with GA and hospital level, with the most use in extremely premature infants and regional centers. Variation reflects a lack of consensus regarding the appropriate use of iNO for preterm infants.

Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis.

There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization. To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals. A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30 566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth. Level and volume of neonatal intensive care at the hospital of birth. In-hospital mortality. There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life. These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

Cytomegalovirus infection among infants in California neonatal intensive care units, 2005–2010

To assess the burden of congenital and perinatal cytomegalovirus (CMV) disease among infants hospitalized in neonatal intensive care units (NICUs). CMV infection was defined as a report of positive CMV viral culture or polymerase chain reaction at any time since birth in an infant hospitalized in a NICU reporting to California Perinatal Quality Care Collaborative during 2005-2010. One hundred and fifty-six (1.7 per 1000) infants were reported with CMV infection, representing an estimated 5% of the expected number of live births with symptomatic CMV disease. Prevalence was higher among infants with younger gestational ages and lower birth weights. Infants with CMV infection had significantly longer hospital stays and 14 (9%) died. Reported prevalence of CMV infection in NICUs represents a fraction of total expected disease burden from CMV in the newborn period, likely resulting from underdiagnosis and milder symptomatic cases that do not require NICU care. More complete ascertainment of infants with congenital CMV infection that would benefit from antiviral treatment may reduce the burden of CMV disease in this population.

Hypothermia in very low birth weight infants: distribution, risk factors and outcomes

The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria. A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression. In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death. Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

The Effect of Preterm Premature Rupture of Membranes on Neonatal Mortality Rates

To estimate the effect of preterm premature rupture of membranes (PROM) on neonatal mortality. A cross-sectional study using a state perinatal database (California Perinatal Quality Care Collaborative) was performed. Prenatal data, including ruptured membranes, corticosteroid administration, maternal age, maternal race, maternal hypertension, mode of delivery, and prenatal care, were recorded. Mortality rates were compared for neonates born between 24 and 34 weeks of gestation without preterm PROM to those with recent (less than 18 hours before delivery) and prolonged (more than 18 hours before delivery) preterm PROM. Neonatal sepsis rates were also examined. Neonates born between 24 0/7 and 34 0/7 weeks of gestation from 127 California neonatal intensive care units between 2005 and 2007 were included (N=17,501). When analyzed by 2-week gestational age groups, there were no differences in mortality rates between those born with and without membrane rupture before delivery. The presence of prolonged preterm PROM was associated with decreased mortality at 24 to 26 weeks of gestation (18% compared with 31% for recent preterm PROM; odds ratio [OR] 1.79; confidence interval [CI] 1.25-2.56) but increased mortality at 28 to 30 weeks of gestation (4% compared with 3% for recent preterm PROM; OR 0.44; CI 0.22, 0.88) when adjusted for possible confounding factors. Sepsis rates did not differ between those with recent or prolonged preterm PROM at any gestational age. The presence of membrane rupture before delivery was not associated with increased neonatal mortality in any gestational age group. The effects of a prolonged latency period were not consistent across gestational ages.

Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom

Objective: To compare gestational age at discharge between infants born at 30–34+6 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United...

296 Earlier Discharge for Moderately Premature Infants at Kaiser Permanente in California

Objective: To compare gestational age at discharge between infants born at 30 to 34 6/7 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts and the United Kingdom (UK).Design: Prospective observational cohort study.Setting: 54 UK, 5 California and 5 Massachusetts NICUs.Subjects: 4359 infants who survived to discharge home following admission to a NICU.Main outcome measures: Gestational age at discharge homeResults: The mean (standard deviation) postmenstrual age at discharge of the infants in California, Massachusetts and the UK were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks, respectively (p=0.001). Compared to the UK, adjusted discharge of infants occurred 3.9 (95% CI 1.4, 6.5) days earlier in California, and 0.9 (95% CI -1.2, 3.0) days earlier in Massachusetts.Conclusions: Infants of 30 to 34 6/7 weeks gestation at birth admitted and cared for in the hospitals in California have a shorter length of stay compared to those in Massachusetts and the UK. We speculate that certain characteristics of the integrated healthcare approach pursued by the health maintenance organization of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants in Massachusetts and the UK.