German Neonatal Intensive Care Units Research Articles

Less Invasive Surfactant Administration in Preterm Infants in Tertiary Neonatal Intensive Care Units in Germany: A Survey

Introduction: The European guideline for treatment of respiratory distress syndrome recommends less invasive surfactant administration (LISA) as the preferred method of surfactant administration in spontaneously breathing preterm infants. However, there is limited evidence on practical aspects such as sedation and catheter types, leading to considerable variability between centers. Methods: An anonymous online survey (www.soscisurvey.de) was sent to 164 tertiary neonatal intensive care units (NICUs) in Germany including 43 questions on practical aspects of LISA. Results: Of 122 (74%) participating NICUs, 117 (96%) reported experience with LISA with 82% of those reporting LISA as their preferred method of surfactant administration. Indications for surfactant administration differed widely between NICUs. Most (89%) used FiO2-thresholds only or in combination with other criteria, such as Silverman score/signs of dyspnea (41%) or lung ultrasound findings (3%). Prophylactic surfactant was administered by 42%. Differences in use of LISA in extremely immature infants were reported (e.g., 36% did not perform LISA in infants below 24–26 weeks). Preferred drugs for sedation were (Es-)Ketamine, followed by Propofol and Midazolam. Minimum time interval between subsequent LISA procedures was 4 (2–6) h. Catheters specifically designed for LISA were used by most NICUs (69%). Conclusion: This survey shows that LISA is common practice in German NICUs, but with considerable variability in practical aspects. These data may serve as a guidance for NICUs that have not yet implemented LISA and might be helpful design clinical trials with the aim to standardize and/or optimize LISA.

Lactation support in neonatal intensive care units in Germany from the mothers’ perspective – a mixed-method study of the current status and needs

BackgroundEstablishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers’ perspectives on lactation support in German neonatal intensive care units (NICUs).MethodsThis paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers’ perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.ResultsThe results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.ConclusionThe overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

Evaluating the Use of Neonatal Colonization Screening for Empiric Antibiotic Therapy of Sepsis and Pneumonia

(1) Background: Since 2013, weekly screening for multidrug-resistant Gram-negative (MDRGN) bacteria has been performed in German neonatal intensive care units (NICU). National guidelines recommend considering these colonization analyses for antibiotic treatment regimens. Our retrospective single center study provides insight into the clinical dichotomy of bacterial colonization and infection rates in neonates. (2) Methods: We analyzed microbiological data of neonates admitted to our tertiary level NICU over nine years. Colonization with MDRGN/Serratia marcescens (SERMA) was compared to microbiological findings in sepsis and pneumonia. (3) Results: We analyzed 917 blood and 1799 tracheal aspirate samples. After applying criteria from the Nosocomial Infection Surveillance for Neonates (NEO-KISS), we included 52 and 55 cases of sepsis and pneumonia, respectively; 19.2% of sepsis patients and 34.5% of pneumonia patients had a prior colonization with MDRGN bacteria or SERMA. In these patients, sepsis was not attributable to MDRGN bacteria yet one SERMA, while in pneumonias, ten MDRGN bacteria and one SERMA were identified. We identified late-onset pneumonia and cesarean section as risk factors for MDRGN/SERMA acquisition. (4) Conclusions: Colonization screening is a useful tool for hygiene surveillance. However, our data suggest that consideration of colonization with MDRGN/SERMA might promote extensive use of last resort antibiotics in neonates.

Existence and perceived application of pain management protocols in German neonatal intensive care units.

We explored the existence and application of standard operating procedures (SOPs) for pain management (PM) in German neonatal intensive care units (NICUs), and identified the factors associated with their application in practice. This study was part of the Safety4NICU project, a cross-sectional survey conducted from 2015 to 2016. All 224 German NICUs were invited to participate, providing written consent from the head neonatologist and head nurse. We distributed questionnaires to the head neonatologist, the head nurse, and the NICU staff (physicians and nurses). We asked the head neonatologist whether written SOPs for PM existed, and we asked the staff whether these SOPs were applied in their daily routine. We received evaluable responses from 468 physicians and 1251 nurses from 76 NICUs. Of these 76 NICUs, the head neonatologists from 54 NICUs (71.1%) reported that written SOPs for PM exist. However, only 48.5% of the physicians and 53.7% of the nurses declared that these existing SOPs were also applied. We found various predictors for the existing SOPs as being applied, depending on the profession. For physicians, clinical training was important (OR: 2.482, p ≤ 0.05), while for nurses their working experience was a decisive predictor (OR: 1.265, p ≤ 0.05). For both, a high level of perceived cooperative norms between physicians and nurses increased the probability that SOPs for PM were applied, whereas a high bed turnover rate decreased that probability. According to the responses from head neonatologists, written SOPs for PM were common in German NICUs. However, if management strategies on pain existed, this did not mean that these were directly applied in the daily routine. Clinical training of the staff, the promotion of adequate interprofessional cooperation, as well as allowing time to deal with these SOPs might be all essential measures to strengthen the application.

Management of prolonged meconium evacuation in preterm infants: A survey-based analysis in German Neonatal Intensive Care Units.

Due to the functional immaturity of bowel motility, a delayed passage frequently requires evacuation of meconium in preterm infants. Often rectal enemas and oral laxatives are used to manage these bowel evacuation disorders. An online survey was sent to all 163 high-level Neonatal Intensive Care Units (NICUs) in Germany. The participants were queried on rectal enemas, laxative therapy and outcome incidences. A total of 110/163 (67.5%) hospitals participated in the study. 103/110 (93.6%) participating sites applied rectal enemas in cases of delayed meconium evacuation and 63/110 (57.3%) additionally used oral laxatives. In total, 15 different solutions and 7 different application systems were used for rectal instillation. Preterm infants receiving enemas within the first 48 hours after birth were found to have a significantly lower incidence of FIP (p=0.006). Altogether 8 different oral laxatives were utilised. Therapeutic approaches to the management of prolongated meconium evacuation differ widely among German NICUs. Our survey highlights the diversity of applied substances, means of application and differences in duration and frequency of interventions. Macrogol was commonly used in neonates as an oral laxative despite the lack of approval from the manufacturer.

Interventions for Promoting Meconium Passage in Very Preterm Infants-A Survey of Current Practice at Tertiary Neonatal Centers in Germany.

Meconium passage is often delayed in preterm infants. Faster meconium passage appears to shorten the time to full enteral feeds, while severely delayed meconium passage may indicate meconium obstruction. Neonatologists often intervene to promote meconium passage, assuming that benefits outweigh potential risks such as necrotizing enterocolitis (NEC). We performed an anonymous online survey on different approaches to facilitate meconium passage among tertiary neonatal intensive care units (NICUs) in Germany between February 2022 and April 2022. We collected information on enteral nutrition, gastrointestinal complications, and interventions to promote meconium passage. We received 102 completed questionnaires (response rate 64.6%). All responders used interventions to promote meconium passage, including enemas (92.0%), orally applied contrast agents (61.8%), polyethylene glycol (PEG) (46.1%), acetylcysteine (19.6%), glycerin suppositories (11.0%), and maltodextrin (8.8%). There was substantial heterogeneity among NICUs regarding frequency, composition, and mode of administration. We found no differences in NEC incidence between users and nonusers of glycerin enemas, high or low osmolar contrast agents, or PEG. There is wide variability in interventions used to promote meconium passage in German NICUs, with little or no evidence for their efficacy and safety. Within this study design, we could not identify an increased risk of NEC with any intervention reported.

Driving new technologies in hospitals: association of organizational and personal factors with the readiness of neonatal intensive care unit staff toward webcam implementation

BackgroundThe use of webcam technology in neonatal intensive care units (NICUs) enables parents to see their child when the parents cannot be present at the NICU. The webcam’s use has been gaining increasing attention. Lead physicians and lead nursing staff play a key role in the decision of whether to implement webcams. This study investigates factors that are associated with the readiness for the implementation of a webcam system among lead NICU staff.MethodsA postal survey was conducted among all lead physicians and lead nursing staff in all German NICUs between December 2020 and April 2021 (total N = 416, one lead physician and one lead nursing staff per NICU, N = 208). On the basis of normalization process theory, personal (technology acceptance) and organizational (innovation climate) attributes were chosen to determine their association with the readiness for the implementation of a webcam system. The association of these factors was determined using multiple linear regression models for both lead physicians and lead nurses.ResultsOverall, a response rate of 66.59% (n = 277) was achieved. Technology acceptance proved to be a significant factor associated with the readiness for the implementation of a webcam system among lead physicians. Furthermore, staff already working with webcams in their NICUs indicated a significantly higher level of technology acceptance than staff without webcam experience and without any desire to use a webcam in the future. No significant association was found between innovation climate and the readiness for the implementation of a webcam system.ConclusionsTechnology acceptance was identified as a factor associated with the readiness for the implementation of a webcam system. The insights from this study can be used to manage potential barriers regarding the readiness for implementation of webcams in NICUs.Trial registrationThe Neo-CamCare study is registered at the German Clinical Trials Register. DRKS-ID: DRKS00017755. Date of Registration in DRKS: 25-09-2019.

Physiotherapy in German Neonatal Intensive Care Units - Indication and Clinical Application of the General Movements Assessments

Standardized recommendations for inpatient and outpatient physiotherapy for preterm infants are lacking in Germany. The aim of this study was to investigate the prescription practice in German neonatal intensive care units. Are standardized assessments used to determine indications? How important is the General Movements Assessment in postnatal diagnostics? We conducted an online survey in German neonatal intensive care units asking 21 questions on indication and prescription practices for inpatient and outpatient physiotherapy in preterm infants' care as well as on General Movements Assessment and its clinical application via Lime Survey. 81% of the participating sites "always" or "often" recommend indication-based inpatient physiotherapy for preterm infants and 53% "always"/"often" recommend outpatient therapy. Indications are mainly based on these symptoms (N=344) or diagnoses (N=273) (multiple answers): hypotonia (94%), abnormal and imbalanced muscle tone (92%), neurological abnormalities (97%) and brain damage (94%). Standardized testing is used by 41% of the participants. The General Movements Assessment is known to 87% of the neonatal intensive care units, 11% use it several times a week, 17% several times a month for indication of physiotherapy. Physiotherapy is frequently prescribed for preterm infants. The majority of indications are based on symptoms or clinical pictures rather than on standardized tests. The General Movements Assessment is a widely known method but not systematically applied at the moment.

Impact of early antibiotic exposure on the risk of colonization with potential pathogens in very preterm infants: a retrospective cohort analysis

BackgroundSepsis is one of the most important complications in preterm infants. For this reason, most preterm infants receive antibiotics during their first postnatal week. Since 2013, a weekly colonization screening has been installed in German neonatal intensive care units (NICUs), including multi-drug resistant organisms (MDRO) and pathogens with increased epidemic potential. We here investigated the impact of early antibiotic exposure on the colonization with these pathogens.MethodsData from 1407 preterm infants with gestational age < 32 + 0 weeks and born in three NICUs in Germany between January 2014 and December 2019 were analysed.ResultsAntibiotics were administered to 911/1407 (64.7%) participating infants during their first postnatal week. Screening-targeted pathogens were detected in 547/1407 (38.9%). Early antibiotic exposure did not increase the risk of colonization with screening-targeted pathogens. The only independent risk factor for colonisation with potential pathogens was the admitting hospital. Interestingly, longer antibiotic therapy (> 7 days) decreased the risk for acquiring pathogens with increased epidemic potential.ConclusionEarly antibiotic exposure did not impact the risk for colonization with MDRO or highly epidemic pathogens in preterm infants. Further studies are needed to identify risk factors for the acquisition of MDRO and highly epidemic pathogens and potential associations with long-term outcome.

Reduction of antibacterial use in patients with very low birth weight on German NICUs after implementation of a mandatory surveillance system. A longitudinal study with national data from 2013 to 2019

To determine the influence of a national surveillance system for neonates (NEO-KISS) in neonatal intensive care units (NICUs) on consumption of antibacterial and to identify risk factors for prescriptions. Data on antibacterial use between 2013 and 2019 from 231 NICUs in Germany was analyzed in this longitudinal study after introduction of a mandatory module for surveillance of antibacterial consumption in preterm infants. 59,411 newborns with a birth weight under 1500 gs were under surveillance in NEO-KISS during the study period. We report the development of antibacterial consumption during the days of treatment (DOT)/1000 patient days (PD) including the name of the substance administered. Risk factors for antibacterial treatment over time were analyzed. A total, 2,090,341 surveillance patient days were monitored. Antibacterial consumption was 430.4 DOT/1000PD (Median 380.3; IQR: 284.2-502.7). Antibacterial use significantly decreased by 19.5% from 2013, 474.3 DOT/1000PD to 382.1 DOT/1000PD in 2019. Use of penicillins with extended spectrum (J01CA), other aminoglycosides (J01GB), glycopeptide antibacterials (J01XA and J01DH), and third-generation cephalosporins (J01DD) decreased, while use of macrolides (J01FA) and combinations of penicillins, including beta-lactamase inhibitors (J01CR), increased over time. Regression analysis identified year of birth as an independent protective factor for the prescription of antibacterials in general. The implementation of a national mandatory surveillance system was associated with a reduction in antibacterial consumption in preterm infants with VLBW. Surveillance of antibacterial use is an integral part of targeting antimicrobial stewardship efforts.

Initiation of lactation and the provision of human milk to preterm infants in German neonatal intensive care units from the mothers\u2019 perspective

BackgroundIf infants with a very low birth weight (VLBW) are to be fed exclusively with human milk, it is essential to focus on lactation initiation. The aim of the study is to learn more about the current state of lactation initiation and human milk provision in neonatal intensive care units in Germany from the mothers' perspective.MethodsWritten surveys were conducted with mothers of VLBW infants to learn more about the timing of initiation of lactation, pumping frequency during the first three days postpartum and feeding of the preterm infant during hospitalisation.ResultsThe data of 437 mothers (response rate: 44.7%) were included in the analyses. Of these, only 7.8% stated that they had initiated lactation immediately after delivery and 38.2% within 6 h. In terms of pumping frequency, 50.1% pumped 7–9 times a day within the first 3 days postpartum; 60.9% reported that their infant received formula feedings during the hospital stay.ConclusionOverall, deficits were still evident with regard to the initiation of lactation in mothers of VLBW infants in Germany, resulting in a large proportion of VLBW infants receiving formula in the hospital.Trial registrationGerman Clinical Trial Register: DRKS00017755.

Do trained nurses feel more psychologically safe?-Results from a multi-level modelling approach.

AimTo analyse the associations between a nurse's psychological safety and her/his additional training.DesignA cross‐sectional survey conducted between September 2015 and August 2016.MethodsA multi‐level modelling approach was used considering unit membership. We used data from 1,239 questionnaires completed by nurses on 75 different German neonatal intensive care units, and 75 questionnaires completed by the corresponding leading nurse.ResultsWe found the additional managerial training as a charge nurse to be a positive predictor for psychological safety (β = .346, p ≤ .05). Surprisingly, the additional clinical training in paediatric intensive care is negatively associated with psychological safety (β = −.192, p ≤ .01). Our model estimates that this negative association can be inhibited if the team's share of nurses with an additional clinical training increases (β = .313, p ≤ .05).

The effects of webcams on German neonatal intensive care units \u2013 study protocol of a randomised crossover trial (Neo-CamCare)

BackgroundThe separation of parents and their prematurely born children during care in a neonatal intensive care unit (NICU) can have far-reaching consequences for the well-being of the parents and also of the children. The aim of this study is to evaluate the use of webcams on NICUs and to conduct a systematic assessment of their possible effects on parents and clinical staff. In addition, it aims at determining the need for webcams in German NICUs and to identify possible barriers and moderators. The development and evaluation of practical guidance for the use of webcams will enable the comprehensive education of clinical staff and parents and, as a result, is intended to mitigate any potential undesirable consequences.MethodsThe study will be based on a mixed methods approach including all groups concerned in the care. Qualitative data will be collected in interviews and focus groups and evaluated using content analysis. The collection of quantitative data will be based on written questionnaires and will aim to assess the status quo as regards the use of webcams on German NICUs and the effects on parents, physicians, and nursing staff. These effects will be assessed in a randomised cross-over design. Four NICUs will be involved in the study and, in total, the parents of 730 premature babies will be invited to take part in the study. The effects on the nursing staff, such as additional workload and interruptions in workflows, will be evaluated on the basis of observation data.DiscussionThis study will be the largest multicentre study known to us that systematically evaluates the use of webcams in neonatal intensive care units. The effects of the implementation of webcams on both parents and care providers will be considered. The results provide evidence to decide whether to promote the use of webcams on NICUs or not and what to consider when implementing them.Trial registrationThe trial has been registered at the German Clinical Trial Register (DRKS). Number of registration: DRKS00017755, date of registration: 25.09.2019,

What matters most and for whom? A cross-sectional study exploring goals of health professionals in German neonatal intensive care units

ObjectivesQuality of care largely depends on successful teamwork, which in turn needs effective communication between health professionals. To communicate successfully in a team, health professionals need to strive for the...

Aminoglycosides were associated with higher rates of surgical patent ductus arteriosus closure in preterm infants.

In animal studies, aminoglycosides induced ductus arteriosus relaxation in a dose-dependent fashion. We tested the hypothesis that antibiotic treatment of preterm infants with aminoglycosides is associated with higher rates of surgical patent ductus arteriosus (PDA) closure. Preterm infants (birthweight <1000grams or gestational age <29weeks) enrolled in 62 German neonatal intensive care units (NICUs) were analysed. NICUs were stratified according to the use of aminoglycosides as first-line antibiotics. Baseline data were not different when NICUs using aminoglycosides (n=9965 infants) were compared to NICUs using other antibiotics (n=1948 infants). Rates of surgical PDA closure were 5.9% for NICUs using aminoglycosides; 6.2% for units using gentamicin; and 5.0% for NICUs using tobramycin compared to 4.1% in NICUs using other antibiotics (P<.001, P<.001 and P=.140, respectively, Fisher's exact test). Indomethacin and ibuprofen use was more common in NICUs using aminoglycosides (41% vs 33%, P<.001, Fisher's exact test). Gentamicin trough levels were higher in NICUs with surgical closure rates above the mean (median 2.0µg/mL, inter-quartile range 0.8-4.0µg/mL vs 1.2µg/mL, IQR 0.8-1.7, P<.001, Mann-Whitney U test). First-line antibiotic treatment of preterm infants with aminoglycosides was associated with higher rates of surgical PDA closure.

Boundaries of Focus and Volume: An Empirical Study in Neonatal Intensive Care

Our study contributes to the scholarly debate whether organizational units should have a narrow focus and admit a homogeneous patient cluster or whether they should admit a pool of patient clusters. We investigate whether the benefits of increased volume through pooling patients outweigh the disadvantages of increased heterogeneity and pursue our analysis in the context of neonatal care. Our empirical studies relies on 4020 patient episodes collected in 18 German neonatal intensive care units and we distinguish between two patient clusters that differ with respect to the inherent medical risk and operational heterogeneity. Cluster 1 consists of very‐low birth weight (VLBW) infants with increased risk of complications but similar service trajectories and lower operational heterogeneity. Cluster 2 contains non‐VLBW infants with lower risk of complications but more diversity in disease patterns and higher operational heterogeneity. Our analysis shows that cluster volume, that is, the unit's absolute patient volume in a cluster, is positively related to process outcomes as indicated by decreasing length of stay. This relationship is found for both clusters. Regarding focus, we do not find any evidence of positive effects. In fact, we even find that cluster focus, that is, the unit's relative volume of the cluster, is detrimentally related to process outcomes for non‐VLBW patients with lower risk of complications and more operational heterogeneity. This indicates that organizational units providing services for complex patients should not have a narrow focus, but should rather provide services for related patient clusters in order to achieve higher volume levels within the unit.

Exploring leading nurses' work values and their association with team safety climate: Results from a questionnaire survey in neonatal intensive care units.

To explore leading nurses' work values and their effect on the safety climate in neonatal intensive care units (NICUs). Despite their significance for behaviour, the work values of leading nurses are still insufficiently studied. We explore the impact of work value dimensions (self-transcendence, self-enhancement, conservation, and openness to change) on the safety climate. A cross-sectional study was conducted in 86 German NICUs between September 2015 and August 2016. Our analyses relate questionnaire data from 75 leading nurses to the shared perceptions regarding safety among their team members (n=1,277). We used fractional response modelling to identify important work values. The analysis showed differences between the dimensions of work values and their association with the safety climate. A significant positive association was found between the work value dimension self-transcendence (including the work values relationships with others and altruism) and safety climate (β=0.255, p=.001). A large team size has a negative impact on the safety climate. The findings indicate that the leading nurse's score on self-transcendence is positively related to the safety climate. The results demonstrate that it might be useful to consider work values in the selection of nurse leaders.

Efficacy of Bifidobacterium animalis subsp. lactis (BB-12), B. infantis and Lactobacillus acidophilus (La-5) probiotics to prevent gut dysbiosis in preterm infants of 28+0–32+6 weeks of gestation: a randomised, placebo-controlled, double-blind, multicentre trial: the PRIMAL Clinical Study Protocol

IntroductionThe healthy ‘eubiosis’ microbiome in infancy is regarded as the microbiome derived from term, vaginally delivered, antibiotic free, breastfed infants at 4–6 months. Dysbiosis is regarded as a deviation from...

Medical Staffing in Neonatal and Pediatric Intensive Care Units - an European Survey

Recently, there is a growing scarcity of qualified personnel in German healthcare system. This can lead to problems especially in the highly specialized neonatal and pediatric intensive care. We conducted a survey to evaluate the staffing situation at 583 European neonatal and pediatric intensive care units (ICU). Response rate was 48.5%. As a main result our evaluation demonstrated a significant lower nurse-staffing in Germany compared to the other countries (90.4 vs. 95.8%, p<0.001). In addition, the average nurse-to-patient ratio was worse in German neonatal ICUs (3.0 vs. 2.3, p<0.001). The presence of senior doctors is also lower in German neonatal and pediatric ICUs compared to the other countries (on weekdays: 12.0 vs. 14.6 h, p=0.04; on weekends: 8.9 vs. 13.2 h, p=0.003). Our survey demonstrates that the nurse-staffing at neonatal and ICUs in Germany is worse than in other European countries. The resulting potential loss of quality is worsened due to lower presence of senior doctors at the ICUs. Possible consequences include increase of complications, impairment of treatment success, closure of intensive care beds, and mental and physical illness of the staff. Compared to other European countries, there is a lack of nurses at neonatal and pediatric ICUs in Germany. This study underlines the importance to take measures to counteract nursing crisis.

Management of early- and late-onset sepsis: results from a survey in 80 German NICUs.

The management of early- (EOS) and late-onset sepsis (LOS) and neonatal intensive care units (NICUs) has not been extensively evaluated. 231 highly specialized level 1 and level 2 NICUs in Germany were asked to participate in an internet-based survey. The final analysis of anonymized datasets from 80 NICUs (response rate 34.6 %) compared university hospitals and regional neonatal referral centers. The survey describes potential areas of improvement concerning empirical treatment of infants with LOS with vancomycin and 3rd generation cephalosporins, minimal volume of blood sampling for aerobic culture, consideration of lumbar tap in any child with blood culture positive LOS and drug monitoring details for gentamicin and vancomycin. In summary, this survey reveals a significant gap between recent national German guidelines and daily practices in German NICUs.