Neonatal Health Care Providers Research Articles

Our Responsibility to Follow Through for NICU Infants and Their Families.

* Abbreviations: PBP — : potentially better practice QI — : quality improvement In America, health and well-being are, to a large extent, determined by a person’s race, ethnicity, income, immigration status, and neighborhood of residence. Racism, segregation, and inequality of income, opportunity, and wealth cause disparities in health outcomes across the life course.1 The effects are particularly pronounced for infants requiring neonatal intensive care and their families because of the already significant risk for neurodevelopmental disabilities and need for specialized services. As health professionals, pediatricians, and neonatal health care providers, we have the responsibility to address these social determinants of health. We must learn to practice social as well as technical medicine2 and follow-through, accepting that our responsibility to the infants and families we serve extends beyond the hospital or clinic walls. Although in this article we focus on follow-through in the neonatal intensive care setting, the ideas for practicing social medicine we present have wider application in pediatrics, obstetrics, and beyond. We have proposed the term “follow-through” to distinguish our proposal from the more typical neonatal practice of “follow-up” in which the services and staffing of clinics are focused, primarily, on medical conditions and assessment of neurodevelopment after discharge from the NICU. Only 70% of follow-up clinics provide any social services, for example, and <10% provide legal services.3 We propose a more comprehensive approach that begins before birth and continues into childhood, involving health professionals, families, and communities as partners to meet the social as well … Address correspondence to Erika M. Edwards, PhD, MPH, Data Science, Vermont Oxford Network, 33 Kilburn St, Burlington, VT 05401. E-mail: eedwards{at}vtoxford.org

Simulator-based ultrasound training for identification of endotracheal tube placement in a neonatal intensive care unit using point of care ultrasound

BackgroundSimulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.MethodsSixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.ResultsThe majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p < 0.001. There was an average reduction of 1.3 s (β = − 1.3; 95% CI: − 1.66 to − 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.ConclusionWe found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings.Trial registrationClinicalTrials.gov Identifier: NCT03533218. Registered May 2018.

Using the RETAIN Tabletop Simulator as a Summative Assessment Tool for Neonatal Resuscitation Healthcare Professionals: A Pilot Study.

Background: Frequent and objective summative assessment of neonatal healthcare providers is important to ensure high-quality care to patients during neonatal resuscitation. Currently, neonatal resuscitation providers are only individually assessed using an at-home online multiple-choice questionnaire. While simulation-based assessment is preferred, resource constraints limit its widespread uptake. An alternative approach to simulation-based summative assessment is needed. Simulation-based serious games may provide a solution.Objective: The aim of this study was to examine if individual performance on the RETAIN (REsuscitation TrAINing for healthcare professionals) tabletop simulator can be used as a summative assessment of neonatal resuscitation providers, regardless of their prior board game experience.Method: Neonatal healthcare providers were recruited from a tertiary perinatal center to complete a (1) demographic pre-survey, (2) neonatal resuscitation scenario using an open-answer written pre-test, (3) neonatal resuscitation scenario using the RETAIN tabletop simulator, and (4) post-survey measuring usage and attitudes toward board games. Multiple linear regression analyses using the Johnson–Neyman technique were conducted in R to probe the moderation effect of years of board game on the relationship between pre-test and game performance.Results: Twenty Neonatal Resuscitation Program-trained healthcare providers (nurses, nurse practitioners, respiratory therapists, and fellows) were recruited for this study (n = 19 females). Participants' mean (standard deviation) pre-test score was 8.35 (1.81) out of a total 16 possible points (52%) and a score of 18 (4.41) out of a total of 40 possible points (45%) using RETAIN. Overall board game experience was 22.5 (12.6) years. Finally, years of board game moderated significantly the relation between the pre-test and game performance (B = −0.13, SE = 0.05, beta = −0.48, t = −2.77, p < 0.05; 95% CI [−0.24, −0.03]). Thus, participants' performance on the two tests (written and simulator) was significantly positively associated, but only for those who reported fewer than 21.5 years of board game experience.Conclusion: This study reports the preliminary results of a pilot study, indicating that the RETAIN tabletop simulator could be used as a simulation-based summative assessment, an enjoyable, low-cost alternative to traditional assessment approaches. RETAIN offers a solution to the need for more frequent and continued assessment of neonatal resuscitation providers.

Exploring perspectives, preferences and needs of a telemonitoring program for women at high risk for preeclampsia in a tertiary health facility of Karachi: a qualitative study protocol

BackgroundIn Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies.MethodsThe study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the out-patient department/ antenatal clinics of JPMC hospital for antenatal check-ups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020.DiscussionThis is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.

Clinicians’ Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan

ObjectiveTo examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers. DesignA cross-sectional survey of neonatal nurses and physicians. SettingTwenty-four NICUs in Jordan. ParticipantsParticipants included 213 nurses and 75 physicians who provided direct care for infants in NICUs. MethodsUsing the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors. ResultsIn 83% of the recalled situations, the physicians in charge of the infants’ care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants’ primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses’ perceived levels of involvement in decision making (χ2[4] = 23.140, p < .001). ConclusionOur results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.

A novel training simulator for portable ultrasound identification of incorrect newborn endotracheal tube placement \u2013 observational diagnostic accuracy study protocol

BackgroundEndotracheal tube (ETT) placement is a critical procedure for newborns that are unable to breathe. Inadvertent esophageal intubation can lead to oxygen deprivation and consequent permanent neurological impairment. Current standard-of-care methods to confirm ETT placement in neonates (auscultation, colorimetric capnography, and chest x-ray) are time consuming or unreliable, especially in the stressful resuscitation environment. Point-of-care ultrasound (POCUS) of the neck has recently emerged as a powerful tool for detecting esophageal ETTs. It is accurate and fast, and is also easy to learn and perform, especially on children.MethodsThis will be an observational diagnostic accuracy study consisting of two phases and conducted at the Aga Khan University Hospital in Karachi, Pakistan. In phase 1, neonatal health care providers that currently perform standard-of-care methods for ETT localization, regardless of experience in portable ultrasound, will undergo a two-hour training session. During this session, providers will learn to detect tracheal vs. esophageal ETTs using POCUS. The session will consist of a didactic component, hands-on training with a novel intubation ultrasound simulator, and practice with stable, ventilated newborns. At the end of the session, the providers will undergo an objective structured assessment of technical skills, as well as an evaluation of their ability to differentiate between tracheal and esophageal endotracheal tubes. In phase 2, newborns requiring intubation will be assessed for ETT location via POCUS, at the same time as standard-of-care methods. The initial 2 months of phase 2 will include a quality assurance component to ensure the POCUS accuracy of trained providers. The primary outcome of the study is to determine the accuracy of neck POCUS for ETT location when performed by neonatal providers with focused POCUS training, and the secondary outcome is to determine whether neck POCUS is faster than standard-of-care methods.DiscussionThis study represents the first large investigation of the benefits of POCUS for ETT confirmation in the sickest newborns undergoing intubations for respiratory support.Trial registrationClinicalTrials.gov Identifier: NCT03533218. Registered May 2018.

Short- and Long-Term Outcomes of Extremely Preterm Infants in Japan According to Outborn/Inborn Birth Status.

Objectives:Outborn (born outside tertiary centers) infants, especially extremely preterm infants, are at an increased risk of mortality and morbidity in comparison to inborn (born in tertiary centers) infants. Extremely preterm infants require not only skilled neonatal healthcare providers but also highly specialized equipment and environment surroundings. Maternal transport at an appropriate timing must be done to avoid the delivery of extremely preterm infants in a facility without the necessary capabilities. Cases of unexpected deliveries at birth centers or level I maternity hospitals need to be attended emergently. We compared the differences in short- and long-term outcomes between outborn and inborn infants to improve our regional perinatal system.Design:Retrospective cohort study.Setting:Neonatal Research Network of Japan database.Patients:Extremely preterm infants (gestational age between 22 + 0 and 27 + 6 wk) in the Neonatal Research Network of Japan database between 2003 and 2011.Interventions:None.Measurements and Main Results:A total of 12,164 extremely preterm infants, who were divided into outborn (n = 785, 6.5%) and inborn (n = 11,379, 93.5%) groups, were analyzed. Significant differences were observed in demographic and clinical factors between the two groups. Outborn infants had higher short-term odds of severe intraventricular hemorrhage (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), necrotizing enterocolitis (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), and focal intestinal perforation (adjusted odds ratio, 1.58; 95% CI, 1.09–2.30; p = 0.02). There were no significant differences in long-term outcomes between the two groups, except in the rate of cognitive impairment (adjusted odds ratio, 1.49; 95% CI, 1.01–2.20; p = 0.04).Conclusions:The frequency of severe intraventricular hemorrhage, necrotizing enterocolitis or focal intestinal perforation, and cognitive impairment was significantly higher in outborn infants. Thus, outborn/inborn birth status may play a role in short- and long-term outcomes of extremely preterm infants. However, more data and evaluation of improvement in the current perinatal environment are needed.

Multi-modal learning using virtual reality technology in neonatal resuscitation: exploring benefits and limitations

mHealth, the use of wireless and portable communication technology to improve the health status of the population, has seen widespread adoption in low- and middle-income countries. It has been used to increase awareness and knowledge of healthcare, to collect health-related data, to deliver healthcare information such as results of investigations or appointment reminders, to aid decision-making by healthcare providers, and to improve communication between various stakeholders of the health system. Developing countries face an immense challenge of periodically updating the professional knowledge of their huge pool of community and facility level healthcare workers. Nearly universal possession of mobile phones, low-cost internet data, and high growth rate of smartphones has facilitated the use of mHealth in delivering evidence-based guidelines and decision-aids to frontline healthcare workers. This review describes the current evidence on the use of mHealth educational interventions targeting maternal and neonatal healthcare providers in low- and middle-income countries. Recent efforts of the National Neonatology Forum of India in integration of mHealth for development and dissemination of clinical practice guidelines are also presented.

Retinopathy of prematurity campaign in Bangladesh: Experience and lessons learnt

Retinopathy of Prematurity (ROP) is a potentially avoidable cause of irreversible blindness or severe visual impairment in many infants born premature. The global incidence of premature birth has been reported to be 11.1 per 100 livebirths in 2010. The present communication share the experience and lessons learnt during a Neonatologist-Ophthalmologist Retinopathy of Prematurity (NO-ROP) campaign and ROP situation analysis in Bangladesh. A weeklong workshop was organised in May 2016 in Dhaka for the paediatricians and ophthalmologists of the country involved in ROP care. This included a programme to train the attendees on basic to advanced ROP care. Finally, a half day session was organised for the government stakeholders, non government organisations, obstetricians, neonatal and child health care providers and ophthalmologists to assess the level of awareness, the gaps and any obstacles for an effective ROP care in the country. Besides, two neonatal units were visited to assess the ROP situation at district levels in Bangladesh. The observations were documented and recommendations suggested. The awareness and resource availability for ROP care was disproportionately less compared to the demand even in Dhaka. At the district levels, the ROP care mostly did not exist. However, the eagerness to help, support and bridge the gaps was tremendous both among the government and non government organisations. There is an urgent need to strengthen and expand the existing ROP services in Dhaka as well as at the district levels. The observations made and lessons learnt could go a long way in combating ROP blindness in Bangladesh and in other developing countries.&#x0D; Bangladesh Med Res Counc Bull 2019; 45: 122-125

NICU Graduate Reunion: "A Celebration of Life".

Few understand the experience of having an infant in the neonatal intensive care unit (NICU). This article provides a discussion about the importance of an annual reunion for former NICU infants, their families, and neonatal staff. The purpose of this article is to explain the impact of the NICU reunion on families and neonatal healthcare providers and describe the experience of organizing this reunion over the past 20 years. This is a description of how a NICU reunion was organized at a regional neonatal center. Graphic-designed invitations were e-mailed to NICU graduates, who previously agreed to being contacted, 2 months prior to the reunion date. Social media were utilized to publicize the event on the hospital's Web site. At the reunion, parents and families introduced their NICU graduate to the neonatal staff who cared for them while hospitalized. Sometimes staff found it difficult to recognize the NICU graduates, who were toddlers or older. Parents were relaxed, expressing their appreciation for care received. The impact of seeing an infant, born at 24 weeks, now walking, talking, and running cultivates pride in the NICU healthcare team. The reunion adds a positive dimension to the work of NICU caregivers. Parents look forward to attending the reunion to reconnect with NICU staff and other NICU parents. Directions for future study include a comparison of staff and families who attend the NICU reunion and those who do not, by using a survey or online evaluation tool, to improve future reunions.

Audit of Golden Hour Practice in Neonate Assiut University Children Hospital

AbstractBackground: A golden-hour strategy is a philosophical approach that reinforces communication and collaboration (inter-and intra-team) using evidence-based protocols and procedures that standardize as many elements as possible for delivery and initial management of a newborn. Golden-hour strategies lay out how the neonatal team will receive notification from the obstetrical service of an impending periviable birth and stress the importance of collaborative counseling of the family.The Vermont Oxford Network (VON), a worldwide non-profit collaborative of neonatal healthcare providers, began to use to describe the first hour of life for the Very Low Birth Weight (VLBW) infant in the late 1990s.Pre-resuscitation check lists are used for briefing the care team to the equipment that they will need to prepare both in the delivery room and Neonatal Intensive Care Unit (NICU) in the form of standardized check lists. Personnel have clearly assigned roles and responsibilities. This promotes training and adherence to the American Academy of Pediatrics/ Amer-ican Heart Association Neonatal Resuscitation Program (NRP) algorithm.Aim of Study: The aim of the study is to assess the degree of adherence of medical physician to Assiut University Chil-dren Hospital protocol for application of golden hour practice in neonate. Also to review potentially better practice that can be applied during the golden hour to ensure the optimal outcome.Patients and Methods: The study included 100 cases that were delivered at Assiut University Maternal Health Hospital and followed-up during the first hour of life. The included cases were chosen according to the inclusion criteria and the data was collected during the period between October 2016 to March 2017.Results: The study included 100 newborn infants their gestational ages ranged from >29 weeks to Conclusion: This study provides valuable insight to assess the degree of adherence of medical physician to Assiut Children Hospital protocol for application and effectiveness of golden hour practice in neonate. Also to review potentially better practice that can be applied to ensure the optimal outcome using a statistically powerful calculated sample size and powerful data.

RETAIN: A Board Game That Improves Neonatal Resuscitation Knowledge Retention.

Background: The current resuscitation guidelines recommend frequent simulation based medical education (SBME). However, the current SBME approach is expensive, time-intensive, and requires a specialized lab and trained instructors. Hence, it is not offered routinely at all hospitals. We designed the board game “RETAIN” to train healthcare providers (HCPs) in neonatal resuscitation in a cost-friendly and accessible way.Objectives: To examine if a board game-based training simulator improves knowledge retention in HCPs.Methods: “RETAIN” consists of a board using an image of a baby, visual objects, adjustable timer, monitors, and action cards. Neonatal HCPs at the Royal Alexandra Hospital were invited to participate. Participants completed a written pre-test (resuscitation of a 24-week infant), then played the board game (starting with a tutorial followed by free playing of three evidence-based neonatal resuscitation scenarios). Afterwards, a post-test with the same resuscitation scenario and an opinion survey was completed. The answers from the pre- and post-test were compared to assess HCPs' knowledge retention.Results: Thirty HCPs (four doctors, 12 nurses, and 14 respiratory therapist) participated in the study. Overall, we observed a 10% increase in knowledge retention between the pre- and post-test (49–59%, respectively). Temperature management showed the most knowledge gain between the pre- and post-test (14–46%, respectively). Placement of a hat (10–43%), plastic wrap (27–67%), and temperature probe (7–30%) improved between the pre- and post-test.Conclusion: Knowledge retention increased by 12% between pre- and post-test (49–61%, respectively). The improvement in performance and knowledge supports the use of board game simulations for clinical training.

Neonatal Cord Care Practices among Mothers and Caregivers in the Volta Region of Ghana.

Background:The umbilical cord is a major route of infection among newborns. In Ghana, infections among neonates accounts for majority of under-five deaths. This study sought to investigate what mothers apply to the umbilical cord of their newborns and what motivates them to put such applications on the cord.Methods:This was a descriptive cross-sectional study of neonatal cord care practices among mothers and caregivers in the Nkwanta South District of the Volta region of Ghana. Quantitative and qualitative methods were used.Results:Majority of the mothers/caregivers used substances that have not been recommended for umbilical cord dressing (64.3%). Factors such as level of education [χ2=8.2, p=0.02], place of delivery [χ2 = 40.1, p<0.001], relationship with whoever has made a recommendation for a particular dressing to be used [χ2=95.2, p<0.001] and number of days it takes the umbilical cord to fall off [χ2=6.2, p=0.05] were found to influence the type of dressing used on the umbilical cord.Conclusion and Global Health Implications:In order to reduce the number of neonates who die due to avoidable cord-related infections, the type of substances used on the umbilical cord should be approved substances. Health education particularly on neonatal cord care targeting community members and health care providers at the lower levels of the healthcare delivery system should be intensified.

Neonatal skin: Handle with care: A case series

The neonatal skin is fragile and should be handled with maximal care. The thin stratum corneum and attenuated rete ridges in neonatal skin makes them vulnerable to physical injury, insensible water loss, thermal instability and infection. The widespread use of Intensive Care Unit facilities for taking specialized care of the neonate brings along with it a better prognosis for survival but has introduced the caveat of many an iatrogenic skin disorder. Most of these iatrogenic disorders are potentially preventable by providing more inclusive rigorous training of neonatal health care providers and observation of utmost vigilance and care.

IMPROVING SYSTEM READINESS, STAFF PREPAREDNESS AND PATIENT SAFETY IN A NEW SINGLE FAMILY ROOM NICU THROUGH IN SITU SIMULATION

Abstract BACKGROUND Transitions to new healthcare environments can negatively impact patient care and threaten patient safety. Immersive in situ simulation conducted in newly constructed single family room (SFR) Neonatal Intensive Care Units (NICUs) prior to occupancy, has been shown to be effective in testing new environments and identifying latent safety threats (LSTs). These simulations overlay human factors to identify LSTs as new and existing process and systems are implemented in the new environment OBJECTIVES We aimed to demonstrate that large-scale, immersive, in situ simulation prior to the transition to a new SFR NICU improves: 1) systems readiness, 2) staff preparedness, 3) patient safety, 4) staff comfort with simulation, and 5) staff attitude towards culture change. DESIGN/METHODS Multidisciplinary teams of neonatal healthcare providers (HCP) and parents of former NICU patients participated in large-scale, immersive in-situ simulations conducted in the new NICU prior to occupancy. One eighth of the NICU was outfitted with equipment and mannequins and staff performed in their native roles. Multidisciplinary debriefings, which included parents, were conducted immediately after simulations to identify LSTs. Through an iterative process issues were resolved and additional simulations conducted. Debriefings were documented and debriefing transcripts transcribed and LSTs classified using qualitative methods. To assess systems readiness and staff preparedness for transition into the new NICU, HCPs completed surveys prior to transition, post-simulation and post-transition. Systems readiness and staff preparedness were rated on a 5-point Likert scale. Average survey responses were analyzed using dependent samples t-tests and repeated measures ANOVAs. RESULTS One hundred eight HCPs and 24 parents participated in six half-day simulation sessions. A total of 75 LSTs were identified and were categorized into eight themes: 1) work organization, 2) orientation and parent wayfinding, 3) communication devices/systems, 4) nursing and resuscitation equipment, 5) ergonomics, 6) parent comfort; 7) work processes, and 8) interdepartmental interactions. Prior to the transition to the new NICU, 76% of the LSTs were resolved. Survey response rate was 31%, 16%, 7% for baseline, post-simulation and post-move surveys, respectively. System readiness at baseline was 1.3/5,. Post-simulation systems readiness was 3.5/5 (p = 0.0001) and post-transition was 3.9/5 (p = 0.02). Staff preparedness at baseline was 1.4/5. Staff preparedness post-simulation was 3.3/5 (p = 0.006) and post-transition was 3.9/5 (p = 0.03). CONCLUSION Large-scale, immersive in situ simulation is a feasible and effective methodology for identifying LSTs, improving systems readiness and staff preparedness in a new SFR NICU prior to occupancy. However, to optimize patient safety, identified LSTs must be mitigated prior to occupancy. Coordinating large-scale simulations is worth the time and cost investment necessary to optimize systems and ensure patient safety prior to transition to a new SFR NICU.

The health care system is making ‘too much noise’ to provide family-centred care in neonatal intensive care units: Perspectives of health care providers and hospital administrators

AimTo describe the perspectives of health care providers and hospital administrators on their experiences of providing care for infants in Level II neonatal intensive care units and their families. Research methodsWe conducted 36 qualitative interviews with neonatal health care providers and hospital administrators and analysed data using a descriptive interpretive approach. Setting10 Level II Neonatal Intensive Care Units in a single, integrated health care system in one Canadian province. FindingsThree major themes emerged: (1) providing family-centred care, (2) working amidst health care system challenges, and (3) recommending improvements to the health care system. The overarching theme was that the health care system was making ‘too much noise’ for health care providers and hospital administrators to provide family-centred care in ways that would benefit infants and their families. Recommended improvements included: refining staffing models, enhancing professional development, providing tools to deliver consistent care, recognising parental capacity to be involved in care, strengthening continuity of care, supporting families to be with their infant, and designing family-friendly environments. ConclusionWhen implementing family-centred care initiatives, health care providers and hospital administrators need to consider the complexity of providing care in Level II Neonatal Intensive Care Units, and recognise that health care system changes may be necessary to optimise implementation.

Effect of earplugs on the physiological response of preterm infants during a nebulizer session

Background High noise levels may be harmful to preterm infants and have negative short-term effects on cardiovascular and respiratory systems. A nebulizer session before suction is the most common stressful procedure for preterm infants. Earplugs protect preterm infants from noise and improve their physiological state. Aim This study aimed to evaluate the effect of earplugs on the physiological response of preterm infants during a nebulizer session. Patients and methods The study, a one group time series quasi-experimental research design, was done on a purposive sample of 30 preterm infants attending the Neonatal Intensive Care Unit (NICU) of El Manial University Hospital (Kasr Al Ainy). A total of 30 preterm infants was involved first as a control group and then as the earplug group. Neonatal assessment, noise, and physiological response tools were utilized for data collection. A sound level meter was used to measure the level of noise before the nebulizer session. Results Results of the study have shown that there was a statistically significant difference in preterm infants before and after using earplugs regarding the mean change of heart rate, oxygen saturation, and systolic and diastolic blood pressure during and after a nebulizer session (P Conclusion The findings of the study concluded that the use of earplugs is effective to decrease the effect of noise on the physiological response of preterm infants during a nebulizer session. Recommendations The educational program is needed to raise awareness among neonatal nurses and other health-care providers about the effect of noise reduction methods such as an earplug on the physiological state of preterm infants.

Committee Opinion No. 712: Intrapartum Management of Intraamniotic Infection.

Intraamniotic infection, also known as chorioamnionitis, is an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua. Intraamniotic infection is a common condition noted among preterm and term parturients. However, most cases of intraamniotic infection detected and managed by obstetrician-gynecologists or other obstetric care providers will be noted among term patients in labor. Intraamniotic infection can be associated with acute neonatal morbidity, including neonatal pneumonia, meningitis, sepsis, and death. Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death. Recognition of intrapartum intraamniotic infection and implementation of treatment recommendations are essential steps that effectively can minimize morbidity and mortality for women and newborns. Timely maternal management together with notification of the neonatal health care providers will facilitate appropriate evaluation and empiric antibiotic treatment when indicated. Intraamniotic infection alone is rarely, if ever, an indication for cesarean delivery.

Committee Opinion No. 712 Summary: Intrapartum Management of Intraamniotic Infection.

Intraamniotic infection, also known as chorioamnionitis, is an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua. Intraamniotic infection is a common condition noted among preterm and term parturients. However, most cases of intraamniotic infection detected and managed by obstetrician-gynecologists or other obstetric care providers will be noted among term patients in labor. Intraamniotic infection can be associated with acute neonatal morbidity, including neonatal pneumonia, meningitis, sepsis, and death. Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death. Recognition of intrapartum intraamniotic infection and implementation of treatment recommendations are essential steps that effectively can minimize morbidity and mortality for women and newborns. Timely maternal management together with notification of the neonatal health care providers will facilitate appropriate evaluation and empiric antibiotic treatment when indicated. Intraamniotic infection alone is rarely, if ever, an indication for cesarean delivery.

EARLY-ONSET NEONATAL SEPSIS: CHANGING ORGANISM PATTERNS BETWEEN 2003 AND 2014

BACKGROUND: Early-onset neonatal sepsis (EONS) is largely caused by vertical transmission of infectious organisms. The predominant pathogens causing EONS appear to be changing over time, however current prevention efforts focus on group B Streptococcus (GBS). Current and accurate characterization of the organism distribution in EONS is imperative to ensure effective antibiotic prophylaxis during labour and appropriate empiric treatment in neonates with suspected EONS. OBJECTIVES: The objective of this study was to evaluate trends in causative organisms of EONS. Congruent with recent reports, we hypothesized there would be an increase in EONS caused by Escherichia Coli. DESIGN/METHODS: Data was collected for infants admitted to neonatal intensive care units (NICU) participating in the Canadian Neonatal Network (CNN) from 2009 to 2014 with a positive blood or cerebrospinal fluid culture (CSF) within 72 hours of birth. Collected data was compared to previously published data on a cohort from 2003-2008 with the same case definition. The distribution of causative organisms over time was analyzed, as well as differences in causative organisms by gestational age grouping. RESULTS: Of the 87,374 NICU admissions between 2009-2014, 435 infants had positive blood and/or CSF culture resulting in an EONS incidence rate of 0.50%. The mean gestational age was 31.25.8 from 2009-2011 and 30.95.6 from 2012-2014, and was not significantly different between the two groups. From 2009-2011 and 2012-2014, E. coli was the causative organism in 40.2% and 46.0% of cases, respectively, and GBS was responsible for 26.3% and 25.1% of cases, respectively. Between 2003 and 2014, there was a significant trend of an increasing number of cases caused by E. coli (p<0.01), and a trend towards a decreasing number of cases due to GBS. EONS due to E. coli was more common among infants <37 weeks gestational age (GA), whereas GBS was the most likely causative organism among infants 37 weeks GA (p<0.01). CONCLUSION: Significant changes in the pattern of organisms causing EONS have important implications for both obstetric and neonatal healthcare providers. Careful surveillance of causative organisms is warranted to inform revisions to antibiotic prophylaxis and treatment guidelines.