Days In Neonatal Intensive Care Unit Research Articles

The long-term impact of a program to prevent central line-associated bloodstream infections in a surgical intensive care unit

Central line-associated bloodstream infections (CLABSIs) are an important type of healthcare-associated infection in intensive care units (ICUs) with high mortality rates and high healthcare costs (1). According to the World Health Organization (WHO), CLABSIs are also the most common cause of healthcare-associated infections of the bloodstream (2). In the United States, the median rate ranges from 1.8 to 5.2 per 1,000 catheter days, according to the Centers for Disease Control and Prevention (CDC) (3). Each year, 100,000 cases and 30,000 deaths occur among patients in ICUs (4). In limited-resource countries, CLABSI rates range from 1.6 to 44.6 cases per 1,000 central line days in adult and pediatric ICUs and from 2.6 to 60.0 cases per 1,000 central line days in neonatal ICUs. CLABSIs are associated with significant additional mortality, with an odds ratio ranging from 2.8 to 9.5 (5). The optimal intervention method for reducing the incidence of CLABSIs has not been definitively identified, but some studies have proven that many practical, low-cost, low-technology educational measures related to inserting and maintaining central lines not only may be successful and effective but can also be sustained (3,4,6)–(10). Within this scenario, the CDC has recommended that an education program be implemented for healthcare personnel (6). The objective of this study was to describe the long-term impact of a program for decreasing CLABSI rates in a surgical ICU in Sao Paulo, Brazil.

Costs of Necrotizing Enterocolitis and Cost-Effectiveness of Exclusively Human Milk-Based Products in Feeding Extremely Premature Infants

This study evaluated the cost-effectiveness of a 100% human milk-based diet composed of mother's milk fortified with a donor human milk-based human milk fortifier (HMF) versus mother's milk fortified with bovine milk-based HMF to initiate enteral nutrition among extremely premature infants in the neonatal intensive care unit (NICU). A net expected costs calculator was developed to compare the total NICU costs among extremely premature infants who were fed either a bovine milk-based HMF-fortified diet or a 100% human milk-based diet, based on the previously observed risks of overall necrotizing enterocolitis (NEC) and surgical NEC in a randomized controlled study that compared outcomes of these two feeding strategies among 207 very low birth weight infants. The average NICU costs for an extremely premature infant without NEC and the incremental costs due to medical and surgical NEC were derived from a separate analysis of hospital discharges in the state of California in 2007. The sensitivity of cost-effectiveness results to the risks and costs of NEC and to prices of milk supplements was studied. The adjusted incremental costs of medical NEC and surgical NEC over and above the average costs incurred for extremely premature infants without NEC, in 2011 US$, were $74,004 (95% confidence interval, $47,051-$100,957) and $198,040 (95% confidence interval, $159,261-$236,819) per infant, respectively. Extremely premature infants fed with 100% human-milk based products had lower expected NICU length of stay and total expected costs of hospitalization, resulting in net direct savings of 3.9 NICU days and $8,167.17 (95% confidence interval, $4,405-$11,930) per extremely premature infant (p < 0.0001). Costs savings from the donor HMF strategy were sensitive to price and quantity of donor HMF, percentage reduction in risk of overall NEC and surgical NEC achieved, and incremental costs of surgical NEC. Compared with feeding extremely premature infants with mother's milk fortified with bovine milk-based supplements, a 100% human milk-based diet that includes mother's milk fortified with donor human milk-based HMF may result in potential net savings on medical care resources by preventing NEC.

Central Line–Associated Bloodstream Infections in Limited‐Resource Countries: A Review of the Literature

Central line-associated bloodstream infections (CLABSIs) are considered a significant cause of mortality in hospitalized patients; however, the incidence of CLABSIs in limited-resource countries has not been explored analytically. Likewise, the appropriate interventions to prevent, control, and reduce CLABSIs have yet to be analyzed thoroughly. This review demonstrates that the CLABSI rate ranged from 1.6 to 44.6 cases per 1000 central line days in adult and pediatric intensive care units (ICUs) and from 2.6 to 60.0 cases per 1000 central line days in neonatal ICUs and is associated with significant extra mortality, with an odds ratio ranging from 2.8 to 9.5. The results of 6 sequential prospective interventional studies showed that hand hygiene and educational programs were related to a significant reduction in CLABSI rates. CLABSI rates in limited-resource countries are higher than US National Healthcare Safety Network benchmark rates and have a significant impact on mortality. Studies showing successful interventions for a reduction in CLABSIs are few. Subsequently, it can be inferred that additional epidemiological studies need to be conducted to achieve an appreciation of the effects of CLABSIs and to develop more-definitive approaches for CLABSI prevention in the form of practical, low-cost, low-technology measures that are feasible to implement in limited-resource countries.

Outcomes of Pregnancies at Risk for Hypertensive Complications Managed Using Impedance Cardiography

We assessed the effect of antihypertensive therapy guided by impedance cardiography on maternal and fetal outcomes in pregnancies at risk for hypertensive complications. We performed a retrospective review of the outcomes of 318 singleton pregnancies with chronic hypertension or prior preterm delivery due to preeclampsia whose antihypertensive therapy was guided by impedance cardiography. Hemodynamic subsets were compared using analysis of variance. Impedance cardiography was used to evaluate cardiac output and total peripheral resistance starting at less than 24 weeks. All patients received atenolol; 24% required additional therapy with a vasodilator. The mean gestational age at delivery was 37 +/- 2 weeks. Preeclampsia developed in 14%. The incidence of birth weight less than the 10th percentile was 10%. There were no perinatal deaths, and 75% of the infants spent <3 days in the hospital. Hyperdynamic patients had less preeclampsia, less severe preeclampsia, fewer deliveries <34 weeks, and fewer neonatal intensive care unit days compared with those requiring a vasodilator. Antihypertensive therapy guided by hemodynamic information results in pregnancies delivering at or near term, little preeclampsia, and no increase in growth restriction. Hyperdynamic patients have better outcomes than patients with increased total peripheral resistance.

New soft clinical indicators of neonatal illness severity (Accepted as a poster)

Background: The Pediatric Risk of Mortality (PRISM) Score serves as a standard for assessing neonatal illness severity. Clinicians also use the Clinical Risk Index for Babies (CRIB) score, American Society of Anesthesiology (ASA) patient classification system, and Patient‐to‐Chart‐Weight Ratio (PCWR).Aims: This study aimed to determine whether parental behaviour itself accurately reflects illness severity.Method: Following Ethics Committee approval, neonates admitted to our Neonatal Intensive Care Unit (NICU) underwent a 12‐week assessment. Investigators determined weekly PRISM and CRIB scores, ASA classifications, and patient and case note weights. Additionally, investigators catalogued possessions in, around, and adhering to patients’ cribs, placing each into ‘soft toys’, ‘spiritual amulets’ or ‘other items’ categories.Results: Investigators followed 102 neonates, collecting 249 observations. PRISM scores correlated best with the ‘spiritual amulets’ category (R2 = 0.82). TOI (Token and Ornament Index), calculated by combining all possessions in the ‘soft toys’, ‘spiritual amulets’, and ‘other items’ categories, correlated nearly so (R2 = 0.71). CRIB Score (R2 = 0.63), ASA classification (R2 = 0.61), and ‘soft toys’ category (R2 = 0.39) all correlated to lesser degrees. Birth and current weight, post conceptual age, NICU days, and PCWR each demonstrated insignificant correlations, the latter even when adjusted for age, NICU days, birth or current weight.Conclusion: Through gift giving, parents reliably reflect PRISM scores and, by extension, neonatal illness severity. Specifically, number of spiritual amulets alone and TOI correlate well and may therefore serve as independent indicators of clinical status and, potentially, anaesthetic risk. Despite widespread application of PCWR, this study found no support for its validity.Keywords: neonatal intensive care; illness severity; PRISM score; parental behaviour.

Families' views upon experiencing change in the neonatal intensive care unit environment: from the ‘baby barn’ to the private room

Parents whose newborns were cared for in the old neonatal intensive care unit (NICU) environment and then moved to the new NICU environment describe their impressions of the impact upon their infant's care, information access and support, of the two care settings. To determine the perceptions of parents in the NICU regarding noise, light, space, access to caregivers and personal privacy as they experience both old and new NICU environments in the continuum of care for their infant. In the first 9 months after moving into the new private room NICU, a convenience sampling of parents was voluntarily administered a 20-question Likert scale survey addressing length of stay (LOS) in the respective NICU environment, environmental stimuli, access to caregivers, access to information and personal privacy. Scores reflect frequency of perceptions as never=1, sometimes=2, usually=3 and always=4. The responses of 53 parents are reported. This represents 10% of admissions to the private room NICU during the 9-month sampling time. Fifty-nine percent had LOS of <or=14 days in the old NICU before moving; 76% had LOS <or=14 days in the new NICU before completing this survey. Median scores for the major content themes are reported (New:Old). Responses suggest that in the new vs old design, parents feel they are able to spend more time with their infant (4:3); have more privacy (4:2) and space for their personal items (4:1); experience less overstimulation with noise and light (1:2); had comparable access to their infant's nurse (4:4) but greater access to their infant's doctor (3:2); and felt comparably informed (4:4) but better supported by the entire team (4:3). The new private room NICU is perceived by parents to offer an enhanced environment that is more spacious and less overstimulating for their infant and themselves. Access to professional caregivers, information and overall support appears to be improved in the new environment despite a larger overall NICU area, floor plan and structural layout.

The changing face of neonatal intensive care in South Africa

In 1991 a cut-off weight of 1 000 g and/or 28 weeks' gestation for neonatal intensive care unit (NICU) admission was decided on by attending neonatologists at a Priorities in Perinatal Care Conference. These recommendations were not based on published evidence. At the time there were few data on the outcome of babies born in the public sector who received NICU. Aim. The aim of this study was to describe the demographic data (mother and baby) and outcomes of babies admitted to a tertiary NICU. Methods. During 1992 - 1996 (1992 cohort) and 1999 - 2000 (1999 cohort) two cohorts of babies treated in the NICU at Tygerberg Hospital, Western Cape, South Africa, were studied. Demographic data were collected prospectively on all admissions with a birth weight of less than 1 501 g and a gestational age of less than 32 weeks. Outcome data were survival, days of ventilation and NICU stay. Results. There were 455 babies in the 1992 cohort and 272 in the 1999 cohort. The mothers' mean income was R892 per month and was higher in the 1999 cohort. The 1999 cohort comprised significantly smaller babies, at a mean birth weight of 1 119 g v. 1 198 g. The mean gestational age in the 1999 cohort was lower (29.2 v. 30.3 weeks), but so was the mortality rate (21.6% v. 26.1%). The main differences between the survivors and non-survivors were in their birth weight and gestational age and the mean income of their mothers. The mean number of ventilation days needed by these infants was low at 8.5 days, with an average stay in the NICU of 13 days. Discussion. Babies admitted to an NICU have a good chance of survival at a low mean number of ventilation and NICU days. The increase in survival in the 1999 cohort, in spite of low income, is in keeping with international trends and underlines the good short-term outcome of these small babies.

Congenital Jejunal and Ileal Atresia

The purpose of this study was to describe the prenatal sonographic features and natural course of congenital jejunal and ileal atresia and correlate the findings with neonatal outcomes. We identified all neonates with surgically confirmed jejunal or ileal atresia that had prenatal sonography and neonatal surgery in our center from January 1, 1995, to April 1, 2005. Sonography reports and images were reviewed, without knowledge of neonatal outcomes, for features of intestinal obstruction. Obstetric and neonatal outcomes were evaluated. Fifteen (60%) of 25 offspring with atresias (10 jejunal, 4 ileal, and 1 jejunoileal) had sonography, of which 13 (86.6%) had features of atresia. Findings, number of affected fetuses, and gestational age at recognition included fetal echogenic bowel (n = 8), mean +/- SD, 21.3 +/- 3.8 weeks (range, 17.7-28.4 weeks); enlarged stomach (n = 5), 27.5 +/- 5.0 weeks (range, 22.0-34.3 weeks); dilated bowel (n = 13), 27.8 +/- 5.8 weeks (range, 18.3-35.9 weeks); and polyhydramnios (n = 6), 33.3 +/- 1.7 weeks (range, 31.0-35.6 weeks). No fetus with ileal atresia had an enlarged stomach or polyhydramnios. Delivery occurred at a mean of 34.7 +/- 3.6 weeks, with 9 (60%) cesarean deliveries. Neonatal outcomes of age at surgery, neonatal intensive care unit days, hospital days, total parenteral nutrition days, and death were similar whether or not fetal echogenic bowel, enlarged stomach, dilated bowel, or polyhydramnios was present. Likewise, these outcomes did not vary by type of atresia or time of diagnosis (prenatal or neonatal). Jejunal and ileal atresia have specific sonographic patterns allowing specific prenatal diagnoses in most affected fetuses. Prenatal sonographic findings and time of diagnosis did not affect neonatal outcome.

A Comparative Pharmacoeconomic Assessment of Two Surfactants for the Prevention of Respiratory Distress Syndrome

The use of exogenous surfactants among preterm infants for the prevention and treatment of respiratory distress syndrome (RDS) has led to economic and cost-effectiveness evaluations of these products. Lucinactant (Surfaxin), a novel, peptide-based, synthetic surfactant, has been shown to significantly reduce RDS-related mortality, compared with the most commonly prescribed animal-derived surfactant, beractant (Survanta). Infants who survive expend significant healthcare resources; therefore, the impact of improved survival through 1-year corrected age was evaluated in a prospectively defined pharmacoeconomic analysis. The objectives of this study were to estimate the healthcare resource utilization, economic impact, and cost-effectiveness of lucinactant versus beractant for the prevention of RDS among surviving very low birth weight (VLBW) preterm infants weighing 600 to 1250 grams. A decision-analytic model was developed to compare the healthcare resource utilization, economic impact, and cost-effectiveness of lucinactant versus beractant. Infants who received lucinactant had fewer neonatal intensive care unit (NICU) days and fewer NICU days on mechanical ventilation compared with infants who received beractant. Total healthcare costs for the initial stay in the NICU were lower by $8,803 among infants who received lucinactant compared with infants who received beractant. The incremental cost per life saved was $40,309 for lucinactant compared with beractant. Administration of lucinactant to surviving VLBW preterm infants resulted in fewer NICU days and fewer NICU days on mechanical ventilation compared with beractant. Fewer NICU days translates into lower total costs among infants who received lucinactant. This comprehensive pharmacoeconomic analysis indicates that lucinactant is a cost-effective therapy for the prevention of RDS among preterm infants.

406 Infants with Necrotizing Enterocolitis: Pharmacoeconomic Analysis of Lucinactant (Surfaxin) Versus Pooled Animal-Derived Surfactants in Preventing RDS

Background: Necrotizing enterocolitis (NEC) is a serious complication among pre-term infants. Surfactant replacement therapy can help to prevent respiratory distress syndrome (RDS) among very low birth weight (VLBW) pre-term infants. Currently, there are no pharmacoeconomic analyses that estimate the cost savings in preventing RDS among pre-term infants diagnosed with NEC who receive surfactant therapy. Objectives: To estimate the economic impact of the synthetic protein-containing surfactant lucinactant (Surfaxin®) and pooled animal-derived surfactants (beractant [Survanta®] and poractant alfa [Curosurf®]) in the prevention of RDS among surviving pre-term infants weighing 600 to 1,250 grams who have been diagnosed with NEC. Methods: A decision-analytic model was developed using a hospital perspective to estimate the economic impact of initial length of stay in the neonatal intensive care unit (NICU) for pre-term infants with NEC. Clinical outcomes consist of the average initial NICU length of stay from the combined Phase III randomized, controlled clinical trials of surfactant therapy (SELECT and STAR). The cost input was the average cost of treating surviving pre-term infants with medical NEC, U.S. $2,039, the combined level II and level III NICU cost per day (2002). Results: Pre-term infants with NEC who survived and received lucinactant had 2.27 fewer initial NICU days compared to the pooled animal-derived cohort (73.73 versus 76.00 days, respectively). The estimated average cost of an initial NICU stay per infant was U.S. $150,320 for infants receiving lucinactant compared to U.S. $154,948 for infants receiving animal-derived surfactants. Due to fewer NICU days, lucinactant therapy results in a medical cost savings of U.S. $4,628 per infant. Conclusion: Among surviving pre-term infants diagnosed with NEC who received surfactant therapy, the synthetic protein-containing surfactant lucinactant reduced total initial NICU hospital costs when compared to pooled animal-derived surfactants.

140 Preventing Respiratory Distress Syndrome: A Comparative Pharmacoeconomic Analysis of Lucinactant (Surfaxin) Versus Pooled Animal-Derived Surfactants

Background: Lucinactant (Surfaxin®) is the first available synthetic surfactant containing a peptide (sinapultide; KL4) that mimics human SP-B. There are currently no published pharmacoeconomic analyses comparing lucinactant to the animal-derived surfactants in the prevention of respiratory distress syndrome (RDS) in very low birth weight (VLBW) pre-term infants.Objectives: To estimate the clinical consequences and economic impact of lucinactant and pooled animal-derived surfactants (beractant [Survanta®] and poractant alfa [Curosurf®]) in the prevention of RDS among surviving pre-term infants weighing 600 to 1,250 grams.Methods: A decision-analytic model was constructed using a hospital perspective to assess the pharmacoeconomics of surfactant replacement therapy. Data sources: a) epidemiologic data regarding low birth weight and VLBW infants is from the U.S. National Centers for Health Statistics (2003), and the Vermont Oxford Network (2004); b) clinical outcomes are from two randomized, controlled clinical trials of surfactant therapy (SELECT and STAR); and c) cost data is from an assessment of daily neonatal intensive care unit (NICU) costs for 244 pre-term infants with severe RDS (2004). Cost variables: Average cost of a day in the NICU on mechanical ventilation (MV) was U.S. $2,386 and was U.S. $1,565 off MV; surfactant pharmacy costs were included at price parity from the Red Book (2005).Results: Surviving infants who received lucinactant compared to pooled animal-derived surfactants had 4.14 fewer NICU days (mean 75.68 days vs. 79.82 days, respectively). Fewer NICU days convert into a total cost savings per infant who survived of U.S. $5,841 in the lucinactant group compared to the pooled animal-derived cohort. Conclusions: When compared to pooled animal-derived surfactants, the synthetic surfactant lucinactant may reduce total initial NICU hospital costs in surviving infants who receive surfactant therapy.

Early NICU discharge of very low birth weight infants: a critical review and analysis

Early neonatal intensive care unit (NICU) discharge has been advocated for selected preterm infants to reduce both the adverse environment of prolonged hospital stay and to encourage earlier parental involvement by empowering parents to contribute to the ongoing care of their infant, and thereby reducing costs of care. Randomized trials and descriptive experiences of early discharge programs are critically reviewed over the last 30 years, and the key elements necessary for successful early discharge are reviewed and defined. Early discharge is clearly achievable for a large number of infants. Variations in neonatal care practices are reviewed since these variations have been documented to influence NICU stay. Management of apnea of prematurity and feeding practices is documented to significantly influence NICU length of stay, as is timing of discharge based on institutional factors. Developmentally centered care, use of nutritional supplements pre- and postdischarge, hearing screening programs, evaluation for retinopathy of prematurity, evaluation for apnea and bradycardia events, and cardiopulmonary stability while in a car seat all influence timing of discharge. Programs of early hospital discharge with home nursing and neonatologist support have been successful in lowering the length of NICU stay. However, trends in length of stay in NICUs indicate that for infants >750 g at birth over the last decade there have been insignificant reductions in length of hospital stay. Thus, because of the increase in the percentage of low birth weight infants in the US, there remain opportunities to improve on variations in care that will be translated to fewer NICU days in hospitals for selected infants. Several professional guidelines are summarized, and standards of care as related to discharge of premature infants are reviewed.

Perinatal outcomes in monoamniotic gestations

Objective: A comprehensive review of monoamniotic twin gestations reported between 1990 and 2002 was performed to estimate current perinatal mortality and morbidity rates, as well as the predictivevalue of an antenatal diagnosis of cord entanglement for poor obstetric outcomes.Method: A Medline literature review using the search term 'monoamniotic' and limited to articles published inthe English language between 1990 and 2002 was performed.Results: A total of 133 continuing, non-conjoined twin monoamniotic pregnancies with delivery information were identified. Perinatalloss per 2-week interval was relatively constant at 2-4% from 15 to 32 weeks. However, of the 131 fetuses reaching 33 weeks, the percentage loss significantly increased to 11.0% at 33-35 weeks and 21.9%at 36-38 weeks compared to that at 30-32 weeks. Overall perinatal mortality was 23.3%. Of all losses, 61.2% involved both twins and 38.8% involved only one fetus. Cord entanglements were documented antenatallyin 22.6% of reports. There was a statistically significant decrease in the average number of neonatal intensive care unit days for non-anomalous neonates (10.6 ± 7.7 vs. 32.6 ± 32.0), averagegestational age at the time of delivery (30.4 ± 7.6 vs. 32.6 ± 4.1), as well as a decrease in the prevalence of total (8.3% vs. 27.7%) and non-anomalous (7.0% vs. 21.6%) perinatal mortalityin pregnancies with an antenatal diagnosis of cord entanglement compared to those without the antenatal diagnosis of cord entanglement. The presence of fetal anomalies was associated with a 42.9% perinatalmortality rate.Conclusions: Contrary to previous reports, there is a significant increase in the incidence of perinatal loss beyond 32 weeks among monoamniotic twins, suggesting that deliveryafter corticosteroid therapy should be strongly considered at this gestational age.

Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent.

Does predictive power for outcomes of neonatal intensive care unit (NICU) patients get better with time? Or does it get worse? We determined the predictive power of Score for Neonatal Acute Physiology (SNAP) scores and clinical intuitions as a function of day of life (DOL) for newborn infants admitted to our NICU. We identified 369 infants admitted to our NICU during 1996-1997 who required mechanical ventilation. We calculated SNAP scores on DOL 1, 3, 4, 5, 7, 10, 14, 21, 28, and weekly thereafter until either death or extubation. We also asked nurses, residents, fellows, and attendings on each day of mechanical ventilation: "Do you think this child is going to live to go home to their family, or die before hospital discharge?" Two thousand twenty-eight SNAP scores were calculated for 285 infants. On DOL 1, SNAP for nonsurvivors (24 +/- 8.7 [standard deviation]) was significantly higher than SNAP for survivors (13 +/- 6.1). However, this difference diminished steadily and by DOL 10 was no longer statistically significant (12.7 +/- 4.9 vs 10.0 +/- 4.8). On each NICU day, at all ranges of SNAP scores, there were at least as many infants who would ultimately survive as would die. Consequently, the positive predictive value of any SNAP value for subsequent mortality was <0.5 on all NICU days. Prediction profiles were obtained for 230 ventilated infants reflecting over 11 000 intuitions obtained on 2867 patient days. One hundred fifty-seven (81%) of 192 survivor profiles displayed consistent accurate prediction profiles-at least 90% of their NICU ventilation days were characterized by 100% prediction of survival. Twenty-five (13%) of 192 surviving infants survived somewhat unexpectedly; that is, after at least 1 day characterized by at least 1 estimate of "death." Thirty-three (60%) of the 55 nonsurvivors died before DOL 10. Eighty-two percent of the prediction profiles for these early dying infants were homogeneous, dismal, and accurate. Twenty-two (40%) of the 55 nonsurvivors died after DOL 10. Seventeen (78%) of these 22 late-dying infants were predicted to live by many observers on many hospital days. Sixty-one (30%) of 230 profiled patients had at least 1 NICU day characterized by at least 1 prediction of death; 26/61 (43%) of these patients were incorrectly predicted; that is, they survived. Seventeen infants who were predicted to die during but survived nonetheless were assessed neurologically at 1 year. Fourteen (82%) of these 17 were not neurologically normal-8 were clearly abnormal, 1 suspicious, and 5 had died. If absolute certainty about mortality is the only criterion that can justify a decision to withhold or withdraw life-sustaining treatment in the NICU, these data would make such decisions difficult on the first day of life, and increasingly problematic thereafter. However, if we acknowledge that medicine is inevitably an inexact science and that clinical predictions can never be perfect, we can ask the more interesting question of whether good but less-than-perfect predictions of imprecise but ethically relevant clinical outcomes can still be useful. We think that they can-and that they must.

Prediction by maternal risk factors of neonatal intensive care admissions: Evaluation of >59,000 women in national managed care programs

Objective: Managed care plans have adopted risk assessment tools as part of pregnancy disease state management strategies to assist in reducing poor pregnancy outcomes and related costs. We evaluated the relationships of maternal risk factors to determine which pregnancy risk factors were associated with neonatal intensive care unit (levels II and III) admission. Study Design: Risk assessments were performed through perinatal telephone interviews of nurses with 59,861 pregnant women during 1996 and 1997 calendar years as part of managed care maternity risk screening and education programs. A series of 3 interviews was conducted, at 17 weeks and 28 weeks average gestational age and at 2 weeks post partum. Univariate χ 2 analysis was performed on >50 historical and pregnancy risk factors to determine the associations with neonatal intensive care unit admission. Significant factors were included in a stepwise logistic regression model. Receiver operating curves were generated for the use of significant factors in a risk scoring system in the prediction of neonatal intensive care unit admission, and the percentages of neonatal intensive care unit days attributable to significant risk factors were calculated. Results: Among the participants most women (90%) had their prenatal visit during the first trimester. The mean maternal age was 30.2 ± 5.2 years, with 74% of women reportedly of white ethnicity, 86% married, and 44.3% primigravid. The mean gestational age at birth decreased with increasing number of fetuses from singletons to quadruplets. The χ 2 analysis identified 26 significant risk factors associated with neonatal intensive care unit admission. Of these, 14 remained significant by logistic regression. Multiple gestation, preterm premature rupture of membranes, diabetes, abruptio placentae, pregnancy-induced hypertension, and preterm labor were independently associated with at least a 3-fold risk of neonatal intensive care unit admission. A modeled risk scoring system that used these and other significant factors was poorly predictive of neonatal intensive care unit admission. However, an analysis of neonatal intensive care unit length of stay attributable to significant risk factors concluded that 19% of all neonatal intensive care unit days in this population were associated with multiple gestations. Furthermore, 85% of neonatal intensive care unit days were the result of infant lengths of stay ≥1 week. Conclusion: This analysis of a managed care population showed similar risk factors to those traditionally associated with neonatal intensive care unit admission. Although many of these risk factors are not preventable, identification of neonatal intensive care unit admission risks with a screening program may be of use for focusing interventions, and earlier identification of these factors may allow maximum impact of interventions. Importantly, a reduction in the incidence of higher-order multiple gestations might help to reduce neonatal intensive care unit admissions and costs. (Am J Obstet Gynecol 1999;181:835-42.)

Outcomes and resource utilization for newborns with major congenital malformations: the initial NICU admission.

Newborns with major congenital malformations (MCM) have contributed to a significant proportion of resource utilization in a regional referral neonatal intensive care unit (NICU). The Children's Hospital Medical Center NICU, Cincinnati, OH. Newborns with and without MCM admitted from August 1, 1993 through July 31, 1994. Total patients studied were 572; 147 with and 385 without MCM. No intervention was performed in this observational study. Statistics were t test, chi-squared, and rank sum analysis. MCM accounted for 27.6% of NICU referrals, 32.4% of total NICU days, and 39.6% of NICU costs. Both median cost per patient and length of stay were significantly (p < 0.01) higher for patients with MCM than those without MCM. Surgery was more frequent in MCM than non-MCM cases. Thirty-three percent of the newborns with MCM received ongoing medical support at discharge. Patients with MCM remain as one of the largest and costliest groups hospitalized in a referral NICU.

Wellness Intervention with Pregnant Soldiers

The purpose of this study was to measure the effects that wellness program intervention for pregnant soldiers, exercise and/or education, had on methods of delivery, pregnancy outcomes, rates of complications, Army Physical Fitness Test scores, and labor and delivery costs. The study consisted of a retrospective review and analysis of 823 active duty Army obstetric and newborn records, 181 Army Physical Fitness Test records, and 411 initial and 148 postpartum subjective questionnaires. Data were collected from records of soldiers who delivered at Madigan Army Medical Center (Tacoma, Washington) between January 1992 and December 1994. Group I (N = 211) included soldiers who received wellness intervention, group II (N = 147) included those who did not receive wellness intervention. Limited data from the records of soldiers who delivered before a wellness program was offered on post constituted group III, a historical control group (N = 413). Group IV included data from a high-risk population (N = 52) collected during the wellness program. Data were also divided into additional subgroups to ascertain if one aspect of the wellness program (i.e., exercise versus education) influenced any or all of the dependent variables. A soldier's data were excluded if a pregnancy was terminated before 20 weeks of gestation or if it was a multiple gestation. Demographic data and variables were compared using multivariate methods of analysis to evaluate the effect of the independent variable, wellness intervention. Results indicated that infants of the wellness group participants had proportionately increased gestational age and birth weight, with reduced incidence of the complications fetal bradycardia, hyperbilirubinemia, preeclampsia, and premature labor. Likewise, African-American female soldiers in this study, assessed in other studies as a high-risk group, had a lower incidence of premature delivery and low birth weight when they participated in wellness intervention. Of clinical interest, it appeared as though wellness intervention shortened labor duration and reduced the number of neonatal intensive care unit admissions and the number of neonatal intensive care unit days, which resulted in reduced health care costs.

The clinical significance of an absent end-diastolic velocity in the umbilical artery detected before the 34th week of pregnancy.

The aim of this study was to evaluate the clinical significance of absent or reversed (ARED) flow detected in the late second or early third trimester in the umbilical artery in high-risk pregnancies. Eighty-three women with hypertensive disorders of pregnancy, gestational diabetes or a suspected disorder of the fetus (e.g. small-for-gestational age) were included in this retrospective study. A constant finding of ARED flow in the umbilical artery was registered with the pulsed Doppler method between the 23+/-0 and 33+/-6 gestational weeks. Perinatal mortality (PNM) rates, Apgar scores and arterial umbilical pH values, birth weights, the frequency of SGA, gestational ages at birth, NICU (=neonatal intensive care unit) days, anomalic fetuses and the mode of delivery were registered. Mann-Whitney U-test and chi-squared test were used for statistical analysis. The PNM in the entire group under study was 19.3% (16 infants/fetuses). The rate of structurally or chromosomally abnormal fetuses was 15.7% (13 infants/fetuses). When anomalic fetuses were excluded the PNM was 18.6%. No non-anomalic fetuses/newborns were lost in cases in which ARED was detected after the 30th week. No statistically significant difference was observed in PNM and SGA frequencies when comparing AEDV (absent end-diastolic velocity) fetuses with those who had REDV (reversed end-diastolic velocity). When anomalic fetuses were excluded the PNM rate in the AEDV group was 8.9% compared with the PNM rate of 35.7% in the REDV group; (p=0.03). An early ARED finding (before the 34th week) in the umbilical artery signifies a marked warning signal of fetal distress. In these cases the rates of perinatal morbidity and mortality are very high, which is a reflection of the severity of the condition. The majority of fetuses can, however, be saved.

Synthetic surfactant for rescue treatment of respiratory distress syndrome in premature infants weighing from 700 to 1350 grams: Impact on hospital resource use and charges

To determine the impact of the use of synthetic surfactant on hospital resource use and charges, we analyzed the economic data from a multicenter, randomized, placebo-controlled clinical trial of synthetic surfactant in infants with neonatal respiratory distress syndrome and birth weights between 700 and 1350 gm. Two 5 ml/kg doses of a synthetic surfactant (Exosurf Neonatal) or air placebo were administered to 419 infants who were receiving mechanical ventilation and had an arterial/alveolar oxygen tension ratio < 0.22. In addition to the clinical endpoints for safety and efficacy, data were collected on length of hospital stay, days in the neonatal intensive care unit, days of mechanical ventilation, days of oxygen supplementation, and hospital charges until the infant reached 1 year adjusted age. Growth and development of infants who received synthetic surfactant therapy in the study and survived to 1 year adjusted age were equivalent to those of the survivors in the air placebo group. For 1-year survivors, synthetic surfactant reduced the average length of stay at the different levels of care needed during the hospitalization such as neonatal intensive care unit days, days of mechanical ventilation, and days of oxygen supplementation. For nonsurvivors, synthetic surfactant increased the average length of stay, especially at more intense levels of care. Total hospital charges for the initial hospitalization and through 1 year adjusted age for a hypothetic cohort of 100 infants treated with synthetic surfactant were, on average, the same as those for a comparable cohort of infants in the air placebo group. These results indicate that rescue therapy with synthetic surfactant in infants with respiratory distress syndrome and birth weights from 700 to 1350 gm can result in significantly improved survival without significant increases in hospital charges. (J P EDIATR 1995;126:94-101)

Intensified versus conventional management of gestational diabetes

OBJECTIVE: We tested the hypothesis that intensified management of gestational diabetes mellitus on the basis of stringent glycemic control, verified glucose data, and adherence to an established criterion for insulin initiation results in near normoglycemia control and reduction of adverse outcomes. STUDY DESIGN: A prospective, population-based study compared the effect on perinatal outcome of conventional (n = 1316) and intensified (n = 1145) management. Group assignment was based on availability of memory-based reflectance meters at entry to the program. A contemporaneous randomized control group (nondiabetic, n = 4922) was selected. RESULTS: The diabetic groups were comparable in demographic characteristics and in factors associated with higher risk for adverse pregnancy outcome, such as previous macrosomia, previous gestational diabetes mellitus, and family history of diabetes. The control group was younger, less obese, and had a lower rate of previous macrosomia. The intensified management group had rates of macrosomia, cesarean section, metabolic complications, shoulder dystocia, stillbirth, neonatal intensive care unit days, and respiratory complications lower than those in the conventional management group and comparable to those of the nondiabetic controls. Other maternal complication rates, such as for preeclampsia, chronic hypertension, and infection, were similar for the three groups. Mean blood glucose levels were a good predictor of perinatal outcome. Gestational age at delivery, previous history of macrosomia, and overall mean blood glucose levels were the only significant predictors of birth weight percentile in both diabetic groups (logistic regression). CONCLUSION: The intensified management approach is significantly associated with enhanced perinatal outcome. This management strategy clarifies the relationship between glycemic control and neonatal outcome. (SM J OBSTET GYNECOL 1994; 170:1036-47.)