Practice In Neonatal Intensive Care Units Research Articles

Effectiveness assessment of a neonatal intensive care program for very low birth weight infants. Impact of surfactant administration

Although many therapeutic interventions have proven efficacy through randomized control trials (RCT) with extensive use in Neonatal Intensive Care Units (NICU) for Very Low Birth Weight Infants (VLBWI), doubts remain about its overall effectiveness. To determine changes in the effectiveness of NICU practices on VLBWI over 14 years in the quality of neonatal survival in a General Hospital, with emphasis in the change in reanimation practices by the introduction of the spread use of surfactant. We included all consecutive VLBWI admitted in our NICU during a period of 14 years: 1989-1992 (n= 145); 1993-2002 (n= 342). All survivors were included in our follow-up program; 80% and 85% were available for assessment at two years of corrected age. The patients were assigned to 4 groups by weight in 250 g categories, between 500 and 1500 g. Survival and adjusted quality of survival (QS). The QS was expressed in life-years gained. We create categories for the estimation of disabilities. We also analyzed time of NICU stay by weight and mortality categories during the 2 periods. The survival rate improved significantly between the 2 periods (23%) from 52% to 75%. The actuarial survival showed a significant increase in all weight groups (p <0.001), especially between 500-749 g (4% vs. 33%). The life-years gained showed differences in the BW <750 g (p <0.002, 3.6 vs. 23.4) y 750-999 g (p <0.001, 22.3 vs. 48); no differences were found in the others groups. The time of stay showed an increase of 30 days in the <750 g group (p <0.01) and decreased 8 days in the> or =1250 g group (p <0.01). The effectiveness of neonatal intensive care for VLBWI improved in the period 1993-2002, after surfactant introduction, especially in the group <1000 g.

Evidence-based Practices to Promote Exclusive Feeding of Human Milk in Very Low-birthweight Infants

Recent studies suggest a dose-response relationship between the amount of fortified human milk (FHM) received by very low-birthweight and extremely low-birthweight infants and protection from select prematurity-specific morbidities. However, the feeding of high doses of FHM in this population often is precluded by insufficient maternal milk volume and the replacement of FHM feedings with calorie-dense infant formulas to achieve adequate weight gain. This article reviews the evidence for preventing, diagnosing, and treating insufficient maternal milk volume and slow infant weight gain while receiving FHM and highlights the utility of incorporating technologies from human milk science, such as maternal milk volume records and the creamatocrit procedure, into routine neonatal intensive care unit practice.

Timing of Umbilical Cord Separation and Neonatal Intensive Care Unit Practices

We investigated the effects of antibiotic and corticosteroid treatment of the mother close to birth and postnatal neonatal intensive care unit (NICU) practices such as phototherapy, parenteral nutrition, and antibiotic treatment of the infant on umbilical cord detachment time. The impact of dry cord care on risk of omphalitis in NICU patients was also investigated. Cord separation time was longer in preterm babies. Antenatal antibiotic and corticosteroid use did not affect cord detachment time. The use of postpartum antibiotics, parenteral nutrition, and phototherapy delayed cord separation. Among these, antibiotic treatment was the most effective factor. Dry cord care did not increase the risk of omphalitis in NICU patients in our series.

An Evaluation of Family-centered Care in a Level III NICU

Family-centered care is critical to successful experiences for infants and their families in the neonatal intensive care unit (NICU). This article describes a retrospective evaluation survey of family-centered practices in an urban, Level III NICU. Evaluation questions focused on parent satisfaction with unit practices in 4 areas: (a) NICU environment, (b) caregiving practices, (c) communication opportunities, and (d) relationships with nursing staff. Quantitative and qualitative data indicated overall parent satisfaction along with suggestions for improvement of unit practices. Specifically, the need for redesign of the NICU environment (eg, increased space at infant's bedside), caregiving practices (eg, increased hands-on practice), communication opportunities (eg, convenient times for care conferences), and relationships with nursing staff (eg, development of parent-professional relationships) are highlighted as avenues for improving NICU practices. Recommendations for family-centered practices are provided.

Variations in Early and Intermediate Neonatal Outcomes for Inborn Infants Admitted to a Canadian NICU and Born of Hypertensive Pregnancies

Objective: To determine whether neonatal intensive care unit (NICU) outcomes vary by centre for inborn neonates of hypertensive pregnancies and, if so, whether that variation might be related to between-centre variations in obstetric practice.Methods: The study comprised a prospective cohort of 13 505 singleton neonates admitted to 17 Canadian NICUs. Adjusting for potential confounders, we used multivariate regression to analyze the relation between centre of delivery and 6 dependent variables: (1) Apgar score < 7 at 5 minutes; (2) Score of Neonatal Acute Physiology-II (SNAP-II) score ≥ 10; (3) neonatal death; (4) neonatal death or morbidity (owing to bronchopulmonary dysplasia [BPD], intraventricular hemorrhage [IVH], necrotizing enterocolitis [NEC], persistent ductus arteriosus [PDA], or periventricular leukomalacia [PVL]); (5) BPD alone; and (6) major neonatal morbidity (that is, at least one of IVH, PVL, NEC, or PDA). NICU practices known to influence these outcomes were included in the modelling for neonatal death and neonatal morbidity. In a sensitivity analysis for practice variation, antenatal steroid exposure was both included and excluded in each regression.Results: For 5 of the 6 dependent variables, we identified between-centre variation that was not explained solely by variation in antenatal corticosteroid use. Adjusted odds ratios varied from 0.11 to 5.6 (the reference centre was the median rate of the adverse outcome).Conclusions: In the pregnancy hypertension setting, between-centre variations in practice are associated with variations in neonatal physiology and survival. For infants admitted to NICU, the obstetric management of hypertensive pregnancies appears to have an effect on both short- and medium-term neonatal outcomes, even after correction for NICU management.

Nurses' Beliefs and Values About Doing Cue-Based Care in an NICU in Taiwan

Although advances in medical technology have increased the survival rate of preterm infants, science is no cure-all for these high-risk patients. A growing number of studies report that caregiving interventions cause physiological and behavioral distress in such infants. The results have prompted changes in caregiving practices, attempting to reduce stress and strengthen protection for the infants, in order to promote their stability and development in the neonatal intensive care unit (NICU) . This study uses qualitative research methods to grasp the richness and diversity of nurses' beliefs and experience in the taking care of preterm infants. Ten groups of questions explore how NICU nurses take care of premature infants, nurses' perspectives on cue-based care, and the extent to which NICU nurses practice cue-based care. The results generated three themes: (1) timely and skillful management of the preterm infants; (2) compassionate and holistic care for the infants and their highly stressed families; and (3) the relationship between good nursing care and meeting the needs of preterm infants, families, physicians, units, and the environment. It is apparent that the approach to care delivery in NICU practice is still clinical-based, and that there are some obstacles to the delivery of cue-based care. The reasons for this include lack of knowledge, incomplete collaboration with team members, and insufficient support from the administrative systems. To improve the quality of nursing care and preterm infant outcomes, it will be necessary to educate NICU nurses on cue-based care, to enhance collaboration among all team members, to reduce their non-nursing workload, and to re-design NICUs for optimal cue-based care.

Antenatal glucocorticoid treatment does not reduce chronic lung disease among surviving preterm infants

Background: Antenatal glucocorticoid treatment (AGT) is associated with a number of postnatal benefits to the preterm infant, including reduced risk of respiratory distress syndrome, patent ductus arteriosus, intraventricular hemorrhage, and necrotizing enterocolitis. Objective: To evaluate the hypothesis that maternal AGT not only reduces the risk of surfactant deficiency but also reduces the occurrence of chronic lung disease (CLD) among surviving preterm infants. Study Design: Case-referent study of 1454 very low birth weight infants born between January 1991 and December 1993 at 4 university medical centers. Results: Rates of AGT varied among the 4 centers (11%-69%), as did rates of CLD (4%-21%), defined as a requirement for supplemental oxygen at 36 weeks' postmenstrual age. CLD rates at each center, however, did not vary with the rate of AGT exposure. In multivariate logistic regression analyses, AGT did not contribute significantly to CLD risk. Conclusion: AGT may play a less prominent role in modifying CLD risk than other factors such as biologic immaturity, infection, or neonatal intensive care unit practices, such as mechanical ventilation, continuous positive airway pressure, and surfactant replacement therapy. (J Pediatr 2001;138:198-204)

Variations in practice and outcomes in the Canadian NICU network: 1996-1997.

Previous reports of variations in outcomes among neonatal intensive care units (NICUs) examined only specific subpopulations of interest (eg, very low birth weight [VLBW] infants <1500 g of birth weight [BW]). We report on current practice and outcomes variations in a population-based national study of Canadian NICUs from January 8, 1996 to October 31, 1997. Information on 20 488 admissions to 17 tertiary level NICUs across Canada was prospectively collected by trained abstractors using a standard manual of operations and definitions. Data were verified and analyzed in concert with a steering committee comprising experienced researchers and neonatologists. Patient information included demographic information, antenatal history, mode of delivery, problems at delivery, status of infant and problems at birth, illness severity (Clinical Risk Index for Babies, Score for Neonatal Acute Physiology, Score for Neonatal Acute Physiology-Version II), therapeutic intensity (Neonatal Therapeutic Intensity Scoring System [NTISS]), selected NICU practices and procedures, use of technology and resources, and selected patient outcomes. Patients were tracked until death or discharge home. The mean number of annual admissions to an NICU was 657, with 26% outborn infants. Fifty-three percent were <2500 g BW, 20% were <1500 g BW (VLBW), and 65% were preterm (<38 weeks' gestational age [GA]). Only 2% of mothers received no prenatal care. Antenatal steroids were given to 58%, but there was wide variation in use (23%-76%). Congenital anomalies were present in 14%, and 4% were small for GA (less than the third percentile). Admission illness severity was lowest among infants 33 to 37 weeks of GA and correlated with risk of death. Ninety-six percent of patients survived until discharge, but fewer survived at lower GA. No infant <22 weeks' GA survived. Seven percent of infants had at least 1 episode of infection, but 75% received antibiotics in the NICU. Forty-three percent received respiratory support, and 14% received surfactant. Nitric oxide was given to 150 term infants and to 102 preterm infants. Selected outcomes of VLBW infants were: survival rate (87%); chronic lung disease (26%); >/=stage 3 retinopathy of prematurity (ROP; 11%); >/=grade 3 intraventricular hemorrhage (IVH; 10%); nosocomial infection (22%); necrotizing enterocolitis (NEC; 7%). Sixty-nine percent of VLBW infants survived without major morbidity (>/=grade 3 IVH, chronic lung disease, NEC, >/=grade 3 ROP). The mean duration of NICU stay was 19 days. Forty-seven percent of infants were discharged from the hospital, and 43% were retrotransferred to a community facility before discharge home. Significant variation in practices and outcomes were observed in all aspects of NICU care. This study provides population-based information about NICU outcomes. Significant variation in NICU practices and outcomes was observed despite Canada's universal health insurance system. This national database provides valuable information for planning research, allocating resources, designing health and public policy, and serving as a basis for longitudinal studies of NICU care in Canada.

Neonatal intensive care nurse stressors: an American study.

The purpose of this study was to determine the frequency of selected stressors and the level of associated stress experienced by neonatal intensive care unit (NICU) nurses in the USA, and to identify their responses/coping mechanisms. The research instrument consisted of demographic data (education, location of practice, age, years in practice, gender) and a modification of the Stress Audit tool developed by Popoff and Funkhouser (1975). Participants were randomly chosen from health-care units located in the upper Midwest of the USA. Fifty-nine nurses (35%) responded to the postal survey. In terms of scale items, floating out of the unit (ability to staff other units when necessary) was the most stressful item and routine procedures the least stressful item. From a subscale perspective, knowledge was the least stressful and management the most. Subscale scores did not differ by marital status, number of years of practice as a registered nurse, or years of practice in NICU. Coping with stress was best facilitated by discussion with coworkers. Consistency of care, inservice education, mental health days (time off for stress relief, paid or unpaid) and staff support groups were reported as helpful in coping with job-related stress.

Lack of evidence of efficacy of cohorting nursing personnel in a neonatal intensive care unit to prevent contact spread of bacteria

Nurse cohorting was investigated in a modern neonatal intensive care unit (NICU). During 99 days bacterial infection and colonization rates were determined in 100 infants experimentally assigned cohort or noncohorted care. Colonizing isolate identity was determined by plasmid profile analyses and biotyping in weekly surveillance cultures. Between Days 2 and 7, 3 infections occurred in cohorted infants but none in noncohorted ones. No secondary spread of infection or definitive colonization cluster occurred. The first colonization rate, at any site, was 0.53/patient-week in the noncohorted and 0.3 to 0.4 in the cohorted units (P greater than 0.05). Colonization ratios with species other than usual skin bacteria in the respiratory tract and with species other than Escherichia coli in the rectum were lower for noncohorted infants. Effective infection control practices in a modern NICU, including alcohol hand antisepsis, should obviate a need for cohorting.