Outborn Neonatal Intensive Care Unit Research Articles

End of life care in a level IV outborn neonatal intensive care unit.

Describe care surrounding the end of life (EOL) in the neonatal intensive care unit (NICU). Retrospective chart review of 208 infants who died in a level IV referral-only NICU over 5 years. A goals of care (GOC) conversation was documented before the day of death for 63% of infants. 73% died following withdrawal of life-sustaining treatment (WD); 13% died in a code. The median age at death was 17.5 days. 72% were held by a parent at EOL. 94% of families desired formal memory-making. We identified associations with mode of death and parental holding at death, including: WD was associated with palliative care consultation, early GOC conversations, and increased unit-specific length of stay. Holding was associated with chaplain visits, memory-making, and increased home-to-hospital distance. We present a detailed description of EOL care in an outborn NICU, including novel data on parental holding and memory-making.

1659. Prokinetic Antibiotic Agents in the Neonatal Intensive Care Unit: Ripe for Antibiotic Stewardship Efforts!

Abstract Background Intolerance to enteral nutrition among infants in the neonatal intensive care unit (NICU) may lead to the use of prokinetic agents to improve gastric emptying and feeding tolerance. Two such oral prokinetic agents are erythromycin and amoxicillin-clavulanate that have been used in cases of dysmotility due to intestinal failure. However, dosing strategies vary and the recommended duration of therapy has not been determined. Moreover, the use of these oral antibiotics in the NICU may fall under the radar of neonatal antimicrobial stewardship programs. Our objective was to quantify their use in the Level 4 outborn NICU at Nationwide Children’s Hospital, Columbus, OH in order to inform antibiotic stewardship efforts. Methods This was a retrospective cohort study of all infants who received enteral erythromycin or amoxicillin-clavulanate in the NICU. The number of doses of each antibiotic was obtained from the Nationwide Children’s Hospital Pharmacy database. Pertinent clinical, laboratory, and outcome data were obtained. Results From January 1, 2022 to April 30, 2023, 15 infants in the NICU received ≥1 dose of erythromycin ethylsuccinate and 19 infants received ≥1 dose of amoxicillin-clavulanate enterally. Erythromycin was always used to improve motility while amoxicillin-clavulanate served as a prokinetic agent in 53% of infants in whom it was prescribed. Demographics and reason for initiation are provided in Table 1. The median (IQR) doses per patient for erythromycin was 64 (28, 125; dosing interval varied from every 6 to every 8 hours) and for amoxicillin-clavulanate was 50 (9, 105) doses per patient (majority of doses were given on a BID schedule). Characteristics of infants who received prokinetic agents in the NICU Conclusion Enteral erythromycin and amoxicillin-clavulanate have not been the target of antimicrobial stewardship programs. These antibiotics may contribute to dysbiosis and adverse events in NICU infants. An automatic stop time with a time-out when ordered in the electronic health record may be a viable strategy to reduce overutilization of these antibiotics. Disclosures Pavel Prusakov, PharmD, Merck & Co: Grant/Research Support|Merck & Co: Employee Michael Storey, PharmD, MS, CSL Behring: Advisor/Consultant|Sarepta Therapeutics: Advisor/Consultant

Predictors of deranged SPO2 and hypoglycaemia in neonates to assess neonatal survival and outcome by Rewa scoring system

Background: Early referral to proper level of neonatal care is vital for neonatal survival. Deranged physiological status studied at the time of admission can be predictive of neonatal outcome. The present study was done in an attempt to discover statistically significant, more objective and feasible variables easily assessable by simple low cost devices for identification of sick newborns in need of stabilization and referral to tertiary facility based care. Primary objective was to study predictors of deranged neonatal percentage saturation of oxygen in blood as well as for neonatal hypoglycemia. Secondary objective was to develop a scoring system comprising of both subjective and objective variables to assess neonatal outcome.Methods: It was a prospective cohort observational study conducted at outborn neonatal intensive care unit in a tertiary level care hospital in Central India. Participants were all outborn neonates of age less than or equal to 28 days from March 2013 to May 2013 admitted in NICU.Results: A significant association was found between percentage saturation of oxygen in blood (SpO2) and other deranged neonatal pathophysiological variables i.e. hypothermia (p=0.001); delayed CRT (p=0.001); gestational age (p=0.002); cyanosis (p=0.003); respiratory distress (p=0.001). On applying multivariate binary logistic regression, hypothermia was found to be an important predictor of hypoglycaemia. The survival percentage was 91.5%, 87.7%, 76.5% and 20% with the scores of less than 5, score 6-10, score 11-16 and score >16 respectively.Conclusions: The scoring system based on both subjective and objective predictors is useful for timely identification and early referral of high risk neonates from primary and secondary level care to higher level. A high score predicts a poor outcome.

Timing of newborn hearing screening in the neonatal intensive care unit: implications for targeted screening for congenital cytomegalovirus infection.

To determine when infants in the neonatal intensive care unit (NICU) have the first hearing screen performed, and thus inform targeted testing for cytomegalovirus (CMV)-related hearing loss. Retrospective review of electronic health records of infants admitted to a Level 4 outborn NICU and had a first hearing screen performed from 8/2016-8/2018. Among 1498 infants, 546 (36%) had a first hearing screen performed at age >21 days when a positive CMV PCR test cannot distinguish congenital from postnatal CMV acquisition. While most infants tested at >21 days of age were <34 weeks' gestational age (71%), 18% (n = 100) and 11% (n = 59) were ≥34 and ≥37 weeks' gestation, respectively. Targeted CMV testing for failed hearing screen in the NICU is problematic as 36% of infants did not have a hearing screen performed before 21 days of age, supporting the need for CMV screening at NICU admission.

Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit.

Background and objectivesExtubation readiness testing (ERT) in the Neonatal Intensive Care Unit (NICU) is highly variable and lacking standardized criteria. To address this gap, an evidence-based, inter-professionally developed ERT protocol was implemented to assess effectiveness on extubation failure within 72 h and on duration of intubation (DOI).MethodsA longitudinal retrospective chart review in a level III, fully outborn NICU, of intubated infants admitted 1-year prior (Group 1), and 1 year after implementation (Group 2). Patients were extubated if they passed a 2-stage ERT protocol (3 min continuous positive airway pressure (CPAP) followed by 7 min CPAP + pressure support). Descriptive, comparative statistics, and univariate and multiple logistic regression were completed on all patients and a ≤32 6/7 weeks subgroup (intubated at day-of-life 1); p < 0.05 is considered significant.ResultsAll patients (n = 589 (n = 294 Group 1, n = 295 Group 2)) were included (preterm, intubated day of life one subgroup: n = 42 Group 1, n = 38 Group 2). For all patients, extubation failure decreased significantly from 9.9% to 4.1% (p = 0.006); Group 1 patients were 2.42 times more likely to experience extubation failure compared with Group 2. Extubation failure in the preterm subgroup decreased from 21.7% to 2.6% (p = 0.01); Group 1 patients were 10.71 times more likely to experience extubation failure. Median DOI was similar in both groups for all patients and in the preterm subgroup.ConclusionsA unique two-stage ERT protocol was effective at reducing extubation failure rate, without increasing DOI, largely in preterm infants. The evidence-based, interprofessionally developed ERT protocol and its integration into the NICU culture largely contributed to its success.

Improving Access to Lactation Consultation and Early Breast Milk Use in an Outborn NICU.

Increasing the use of breast milk in critically ill neonates is an important priority to improve neonatal care. Lactation consultants (LCs) educate mothers about evidence-based benefits of breast milk and provide technical support. LC support can lead to increased breastfeeding initiation. The project aim was to improve access to lactation services for mothers of patients admitted at <48 hours after birth to an exclusively outborn level III/IV neonatal intensive care unit (NICU). The interventions included (1) implementation of an automatic electronic admission order for a lactation consult, (2) initiation of a daily lactation team notification, (3) assignment of a consistent NICU LC, and (4) targeted education. The percent of mothers who received lactation consults, the time to the first consultation, and the percent of patients receiving breast milk at 7 days of age were measured over 32 months and analyzed using statistical process control charts. The lactation consultation rate increased significantly from 74% to 88% with a shift in the mean by statistical process control chart analysis that was sustained over time. Concurrently, the time to first lactation consultation significantly decreased from hospital days 5 to 3.3, and variation decreased. Rates of breast milk use at 7 days of age also significantly increased from 75.6% to 89.6%. Targeted quality improvement interventions led to an increased rate of lactation consultations, decreased time to first lactation consult, and increased rate of breast milk use at 7 days of age. These interventions could feasibly be implemented in similar referral NICU settings.

Quality Improvement Initiative to Improve the Screening Rate of Retinopathy of Prematurity in Outborn Neonatal Intensive Care Graduates

To improve the screening rate of Retinopathy of prematurity (ROP) in the outborn neonatal intensive care unit, using the quality improvement method. 40 neonatal nurses, 89 parents from an outborn neonatal intensive care unit of a tertiary-care hospital were included in the study between May 2017 and March 2018. Universal sampling method was used. In 345 neonates, ROP screening rate increased from 10.7% in the pre-intervention phase to 45.5% and 87.3% in the intervention and post-intervention phase, respectively. Point of care quality improvement (POCQI) method can be effectively used to improve ROP screening rate in outborn neonates.

“Targeted” Screening for Cytomegalovirus (CMV)-Related Hearing Loss: It’s Time for Universal CMV Screening in the NICU!

BackgroundCongenital CMV infection is the leading cause of non-genetic sensorineural hearing loss in infancy. Antiviral therapy has been shown to improve hearing outcomes, and thus “targeted” CMV screening for newborns who do not pass the hearing screen has been recommended. Diagnosis of congenital CMV infection requires that the infant be tested for CMV in the first 3 weeks of age. Our objective was to determine when infants in the neonatal intensive care unit (NICU) have their first hearing screen performed and thus inform the practice of targeted screening for determination of CMV-related hearing loss.MethodsRetrospective review of the electronic health records of all infants admitted to the Level 4 outborn NICU at Nationwide Children’s Hospital, Columbus, OH from August 2016 to May 2017. Demographic and clinical data were obtained, and the age that the first hearing screen was performed was assessed.ResultsDuring the 10 month study period, 362 infants were admitted to the NICU and had a first hearing screen performed. The majority of neonates (204, 56%) had a first hearing screen performed in the first 3 weeks of age. However, 158 (44%; median birth weight [IQR], 1072 g [747–1766]; median gestational age [IQR], 28 weeks [25–32]) infants received the first hearing screen at >3 weeks of age when a positive CMV PCR or culture cannot distinguish congenital infection from intrapartum/postnatal acquisition of CMV. Of the 158 infants, 20 (13%) did not pass the first hearing screen (13, unilateral; 7, bilateral), and subsequently, 9 of them did pass a second hearing screen. However, 11 of the 20 infants did not pass a second hearing screen and had urine CMV PCR testing, and 1 (9%) was positive. This latter infant’s newborn dried blood spot CMV DNA PCR was negative so a diagnosis of congenital CMV infection was not possible.ConclusionTargeted screening in the NICU for CMV-related hearing loss is problematic as a substantial number of infants do not have a hearing screen performed until after 21 days of age, thus representing a missed opportunity for diagnosis of congenital CMV infection and institution of antiviral therapy if indicated. Our findings support universal CMV screening of neonates on admission to the NICU.Disclosures O. Adunka, MED-EL Corporation: Consultant, Consulting fee, Educational grant and Research support; Advanced Bionics: Consultant, Consulting fee and Licensing agreement or royalty; Advanced Cochlear Diagnostics: President, Ownership interest; AGTC Corporation: Consultant, Consulting fee

The Use of Intensive Phototherapy in Severe Neonatal Hyperbilirubinemia

Phototherapy has been the therapy of choice for the newborn with indirect hyperbilirubinemia. Intensive phototherapy requires a spectral irradiance of 30 microw/ cm2/nm, delivered over as much of the body surface as possible and is nowadays recommended for cases of neonatal hyperbilirubinemia with elevated total serum bilirubin (TSB) levels according to the guidelines. This study was conducted on neonates presenting to the out-born Neonatal Intensive Care Unit (NICU) of Cairo University Hospital with severe and extreme neonatal unconjugated hyperbilirubinemia during a 6 month period from August 2011 to January 2012. A total of 212 neonates presented with TSB > or = 20 mg/dl and were admitted for intensive phototherapy. The mean TSB on admission for all the cases was 26.8 +/- 6.2 mg/dl, ranging from 20 to 44 mg/dl. The mean duration of intensive phototherapy use was 14 hr. The mean rate of TSB declined during stay in the bilisphere was 1.019 mg/dl/hr. Exchange blood transfusion was indicated in 13 cases with extreme hyperbilirubinemia. 31 cases (14.62%) had rebound hyperbilirubinemia after phototherapy removal.

Accuracy of clinical diagnosis and decision to commence intravenous prostaglandin E 1 in neonates presenting with hypoxemia in a transport setting

Background Setting goals for monitoring and initiating life-saving interventions such as prostaglandins (prostaglandin E 1 [PGE 1]) during transport stabilization are dependent on establishing an accurate clinical diagnosis. Objective The aim of this study was to determine the accuracy of clinical diagnosis of suspected congenital heart disease (CHD) and the decision to initiate PGE 1 in neonates presenting with hypoxemia. Methods A retrospective cohort study (2002-2004) on hypoxemic neonates who were transported to an outborn neonatal intensive care unit (NICU) was conducted. Provisional diagnosis established by the transport team was categorized as suspected CHD (group 1), suspected persistent pulmonary hypertension of the newborn (group 2), and suspected CHD and/or persistent pulmonary hypertension of the newborn (group 3) based on history, physical examination, laboratory test, chest radiograph, and initial response to treatment. A definitive diagnosis was established on arrival to NICU by echocardiography. Results A total of 115 neonates were included in the study. The mean gestational age at birth, median age at admission to NICU, and the mean stabilization time were 38.2 (2.4) weeks, 1 (1-26) days, and 217 (108) hours, respectively. The interventions provided during transport stabilization included mechanical ventilation (n = 86, 75%), PGE 1 (n = 70, 61%), inotropes (n = 41, 36%), and fluid bolus (n = 50, 43%). The accuracy of a provisional diagnosis of CHD by transport team was 87.7% and the positive predictive value was 88.1%. Sixty neonates (88%) received PGE 1 appropriately. Eight neonates (12%) with duct-dependent CHD (n = 68) did not receive PGE 1 and were considered as missed opportunities. Ventilated neonates in groups 1 and 3 were identified as the groups that can potentially benefit from more liberal use of PGE 1 and without any adverse effects. Conclusion Although the accuracy of a diagnosis of CHD and the decision to initiate PGE 1 was high, 12% of neonates with a duct-dependent CHD were transported without commencement of PGE 1. Lower thresholds for PGE 1 administration to hypoxemic neonates may potentially improve preoperative stabilization and minimize neonatal morbidity.

The utility of tracheal aspirate cultures in the immediate neonatal period

Determine the contemporary incidence of pathogenic tracheal aspirate (TA) cultures when obtained within 12 h of birth, and to associate TA culture results with specific clinical conditions that increase the risk of infection. A retrospective study over a 6-month period of admissions to a single outborn neonatal intensive care unit when a TA sample was collected within 12 h of birth (n=139). In total, 9 of 139 (6.5%) TA cultures were positive for pathogenic bacterial growth. Maternal fever (relative risk (RR)=7.7, P<0.04) and clinical chorioamnionitis (RR=6.4, P<0.02) were significantly associated with pathogenic TA culture results. Infants with a pathogenic TA culture had lower white blood cell counts (7,500 vs 13,900 mm(-3), P<0.05) when compared with infants with a negative culture. In eight of the nine patients with pathogenic cultures, either the mother or the infant received antibiotics before TA sample collection. Early TA culture is a helpful tool in diagnosing pneumonia, especially in certain clinical scenarios, including maternal fever, clinical chorioamnionitis and leukopenia. Administration of antibiotics before sample collection does not seem to preclude culture growth.

Moral distress in the neonatal intensive care unit: caregiver's experience

The Neonatal Intensive Care Unit (NICU) can be ethically charged, which can create challenges for health-care workers. To determine the frequency with which nurses and residents have experienced ethical confrontations and what factors are associated with increased frequency. An anonymous questionnaire was distributed to nurses in a university center, a high-risk obstetric service, a maternity hospital NICU with 85% in-born patients and an outborn NICU, most of whose preterm admissions are those with surgical complications. Obstetric and pediatric residents in the four universities of the province also received the questionnaire, which included demographics, opinions regarding the gestational age threshold at which resuscitation of a premature infant with bradycardia was appropriate, knowledge of cerebral palsy (CP) outcomes (as an indicator of knowledge about long-term sequelae of prematurity) and questions about ethical confrontation in the NICU. Two hundred and seventy-nine caregivers participated (115 full time nurses and 164 residents). All the distributed questionnaires were completed. Frequent ethical confrontation was reported by 35% of the nurses and 19% of the residents. Among the nurses, moral distress differed significantly between work environments. Nurses working in an out-born NICU and obstetric nurses were more likely to overestimate CP prevalence (P<0.05). Nurses who overestimated CP rates had higher thresholds for resuscitation and were more likely to experience ethical confrontations. Of the residents, 60% were pediatric and 40% obstetric. All groups of residents frequently overestimated the prevalence of CP, and knowledge differed significantly by residency program (P<0.05). The residents who overestimated CP rates had higher thresholds for resuscitation, had more incorrect answers regarding prematurity outcomes and were less likely to have ethical confrontations. A large proportion of nurses and residents report frequent ethical confrontations. Many residents and nurses have limited knowledge of outcomes and high threshold for resuscitation. Ethical confrontation is more common among nurses with poor knowledge about outcomes, and less common in residents with poor knowledge about outcomes.

United States neonatology practice survey: personnel, practice, hospital, and neonatal intensive care unit characteristics.

The efficiency and access to existing perinatal resources has become a focus of debate. Despite inconsistent references to the number of neonatologists and unsubstantiated personnel requirement recommendations, recent commentaries have suggested a current 30% to 50% excess in workforce. To describe the current neonatology workforce and its practice patterns. Using a questionnaire developed by the Committee on Practice of the Section on Perinatal Pediatrics of the American Academy of Pediatrics and distributed to 675 neonatology practices identified in the United States Neonatologists Directory 1996, a survey was conducted from July 1, 1995 to June 30, 1996 requesting specific information relating to personnel, type and size of practice, and clinical services provided at practice hospitals. Respondents included 420 neonatology practices (62.2% response rate) representing 2006 neonatologists providing clinical care in 695 hospitals, 652 with delivery services that accounted for 1 646 881 live births in 1994. More than 95% of practices and neonatologists identified themselves as based in university, private, or hospital settings. Eighty percent of neonatologists were <50 years old. There was an overall 2:1 male to female gender distribution. Sixty percent of practices consisted of 4 or fewer neonatologists, 25% of practices 5 to 7 neonatologists, and 15% of practices 8 or more neonatologists. Sixty percent of practices provided clinical care in only 1 hospital and 1 neonatal intensive care unit (NICU) as compared with 15% of practices in 3 or more hospitals and <5% of practices in 3 or more NICUs. Of the total 478 NICUs (22 in children's hospitals), 67% had <501 annual admissions and 33% had more then 500 admissions. Of the 456 NICUs in 652 practice hospitals with delivery services, 61% of hospitals had <2501 annual deliveries (57% with NICUs) and 39% of hospitals had more than 2500 annual deliveries (90% with NICUs). The average inborn admission rate for these practice hospitals was 11.7%. University, private, and hospital practices had consistent rates of admissions for inborn and outborn NICU and special care nursery admissions. More than 60% of neonatology practices were involved in normal newborn care on a routine basis, in addition to staffing developmental clinics and providing inpatient and outpatient pediatric care. Additional information was analyzed for utilization of residents and neonatal nurse practitioners. By 1999, 50% of practices anticipated hiring 279 neonatologists and 575 neonatal nurse practitioners. Significant discrepancies between earlier projected neonatologist requirements and current neonatology workforce and service responsibilities are discussed in relation to demands of reallocation of subspecialty resources within an evolving health care system.

Extreme immaturity: Outcome of 568 pregnancies of 23–26 weeks' gestation

To provide guidelines to the perinatologist regarding extremely premature infants based on the experience of the University of Toronto Newborn Service (two high-risk perinatal units and one outborn neonatal intensive care unit), with a catchment area of 60,000 deliveries annually.The study included all births or admissions in the Newborn Service from January 1, 1982 to June 30, 1987 with gestational age determined by the best obstetric estimate of gestational age, ranging from 23-26 completed weeks. The obstetric records were reviewed and the surviving infants followed prospectively for a minimum of 2 years after delivery.Analysis of the neonatal and 2-year follow-up data on 568 infants born between 23-26 weeks' gestation revealed a 39% mortality rate, which increased with decreasing gestation. The highest mortality rates occurred following complicated pregnancies, including fetal growth restriction. Intact survival increased with increasing gestational age, from 11% at 23 weeks to 50% at 26 weeks. There was a marked improvement in both mortality and morbidity by 25 completed weeks.The results suggest that an aggressive approach before 24 completed weeks' gestation is not warranted. From a total of 60,000 live births per year, only one child born at 23 weeks' gestation and three at 24 weeks were free of major handicap at 2 years.