Regional Neonatal Intensive Care Unit Research Articles

Bereaved Parents' Perceptions of Infant Suffering in the NICU

ContextIt is challenging to provide supportive intensive care to infants in the neonatal intensive care unit (NICU), giving them every chance for survival, while also trying to minimize suffering for both the infant and parents. Parents who believe their infant is suffering may alter treatment goals based on their perceptions; however, it is unknown how parents come to believe that their infant may be suffering. ObjectivesTo examine bereaved parents' perceptions of infant suffering in the NICU. MethodsParents completed a qualitative interview exploring their perceptions of the level of suffering that their infant experienced at the end of life. Parents whose infant died in a large Midwestern Level IV regional referral NICU from July 2009 to July 2014 were invited to participate. Thirty mothers and 16 fathers from 31 families (31 of 249) participated in telephone interviews between three months and five years after their infant's death. ResultsFour themes emerged from the qualitative analysis: 1) the presence/absence of suffering, 2) indicators of suffering, 3) temporal components of suffering (trajectory), and 4) influence of perceived suffering on parents, infants, and clinical decision making. ConclusionParents used signs exhibited by infants, as well as information they received from the health care team to form their perceptions of suffering. Perceived suffering followed different trajectories and influenced the decisions that parents made for their infant. Soliciting parent perspectives may lead to improvements in the understanding of infant well-being, particularly suffering, as well as how parents rely on these perceptions to make treatment decisions for their infant.

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units

To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Association of Neonatologist Continuity of Care and Short-Term Patient Outcomes

To describe neonatologist continuity of care and estimate the association between these transitions and selected patient outcomes. We linked Children's Hospitals Neonatal Database records with masked neonatologist daily schedules at 4 centers, which use 2- and 3-week and 1-month "on service" blocks to provide care. After describing the neonatologist transitions, we estimated associations between these transitions and selected short-term patient outcomes using multivariable Poisson, logistic, and linear regression analyses, independent of length of stay (LOS) and case-mix. We also completed analyses after stratifying the cohort by LOS, birthweight, age at admission categories, and selected diagnoses. Stratified by LOS, patient transitions varied between centers in both unadjusted (P<.001) and multivariable analyses (adjusted incidence rate ratio; 95% CI for center B=3.98 (3.81-4.15), center C=4.92 (4.71-5.13), center D=4.2 (4.0-4.4), P<.001), independent of LOS, gestational age, birthweight, surgical intervention, ventilator duration, and mortality. Only central venous line duration (adjusted incidence rate ratio 1.015, 95% CI 1.01-1.02) was minimally and independently associated with the number of transitions. No differences were observed in ventilator duration, oxygen use at neonatal intensive care unit discharge, bloodstream infections, or urinary tract infections. Surviving infants with meconium aspiration, hypoxic ischemic encephalopathy, cerebral infarction, bronchopulmonary dysplasia, and diaphragmatic hernia demonstrated similar findings. Transitions in neonatologists are frequent in regional neonatal intensive care units but appear unrelated to short-term patient outcomes. Future work to define continuity of care and develop effective strategies that promote longitudinal inpatient management is needed.

Diagnostic Accuracy of Adjusted Growth Curves to Predict Cognitive Scores at 24 Months in Extremely Preterm Infants (P11-054-19)

ObjectivesTo compare the diagnostic accuracy of adjusted and unadjusted growth curves to define postnatal growth and predict neurodevelopment at age 2 years in extremely preterm infants. MethodsWe performed a retrospective cohort study assessing infant growth at 36 weeks post-menstrual age (PMA) in 350 extremely preterm infants born ≤ 26 6/7 weeks gestational age (GA) between 01/01/2006-12/31/2014 at University of Alabama at Birmingham Regional Neonatal Intensive Care Unit. Postnatal growth was defined as below, within, or above target using adjusted and unadjusted growth curves. Linear regression models were used to compare adjusted and standard growth trajectories at 36 weeks PMA. The primary outcome was Cognitive Composite Score (CCS) of the Bayley Scales of Infant Development-III (Bayley-III) at 24 months. ResultsMean birthweight (BW) was 750 ± 138 g and median GA was 25 weeks (interquartile range: 24 to 26). A multivariate analysis of postnatal growth defined with adjusted curves and eight covariates (GA, BW, weight-Z-score at birth, sex, race, antenatal steroid use, singleton birth, and corrected age at follow-up assessment) predicted higher CCS-Bayley-III scores at 24 months in infants with postnatal growth within target (adjusted mean ± standard error: 89 ± 3) and lower scores in infants with postnatal growth below and above target (85 ± 3 vs. 83 ± 6, respectively) at 36 weeks PMA (P = 0.04). A multivariate analysis of postnatal growth defined with unadjusted curves and the same covariates did not predict significant differences in scores of infants with postnatal growth below (86 ± 3), within (86 ± 3), or above target (86 ± 6) at 36 weeks PMA (P = 0.99). ConclusionsAdjusted growth curves identified an inverted “U-shaped” association between postnatal growth and CCS-Bayley-III scores at 24 onths. Individualized growth trajectories adjusted for physiologic weight loss may predict cognitive impairment more accurately than traditionally defined growth standards. Additional well-powered studies are needed to validate the diagnostic ability of adjusted growth curves in routine clinical practice. Funding SourcesNone.

Intermittent hypoxia in preterm infants: Measurement using the desaturation index.

The aims of this study were to: (i) Determine in preterm infants at neonatal discharge the prevalence of intermittent hypoxia (IH), as measured by the oxygen desaturation index (DSI) recorded by pulse oximetry and (ii) Determine the change in values for very preterm infants at 1-month post discharge. Preterm infants were recruited from the Wellington regional neonatal intensive care unit (NICU) and 24-h pulse oximetry recordings performed immediately before discharge. Infants born <32 weeks gestational age (GA) had repeat oximetry 1-month post discharge. Oxygenation measures included the 3% and 4% desaturation (DSI 3%, DSI 4%) indices. At discharge from the neonatal unit the median and interquartile range (IQR) for DSI 4% was 51 (31-74) events per hour with normal mean SpO2 (median of 97.9% [97.2-98.8 IQR]). Episodes of IH 1 month post discharge decreased with improvements of between 42% and 57% seen for the three DSI measures. Infants <32 weeks GA had higher median DSI 3 and 4% values at discharge but differences when compared with late preterm infants were not significant. Preterm infants have frequent episodes of IH as measured by the 3% and 4% DSI when deemed otherwise ready for discharge home. Further research in a larger cohort of very preterm infants and also in term infants is needed to determine the significance of this finding.

2303. Differential Effects on MRSA and MSSA Epidemiology in a Neonatal Intensive Care Unit (NICU) During a Year-Long Surveillance and Decolonization Effort

Background Staphylococcus aureus (SA) causes morbidity and mortality in the NICU. While surveillance, with decolonization, is recommended for MRSA outbreak control, the impact of such strategies on endemic MSSA infections is less known. We compare the impact of a year-long surveillance and decolonization effort on MRSA and MSSA colonization dynamics and invasive infection rates in the NICU.MethodsAll infants hospitalized in our academically affiliated, regional perinatal NICU (1032 annual admissions) between January and December 2017 were screened twice monthly for SA colonization by culturing the anterior nares and three skin sites. Eligible patients with positive SA cultures underwent decolonization with mupirocin and/or chlorhexidine bathing. The following parameters for MRSA and MSSA were compared using frequencies and Fisher’s exact tests: 1) Colonization density (proportion of positive surveillance cultures; 2) rates of effective decolonization (proportion of successful decolonization efforts); 3) rates of invasive infections; and 4) mupirocin resistance.ResultsOverall, 25 twice monthly surveillance efforts were undertaken from which 1351/1375 (98%) screening cultures were obtained. Screening identified newly detected MSSA vs. MRSA in 145 vs. 20 infants, respectively. Colonization density decreased more for MRSA (Q1 vs. Q4 decrease of 67%) vs, MSSA (Q1 vs. Q4 decrease of 5%). Decolonization was more effective for MRSA (78%) vs. MSSA (71%). Compared with 2016, rates of invasive infections decreased more for MRSA (2.4 vs. 1.6 /10,000 patient-days, 33%) than MSSA (9.4 vs. 7.8 /10,000 patient-days, 17%). Prevalence of mupirocin resistance through study period was higher for MSSA (24% vs. 10%). No outbreaks were detected.ConclusionA year- long surveillance and decolonization effort was more successful in decreasing MRSA colonization density and invasive infections compared with MSSA. These results are likely due to continual importation of MSSA into the NICU from the community. Since MSSA caused more invasive infections than MRSA, strategies primarily aimed to decrease the burden of MRSA need to be modified to decrease the burden of MSSA in NICUs.Disclosures All authors: No reported disclosures.

The Use of Telemedicine to Address Disparities in Access to Specialist Care for Neonates.

Introduction: Outcomes for premature and critically ill neonates are improved with care provided by neonatologists in a neonatal intensive care unit (NICU). For smaller hospitals, maintaining the personnel and equipment necessary for the delivery and care of unexpectedly high-risk neonates is a significant challenge. To address this disparity in access, telemedicine has been increasingly used to support providers, patients, and their families in community newborn nurseries and NICUs. The purpose of this review is to present the current state of the use of telemedicine by regional NICUs to support community newborn nurseries, NICUs, and families. Methods: A literature review was conducted by two independent reviewers. Articles were selected for inclusion if they described the use of telemedicine with neonates or in the NICU. Two reviewers assessed the quality of the articles using the National Heart, Lung, and Blood Institute Study Quality Assessment Tools. Results: Fourteen articles were identified. After consensus discussion, eight of the articles were rated good and six were rated fair by the two reviewers. Many of the articles suggested improvements in quality of care, family satisfaction, and reductions in the cost of care. Unfortunately, a majority of the studies to date have had small sample sizes or were performed in a single institution and lacked robust evaluations of patient- and family-centered outcomes and provider decision making. Conclusions: While these early studies are promising, more robust studies involving more patients and more institutions are needed to identify opportunities where telemedicine can impact health outcomes, patient-centeredness, or costs of care of neonates.

Airway Clearance of the Term Newborn.

The purpose of this study was to explore airway clearance practices for the preterm newborn in the neonatal intensive care unit (NICU). This descriptive, retrospective medical record review analyzed airway clearance practices in a level III regional NICU from 2016 to 2017 in preterm newborns ranging from 32 weeks to 36 weeks and 6 days. There were 87 preterm newborns and 384 suctioning events reviewed during the entire length of stay. Practices reviewed include device used, frequency, color, consistency, and tolerance of airway clearance. Method of nursing documentation for these practices was also reviewed. Babies born via cesarean required more suctioning (65.5%). Males (60.9%) required more airway clearance events than females (39.1%). After suction events, nurses reported no distress (74%), equal bilateral breath sounds (30%), desaturation (6%), and collectively color change, apnea, or bradycardia (<1%). The most common discharge diagnosis was respiratory distress syndrome (90%). Preterm newborns were suctioned with the blue bulb syringe (15.6%), oral/nasal-pharyngeal suction device (42.7%), and endotracheal suction devices (41.7%). Electronic medical records promote less detailed, narrative documentation and more point and click documentation. If electronic medical record systems are not designed to gather airway clearance indications, specifics about the procedure and the preterm newborn response to the procedure, evidence-based practice cannot be measured. More studies are needed to evaluate suction practices applied in the NICU setting.

Prevalence and Predictors of Back-Transport Closer to Maternal Residence After Acute Neonatal Care in a Regional NICU.

Objectives To describe the demographics, clinical characteristics and referral patterns of premature infants to a regional level IV neonatal intensive care unit (NICU); to determine the prevalence and predictors of back-transport of infants ≤ 32weeks gestational age in a level IV NICU; for infants not back-transported closer to maternal residence, determine the length of stay beyond attainment of clinical stability. Methods Data (2010-2014) from the Children's Hospital Neonatal Database and individual chart review for infants ≤ 32weeks admitted to a level IV NICU whose maternal residence was outside the metro area were included. Bivariate associations of maternal and infant characteristics with back-transport were estimated using two-sample t tests and Fisher's exact test. Multivariable logistic regression was used to measure independent predictors of back-transport. Clinical stability was defined as the attainment of full volume enteral feedings and low flow nasal cannula. Results A total of 223 infants were eligible for analysis; of whom 26% were back-transported after acute care. In the adjusted analysis, insurance status, distance from maternal residence and gestational age were significantly associated with back-transport. For infants not back-transported closer to maternal residence, median length of stay in the level IV NICU beyond attainment of clinical stability was 28.5days. Conclusion for Practice Predictors of back-transport include private insurance, greater distance of maternal residence from NICU and younger gestational age. Many preterm infants admitted to a regional NICU for acute care remained hospitalized in a level IV NICU after achieving clinical stability, for which care in a NICU closer to maternal residence may be appropriate.

Predicting Risk of Infection in Infants with Congenital Diaphragmatic Hernia

To predict incident bloodstream infection and urinary tract infection (UTI) in infants with congenital diaphragmatic hernia (CDH). We conducted a retrospective analysis using the Children's Hospital Neonatal Database during 2010-2016. Infants with CDH admitted at 22 participating regional neonatal intensive care units were included; patients repaired or discharged to home prior to admission/referral were excluded. The primary outcome was death or the occurrence of bloodstream infection or UTI prior to discharge. Factors associated with this outcome were used to develop a multivariable equation using 80% of the cohort. Validation was performed in the remaining 20% of infants. Median gestation and postnatal age at referral in this cohort (n = 1085) were 38 weeks and 3.1 hours, respectively. The primary outcome occurred in 395 patients (36%); and was associated with low birth weight, low Apgar, low admission pH, renal and associated anomalies, patch repair, and extracorporeal membrane oxygenation (P < .001 for all; area under receiver operating curve = 0.824; goodness of fit χ2 = 0.52). After omitting death from the outcome measure, admission pH, patch repair of CDH, and duration of central line placement were significantly associated with incident bloodstream infection or UTI. Infants with CDH are at high risk of infection which was predicted by clinical factors. Early identification and low threshold for sepsis evaluations in high-risk infants may attenuate acquisition and the consequences of these infections.

Energy and Protein Intake During the Transition from Parenteral to Enteral Nutrition in Infants of Very Low Birth Weight

To evaluate the association between nutrition delivery practices and energy and protein intake during the transition from parenteral to enteral nutrition in infants of very low birth weight (VLBW). This was a retrospective analysis of 115 infants who were VLBW from a regional neonatal intensive care unit. Changes in energy and protein intake were estimated during transition phase 1 (0% enteral); phase 2 (>0, ≤33.3% enteral); phase 3 (>33.3, ≤66.7% enteral); phase 4 (>66.7, <100% enteral); and phase 5 (100% enteral). Associations between energy and protein intake were determined for each phase for parenteral nutrition, intravenous lipids, central line, feeding fortification, fluid restriction, and excess non-nutritive fluid intake. In phases 2 and 3, infants receiving feeding fortification received less protein than infants who were unfortified (-1.1 and -0.3 g/kg/d, respectively; P < .001). However, this negative association was not observed after adjusting for relevant nutrition delivery practices. Despite greater enteral protein intake during phases 2 and 3 (0.3 and 0.8 g/kg/d, respectively; P < .001), infants with early fortification received less parenteral protein than infants who were unfortified (-1.4 and -1.1 g/kg/d, respectively; P < .001). Similar patterns were observed for energy intake. Protein intake declined during phases 3 and 4. Infants paradoxically received less protein and energy on days with early fortification, suggesting that clinicians may lack easily accessible data to detect the association between nutrition delivery practices and overall nutrition in infants who are VLBW.

Neonatal seizures and white matter injury: Role of rotavirus infection and probiotics

BackgroundRecent reports associate rotavirus infection with neonatal seizures of distinctive white matter injury (WMI) pattern, but evidence is lacking. We examined this association prospectively and analyzed factors related to occurrence of seizures and WMI pattern in neonates with rotavirus infection. MethodsWe prospectively included 228 neonates (≥34 gestational weeks) who were admitted to a regional neonatal intensive care unit between February 2015 and April 2016 and underwent rotavirus antigen testing using stool samples. Patients with neonatal seizures of other etiologies were excluded. ResultsSeventy-eight (34.2%) neonates were rotavirus-positive. Otherwise-unexplained seizures were more frequently observed among rotavirus-positive than among rotavirus-negative neonates (20.5% vs. 4.0%, p < 0.001). Rotavirus infection increased the risk of seizures (odds ratio [OR], 6.19; p < 0.001), even after adjustment for confounders (OR, 4.46; p = 0.007). After stratification according to probiotic administration immediately after birth, rotavirus infection remained a significant risk factor only in patients without probiotic medication (OR, 4.83; p = 0.01 vs. OR, 2.44; p = 0.49). The WMI pattern was observed in 9 of 22 neonates with seizures, and this subgroup was characterized by rotavirus infection (100% vs. 53.8%, p = 0.004) and seizure onset on days 4–6 of life (66.7% vs. 15.0%; p = 0.02). G9P[8] was the most common genotype in this subgroup but was also commonly detected in neonates without seizures. ConclusionRotavirus infection is an independent risk factor for neonatal seizures, and associated with the WMI. Immediate administration of probiotics after birth may reduce rotavirus-associated neonatal seizures.

Utilization of conventional radiography in a regional neonatal intensive care unit in Ireland

Objective: To audit the demand and radiation exposure of conventional radiography in a regional neonatal intensive care unit (NICU) in Ireland.Methods: A retrospective study of radiographs performed on all admissions to the NICU in University Maternity Hospital Limerick (UMHL) over 2 years.Results: A total of 1405 radiographs were performed on 506 infants. 153.5 radiographs per 1000 live births was the observed demand and 44% of radiographs were done out of hours. 47% of all radiographs were performed on infants <1500 g. Median number of radiographs per infant was one (IQR 1–2; range 1–39). Significant negative correlation was observed between number of radiographs and gestational age. Mean lung radiation doses estimated using published values for normal weight (>2500 g), very low birth weight (VLBW), and extremely low birth weight (ELBW) infants based on the median number of chest X-rays were 31.7 µGym, 84.66 and 232.75 µGy, respectively.Conclusions: Conventional radiography remains a key diagnostic tool in neonatology particularly in VLBW and ELBW infants and is invaluable in supporting timely clinical decision making. Clinicians should be aware of the cost and potential hazards of neonatal radiography and is recommend that the cumulative radiation exposure among the ELBW and VLBW infants is monitored. Increasing awareness and standardisation of point-of-care ultrasonography could decrease the reliance on conventional radiography in neonatal units.

A Sterile Collection Bundle Intervention Reduces the Recovery of Bacteria from Neonatal Blood Culture

Background: In neonatal intensive care, coagulase-negative Staphylococcus species can be both blood culture contaminants and pathogens. False-positive cultures can result in clinical uncertainty and unnecessary antibiotic use. Objective: This study sought to assess whether a sterile blood culture collection bundle would reduce the incidence of false-positive blood cultures in a regional neonatal intensive care unit. Method: Clinical data was collected from all infants who had blood cultures taken before and after the introduction of the sterile blood culture collection bundle intervention. This intervention required 2% chlorhexidine and full sterile precautions for blood culture collection. False-positive blood culture rates (presence of skin commensals and ≥3 clinical infection signs) were compared before and after the intervention. The number of days of unnecessary antibiotics associated with false-positive blood cultures was also analysed. Results: In the pre-intervention group (PRE) 197 cultures were taken from 161 babies. In the post-intervention group (POST) 170 cultures from 133 babies were acquired. Baseline demographics were similar in both groups. The rate of false-positive cultures in the PRE group versus the POST group was 9/197 (4.6%) compared to 1/170 (0.6%) (p < 0.05). Unnecessary antibiotic exposure was reduced in the PRE group in comparison to the POST group (27 vs. 0 days, p < 0.01). Conclusions: Implementation of sterile blood culture collection intervention reduced the number of false-positive results. This has potential benefit in reducing unnecessary antibiotic use.

Use of a single C-reactive protein level in decision-making during neonatal sepsis evaluation

Background: Use of a single C-reactive protein (CRP) level has been studied in the pediatric population, but limited information is available for the neonatal, particularly Neonatal Intensive Care Unit (NICU) infants. Objective: The objective of this study is to determine if a single CRP level in the context of other laboratory and clinical parameters, can assist in decision-making for antibiotic management. Materials and Methods: We reviewed the medical records of infants admitted to a large regional perinatal center NICU over a 2-year period. Infants in whom a CRP level had been measured were divided into sepsis-treated group if antibiotic therapy was instituted for ≥7 days or the no sepsis group if antibiotics were discontinued after 48 h. Characteristics of delivery, general characteristics of the infant and data at the time of sepsis evaluation were collected. This was a powered study to detect at least 10% difference in the proportion of those with CRP

The Impact of Neonatal Service ReOrganisation on Feeding of Preterm Infants (&lt;34 Weeks): A Prospective Cohort Study in a Regional Neonatal Unit from 1992 to 2010

Objectives: To describe Neonatal Intensive Care Unit (NICU) feeding practices during the neonatal period and explore predictors of any breast milk feeding at discharge among very preterm infants admitted before and after re-organisation of neonatal services in a region of the UK. Methods: Data on feeding of preterm infants (<34+0 weeks) at four time-points in the neonatal period and at discharge were collected prospectively on 1018 infants admitted to a regional NICU over a 19-year period. These data were subjected to unadjusted and adjusted analyses and time trends calculated before and after the transition. Results: Initiation of breast milk feeding in preterm infants increased throughout the study. However, the proportion of infants receiving breast milk declined steadily through the neonatal period and beyond. Before re-organisation, breast milk feeding (any) at discharge increased year-by-year (slope coefficient for trend 0.127, p<0.001). After re-organisation, the trend slowed down/decelerated (slope coefficient for trend 0.071, p 0.32). Any breast milk feeding at day 7 of life, singleton pregnancy, and length of hospital stay were associated with any breast milk feeding at discharge. Conclusions: Breast milk feeding of preterm infants increased in line with secular trends. However, this trend fell away following neonatal service reorganisation. This finding suggests that service providers and commissioners should monitor infant feeding trends in NICUs against national trends, as a benchmark of maternal and infant wellbeing and service delivery. The early predictors of any breast milk feeding at discharge found in this study need further research to validate their usefulness.

Is it the baby or the beds?

Since the 1960s, reductions in neonatal mortality in the United States track closely with the increased availability of neonatal intensive care unit beds. Not surprisingly, as the number of intensive care unit beds have increased, the number of babies admitted to these units to fill these beds has increased. While there is no doubt that the large proportion of these admissions are necessary and result in improved outcomes, there is also the possibility that the mere prospect of bed availability drives NICU admission. In this volume of The Journal, Harrison et al use large national data sets to determine the relationship between NICU admission and regional bed supply. Importantly, the authors have uncovered regional variation in NICU bed availability that is not explained by validated markers of need. Furthermore, it appears that bed availability may drive NICU admission rates, especially for larger (potentially “less sick”) babies. The implications for resource allocation and utilization are staggering. These results scratch the surface of a complex set of issues and reveal important questions that we must begin to answer in order to provide responsible, appropriate, and effective health care. We must do better in deciding where to provide services, and work hard and continually re-evaluate whether the services we provide are safe, necessary, beneficial, and cost-effective. Article page 73 ▶ Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed SupplyThe Journal of PediatricsVol. 192PreviewTo characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. Full-Text PDF

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity

Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Live birth at GA of 34 weeks or more. Inborn NICU admission rate. Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41). Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Effect of Dedicated Lactation Support Services on Breastfeeding Outcomes in Extremely-Low-Birth-Weight Neonates.

Breastfeeding is associated with major benefits for high-risk infants born prematurely, yet this population faces significant challenges to breastfeeding. Lactation services provide successful interventions, yet the impact of lactation services on breastfeeding outcomes in preterm infants is understudied. Research aim: The provision of full-time lactation support in the neonatal intensive care unit (NICU) will improve quantitative breastfeeding measures in premature infants. A longitudinal retrospective nonexperimental design was used. Data were collected from medical records of breastfeeding outcomes in patients 30 weeks' gestational age and under admitted to a level IV regional NICU over three epochs of varying levels of lactation services, from none to full time. Demographic, medical, and breastfeeding data were collected. Data analysis was performed using standard statistical tests and hierarchical regression analysis. A significant increase in the number of lactation consults was observed across epochs, and the number of infants who received human milk via feeding at the breast, as the first oral feeding, increased across epochs. After controlling for covariates, the odds of infants receiving any human milk compared with exclusive formula feeding increased across epochs. The provision of full-time dedicated NICU lactation support is associated with an increase in breastfeeding outcome measures for high-risk preterm infants.

Creation of a Regional Human Milk Assembly: A Model to Influence Practice and Policy Change in the NICU.

The 2011 Surgeon General's Call to Action to Support Breastfeeding highlights a need for optimizing lactation-based education for all health professionals; however, few schools of nursing and medicine offer lactation-based curriculum. In an effort to address these gaps in education and care, the director of the lactation program at a large urban children's hospital developed and instituted the annual regional Human Milk Assembly (HMA), a half-day collaborative meeting of the hospital's regional and referral hospitals' neonatal intensive care unit (NICU) nursing staff, to address lactation-based educational and training needs of all participating institutions. The purpose of this study was to determine whether and how participating HMA hospitals implemented the best practices surrounding human milk and breastfeeding shared by the host institution during a 10-year span of the HMA. A prospective descriptive study was designed using an electronic web-based survey (SurveyMonkey.com) to elicit participant data. Quantitative data were analyzed using descriptive statistics whereas qualitative data were analyzed for themes via content analysis. Thirty-one of the 50 hospitals surveyed responded to the electronic survey for a total of 34 individual participants. Seventeen of the 22 (77%) of best practices were implemented at rates of over 50%. By enabling a culture of transparency and sharing, hospital staff can be encouraged to implement best practices across a network of regional care centers. This annual regional HMA could be a model for other areas and research should be conducted to evaluate such programs nationwide.