Impact of a family-centered care initiative on NICU care, staff and families.

OBJECTIVE: Family-centered care is becoming a standard of care in neonatal intensive care units (NICUs). The purpose of this study was to evaluate the impact of a national program designed to promote family-centered care in NICUs and to provide information and comfort to families during the NICU hospitalization of their newborn. STUDY DESIGN: A quasi-experimental, post-only design was utilized, examining eight March of Dimes NICU Family Support((R)) (NFS) sites. Data were gathered via telephone interviews with NICU administrators and surveys of both NICU staff and NICU families. RESULT: NICU administrators interviewed identified benefits of NFS, including culture change and additional support to families. Surveys of NICU staff showed that NFS enhances the overall quality of NICU care resulting in less stressed, more informed and confident parents. Surveys of NICU families showed that NFS both reduced their stress and made them feel more confident as their baby's parent. CONCLUSION: March of Dimes NFS has had a positive impact on the stress level, comfort level and parenting confidence of NICU families. In addition, it has enhanced the receptivity of staff to the presence and benefits of family-centered care.

Results of the premature birth national need-gap study.

OBJECTIVE: Family-centered care is a standard of practice in neonatal intensive care units (NICUs). The purpose of the study was to assess successes and opportunities for improvement with parents' experiences and involvement in their premature infants' care in NICUs. STUDY DESIGN: Researchers' surveyed 502 parents whose children were currently < or =30 months old, had been born at a gestational age < or =36 weeks and had gone through or were currently in NICUs. RESULT: Most parents of premature infants were reasonably satisfied with the access, attention and information received from physicians and nurses in the NICU. However, approximately one-fourth were only moderately satisfied and nearly 10% were dissatisfied. CONCLUSION: While progress has been made in meeting the needs of parents in the NICU, more work needs to be carried out to improve family-centered care efforts. Specific attention should be given to providing more information and interaction opportunities for families, which may ultimately improve NICU outcomes.

Unsuspected splenic rupture in a neonate.

Serious intra-abdominal injuries in neonates are very rare. In addition, the signs and symptoms of hemoperitoneum caused by bleeding from solid viscera are vague and nonspecific and often are not recognized before the onset of hypovolemic shock or death. In this report, we describe a 2-day-old infant who presented with shock and pallor who had a ruptured spleen, presumably from birth. We also review the literature and the importance of recognizing this injury in the emergency department setting.

The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium.

This article describes emergency department care work teams designed to improve team communication and coordination and reduce error. The core of this teamwork system is the teaching of teamwork behaviors and skills, development of teamwork habits, and creation of small work teams, all of which are key teamwork concepts largely drawn from successful aviation programs. Arguments for enculturating teamwork into ED practice are drawn from a retrospective study of ED malpractice incidents. Fifty-four incidents (1985-1996), a sample of convenience drawn from 8 hospitals, were identified and judged mitigable or preventable by better teamwork. An average of 8.8 teamwork failures occurred per case. More than half of the deaths and permanent disabilities that occurred were judged avoidable. Better teamwork could save nearly $3.50 per ED patient visit. Caregivers must improve teamwork skills to reduce errors, improve care quality, and reduce litigation risks.

Effect of phlebotomy technique on serum bicarbonate values.

OBJECTIVES: To determine whether the following phlebotomy technique factors result in spuriously low serum bicarbonate values: 1) small needle size, 2) prolonged tourniquet time, and 3) underfilling of Vacutainer tubes. METHODS: Thirty-eight healthy young adult student volunteers from Brown University (mean age = 22 years) were randomly assigned to 1 of 2 (24-ga or 20-ga) IV needle size groups. With a tourniquet applied, the subjects had blood sampled initially and then at 3 intervals 1 minute apart. In addition, the initial blood sample was separated into four 4-mL Vacutainer tubes in blood volumes of 0.5, 1, 2, and 3 mL. Serum bicarbonate values (mmol/L) were compared using these techniques. RESULTS: 1) Small needle size did not affect serum bicarbonate values (p > 0.60); 2) prolonged tourniquet time resulted in a statistically significant serum bicarbonate elevation (32.0, 32.5, 33.8, and 33.6, respectively; p < 0.01); and 3) underfilling of Vacutainer tubes resulted in significantly lower serum bicarbonate values for all 4 Vacutainer blood volume groups (21.4, 23.0, 25.0, and 26.2, respectively; p < 0.001). CONCLUSIONS: Small needle size does not affect serum bicarbonate values. Prolonged tourniquet time results in a statistically significant elevation of serum bicarbonate, although this elevation may not be clinically meaningful. Underfilling of Vacutainer tubes significantly influences the accuracy of serum bicarbonate values.

The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department.

BACKGROUND: Many studies have evaluated conscious sedation regimens commonly used in pediatric patients. Recent advances in capnography equipment now enable physicians to assess respiratory parameters, specifically end-tidal CO2 (et-CO2), more accurately in spontaneously breathing sedated children than was possible in the earlier studies. This study was designed to: 1) compare the safety and efficacy of intravenous fentanyl, intravenous fentanyl combined with midazolam, and intramuscular meperidine-promethazine-chlorpromazine (MPC) compound when used for painful emergency department (ED) procedures: and 2) to determine whether the addition of et-CO2 monitoring enabled earlier identification of respiratory depression in this population. METHODS: Forty-two children requiring analgesia and sedation for painful ED procedures were randomly assigned to receive either fentanyl, fentanyl-midazolam, or MPC compound. Vital signs, oxygen saturation, and et-CO2 were monitored continuously. Pain, anxiety, and sedation scores were recorded every five minutes. RESULTS: Respiratory depression (O2 saturation < or = 90% for over the minute or any et-CO2 > or = 50) occurred in 20% of fentanyl, 23% of fentanyl-midazolam, and 11% of MPC patients (P = NS). Of those patients manifesting respiratory depression, 6/8 were detected by increased et-CO2 only. MPC patients required significantly longer periods of time to meet discharge criteria than fentanyl and fentanyl-midazolam patients (P < 0.05). No differences were noted in peak pain, anxiety, or sedation scores. CONCLUSIONS: Fentanyl, fentanyl-midazolam, and MPC produced a high incidence of subclinical respiratory depression. End-tidal CO2 monitoring provided an earlier indication of respiratory depression than pulse oximetry and respiratory rate alone. MPC administration resulted in a significantly delayed discharge from the ED.

Oral intubation using a lighted stylet vs direct laryngoscopy in older children with cervical immobilization.

OBJECTIVE: To compare the tracheal intubation success rates of blind oral intubation using a lighted stylet vs standard of direct laryngoscopy in anesthetized pediatric patients wearing rigid cervical collars. METHODS: Seventy-eight children were randomly assigned to method of intubation (lighted stylet or direct laryngoscopy) and intubator; five patients were excluded after randomization. After sedation and paralysis, the patients were placed in rigid cervical spine collars to simulate intubating conditions for trauma patients. Three attempts at intubation were allowed. An observer recorded the following parameters during the procedure: 1) number of intubation attempts, 2) duration of each intubation attempt, and 3) complications. The intubators had limited prior experience with the lighted stylet technique. RESULTS: Thirty-three patients were in the lighted stylet group and 40 were in the laryngoscopy group. The patients in the lighted stylet group required more attempts prior to successful intubation (2.2 vs 1.5, p < 0.01), and the success rate was higher for the laryngoscopy group (26/33 vs 39/40, p < 0.05). CONCLUSIONS: Blind oral intubation using a lighted stylet under controlled conditions took longer than direct laryngoscopy. However, among those successful on the first intubation attempt, the times to intubation were not significantly different between groups (44.5 vs 52.9 sec). The lighted stylet technique is a viable alternative technique for intubating children who have concurrent cervical spine immobilization.

Near-hanging caused by a toy necklace.

Hanging injuries and fatalities are rare among children and are usually unintentional. In this report we describe a 23-month-old girl who almost died when she accidentally hanged herself with a popular toy necklace, and we discuss recent epidemiological trends in accidental strangulations among children. This case emphasizes the need for increased awareness among consumers, health care providers, and product manufacturers about the dangers of toys such as the one described here.

Appropriate use of a pediatric emergency department: is the pediatrician called before the visit?

The objective of this study was to examine the appropriateness of utilization of an urban pediatric emergency department (ED) by children who had a pediatrician and factors relating to whether the pediatrician was called before an ED visit. This was done prospectively and randomly in an urban teaching hospital pediatric ED. One hundred and sixty-six patients, 18 years old and younger, who presented for nontraumatic conditions and had a pediatrician, classified as private or nonprivate, were enrolled. A questionnaire was completed and appropriateness of visit was determined using previously published criteria. No difference in appropriateness of visit was found between private and nonprivate patients (58/98, 40/68, NS). Thirty-five of 54 (65%) parents who called their pediatrician were classified as an appropriate ED visit as opposed to 62 of 112 who did not call (55%, NS). Private patients called their physicians more often then nonprivate patients (P < 0.001). Lack of access to their primary care providers was the more common reason among nonprivate patients (P < 0.05) for not calling their pediatricians. We conclude that appropriateness of pediatric ED visits is independent of type of physician. Nonprivate patients tend to consult their physician less often before ED visits because of access problems.

Pediatric acepromazine poisoning: the importance of child-resistant packaging for veterinary drugs.

The first reported case of acepromazine ingestion in a pediatric patient is presented. It is an aliphatic phenothiazine that is structurally similar to chlorpromazine (thorazine). In our case, a 2 1/2-year-old male ingested 3 to 4 of his 80-pound Doberman's 25-mg tablets. The pills were stored in a vial without a child-resistant closure. The child displayed signs and symptoms of phenothiazine toxicity. There is no federal law which requires veterinary medicines to be dispensed in special packaging. All prescription medications should require child-resistant packaging.

Pericardial tamponade secondary to central venous catheterization and hyperalimentation in a very low birthweight infant.

A very low birthweight infant developed pericardial tamponade secondary to leakage of fat emulsion through a catheter lodged in the right atrial appendage. At autopsy examination a thrombus was lodged in the appendage, which presumably resulted in immobilization of the catheter and leakage of the fluid through an attenuated and necrotic myocardial wall.