Prospective, controlled study of an intervention to reduce errors in neonatal antibiotic orders.

OBJECTIVE: To evaluate the effectiveness of an interactive computerized order set with decision support (ICOS-DS) in preventing medication errors in neonatal late-onset sepsis (LOS). STUDY DESIGN: Prospective, controlled comparison of error rates in antibiotic orders for neonates admitted to the Medical University of South Carolina neonatal intensive care unit with suspected LOS (after postnatal day of life 3) prior to (n=153) and after (n=146) implementation of the ICOS-DS. Antibiotic orders were independently evaluated by two pharmacists for prescribing errors, potential errors and omissions. Prescribing errors included>10% overdoses or underdoses, inappropriate route, schedule or antibiotic, drug-drug or drug-disease interactions, and incorrect patient demographics. Potential errors included misspelled drugs, leading decimals, trailing zeroes, impractical doses and error-prone abbreviations. Multiple errors and omissions in an order were counted individually. RESULTS: Overall error rate per order decreased from 1.7 to 0.8 (P<0.001) and potential error rate from 1.0 to 0.06 (P<0.001). The reduction in omission error rate per order from 0.2 to 0.1 was not significant (P=0.17). The prescribing error rate per order increased from 0.4 to 0.7 (P=0.03) because of the use of incorrect patient weights (P<0.001). Renal dysfunction was significantly associated with an increased risk of prescribing errors (odds ratio=3.7, P=0.01) which was not significantly different for handwritten versus ICOS-DS orders (P=0.15). CONCLUSIONS: The ICOS-DS significantly improved the quality of neonatal LOS antibiotic orders although the use of incorrect patient weights was increased. In both groups, orders for patients with renal dysfunction were at risk for prescribing errors. Further evaluation of interventions to promote medication safety for this population is needed.

Secondary surfactant administration in neonates with respiratory decompensation.

OBJECTIVE: To evaluate blood gases and ventilatory parameters before and after two doses of surfactant in premature infants with respiratory decompensation after recovery from primary respiratory distress syndrome (RDS). STUDY DESIGN: This prospective pilot study enrolled infant's > or =500 g birth weight, from 7 days to 3 months of age, with a secondary respiratory decompensation lasting at least 4 h prior to study entry. Infants received two doses of surfactant, 12 h apart. RESULT: A total of 20 neonates qualified for secondary surfactant administration. PCO2 (P<0.001); pH (P<0.001); mean airway pressure (P<0.05); FiO2 (P<0.05); modified ventilatory indices (P<0.004) and respiratory severity scores (P<0.001) improved significantly at both 12 and 24 h after surfactant administration. CONCLUSION: Secondary surfactant administration may be effective in reducing short-term ventilatory requirements in neonates who have a respiratory decompensation after recovery from initial RDS. Randomized controlled trials are needed to confirm these preliminary findings.

A cost-effectiveness analysis of neonatal nurse practitioners.

This retrospective study compares the cost and quality outcomes of two matched groups of infants; one of which received neonatal care provided by neonatal nurse practitioners (NNPs), the other delivered by the medical house staff in one hospital's NICU. Parameters evaluated for both groups included LOS, days on ventilator, days on oxygen, mortality, morbidity, and costs. The infants in the study were matched by place of birth, gestational age, birth weight, sex, race, and Apgar scores. This study showed that in the 35 cases cared for by NNPs, in collaboration with neonatoologists, neonates received care equal in quality to the 35 matched cases cared for by medical house staff at lower cost with greater continuity and consistency. Cost effectiveness of the NNP group was documented as $18,240 less per infant than those managed by medical house staff. Differences were seen as chiefly attributable to the NNP's unique blend of knowledge, communication skills, and continuous presence plus early identification of service coordination needs.

Renal physiology Part 1: Structure and function.

To assess, plan, and implement care of the critically ill neonate, the nurse must have a thorough understanding of renal embryology and physiology. This articles focuses on the developmental and anatomical structure of the kidney and the general physiological activities of the renal components. Renal embryological development begins during the 1st week of gestation and continues until around the 36th week of gestation. Functional capacity, although not mature, begins around the 6th week of gestation. Infants born premature have underdeveloped structures and decreased renal function. Comprehending renal anatomy and physiology requires a complete understanding of a single nephron, the functional unit of the kidney. Each nephron consists of a glomerulus, Bowman's capsule, and tubules, which work together to maintain ion balance for cellular function and elimination of unwanted substances from the plasma. Renal blood flow, controlled by either autoregulation or hormonal control, must remain both rapid and constant for glomerular filtration to occur. Alterations in any of these components of renal anatomy and physiology will alter the condition of the neonate. Renal evaluations are done based on output, urine chemistries, and serum chemistries. These evaluations lead to a diagnosis on which the nurse can base her plan of care.