ABSTRACT
BACKGROUND: Patent ductus arteriosus (PDA) management varies widely among neonatologists. LOCAL PROBLEM: Lack of institution-specific evidence-based guidelines for therapeutic closure of PDA. METHODS: Quality improvement project among infants <30 weeks gestational age (GA) designed to determine whether the odds of therapy for closing the PDA, adjusted for GA, decreased after implementing evidence-based guidelines. INTERVENTION: Implementation of guidelines with conservative approach to PDA management. RESULTS: The frequency of PDA treatment decreased from 446/1125 (40%) in Epoch 1 to 96/482 (20%) in Epoch 2. PDA treatment was more frequent in neonates 23-26 weeks GA than those of 27-29 weeks GA (43% vs. 28%, respectively). Among 542 infants receiving indomethacin for PDA, 25% had subsequent ligation; the odds of ligation after indomethacin were lower in neonates 27-29 weeks GA and decreased during Epoch 2. CONCLUSIONS: The frequency of medical and surgical treatment for therapeutic closure of PDA decreased after implementing evidence-based treatment guidelines.
Subject(s)
Cardiac Surgical Procedures/statistics & numerical data , Ductus Arteriosus, Patent/therapy , Guideline Adherence , Quality Improvement , Time-to-Treatment , Consensus , Cyclooxygenase Inhibitors/therapeutic use , Disease Management , Female , Gestational Age , Humans , Indomethacin/administration & dosage , Infant, Newborn , Infant, Premature , Intensive Care Units, Neonatal , Ligation , Logistic Models , Male , Texas , Treatment FailureABSTRACT
OBJECTIVE: Parkland Memorial Hospital (PMH) participated in Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT), an unblinded controlled trial, in which preterm neonates of 24(0/7) to 27(6/7) weeks' gestational age (GA) were randomized in the delivery room (DR) to endotracheal intubation or nasal continuous positive airway pressure. We hypothesized that DR intubation could change in nonenrolled patients at PMH and that the change would be larger than in comparable centers not participating in the trial. METHODS: The PMH Cohort included eligible but nonenrolled neonates of 24(0/7) to 27(6/7) weeks (primary) and noneligible neonates of 28 to 34(6/7) weeks (confirmatory). A subset (24(0/7)-29(6/7)weeks) of that cohort was compared with a contemporaneous cohort born in centers participating in the Vermont Oxford Network (VON). We used a Poisson regression model to obtain adjusted relative risks (RRs) of DR intubation (during/after SUPPORT versus before SUPPORT) for PMH and for VON along with the ratio of these RRs. RESULTS: In the PMH cohort (n = 3527), the proportion of DR intubation decreased during/after SUPPORT in the lower GA group (adjusted RR 0.76, 95% confidence interval [CI] 0.59-0.96) and the upper GA group (adjusted RR 0.57, 95% CI 0.46-0.70). Compared with the RR for DR intubation in VON, the RR at PMH was smaller in the lower (ratio of RR 0.76, 95% CI 0.65-0.87) and the upper GA group (ratio of RR 0.52, 95% CI 0.39-0.68). CONCLUSIONS: A center's participation in an unblinded randomized trial may affect process of care of nonenrolled patients.
Subject(s)
Patient Care/trends , Patient Selection , Premature Birth/therapy , Cohort Studies , Continuous Positive Airway Pressure/methods , Continuous Positive Airway Pressure/trends , Female , Humans , Infant, Newborn , Intubation, Intratracheal/methods , Intubation, Intratracheal/trends , Patient Care/methods , Premature Birth/diagnosis , Premature Birth/epidemiology , Pulmonary Surfactants/therapeutic use , Respiratory Distress Syndrome, Newborn/diagnosis , Respiratory Distress Syndrome, Newborn/epidemiology , Respiratory Distress Syndrome, Newborn/therapy , Time FactorsABSTRACT
OBJECTIVE: To determine short-term outcomes of infants who had perinatal acidemia and were evaluated for hypothermia therapy but did not qualify based on a standardized neurologic examination. STUDY DESIGN: Retrospective, single-site cohort study of inborn infants of ≥ 36 weeks gestation who had perinatal acidemia from October 2005-September 2008 and had a standardized neurologic examination performed by a certified neonatologist to assess eligibility for hypothermia therapy. An abnormal short-term nursery outcome was defined as death, seizures, brain magnetic resonance imaging consistent with hypoxic-ischemic encephalopathy, abnormal neurologic examination at discharge, gastrostomy tube feeding, or inability to nipple all feeds beyond the first week of age. RESULTS: One hundred forty-four (0.3%) of 46 887 newborns with perinatal acidemia had a neurologic examination performed that was either normal (n = 29) or consistent with mild encephalopathy (1 or 2 abnormal categories; n = 60). Of the latter infants classified as having mild encephalopathy, 12 (20%) experienced an abnormal short-term outcome (feeding difficulties, n = 8; abnormal neurologic examination at discharge, n = 7; abnormal brain magnetic resonance imaging, n = 6; seizures, n = 5; gastrostomy, n = 1; or death, n = 1). CONCLUSIONS: Twenty percent of newborns with perinatal acidemia and a neurologic examination that revealed only mild encephalopathy had abnormal short-term outcomes that could be attributed to the encephalopathy. Adjunctive tools or biomarkers for optimal assessment of infants with fetal acidemia for hypothermia therapy are needed.
