Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

BACKGROUND: Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. METHOD: Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. RESULTS: Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. CONCLUSION: Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

Epidemiology and genomics of a slow outbreak of methicillin-resistant Staphyloccus aureus (MRSA) in a neonatal intensive care unit: Successful chronic decolonization of MRSA-positive healthcare personnel.

OBJECTIVE: To describe the genomic analysis and epidemiologic response related to a slow and prolonged methicillin-resistant Staphylococcus aureus (MRSA) outbreak. DESIGN: Prospective observational study. SETTING: Neonatal intensive care unit (NICU). METHODS: We conducted an epidemiologic investigation of a NICU MRSA outbreak involving serial baby and staff screening to identify opportunities for decolonization. Whole-genome sequencing was performed on MRSA isolates. RESULTS: A NICU with excellent hand hygiene compliance and longstanding minimal healthcare-associated infections experienced an MRSA outbreak involving 15 babies and 6 healthcare personnel (HCP). In total, 12 cases occurred slowly over a 1-year period (mean, 30.7 days apart) followed by 3 additional cases 7 months later. Multiple progressive infection prevention interventions were implemented, including contact precautions and cohorting of MRSA-positive babies, hand hygiene observers, enhanced environmental cleaning, screening of babies and staff, and decolonization of carriers. Only decolonization of HCP found to be persistent carriers of MRSA was successful in stopping transmission and ending the outbreak. Genomic analyses identified bidirectional transmission between babies and HCP during the outbreak. CONCLUSIONS: In comparison to fast outbreaks, outbreaks that are "slow and sustained" may be more common to units with strong existing infection prevention practices such that a series of breaches have to align to result in a case. We identified a slow outbreak that persisted among staff and babies and was only stopped by identifying and decolonizing persistent MRSA carriage among staff. A repeated decolonization regimen was successful in allowing previously persistent carriers to safely continue work duties.

Capillary blood draws in the NICU: the use of the Innovac quick-draw whole blood collection system versus traditional capillary blood draws.

PURPOSE: (1) To determine the rate of damaged and discarded capillary blood draws in the NICU; (2) to compare the rate of damaged and discarded samples between traditional capillary blood draws and the Innovac Quick-Draw device; (3) to determine whether in-service training for nurses on capillary blood draws decreased the rate of damaged and discarded blood samples. DESIGN: During Phase I of the study, the rate of capillary blood draws by the traditional method was determined. At the completion of Phase I, the manufacturer provided in-service training to senior nurses in the NICU with the use of the Innovac Quick-Draw device. Additional in-service training was also provided for the traditional capillary blood draw technique. Within a month of in-service training, an openly randomized study (Phase II) was carried out comparing traditional versus Innovac device capillary blood draws. SAMPLE: All infants admitted to the NICU between June 2008 and June 2009 were eligible to be in the study. There were no exclusion criteria based on weight, gestational age, or gender because the sampling method was the only variable being assessed. Phase I lasted two months, whereas Phase II lasted approximately four months. MAIN OUTCOME VARIABLE: Occurrence of damaged capillary samples with the Innovac device versus the traditional method. RESULTS: In Phase I, the rate of damaged and discarded samples was 10 percent (28/278). In Phase II, the rate of damaged and discarded samples for traditional and Innovac device was 7.2 percent and 10 percent, respectively. Comparisons between traditional and Innovac for different type of samples were as follows: complete blood count, 11.0 percent (12/104) vs. 13.4 percent (14/104); serum electrolytes, 6.4 percent (6/94) vs. 9.5 percent (9/95); C-reactive protein, 5.7 percent (4/70) vs. 8.0 percent (5/62); and liver panel, 5.3 percent (7/131) vs. 8.3 percent (9/108). There were no statistically significant differences of damaged and discarded samples for the overall or individual sample type comparisons.

Vacuum-assisted closure for complicated neonatal abdominal wounds.

BACKGROUND: Neonatal experience in vacuum-assisted closure (VAC) for complex abdominal wounds remains scant. METHODS: A neonatal VAC protocol was instituted in 2004. The medical records of patients treated with this protocol for the ensuing 3 years were retrospectively reviewed. Continuous data are reported as mean +/- SD (range). RESULTS: Ten VAC applications occurred in 8 neonates for a 3-year period. Gestational age and age at VAC application were 30 +/- 6.9 (24-40) weeks and 84.5 +/- 51 (21-165) days, respectively. Birth weight and weight at VAC application were 1495 +/- 1118 (615-3415) g and 3515 +/- 2118 (989-7965) g, respectively. All wound complications occurred after laparotomies (7 elective, 3 emergent). Three wounds included intestinal stomas, and 3 included enterocutaneous fistulae. Average wound area at VAC initiation was 13.6 +/- 6.0 (8.5-25) cm(2). Duration of VAC use was 19.1 +/- 15.3 (7-60) days. Vacuum-assisted closure resulted in complete wound closure in all cases and did not result in any local or systemic complications. Five patients (63%) survived to discharge. CONCLUSIONS: Vacuum-assisted closure for complicated abdominal wounds is safe and successful in neonates of any gestational age and birth weight. It provides effective wound management, even in the presence of stomas or enterocutaneous fistulae.

Percutaneously inserted central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower extremity insertion.

OBJECTIVE: The objective of this study was to compare the complication rates of upper versus lower extremity percutaneously inserted central catheters used for total parenteral nutrition in neonates. METHODS: During a 48-month study period, 396 neonates were identified as having had percutaneously inserted central venous catheters. A total of 370 catheters were inserted from the upper and 107 from the lower extremity. Data retrieved and analyzed were birth weight, gestational age, age at placement, duration in place, duration of total parenteral nutrition, type of infusates, catheter-related bloodstream infection, phlebitis, leakage, occlusion, necrotizing enterocolitis, intraventricular hemorrhage, serum creatinine, liver function tests, and length of hospitalization. RESULTS: The median birth weight and gestational age were 940 g and 28 weeks. The rate of catheter-related bloodstream infection was 11.6% for the upper and 9.3% in the lower extremity catheters. The most common organism was coagulase-negative Staphylococcus for both upper and lower extremity catheters and significantly higher with catheters from the upper extremity. Lower extremity catheters were in place longer, and the time from insertion to complication was also longer. The rate of cholestasis was higher for the upper extremity catheters. Multiple regression analysis showed that the most significant contributor to cholestasis was duration of time the catheters were in place and the duration of total parenteral nutrition administration. Receiver operating characteristics curve demonstrated higher sensitivity for duration of catheters in predicting cholestasis with duration of total parenteral nutrition being more specific. CONCLUSION: Lower extremity percutaneously inserted central venous catheters had lower rates of catheter-related bloodstream infection, longer time to first complication, and lower cholestasis despite longer duration of total parenteral nutrition. When possible, lower extremity inserted catheters should be used for the administration of total parenteral nutrition.