A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates.

BACKGROUND: Skin-to-skin (STS) care effectively improves neonatal outcomes, particularly for preterm neonates. However, utilization of STS remains suboptimal for the most vulnerable preterm neonates in the first 4 weeks of life. This quality improvement (QI) project aimed to increase STS duration for neonates under 35 weeks gestation. METHODS: The QI initiative was conducted in a 35-bed level IV NICU within a teaching hospital in New York City from July 2021 to January 2023. Six months of baseline data and a staff survey determined interventions across "Plan, Do, Study, Act" cycles. Interim analyses guided interventions using run charts. Interventions included parental counseling and information leaflets, discussion during rounds on STS eligibility, STS education for residents, nurses' feedback, and visual reminders. The primary outcome measure was the mean duration of STS per eligible patient day. The process measures were the age at first STS and documentation of eligibility for STS care in the electronic medical records. Balancing measures included adverse events such as apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tube. RESULTS: The study included 185 infants with a mean gestational age of 29.1 weeks. The mean STS duration per eligible patient day increased from a baseline of 13.3 minutes to 32.4 minutes without significantly increasing adverse events. CONCLUSIONS: The QI interventions implemented have successfully increased the duration of STS in preterm infants. Our interventions combined into an STS bundle can be a potential model for other NICUs to improve STS practice.

A Deep Intronic PKHD1 Variant Identified by SpliceAI in a Deceased Neonate With Autosomal Recessive Polycystic Kidney Disease.

The etiologies of newborn deaths in neonatal intensive care units usually remain unknown, even after genetic testing. Whole-genome sequencing, combined with artificial intelligence-based methods for predicting the effects of non-coding variants, provide an avenue for resolving these deaths. Using one such method, SpliceAI, we identified a maternally inherited deep intronic PKHD1 splice variant (chr6:52030169T>C), in trans with a pathogenic missense variant (p.Thr36Met), in a newborn who died of autosomal recessive polycystic kidney disease at age 2 days. We validated the deep intronic variant's impact in maternal urine-derived cells expressing PKHD1. Reverse transcription polymerase chain reaction followed by Sanger sequencing showed that the variant causes inclusion of 147bp of the canonical intron between exons 29 and 30 of PKHD1 into the mRNA, including a premature stop codon. Allele-specific expression analysis at a heterozygous site in the mother showed that the mutant allele completely suppresses canonical splicing. In an unrelated healthy control, there was no evidence of transcripts including the novel splice junction. We returned a diagnostic report to the parents, who underwent in vitro embryo selection.

Ventriculoperitoneal Shunt Tap Task Trainer: A Technical Report.

This technical report describes the creation of a model of an infant with a ventriculoperitoneal shunt (VPS). This model is authentic, assembled easily, and reusable which allows for pediatric and neurosurgical practitioners to gain experience in performing VPS taps. Learning objectives have been provided to guide task training.

Neonatal Transport Ventilation: Simulation to Improve Knowledge and Skills.

Introduction: Neonatal transport is a frequent activity in most tertiary and regional perinatal centers. Neonatal transport teams serve as mobile intensive care units and are equipped with specialized incubators that have built-in ventilators that can provide several levels of support. In our institution, we aim to educate all neonatal transport providers, including neonatal-perinatal fellows, neonatal intensive care unit-dedicated advanced practice providers, and neonatal intensive care unit-dedicated registered respiratory therapists, on transport ventilation management and troubleshooting, utilizing simulation to optimize patient care during transport. Methods: We developed scenarios based on the equipment used at our institution: an AirBorne Voyager transport incubator with a built-in Crossvent 2i+ infant ventilator, AirBorne TXP-2D high-frequency ventilator, and AeroNOx inhaled nitric oxide system (International Biomedical). Equipment and troubleshooting knowledge were assessed via knowledge tests prior to and at intervals after simulation scenario completion. We performed paired t tests to analyze change in test scores at each time point postsimulation compared to presimulation. Facilitated debriefing and a survey elicited feedback on learner confidence and comfort. Results: Ten learners participated in the simulations and completed the knowledge assessments. At all postsimulation time points, mean knowledge scores showed statistically significant improvements compared to presimulation scores. Feedback from learners on confidence in their skills and comfort with the equipment was positive. Discussion: Neonatal transport team ventilator knowledge and troubleshooting skills have improved after instituting this semiannual simulation training.

Discharge of Medically Complex Infants and Developmental Follow-up.

At the time of discharge from the NICU, many infants have ongoing complex medical issues that will require coordinated, multispecialty follow-up. Discharge planning and transfer of care for infants with medical complexity require a multidisciplinary team effort that begins early during the NICU hospitalization. It is critical that the primary care physician is involved in this process because he or she will serve as the chief communicator and coordinator of care after discharge. Although some infants with medical complexity may be followed in specialized multidisciplinary NICU follow-up clinics, these are not universally available. The responsibility then falls to the primary care physician to coordinate with different subspecialties based on the infant's needs. Many infants with medical complexity are technology-dependent at the time of discharge and may require home oxygen, ventilators, monitors, or tube feeding. Prematurity, critical illness, and prolonged NICU hospitalization that lead to medical complexity also increase the risk of neurodevelopmental delay or impairment. As such, these infants will not only require routine developmental surveillance and screening by the primary care physician but also should be followed longitudinally by a neurodevelopmental specialist, either a developmental-behavioral pediatrician or a neonatologist with experience in neurodevelopmental assessment.

Neonatal Hydrops Simulation Model: A Technical Report.

This technical report describes the creation of a model of a newborn with hydrops fetalis (HF). This model is easy to assemble, quite authentic and reusable allowing for many neonatal intensive care providers to practice rare, life-saving procedures. Learning objectives and a critical action checklist have been included to guide the simulation and add additional complexity to the scenario, if desired.