Evolución de la atención a domicilio para niños prematuros y de bajo peso de nacimiento desde 2002 hasta 2014 / Changes in homecare for preterm and low-birth-weight infants from 2002 to 2014

INTRODUCCIÓN: La atención domiciliaria (AD) se caracteriza por ofrecer al paciente en su domicilio atención médica y enfermera en igual cantidad y calidad que en el hospital. El objetivo es describir los cambios en la evolución de la AD del neonato en nuestro servicio, desde 2002 hasta 2014. MATERIAL Y MÉTODOS: Se revisa la base de datos de AD analizando las características propias de la AD y las características sociales de la familia en 3 periodos consecutivos. También se presenta una encuesta de satisfacción de los padres. RESULTADOS: En la evolución de la AD en los 3 periodos cabe destacar una disminución del peso al alta hospitalaria (de 1.880g en el periodo 2002-2006 a 1.850g en el periodo 2011-2014; p = 0,006) y al alta definitiva (de 2.187g a 2.163g; p = 0,001), un aumento de la duración de la AD (de 10 a 11 días; p = 0,007) y una menor incidencia de rehospitalizaciones (del 3,4 al 1,3%; p = 0,019) Las características sociales de la familia muestran una mayor edad materna con más hijos vivos previos, un contexto familiar mejor adaptado en una vivienda más correcta y un aumento de la lactancia materna exclusiva al alta hospitalaria (del 25,5 al 49,0%; p < 0,001). La valoración global del programa es ≥ 7/10 en el 98,8% de respuestas. CONCLUSIONES: Los resultados de la AD del prematuro y recién nacido de bajo peso han ido mejorando a lo largo del tiempo, permitiendo ahorrar aproximadamente 10-11 días de ingreso hospitalario, sin menoscabar la calidad asistencial ni disminuir la satisfacción familiar

INTRODUCTION: Homecare (HC) is a service offering home medical and nursing care to the patient at home in equal quantity and quality as in the hospital. The aim of the article is to describe the changes in the HC of preterm and full-term low-birth-weight infants in our department from 2002-2014. MATERIAL AND METHODS: The HC database is revised. The characteristics of the newborns and the social characteristics of the family in three consecutive time periods are analysed. A satisfaction survey of parents is also presented. RESULTS: The main changes in HC include a decrease in the weight at discharge (from 1880g in the 2002-2006 period to 1850g in the 2011-2014 period; P=.006) and at the end of HC (from 2187g to 2163g; P=.001), an increase in the duration of HC (from 10 to 11 days; P=.007) and a lower incidence of new hospitalization (from 3.4% to 1.3%; P=.019) The social characteristics of the family show a higher maternal age with more previous alive children, a family context better suited with a more appropriate housing, and an increase in exclusive breastfeeding at hospital discharge (from 25.5% to 49.0%; P<.001). The overall assessment of the program is ≥7/10 in 98.8% of responses. CONCLUSIONS: The results of the HC of preterm and low-birth-weight infants have improved over time, saving approximately 10-11 days of hospitalisation, and without compromising the quality of care or reducing family satisfaction

[Changes in homecare for preterm and low-birth-weight infants from 2002 to 2014]. / Evolución de la atención a domicilio para niños prematuros y de bajo peso de nacimiento desde 2002 hasta 2014.

INTRODUCTION: Homecare (HC) is a service offering home medical and nursing care to the patient at home in equal quantity and quality as in the hospital. The aim of the article is to describe the changes in the HC of preterm and full-term low-birth-weight infants in our department from 2002-2014. MATERIAL AND METHODS: The HC database is revised. The characteristics of the newborns and the social characteristics of the family in three consecutive time periods are analysed. A satisfaction survey of parents is also presented. RESULTS: The main changes in HC include a decrease in the weight at discharge (from 1880g in the 2002-2006 period to 1850g in the 2011-2014 period; P=.006) and at the end of HC (from 2187g to 2163g; P=.001), an increase in the duration of HC (from 10 to 11 days; P=.007) and a lower incidence of new hospitalization (from 3.4% to 1.3%; P=.019) The social characteristics of the family show a higher maternal age with more previous alive children, a family context better suited with a more appropriate housing, and an increase in exclusive breastfeeding at hospital discharge (from 25.5% to 49.0%; P<.001). The overall assessment of the program is ≥7/10 in 98.8% of responses. CONCLUSIONS: The results of the HC of preterm and low-birth-weight infants have improved over time, saving approximately 10-11 days of hospitalisation, and without compromising the quality of care or reducing family satisfaction.

[Medication errors in a neonatal unit: One of the main adverse events]. / Los errores de tratamiento en una unidad neonatal, uno de los principales acontecimientos adversos.

INTRODUCTION: Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS: An analysis was performed on the ME declared in a neonatal unit. RESULTS: A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. CONCLUSIONS: It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

[Towards a safety culture in the neonatal unit: Six years experience]. / Caminando hacia una cultura de seguridad en la unidad neonatal: experiencia de 6 años.

INTRODUCTION: A safety culture is the collective effort of an institution to direct its resources toward the goal of safety. MATERIAL AND METHODS: An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment. RESULTS: A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10. CONCLUSIONS: A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.

[Influence of in-home nursing care on the weight of the early discharged preterm newborn]. / Evolución del peso del prematuro con alta precoz y atención domiciliaria de enfermería.

INTRODUCTION: In-Home nursing care of the preterm newborn helps to bring the family situation to normal, promotes breastfeeding and development of the newborn, and enables the reorganization of health care resources. The purpose of this paper is to demonstrate that in-home nursing care of the preterm newborn leads to an increase in weight and a similar morbidity. PATIENTS AND METHODOLOGY: A total of 65 cases and 65 controls (matched by weight, age and sex) were studied, all of them preterm newborns born in hospital and weighing less than 2100 g at discharge. In-home nursing care was carried out by a pediatrician neonatologist, as well as two nurses specialized in neonatology who made several visits to the home. Weight gain was calculated as g/day and g/Kg/day, comparing the first week of the study with the week prior to the beginning of the study. RESULTS: The groups were comparable. Weight gain in the group with home nursing care was 38 g per day, significantly higher than the weight gain in the control group (31 g/day). The independent predictive variables of the increase in g/Kg/day during the study were in-home nursing care, male gender, breastfeeding less, and not having suffered from a peri-intraventricular hemorrhage. Neonatal morbidity was similar in both groups. CONCLUSIONS: In-home care was associated with a greater weight gain of the newborn at home than during their stay in the hospital, and can be considered safe because neonatal morbidity was not increased.

La esperanza desde una perspectiva profesional / Hope from the professional´s perspective

Fundamento. La esperanza, entendida como la confianza en el futuro, requiere la participación activa de la persona, por tanto, es un valor que hay que cultivar. Objetivo. Responder a las preguntas: ¿Puede existir esperanza en medio del sufrimiento? ¿Cuál es la responsabilidad de los profesionales de la salud cuando se trata de esperanza? Método. Revisión bibliográfica y reflexión. Resultados. Ante el sufrimiento, la respuesta no debe ser la huida, sino la esperanza, enfrentarse a él reconociéndolo, rendirse a la L’esperança des d’una perspectiva professional M. Glòria Moretones-Suñol, M. Teresa Esqué-Ruiz Servei de Neonatologia. Hospital Clínic - Maternitat. ICGON. Barcelona evidencia y trascenderlo, haciendo una interpretación positiva que permita reconocer el potencial de crecimiento personal. En el ámbito de la salud, la esperanza del enfermo no sólo se refiere a la curación, sino a que se le tratará con respeto y no se le abandonará. Los profesionales tenemos una responsabilidad con los pacientes en el esfuerzo de reconducir la esperanza, fortaleciendo la confianza en sí mismos y en los profesionales, ayudando a contemplar las posibilidades y alternativas, clarificando las opciones, transmitiendo futuro real, sin falsas expectativas ni espejismos. Se puede resumir en: presencia, disponibilidad, escucha, acompañamiento y compromiso. Se trata de la realización de los valores fundamentales de la profesión. Conclusiones. El ser humano es más profundo de lo que aparenta, y capaz de realizarse a través de las crisis de la vida (AU)

Background. Hope, understood as trust in the future, requires the active participation of the individual; therefore it is a value that needs to be nurtured. Objective. To answer to the questions ‘Could hope exist in the midst of suffering?’ and ‘What is the responsibility of healthcare providers in providing hope?’ Method. Literature review and personal considerations. Results. When facing suffering, the response should not be to flee but to hope, recognizing and facing it, surrendering to the evidence, and going beyond to make a positive interpretation, which recognizes the potential for personal growth. In the field of health services, hope does not only refer to healing of the patient, but also to the respectful treatment and constant support. Professionals have a responsibility towards patients to bring back hope, help build self-confidence and trust in the professionals, help see clearly, consider the possibilities and alternatives, and transmit real future possibilities without false expectations and delusions. The healthcare provider’s role can be summarized as presence, availability, listening, support, and commitment; these are the fundamental values of the profession. Conclusions. The human being is greater and deeper than it appears, and is capable of overcoming life’s crises (AU)

¿Debemos informar al paciente cuando sucede un error asistencial? Apuntes para la reflexión / Should we inform the patient when a medical error occurs? Food for thought

Fundamento. La seguridad asistencial pasa por el compromiso de todos los estamentos de la asistencia sanitaria con los valores de la cultura de seguridad. Uno de estos valores es la transparencia, es decir, informar al paciente cuando existe un cambio no deseado en su proceso clínico. Objetivo. Argumentar y ofrecer datos para la reflexión sobre la necesidad de informar al paciente cuando sucede un error asistencial grave. Método. Revisión bibliográfica. Hem d’informar el pacient quan succeeix un error assistencial? Apunts per a la reflexió M. Glòria Moretones-Suñol, Josep Figueras-Aloy, Sandra Parés-Tercero, Rocío Cortés-Albuixech, Lourdes Arroyo-Gili, M. Teresa Esqué-Ruíz Servei de Neonatologia. Hospital Clínic-Maternitat. ICGON. Barcelona Resultados. Se organizan en 5 apartados que se refieren al paciente, el profesional, aspectos legales, ética y repercusión sobre la seguridad asistencial. Conclusiones. La mayor parte de los pacientes desean ser informados. Cuando el profesional se equivoca con consecuencias graves para la salud del paciente, las emociones negativas y los prejuicios obstaculizan el camino hacia la resolución del error abocando a su perpetuación. Hablar con el paciente ayuda a recuperar la confianza en uno mismo y refuerza la relación. No hablar del error pone los propios intereses por delante de los del paciente y viola los principios éticos de la profesión. El cambio a favor de la seguridad requiere estrategias que no culpabilicen y basadas en la confianza, con el compromiso de pacientes, organizaciones, profesionales y sociedad. Los profesionales deberían ser instruidos en cómo hacer frente a la situación con actitud respetuosa y dialogante, y a pedir perdón(AU)

Background. Patient safety needs the commitment of all health care levels with the values of a safety culture. One of those values is transparency, i.e., to inform the patient when there is an unwanted change in their clinical process. Objective. To review and analyze data on the need to inform the patient when a medical error has occurred. Method. Literature review. Results. The paper is organized in five sections that refer to the patient, the health care provider, the legal aspects, the ethics, and the impact on safety. Conclusions. Most patients would like to be kept informed. When medical errors with serious consequences for the patient occur, the negative emotions and the prejudices that follow obstruct the proper resolution of the error, thus leading to its perpetuation. To inform the patient helps recover the self-confidence and strengthens the relationships. To avoid discussing the error places the provider’s own interests above the patient’s and violates the ethical principles of the profession. Improvements in patient safety require trust-based strategies that do not penalize, and that integrate a compromise of patients, healthcare organizations and providers, and society. The healthcare professionals should be trained on how to apologize and deal with this situation with a very respectful attitude(AU)

[Neonatal convulsions and subarachnoid hemorrhage after in utero exposure to paroxetine]. / Convulsiones y hemorragia subaracnoidea tras exposición a paroxetina in utero.

INTRODUCTION: Selective serotonin reuptake inhibitors (SSRIs) are often used as antidepressants in pregnant women. SSRIs do not appear to increase the teratogenic risk when used in their recommended doses. However, not enough information is available at this time about the risk of toxicity and complications in newborns, after mother treatment with SSRI during the third trimester of pregnancy. We are limited to the existing reports that describe newborns with symptoms due to hyperserotoninemia or withdrawal. CASE REPORT: One newborn whose mother had been treated with paroxetine 20 mg/day during pregnancy, presented convulsions and subarachnoid haemorrhage in the first six hours of life. The newborn did not present symptoms of hypoxic ischaemic encephalopathy, withdrawal syndrome, infection, metabolic alterations, cerebral malformations or coagulopaties. DISCUSSION: The most probable etiology is that the paroxetine could decrease the seizure threshold, taking place the first seizure during delivery. The difficult fetal extraction would have provoked the subarachnoid haemorrhage in a patient with an impaired haemostatic function due to a depletion of platelet serotonin and may also contribute the increased vascular fragility due to paroxetine and reported in adults or in animals. CONCLUSION: Neonatal convulsions and subarachnoid haemorrhage may occur after paroxetine treatment in the third trimester of pregnancy. An accurate follow up of these newborns in the firsts days of life is strongly recommended.

[Blood ammonia and transaminases in full term infants suffering from perinatal asphyxia]. / Amoniaco y transaminasas en sangre en el recién nacido a término afectado de asfixia perinatal.

AIMS: To find hepatic markers of perinatal asphyxia. PATIENTS AND METHODS: Variations in blood ammonia during the first week of life and in transaminase in serum during the first 48 hours were analysed in four groups of newly born infants (NBI): Group I or control, in which 65 NBI were included, with suspected unconfirmed infection and no other pathologies; Group II, made up of 15 NBI with loss of foetal well being (LFW) with no posterior neurological clinical features; Group III, consisting of 27 NBI with LFW criteria and mild hypoxic ischemic encephalopathy (HIE); and Group IV, with 25 NBI with LFW criteria and mild HIE according to Amiel s criteria. RESULTS: The average blood ammonia values in full term infants remain steady during the first week of life (87.66 21.69 mg/dL), as occurs in infants with LFW but without HIE (89.08 24.69 mg/dL) and in those with mild HIE (89.08 20.75 mg/dL). In moderate HIE, the blood ammonia level rises until the third day (108.55 7.04 mg/dL) and then drops back to the initial values (p= 0.0045). When grouped by days, these values show significant differences (p= 0.04), with higher values in Group IV. The NBI with HIE presented higher levels of transaminases, especially of AST (GOT) (p= 0.000001), and this increase is proportional to its gravity. No relation was found between values of blood ammonia and transaminases. CONCLUSIONS: Both blood ammonia and transaminases can be considered to be perinatal asphyxia markers.

Recomendaciones para el transporte perinatal / Recommendations for perinatal transport

El transporte perinatal debe formar parte de los programas de regionalización y planificarse de acuerdo con el mapa sanitario de cada comunidad dentro de un sistema de atención perinatal. Se describen los diferentes tipos de transporte, los medios utilizables con sus ventajas e inconvenientes, el material necesario, la dinámica que se debe seguir ante la necesidad de un traslado perinatal insistiendo en la relevancia del transporte intraútero y del transporte de retorno. La organización del traslado merece una consideración especial, destacando las distintas funciones de los centros coordinador, emisor, receptor y del equipo asistencial del transporte, así como algunos aspectos ético-legales (AU)

[Recommendations for the care of healthy newborn infants]. / Recomendaciones de mínimos para la asistencia al recién nacido sano.

This article makes certain recommendations on the care of the healthy newborn. Firstly, we discuss the situations that should be reported to the pediatrician/neonatologist and the reasons why the presence of these specialists is required in the delivery room (urgent or elective cesarean section, preterm labor). Secondly, we discuss the most important guidelines to follow in the delivery room and after birth. Concerning care in the delivery room, we stress the importance of care of the newborn (especially of the umbilical cord), bonding between the mother and child, identification of the newborn, assessment of neonatal adaptation to extrauterine life, prevention of ophthalmia neonatorum and hypoprothrombinemia, placing the baby correctly in the crib and hepatitis B prophylaxis. Concerning the postnatal period, we recommend feeding (promotion of breast feeding), rooming-in with the mother if the newborn is hospitalized in the nursery screening for hypoacousia and metabolic diseases, and discharge with special surveillance in cases of early discharge.

[Recommendations for perinatal transport]. / Recomendaciones para el transporte perinatal.

Perinatal transport should be integrated into a system of perinatal care within a regional health care program and should be planned according to the healthcare map of each community. We describe the various types of transport, their advantages and disadvantages, the resources required, and the protocol that should be followed in perinatal transfer. We highlight the importance of maternal and neonatal transport. The organization of transfers receives special attention, and we discuss the different functions of the coordinating, referral and receiving centers as well as those of the transport assistance team. We also discuss ethical-legal questions.

Asfixia perinatal y parálisis cerebral / Asfixia perinatal y parálisis cerebral

No disponible

[Invasive catheters in neonates]. / Catéteres invasivos en el recién nacido.

OBJECTIVE: The care of very sick babies requires the use of invasive catheters in the neonatal intensive care unit. Our objective was to review the invasive catheters placed (umbilical and epicutaneous) between 1994 and 1998 and describe the guidelines used to take care of the intravenous lines. PATIENTS AND METHODS: Two periods were compared (January 1994 until June 1997 and July 1997 until September 1998) and characteristics of the patient and catheter were analyzed. During the first period, sepsis related to the catheter was diagnosed according to clinical and analytical criteria and required a positive blood culture. The same criteria were required in the second period, but coincidence of the organisms in the peripheral and catheter blood culture was also needed. RESULTS: A total of 1,285 central catheters were studied in 958 newborn admissions. Umbilical catheter were used in 6% of the cases and epicutaneous in 23%, most of which were in the upper extremities. The most frequent reason to remove the catheter was the end of the indication. The incidence of catheter related sepsis in the first period was 1% and during the second period 6%. Strict diagnostic criteria used in the second period were more predictive for sepsis. If premature babies were considered alone, the incidence increased to 14%. The most frequent organism isolated was Staphylococcus epidermidis. CONCLUSIONS: To decrease the incidence of sepsis related to catheters, a strict protocol for placement and maintenance must be followed.

[Risk and outcome factors in necrotizing enterocolitis]. / Factores de riesgo y pronósticos en la enterocolitis necrotizante.

OBJECTIVE: The objective of this study was to identify risk and outcome factors in necrotizing enterocolitis (NEC). PATIENTS AND METHODS: We have studied 72 cases of NEC collected from 1987 until 1994 in the three hospitals of the integrated Unit. A case-control study matched for gestational age and center was performed for 26 risk factors. Conditional logistic regression was used in significant bivariate variables. The 18 outcome factors had the same statical treatment, but without the paired design. RESULTS: Serous infections previous to NEC, apnea and feeding increments greater than 20 cc/kg/day have been identified as risk factors for preterm babies (p < 0.05). Severe acidosis and pneumoperitoneum have been found significant outcome variables, but with very low discriminatory capacity. CONCLUSIONS: It has been found difficult to identify risk factors for NEC besides the gestational age. Outcome factors have very low sensitivity. Preventive treatment should be directed to decrease the effect of the inflammatory mediators in the gastrointestinal tract.

[Severe infection caused by Candida parapsilosis in an infant]. / Infecciones graves por Candida parapsilosis en el lactante.

Three cases of serious infections due to Candida parapsilosis in infants are reported. Two patients are children exposed to abdominal surgery, parenteral nutrition and antibiotic treatment, who developed catheter-associated sepsis with successful response to change of catheter and intravenous amphotericin B, despite one of the patients showed a relapse some weeks after. Third patient, a hydrocephalic child with external ventricular shunt, developed cerebrospinal fluid infection without response to antifungal treatment and died. Sepsis and meningitis due to Candida parapsilosis can be observed in infants with some risk factors, as use of intravascular or intraventricular catheters. Change of the catheter and treatment with amphotericin B are indicated in these infections.