A recorder/time coach decreases time errors during neonatal resuscitation: A randomized, simulation-based clinical trial.

Aim: To evaluate the effects of a hands-off recorder/time coach versus an additional hands-on healthcare provider on Neonatal Resuscitation Program (NRP) algorithm compliance and team member workload in neonatal resuscitations. Methods: Two interventions were studied using a 2 × 2 factorial design: an additional hands-on team member and the presence of a designated, hands-off recorder/time coach. The recorder/time coach documented interventions and delivered pre-specified prompts at defined points during the resuscitation. The primary outcome was cumulative time error. Secondary outcomes were time to first dose of IV epinephrine, overall team performance as assessed by the Neonatal Resuscitation Performance Evaluation (NRPE) score, and workload assessed by the NASA Task Load Index (NASA TLX). Results: 64 teams were studied. Teams with a recorder had a significantly lower cumulative time error compared to teams without a recorder (p < 0.001). An additional hands-on team member did not change cumulative time error. There was no difference in time to first dose of IV epinephrine or NRPE score in these comparisons. Ad-hoc analysis did reveal a significant increase in time to IV epinephrine in teams with the minimum of four total members (p = 0.025). A recorder/time coach increased team leader NASA TLX overall workload score (p = 0.047), but an additional hands-on team member did not. Conclusion: A designated, hands-off recorder/time coach improved compliance by decreasing cumulative time error in teams performing complex simulated neonatal resuscitations.

Improving communication between obstetric and neonatology teams for high-risk deliveries: a quality improvement project.

Summoning is a key component of communication between obstetrics and neonatal resuscitation team (NRT) in advance of deliveries. A paging system is a commonly used summoning tool. The timeliness and information contained in the page help NRT to optimally prepare for postdelivery infant care. Our aim was to increase the frequency that summoning pages contained gestational age and reason for NRT attendance to >90%. At baseline, 8% of pages contained gestational age and 33% of pages contained a reason for NRT attendance. Sequential Plan-Do-Study-Act cycles were used as our model for quality improvement. During the 8-month improvement period, the per cent of pages increased to 97% for gestational age and 97% for reason for NRT attendance. Measures of page timeliness, our balancing measure, did not change. Summoning communication between obstetric and NRT is crucial for optimal perinatal outcomes. The active involvement of all stakeholders throughout the project resulted in the development of a standardised paging tool and a more informative paging process, which is a key communication tool used in many centres.

Nasal Staphylococcus aureus colonization among mothers of term and late preterm previously healthy neonates with community-acquired Staphylococcus aureus infections.

We enrolled 35 case neonates with community-acquired Staphylococcus aureus infection and their mothers and 19 control mother-neonate pairs. We obtained neonatal and maternal anterior nasal cultures, and clinical isolates. S. aureus nasal colonization was greater in case than control pairs. Neonates were more often infected with their nasal strain than their mother's nasal strain.

Evaluation and treatment of community-acquired Staphylococcus aureus infections in term and late-preterm previously healthy neonates.

OBJECTIVE: We describe the evaluation and treatment of neonatal community-acquired Staphylococcus aureus disease in the era of community-acquired methicillin-resistant S. aureus. METHODS: We retrospectively reviewed the evaluation and treatment of 126 community-acquired S. aureus infections of term and late-preterm previously healthy neonates who were < or = 30 days of age between August 2001 and July 2006 at Texas Children's Hospital. RESULTS: S. aureus infections included 43 pustulosis, 68 cellulitis/abscess, and 15 invasive infections. We found 84 methicillin-resistant and 42 methicillin-susceptible S. aureus isolates. Twenty-one patients received outpatient antibiotics before hospital presentation. Systemic infection evaluation included urine, blood, and cerebrospinal fluid cultures in 79, 102, and 84 neonates, respectively. Culture revealed S. aureus urinary tract infections in 1, S. aureus bacteremias in 6, and aseptic cerebrospinal fluid pleocytosis of unclear cause in 11 neonates. Physicians admitted 106, transferred 5 to other hospitals, and discharged 15 afebrile patients with topical or oral antibiotics. Clindamycin was the predominant antistaphylococcal intravenous and oral antibiotic for pustulosis and cellulitis/abscess infections. One patient with systemic S. aureus and herpes simplex virus infection died. At discharge after inpatient treatment, physicians prescribed no antibiotics for 43 patients and oral or topical antibiotics for 62 patients. Outpatient treatment failed for 1 patient who was discharged after intravenous therapy and was readmitted. Eighty percent (16 of 20) of patients with mastitis alone completed treatment with outpatient oral antibiotics. CONCLUSIONS: Evaluation and treatment strategies for neonatal community-acquired S. aureus disease are varied at our hospital. Prospective studies are needed to determine optimal management strategies.

Subtle genetic changes enhance virulence of methicillin resistant and sensitive Staphylococcus aureus.

BACKGROUND: Community acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) increasingly causes disease worldwide. USA300 has emerged as the predominant clone causing superficial and invasive infections in children and adults in the USA. Epidemiological studies suggest that USA300 is more virulent than other CA-MRSA. The genetic determinants that render virulence and dominance to USA300 remain unclear. RESULTS: We sequenced the genomes of two pediatric USA300 isolates: one CA-MRSA and one CA-methicillin susceptible (MSSA), isolated at Texas Children's Hospital in Houston. DNA sequencing was performed by Sanger dideoxy whole genome shotgun (WGS) and 454 Life Sciences pyrosequencing strategies. The sequence of the USA300 MRSA strain was rigorously annotated. In USA300-MRSA 2658 chromosomal open reading frames were predicted and 3.1 and 27 kilobase (kb) plasmids were identified. USA300-MSSA contained a 20 kb plasmid with some homology to the 27 kb plasmid found in USA300-MRSA. Two regions found in US300-MRSA were absent in USA300-MSSA. One of these carried the arginine deiminase operon that appears to have been acquired from S. epidermidis. The USA300 sequence was aligned with other sequenced S. aureus genomes and regions unique to USA300 MRSA were identified. CONCLUSION: USA300-MRSA is highly similar to other MRSA strains based on whole genome alignments and gene content, indicating that the differences in pathogenesis are due to subtle changes rather than to large-scale acquisition of virulence factor genes. The USA300 Houston isolate differs from another sequenced USA300 strain isolate, derived from a patient in San Francisco, in plasmid content and a number of sequence polymorphisms. Such differences will provide new insights into the evolution of pathogens.

Community-acquired Staphylococcus aureus infections in term and near-term previously healthy neonates.

BACKGROUND: Community-acquired, methicillin-resistant Staphylococcus aureus infections are increasing among children. OBJECTIVE: Our goal is to describe the clinical presentation of neonatal community-acquired S aureus disease and provide molecular analyses of the infecting isolates. PATIENTS AND METHODS: We retrospectively reviewed the demographics and hospital course of term and near-term previously healthy neonates, < or = 30 days of age, with community-acquired S aureus infections presenting after nursery discharge between August 2001 and March 2005 at Texas Children's Hospital. Prospectively collected isolates were characterized by pulsed-field gel electrophoresis, staphylococcal cassette chromosome mec type, and the presence of PVL genes. RESULTS: Of 89 S aureus infections, 61 were methicillin-resistant S aureus; S aureus infections increased each year. Methicillin-resistant S aureus infections increased from 10 of 20 to 30 of 36 infections from 2002 to 2004. Most subjects, 65 of 89, were male. Symptoms began at 7 to 12 days of age for 26 of 45 male infants with methicillin-resistant S aureus. Most infections, 77 of 89, involved skin and soft tissue; 28 of 61 methicillin-resistant S aureus versus 7 of 28 methicillin-susceptible S aureus infections required drainage. Invasive manifestations included shock, musculoskeletal and urinary tract infection, perinephric abscess, bacteremia, empyema/lung abscess, and a death. Maternal S aureus or skin-infection history occurred with 13 of 61 methicillin-resistant S aureus versus 1 of 28 methicillin-susceptible S aureus infections. The predominant community clone, USA300 (PVL genes +), accounted for 55 of 57 methicillin-resistant S aureus and 3 of 25 methicillin-susceptible S aureus isolates. CONCLUSIONS: Community-acquired methicillin-resistant S aureus is a substantial and increasing proportion of S aureus infections in previously healthy neonates. Male infants 7 to 12 days of age are affected most often. Neonatal community-acquired S aureus infection may be associated with concurrent maternal infection. USA300 is the predominant clone among these neonatal isolates in our region.