ABSTRACT
OBJECTIVE: Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities? STUDY DESIGN: Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies. RESULTS: Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era. CONCLUSIONS: In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making.
Subject(s)
Infant, Very Low Birth Weight , Multiple Chronic Conditions/classification , Multiple Chronic Conditions/mortality , Quality Improvement/standards , Birth Weight , Female , Gestational Age , Humans , Infant , Infant, Newborn , Intensive Care Units, Neonatal/organization & administration , Male , Morbidity , Oregon/epidemiology , Practice Guidelines as Topic , Prospective Studies , Quality Improvement/organization & administrationABSTRACT
La efusión en el iodo medio es una de las patoligías más frecuentes en pediatría y requiere para su diagnóstico la confirmación de liquido en el oido. La timpanometría es el método objetivo más usadopara confirmar la efusión en el oido medio cuando la otoscopía es dudosa o alterada. La reflectometría acústica es un nuevo método que oferce las ventajas de ser portátil, inodoro y de facil manejo. Objetivo: evaluar la utilidad de la reflectometría acústica en el estudio de efusión del oido medio. Pacientes y método: se estudiaron 105 niños entre 6 meses y 18 años a los que se les realizó timpanometríay reflectometría acústica con un total de 204 iodos evaluados, considerando como riesgo de efusión en el oido medio valores de ángulo de gradiente espectral entre 0 y 64 grados. Resultados: Al comparar la reflectometría con la timpanometría (prueba estandar) se observó una especificidad de 99 por ciento, una sensibilidad de 57 por ciento, un valor predictivo positivo de 97 por ciento y un valor predictivo negativo 75 por ciento. Conclusiones: Estos resultados nos premiten recomendar a la reflectometría acústica como método objetivo para descartar con alta seguridad la presencia de liquido en el oido medio. Por sus ventajas sugerimos su implementación y utilización masiva en la población pediátrica lo que ayudaría a un manejo más expedito y adecuado de la otitis media secretora
