Diagnosis and management of cardiopulmonary events in very low birth weight infants close to discharge: a quality improvement initiative.

BACKGROUND: Cardiopulmonary events (CPE) have a central, obstructive, or mixed etiology. Lack of standardized diagnosis and management of CPE may prolong the length of stay (LOS). OBJECTIVE: To increase the accuracy of CPE diagnosis and decrease LOS by 10% for preterm infants over a 12-month period. METHODS: Develop an evidence-based algorithm to identify type of CPE, determine management approach, and evaluate cardio-respiratory monitors output. Apply model for improvement and statistical process control charts to determine special cause variation. RESULTS: Identification of central apnea increased from 15 to 39% (p < 0.01). LOS decreased 26% from 52.6 days to 39.2 days, with an estimated cost savings of $13,119 per each of the 225 infants in the initiative. CONCLUSION: After implementing an evidence-based algorithm for management of neonatal CPE, a significant increase in the accuracy of the diagnosis of central apnea and cost savings associated with a decrease in LOS were observed.

Necrotizing Enterocolitis and Growth in Preterm Infants Fed Predominantly Maternal Milk, Pasteurized Donor Milk, or Preterm Formula: A Retrospective Study.

Objective To evaluate the association between necrotizing enterocolitis (NEC), growth, and feeding. Methods This is a retrospective study of 551 infants (birth weight ≤ 1,500 g, ≤32 weeks' gestation). NEC, Bell's stage ≥ 2, was confirmed by independent review of sentinel radiographs. Feeding type was defined as ≥ 50% maternal milk (MM), pasteurized donor human milk (PDHM), or preterm formula (PF). Demographic and clinical characteristics including growth were compared between the three groups. Multivariable regression analysis was performed to control variables that differed in bivariate analysis. Results PDHM and PF mothers were more likely to be African-American, be enrolled in Medicaid, and have chorioamnionitis. PF mothers received antenatal steroids less frequently. NEC rates were different by feeding group (MM: 5.3%; PHDM: 4.3%; PF: 11.4%; p = 0.04). Adjusting for group differences, lower gestational age (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [CI]: 0.74-0.97; p = 0.02], and PF (aOR: 2.53; 95% CI: 1.15-5.53; p = 0.02] were associated with NEC. There were no differences in other health outcomes or growth at hospital discharge. Conclusion MM and PDHM feedings, given until 34 weeks postmenstrual age, were associated with lower rates of NEC in very low birth weight infants without interfering with growth.

First Golden Hour of Life: A Quality Improvement Initiative.

BACKGROUND: Very low birth-weight (<1500 g) infants are vulnerable to their environment during the first hour after birth. We designed an evidence-based golden hour protocol (GHP) with a goal to stabilize and perform admission procedures within 1 hour of birth at a level IIIB neonatal intensive care unit (NICU). PURPOSE: The aim of this quality improvement project was to ascertain whether an evidence-based GHP would improve care efficiency and short-term outcomes. METHODS: Rapid cycles of change using Plan Do Study Act were utilized to document progress and gain knowledge during the quality improvement project. Measures were plotted with statistical process control methods (SPC), which analyzed improvement over time. RESULTS: Both admission temperature and glucose-level means were within reference range throughout the project and predicted a stable process. We observed significantly decreased time to initiation of intravenous fluids and antibiotics. An upward trend of surfactant administration within the first 2 hours of life was also observed. IMPLICATIONS FOR PRACTICE: The use of a GHP provided an organized approach to admission procedures and care. By using a checklist and recording intervention times, NICU caregivers were more aware of time management for each intervention and were able to decrease time to initiation of intravenous fluids and antibiotics. IMPLICATIONS FOR RESEARCH: Future research should focus on establishing normal blood pressure ranges and safe pain management during the "golden hour" and beyond. Future quality improvement should focus on improving subsequent temperature and blood glucose levels after admission umbilical artery and venous catheter placement.