Impact of pharmaceutical validation on prescribing errors in a neonatal intensive care unit. Randomised and controlled study.

Purpose: To compare the frequency of electronic prescription errors when the prescription was validated by the clinical pharmacist vs. when it was not. Methods: This prospective randomised controlled study was conducted in three phases. A randomised phase, in which patients were divided into control and intervention groups, and a pre- and post-intervention phase were consecutively performed to analyse the impact of pharmaceutical validation of prescriptions in a neonatal intensive care unit (NICU). This study was performed at a highly complex NICU at a tertiary hospital. All patients born during the study period who were admitted to the NICU, with a stay lasting ≥24 h, and received active pharmacological treatment were included in the study. Pharmaceutical validation was performed according to the paediatric pharmaceutical care model. A high level of validation was selected for this study. In the intervention group, discrepancies found during the review process were communicated to the medical team responsible for the patients and resolved on the same day. Results: In total, 240 patients were included in this study. Sixty-two patients were allocated to the pre-intervention (n = 38) or post-intervention (n = 24) groups, and 178 patients were randomly sorted into two groups, control (n = 82 newborns) and intervention (n = 96 newborns). During the randomisation phase, the number of prescription errors detected was significantly lower in the intervention group than that in the control group (129 vs. 270; p < 0.001). Similarly, prescription errors reaching the patient were significantly reduced from 40% (n = 108) in the control group to 1.6% (n = 2) in the intervention group. In the pre- and post-intervention periods, the prescription lines containing prescription errors decreased from 3.4% to 1.5% (p = 0.005). Conclusions: This study showed that the pharmaceutical validation process decreased both the number of errors in the electronic prescribing tools and the number of prescription errors reaching the patient.

Comparison of two methods for cleaning breast pump milk collection kits in human milk banks.

BACKGROUND: Appropriate decontamination of breast pump milk collection kits (BPKs) is critical to obtain safe milk for infants and to avoid discarding donor human milk (DHM). AIM: To evaluate two strategies for BPK decontamination by assessing microbial cultures and the proportion of discarded DHM, according to the criteria of the National Institute for Health and Care Excellence for pre-pasteurization cultures. METHODS: Prospective comparative study, allocation ratio 1:1, microbiologist-blind. PARTICIPANTS: 47 new donors in a human milk bank in Madrid. INTERVENTIONS: Study group (N=21): BPKs washed with water and detergent after each use and further steam decontamination within a microwavable bag. Control group (N=26): washing, rinsing and drying only. Five samples: first sample by hand expression and four samples (one per week) collected using the same pump and method. OUTCOMES: Primary: proportion of DHM discarded due to contamination. Secondary: comparison of the microbiota between samples obtained by hand expression and breast pump in both groups. FINDINGS: In total, 217 milk samples were collected: 47 by hand expression and 170 by pump expression (78 from study group). Steam decontamination of BPKs using a microwavable bag after washing resulted in a lower proportion of discarded DHM samples (1.3% vs 18.5%, P<0.001) and samples contaminated with Enterobacteriaceae (1.3% vs 22.8%, P<0.001) and Candida spp. (1.3% vs 14.1%, P<0.05) compared with samples collected with BPKs that were washed but not steam decontaminated. There were no differences in bacterial contamination between samples obtained using steam decontaminated BPKs and those obtained by hand expression. CONCLUSIONS: Steam decontamination of BPKs using a microwavable bag after washing decreases the amount of discarded DHM and the number of samples with potentially pathogenic bacteria.

Short communication: Effect of refrigerated storage on the pH and bacterial content of pasteurized human donor milk.

Once pasteurized donor milk is thawed for its administration to a preterm or sick neonate, and until it is administered, it is kept refrigerated at 4 to 6°C for 24 h. After this time, unconsumed milk is discarded. This time has not been extended, primarily because of the concern of bacterial contamination. The aim of this study was to determine the changes in pH and bacterial count when pasteurized donor milk was kept under refrigeration for a prolonged period (14 d). In this prospective study, 30 samples of pasteurized donor milk from 18 donors were analyzed. Milk was handled following the regular operating protocols established in the neonatal unit and was kept refrigerated after thawing. pH measurements and bacteriology (on blood agar and MacConkey agar plates) were performed on each sample at time 0 (immediately after thawing) and then every day for 14 d. Changes in pH of samples over time were evaluated with linear mixed-effects regression models. A slow but gradual increase in milk pH was observed starting from the first day [mean (±SD) pH of 7.30 (±0.18) at time 0 and 7.69 (±0.2) on d 14]. No bacterial growth was observed in any of the samples throughout the complete trial except in one sample, in which Bacillus flexus was isolated. In conclusion, pasteurized human donor milk maintains its microbiological quality when properly handled and refrigerated (4-6°C). The slight and continuous increase in milk pH after the first day could be due to changes in the solubility of calcium and phosphate during refrigerated storage.

[Magnetic resonance imaging without sedation in neonates]. / Resonancia magnética sin sedación en recién nacidos.

INTRODUCTION: The ability to perform magnetic resonance imaging (MRI) without sedation in the neonatal period increases patient safety, availability and profitability of the diagnostic tool. The aim in this study was to evaluate a new protocol of MRI without sedation during a 20-month period. In the protocol, the patients are prepared in the neonatal unit. PATIENTS AND METHOD: Prospective descriptive study, from May 2012 to December 2013. Patients included were neonates requiring MRI, clinically stable and not requiring ventilatory support. The method was based on the application of developmental centered care and the use of a vacuum matress to immobilize the baby. The principal outcome parameter of interest was the percentage of succesfully completed MRIs. The duration of the MRI and the number of interruptions, was also studied from October 2012. RESULTS: A total of 43 MRIs without sedation were carried out on 42 patients: 41 cerebral and 2 spinal. The success rate was 97.7% (42/43). The mean MRI time was 26.3 minutes (95% CI 23.3-29.3 mins; range 16-50 mins). MRIs were completed without interruption in 20 of the 34 cases (58%) in which the duration was recorded. The number of interruptions per procedure varied from 0 to 3, with a mean of 0.6 (95% CI 0.3-0.8) and a median of 0. CONCLUSION: The protocol had a success rate of over 90%. Thus MRI without sedation seems applicable in Spanish hospitals, with most of the preparation being performed in the neonatal unit, in order to reduce the occupation of the MRI unit, as well as minimizing stress to the baby.

[Clinical impact of opening a human milk bank in a neonatal unit]. / Impacto en la práctica clínica de la apertura de un banco de leche en una unidad neonatal.

INTRODUCTION: The benefits of donor human milk compared with artificial formulas have been well demonstrated; nevertheless the impact in the clinical practice of opening a human milk bank within a neonatal unit has not yet been studied. The main aim of this study was to analyze the impact on the clinical practice of opening a human milk bank in a neonatal unit to provide donor human milk for preterm infants ≤ 32 weeks of gestational age. METHODS: A before and after study was designed, with the intervention being the opening a human milk bank. Preterm infants ≤ 32 weeks of gestational age born in the Hospital 12 Octubre from July to December 2005 and January to June 2008 (firsts 6 months after opening the human milk bank) were included. RESULTS: After opening the human milk bank, enteral feedings were started 31h before (P<.001), 100ml/kg/day were achieved 59.5h before (P<.001) and 150 ml/kg/day 52 h before (P=.002). Enteral feedings were never started LM with artificial formula, the exposure to formula in the first 15 days of life was reduced from 50% to 16.6%, and it's consumption during the first 28 days of life was significantly reduced. There was a higher consumption of own mother's milk during the hospital stay, and a higher rate of exclusive breastfeeding at hospital discharge (54% vs 40%). CONCLUSIONS: The availability of donor human milk has led to quicker progression with enteral feedings and earlier withdrawal of parenteral nutrition. It has reduced the exposure to artificial formulas, and has also increased the intake of own mother's milk during the hospital stay and the rate of exclusive breastfeeding at hospital discharge.

[Incidence of unplanned extubations in a neonatal intensive care unit. A before and after study]. / Frecuencia de extubaciones no programadas en una unidad de cuidados intensivos neonatales. Estudio antes y después.

INTRODUCTION: Unplanned extubations (UE) of mechanically ventilated newborns involves an undesirable increase in morbidity and mortality. OBJECTIVE: A 2-stage study compared the frequency of UE in a Neonatal Intensive Care Unit before and after the implementation of a program of preventive measures to decrease UE. PATIENTS AND METHODS: A before and after prospective study included all mechanically ventilated newborns participating in the 2 stage study from May-December 2011 and June-December 2012. In stage 1, the rate of UE per 100 intubated patient days was calculated and the characteristics of unplanned extubated newborns, circumstances of UE occurrence and need for re-intubation were studied. Consequently, a program of preventive measures for UE was designed and implemented, with the same variables being analysed in stage 2. RESULTS: No differences were found in patient characteristics during the two stages. Stage 1, incidence of UE was 5/100 intubated patient days; Stage 2, 4.5 UE/100 intubated patient days (P=.657). In both stages, most UE occurred during patient handling with re-intubation incidence at 77.4% and 67.7%, respectively. The combined rate of both stages during summer months of July, August and September was 6.2 UE/100 intubation days, in contrast with the remaining months of both stages: UE incidence rate, 3.4 UE/100 intubation days (p=.043). CONCLUSIONS: The implementation of a preventive measures program did not significantly reduce the incidence of UE. The summer period showed the highest incidence of UE.

[Profile of human milk bank donors and relationship with the length of the donation]. / Características de las mujeres donantes de un banco de leche materna y relación con el tiempo de donación.

INTRODUCTION: The promotion of Human Milk Banks is an important social service. The Human Milk Banks depend on donors, and knowing the profile of donors seems quite important. OBJECTIVE: To study the demographics and lifestyles of the donors, the reasons or influences for donating, and to associate these variables with the length of the donation. METHODS: This is a descriptive, cross-sectional study conducted on 168 mothers who answered the written questionnaire when they agreed to become donors. 98 (58%) responded to the telephone interview. RESULTS: The mean age was 33.1 ± 4.5 years. Of the total 27.9% lived outside Madrid and 21.4% were immigrants, with 23.7% working full time, 65.3% had a university education, and 96.2% had a stable partner. The main reasons for donating were too much milk (77%), and to help others (75%). The main obstacle was transportation to the Human Milk Bank for 20% of the donors, and for 61% the main reason for terminating donation was due to reaching the end of lactation. A longer donation is associated with: having a term newborn, with birth weight over 1500 g, starting donating early and reconciling the donation to the work situation. CONCLUSION: The most common donor profile was a young woman, with university education and a stable partner. Having a term new born, starting donating early, and the conciliation with work is associated with longer donations. Milk pick-up at home would make donation easier.

[Effect of freezing on the "creamatocrit" measurement of the lipid content of human donor milk]. / Medida por crematocrito del contenido calórico de la leche materna donada congelada.

OBJECTIVE: To determine, by the creamatocrit measurement, the effect on the fat content of raw and pasteurized donor milk of freezing during 3 months at -20 °C. METHODS: The evolution of the creamatocrit measurement (following Lucas technique) on frozen (-20 °C), raw and pasteurized human milk, was analyzed during 3 months. RESULTS: The fat content of raw milk (n=44) was 3.19 g/dl at the beginning and 2.86 g/dl after 3 months frozen (p=0.02). In pasteurized milk (n=36) fat content at the first determination was 2.59 g/dl and 2.20 g/dl after 1 month frozen (p=0.01). Afterwards there were no significant changes up to 3 months frozen. Variability was observed in the intermediate values. CONCLUSIONS: A reduction on the fat content measurement of raw and pasteurized donor human milk after freezing was observed. Freezing does not inactivate the milk lipase but does destroy the fat globule. Creamatocrit measurement may not be the best method to determine the fat content of processed human milk.

[Study of anxiety levels in neonatal unit staff]. / Estudio de los niveles de ansiedad en los profesionales de una unidad neonatal.

INTRODUCTION: The professionals who routinely work in neonatal units become under stress due to the working conditions and the nature of the tasks carried out. As a consequence of this, they may have high levels of anxiety. Anxiety is defined as an emotional response or response patterns that include cognitive, physiological and behavioural aspects. METHODS: A prospective cross-sectional study was conducted on all neonatologist, nurses and care assistants who were given two self-administered questionnaires under baseline conditions, to assess Sate Anxiety and Trait Anxiety. (IDDA-EA; STAI, State-Trait Anxiety Inventory). RESULTS: The response rate was 88.5%, and 36% scored between 30 and 70 percentiles on State Anxiety, with 11.8% above the 70 percentile and 51% below the 30 percentile. There were no significant differences in relation to occupation or age. There were also no significant differences between State and Trait Anxiety. Regarding gender, it has obtained A statistically significant difference of 8 points higher was obtained for women. CONCLUSIONS: For the majority professionals everyday situations in which are involved do not significantly raise the burden of anxiety, as half of them have levels below the average. They perceive themselves as competent and able to cope with their tasks. They have a high degree of interest and attention in the activities performed.

[Profile of parenteral nutrition prescription in very low birth weight infants: period 2006 to 2010]. / Perfil de prescripción de nutrición parenteral en recién nacidos de muy bajo peso al nacer: período 2006 a 2010.

INTRODUCTION: Early administration of nutrients in adequate amounts is of vital importance to preterm infants because it decreases the time needed to reach the expected weight and tolerate enteral nutrition as well as reducing their hospital stay. The main objective of this study was to analyze the prescription of parenteral nutrition (PN) in patients weighing less than 1,500 g at birth in their first 7 days of life during the years 2006-2010 in our hospital and the adequacy of those requirements to the recommendations. MATERIALS AND METHODS: Amino acids, glucose, lipids (g/ kg/day) and calories (kcal/kg/day) prescribed in the PN of the first week of life were collected. RESULTS: We studied 1899 parenteral nutrition prescriptions from 2006 to 2010 corresponding to the first week of life of 360 patients weighing less than 1,500 g. The caloric content increased from an average of 41.83 kcal/kg/day (1.89 g/kg/ day of amino acids and 0.69 g/kg/day lipids) on the first day of life to 80.61 kcal/kg/day (3.2 g/kg/day of amino acids and 2.4 g/kg/day of lipids) on the seventh day. About 70% of prescriptions for the children who had PN on the first day of life contained lipids. But when all children who had PN on the fourth day were considered, only 17% of these patients had lipid intake on the first day of life. No prescription exceeded 120 kcal/kg/day. Only 17.9% on the sixth day and 25.5% on the seventh day received more than 90 kcal/kg/day. In our hospital PN is not prepared on Sundays and holidays. 30.1% and 56.9% of children born on weekdays received PN the first and second day versus 11.6% and 38.8% of those born on a holiday or the day before holiday. CONCLUSIONS: A high percentage of premature babies do not get the recommended amounts of nutrients in their first week of life in our hospital.

[Use of pacifiers and breastfeeding]. / Uso del chupete y lactancia materna.

Pacifiers are widely used in developed societies. They are used for soothing infants, reducing their stress and pain during procedures and to help them sleep. The use of pacifiers has been associated, however, with a shorter duration and exclusivity of breastfeeding, with higher rates of otitis media and dental problems, as well as a higher risk of accidents during infancy. Recent studies have also described a relationship between pacifier use and SIDS, especially when used during infant́s sleep. Other described benefits are analgesia and stimulation of non-nutritive sucking in preterm and term infants. There is, at present, wide debate and controversy on whether or not to recommend its use; thus it seems important for professionals and parents to be aware of the risks and benefits associated to its use, particularly related to breastfeeding. Due to the existing controversy of scientific findings, the Committee on Breastfeeding of the Spanish Paediatrics Society, publishes this review, trying to summarise present evidence with the objective of, after analysing scientific results and recommendations, making recommendations regarding the use of the pacifier in the breastfed infant.

[Outcome of newborn with birth weight less than or equal to 1500g and gestational age less than or equal to 32 weeks, during the 2 first years of age corrected: comparison of two time periods]. / Seguimiento de recién nacidos de peso menor o igual a 1.500g y edad gestacional menor o igual a 32 semanas durante los 2 primeros años de edad corregida: comparación de 2 periodos de tiempo.

INTRODUCTION: Advances in perinatal care have resulted in increased survival rates for extremely low birth weight children, but it is fundamental to know if these improved survival rates have been accompanied by increased impairment rates. OBJECTIVE: To compare, over two different time periods, the survival and disability rates at 2 years of corrected age, among newborns < or =32 weeks and weighed < or = 1500 g at birth. METHODOLOGY: Follow-up study that included 963 children born in the hospital between 1991 and 2004 who met the study criteria. Neonatal morbidity, mortality and disability to 2 years of corrected age in 2 time periods 1991-1998 (period I) and 1999-2004 (period II) have been evaluated and analysed by subgroups of weight (weight < 1000 g and 1000-1500 g). RESULTS: Mortality decreased significantly during the second period, both for children with birth weight <1000 g (32% vs 44%) as for those with birth weight between 1000 and 1500 g ( 3,6% vs 9%). Analysing all children < or = 1500 g, an increase in the survivors without disability was observed in the second period (69% vs 60%, p=0.003); but by subgroups this increase only was significant in children with birth weight 1000-1500 g (67% vs 82%). CONCLUSIONS: In our study, globally analysing all children with birth weight < or = 1500 g, it can be seen that there has been an increase in survival without an increase in the frequency of disabilities. Analysing by weight subgroups, survival has increased in both groups, but disability has decreased only in the birth weight 1000-1500 g subgroup.

[Retinopathy of prematurity. Prevention, screening and treatment guidelines]. / Retinopatía de la prematuridad. Recomendaciones para la prevención, el cribado y el tratamiento.

ROP screening is carried out at all the Spanish hospitals, but there is little agreement on the criteria used for its screening and other aspects related to its practice. Our aim is to report on recommendations for prevention, screening, treatment and follow-up of the retinopathy of prematurity in Spain. Prevention strategies and recommendations for screening, exploration and treatment of ROP, as well as of the organisation of the services to carry out it are reviewed. The most recent bibliography on the basis of the scientific evidence is considered, taking as reference, the guidelines published by the American Academy of Pediatrics (AAP) in 2006 and the recommendations updated in 2007 in the United Kingdom. The recommended prevention strategies are based on the best neonatal practice. The standards, as far as the screening is concerned, are established by birth weight (< or =1,500 g), gestational age (< or =32 weeks) and unstable neonatal clinical course. Indirect ophthalmoscopy is the standard technique for exploration and laser therapy the treatment of choice.