An audit of admissions and mortality of orthopedic indoor patients in a tertiary care hospital of India.

INTRODUCTION: Mortality in orthopaedics is different in underdeveloped, developing and developed countries depending on the health, orthopaedic and trauma care services, education status and social awareness. Analysis of mortality and causes of death is an important step to identify the risk factor. Such study is invaluable for epidemiological monitoring and health care planning. METHODS: Between September 2015 to August 2018 demographic data, timing and primary diagnosis of both mortality and admission were collected retrospectively in a leading tertiary care hospital in the city of Mumbai, India. RESULTS: Total admissions of 10,937 in the 3-year period with increased average monthly admission in the month of June, July and August. Trauma to be most common cause of admission and death and Road traffic accident to be the most common cause of trauma followed by slip and fall. The death rate was 0.55 per 100 admissions per year. In males most common age group was 18-60 years and in females above 60 years of age. CONCLUSION: There is a link of increased admission rate in the monsoon months (rainy season) in India and road traffic accident and slip and fall. So accident prevention and health care planning and management of trauma victim, improvement of quality of life of general population will reduce trauma and related complications.

Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants.

BACKGROUND: Lactoferrin, a normal component of human colostrum and milk, can enhance host defenses and may be effective for prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. OBJECTIVES: To assess the safety and effectiveness of lactoferrin supplementation to enteral feeds for prevention of sepsis and NEC in preterm neonates. Secondarily, we assessed the effects of lactoferrin supplementation to enteral feeds on the duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to update our search. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 9), MEDLINE via PubMed (1966 to 20 January 2020), PREMEDLINE (1996 to 20 January 2020), Embase (1980 to 20 January 2020), and CINAHL (1982 to 20 January 2020). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA: In our search, we included randomized controlled trials (RCTs) evaluating enteral lactoferrin supplementation at any dose or duration to prevent sepsis or NEC in preterm neonates. DATA COLLECTION AND ANALYSIS: We used the standard methods of Cochrane Neonatal and the GRADE approach to assess the certainty of evidence. MAIN RESULTS: Meta-analysis of data from twelve randomized controlled trials showed that lactoferrin supplementation to enteral feeds decreased late-onset sepsis (typical RR 0.82, 95% CI 0.74 to 0.91; typical RD -0.04, 95% CI, -0.06, -0.02; NNTB 25, 95% CI 17 to 50; 12 studies, 5425 participants, low-certainty evidence) and decreased length of hospital stay (MD -2.38, 95% CI, -4.67, -0.09; 3 studies, 1079 participants, low-certainty evidence). Sensitivity analysis including only good methodological certainty studies suggested a decrease in late-onset sepsis with enteral lactoferrin supplementation (typical RR 0.87, 95% CI, 0.78, 0.97; typical RD -0.03, 95% CI, -0.05, -0.0; 9 studies, 4702 participants, low-certainty evidence). There were no differences in NEC stage II or III (typical RR 1.10, 95% CI, 0.86, 1.41; typical RD -0.00, 95% CI, -0.02, 0.01; 7 studies, 4874 participants; low-certainty evidence) or 'all-cause mortality' (typical RR 0.90, 95% CI 0.69, 1.17; typical RD -0.00, 95% CI, -0.01, 0.01; 11 studies, 5510 participants; moderate-certainty evidence). One study reported no differences in neurodevelopmental testing by Mullen's or Bayley III at 24 months of age after enteral lactoferrin supplementation (one study, 292 participants, low-certainty evidence). Lactoferrin supplementation to enteral feeds with probiotics decreased late-onset sepsis (RR 0.25, 95% CI 0.14 to 0.46; RD -0.13, 95% CI -0.18 to -0.08; NNTB 8, 95% CI 6 to 13; 3 studies, 564 participants; low-certainty evidence) and NEC stage II or III (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; 1 study, 496 participants; very low-certainty evidence), but not 'all-cause mortality' (very low-certainty evidence). Lactoferrin supplementation to enteral feeds with or without probiotics had no effect on CLD, duration of mechanical ventilation or threshold retinopathy of prematurity (low-certainty evidence). Investigators reported no adverse effects in the included studies. AUTHORS' CONCLUSIONS: We found low-certainty evidence from studies of good methodological quality that lactoferrin supplementation of enteral feeds decreases late-onset sepsis but not NEC ≥ stage II or 'all cause mortality' or neurodevelopmental outcomes at 24 months of age in preterm infants without adverse effects. Low- to very low-certainty evidence suggests that lactoferrin supplementation of enteral feeds in combination with probiotics decreases late-onset sepsis and NEC ≥ stage II in preterm infants without adverse effects, however, there were few included studies of poor methodological quality. The presence of publication bias and small studies of poor methodology that may inflate the effect size make recommendations for clinical practice difficult.

Development and Validation of Early Warning Criteria to Identify Escalated Care Events in Neonatal Intensive Care Unit Patients.

OBJECTIVE: This study aimed to identify and validate the diagnostic utility of a set of clinical and laboratory criteria (early warning criteria [EWC]) that portend a clinical deterioration event (escalated care event [ECE]) in neonatal intensive care unit (NICU) patients. STUDY DESIGN: Using the RAND appropriateness method, we first established a consensus on seven ECE, that is, events that require additional monitoring, treatment, or stay in the NICU or that were associated with morbidity. We then established consensus on EWC that could portend an ECE from an initial set of 32 potential EWC items to a final set of 10 items. The occurrence and nonoccurrence of EWC and ECE were prospectively identified and tracked over 9 weeks. RESULTS: Among 170 NICU patients studied (2,502 patient-days), the frequency of an EWC was 53 per 1,000 patient-days. Of these patients, 41% had an EWC and 16% had an ECE. An EWC was followed by an ECE within 72 hours, 37% of the time, and within a median time interval of 113 minutes. The sensitivity, specificity, positive predictive values, and negative predictive values of EWC in identifying an ECE were 0.96, 0.69, 0.37, and 0.99, respectively. CONCLUSION: A simple bedside NICU-specific EWC identifies neonates likely to develop ECEs in the NICU.

Mortality and morbidity in outborn extremely low birth weight neonates: a retrospective analysis.

OBJECTIVE: We aimed to identify differences in morbidity and mortality between inborn versus outborn extremely low birth weight (ELBW) infants admitted to the Texas Children's Hospital neonatal intensive care unit (NICU). STUDY DESIGN: Vermont Oxford Network data were analyzed between January 2014 and December 2017. Inborn versus outborn outcomes were compared. RESULT: Of 533 ELBW infants, 402 were inborn, and 131 were outborn. Gestational age and birth weight (BW) were similar. After adjusting outcomes to control for maternal steroids, maternal hypertension, maternal prenatal care, and temperature below 36 °C at admission, no outcomes were significantly different except inborn patients had decreased odds of late onset sepsis (adjusted odds ratio = 0.606, 95% confidence interval: 0.377-0.973, p = 0.038). CONCLUSION: In this study, outborn ELBW patients had increased odds of late onset sepsis compared with inborn ELBW patients after controlling for covariates that differed significantly between these two cohorts.

Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates.

BACKGROUND: Preterm infants who are fed breast milk in comparison to infant formula have decreased morbidity such as necrotizing enterocolitis. Multi-nutrient fortifiers used to increase the nutritional content of the breast milk are commonly derived from bovine milk. Human milk-derived multi-nutrient fortifier is now available, but it is not clear if it improves outcomes in preterm infants fed with breast milk. OBJECTIVES: To determine whether the fortification of breast milk feeds with human milk-derived fortifier in preterm infants reduces mortality, morbidity, and promotes growth and development compared to bovine milk-derived fortifier. SEARCH METHODS: We searched the following databases for relevant trials in September 2018. Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 9), electronic journal reference databases including MEDLINE (1980 to 20 September 2018), PREMEDLINE, Embase (1974 to 20 September 2018), CINAHL (1982 to 20 September 2018), biological abstracts in the database BIOSIS and conference abstracts from 'Proceedings First' (from 1992 to 2011). We also included the following clinical trials registries for ongoing or recently completed trials: ClinicalTrials.gov (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP; www.whoint/ictrp/search/en/) and the ISRCTN Registry (www.isrctn.com/), and abstracts of conferences: proceedings of Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research and European Society for Paediatric Research) from 1990 in the 'Pediatric Research' journal and 'Abstracts online' (2000 to 2017). SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials that compared preterm infants fed breast milk fortified with human milk-derived fortifier versus those fed with breast milk fortified with bovine milk-derived fortifier. DATA COLLECTION AND ANALYSIS: The data were collected using the standard methods of Cochrane Neonatal. Two authors evaluated trial quality of the studies and extracted data. We reported dichotomous data using risk ratios (RRs), risk differences (RDs), number needed to treat (NNT) where applicable, and continuous data using mean differences (MDs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: One randomized trial with 127 infants met the eligibility criteria and had low risk of bias. Human milk-based fortifier did not decrease the risk of necrotizing enterocolitis in exclusively breast milk-fed preterm infants (RR 0.95, 95% CI 0.2 to 4.54; 1 study, 125 infants, low certainty of evidence). Human milk-derived fortifiers did not improve growth, decrease feeding intolerance, late-onset sepsis, or death. AUTHORS' CONCLUSIONS: There is insufficient evidence evaluating human milk-derived fortifier with bovine milk-derived fortifier in exclusively breast milk-fed preterm infants. Low-certainty evidence from one study suggests that in exclusively breast milk-fed preterm infants human milk-derived fortifiers in comparison with bovine milk-derived fortifier may not change the risk of necrotizing enterocolitis, mortality, feeding intolerance, infection, or improve growth. Well-designed randomized controlled trials are needed to evaluate short-term and long-term outcomes.

The relationship between patient safety and quality improvement in neonatology.

Patient safety and healthcare quality have become foundational components of neonatal care, and hospitals and neonatal intensive care units have developed robust programs and structures committed to improving outcomes through rigorous quality improvement methods. Despite increasingly more sophisticated frameworks for defining and understanding quality, the relationship between patient safety and health care quality is not clearly defined. Safety is often defined as the avoidance of injury and harm, while quality is typically defined as achieving the best possible health care outcomes. Safety can be considered one of multiple domains of quality, and safety can also be considered synonymous with quality. Regardless, both safety and quality are driven by systems of care, and improvement methods should focus on understanding and improving these systems. While many improvement methods will apply to safety goals or quality goals, there are unique aspects of patient safety that require specific tools and approaches. Achieving the safest and highest quality healthcare for our patients and families requires an understanding of the tools needed to improve both safety and quality.

Diagnostic errors in the neonatal intensive care unit: State of the science and new directions.

Diagnostic errors remain understudied in neonatology. The limited available evidence, however, suggests that diagnostic errors in the neonatal intensive care unit (NICU) result in significant and long-term consequences. In this narrative review, we discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. We then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error. This multifactorial causation has limited the development of methodology to measure diagnostic errors as well as strategies to mitigate and prevent their adverse effects. We recommend research focused on the frequency and etiology of diagnostic error in the NICU as well as potential mitigation strategies to advance this important field in neonatal intensive care.

Mask versus Prongs for Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis.

Nasal continuous positive airway pressure (NCPAP) is an effective method of respiratory support for preterm infants. Nasal masks and binasal prongs are two interfaces available to deliver NCPAP, and it is unclear if one is superior to the other. We conducted a systematic review and meta-analysis, using the methodology recommended by the Cochrane Collaboration, to compare the efficacy and safety of nasal masks versus binasal prongs to deliver NCPAP in preterm infants <37 weeks of gestation. Ovid MEDLINE, Embase, Scopus, the Cochrane database, and PubMed were searched in February 2019. Seven trials met the inclusion criteria. Among preterm infants requiring NCPAP, the use of a nasal mask, compared to nasal prongs, decreased the rate of NCPAP failure within 72 h (RR 0.72, 95% CI 0.53-0.97; number needed to treat for an additional beneficial outcome [NNTB] 12.5, 95% CI 7.1-100; 5 trials, 576 participants; low-certainty evidence) and the incidence of nasal injury (RR 0.71, 95% CI 0.59-0.85; NNTB 8.3, 95% CI 5.6-16.7; 6 trials, 665 participants; low-certainty evidence). In a subgroup of preterm infants requiring NCPAP after resuscitation at birth, the use of a nasal mask decreased the incidence of moderate-to-severe bronchopulmonary dysplasia (RR 0.47, 95% CI 0.23-0.95; NNTB 16.7, 95% CI 9.1-100; 4 trials, 395 participants; very-low-certainty evidence) and the need for subsequent surfactant administration (RR 0.78, 95% CI 0.64-0.96; NNTB 8.33, 95% CI 4.54-33.33; 4 trials, 395 participants; low-certainty evidence). The use of nasal masks for preterm infants requiring NCPAP was associated with a reduction in NCPAP failure, need for surfactant administration, and moderate-to-severe bronchopulmonary dysplasia (low- to very-low-certainty evidence). Given the potential clinical benefit and minimal risk associated with a change in patient interface, nasal masks should be considered the preferred interface for NCPAP delivery in preterm infants.

Aletheia-20 unconcealed observations from quality improvement and evidence-based medicine.

Quality improvement (QI) and evidence-based medicine (EBM) activities ideally generate value (benefit/cost). Physicians and hospitals vary in ability to demonstrate efficiency despite common methodology available to all. Based upon our 60-some years of combined QI and EBM experience, we suggest reasoned consideration of meta-cognition-thinking about thinking. How do we observe, analyze, intuit, then share observations and learning with collaborative networks? The Greek word aletheia denotes disclosure of the essence of an object or event as its genuine nature, "unhidden, revealed, unconcealed". Aletheia is authenticity, not a claim or opinion, not an argument or hypothesis, nor an intervention-based assertion. QI and EBM have crucial features obscured by the lure and distraction of technology, economic conflicts, and inherent self-interests. We offer 20 QI and EBM observations in the spirit of aletheia. Enhancing the well-being of children is the foundation of a civilized society, a journey needful of shared QI understanding.

Diagnostic Errors in the Neonatal Intensive Care Unit: A Case Series.

Diagnostic errors remain understudied in neonatal intensive care units (NICUs). The few available studies are primarily autopsy-based, and do not evaluate diagnostic errors that did not result in the patient's death. This case series presents 10 examples of nonlethal diagnostic errors in the NICU-classified according to the component of the diagnostic process which led to the error. These cases demonstrate the presence of diagnostic error in the NICU and highlight the need for further research on this important topic.

Decreasing Central Line-associated Bloodstream Infections Through Quality Improvement Initiative.

OBJECTIVE: To study the impact of a quality improvement (QI) initiative using care bundle approach on Central-line associated bloodstream infections (CLABSI) rates. METHODS: A QI team for infection control in NICU was formed in a tertiary-care neonatal intensive care unit (NICU) from June 2015 to August 2016. Baseline data were collected over first 3 months followed by the intervention period of 1 year. Measures with respect to strengthening hand hygiene and central line bundle care were implemented during the intervention period. Audits assessing the compliance to hand hygiene and CLABSI bundle protocols were used as process indicators. Multiple PDSA cycles were used to strengthen the practices of proposed interventions, documentation of data and audits of the processes during the study period. RESULTS: The QI initiative achieved a 89% reduction in CLABSI from the baseline rate of 31.7 to 3.5 per 1000 line-days. The blood stream Infections reduced from 7.3 to 2.3 per 1000 patient-days. The overall mortality showed a reduction from 2.9% to 1.7% during the intervention period. There was a significant improvement in compliance with hand hygiene protocol and compliance with CLABSI protocols. CONCLUSION: This study demonstrated that simple measures involving hand hygiene and strengthening of the care bundle approach through quality improvement could significantly reduce the blood stream Infections and CLABSI rates.