Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial: a protocol for a multicentre, stepped-wedge cluster randomized trial.

BACKGROUND: Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada. METHODS: In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process. INTERPRETATION: The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT05231200.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention.

BACKGROUND: Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes. METHODS: A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation. DISCUSSION: The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0522662. Registered February 4th, 2022.

Fostering Hope: Comprehensive Accessible Mother-Infant Dyad Care for Neonatal Abstinence (CAIN).

Hospital and community healthcare providers have expressed concerns around the continuity and quality of care for infants with neonatal abstinence syndrome (NAS) during hospitalization and transition home. This qualitative study explored the experiences of hospital and community-based healthcare providers and identified themes related to the management of NAS for mothers and infants. Healthcare providers that cared for women with substance use disorders and/or cared for newborns with NAS in a large urban setting in Canada met inclusion criteria for this study and were interviewed in groups or as individuals. Interview transcripts were reviewed iteratively using inductive thematic analysis to identify an overarching theme linked with primary themes. In total, 45 healthcare providers were interviewed. Qualitative analysis of their experiences derived the overarching theme of hope with five primary themes being: mother/infant, mental health, system, judgement, and knowledge. The study identified gaps in NAS care including fear, stigma, and language. This research demonstrates that programs and interventions that work with mothers and newborns with NAS must foster hope in mothers, families, and in the extended care provider team and improve communication between hospital and community networks.

To Improve Homicide Firearm Information Reporting - Rhode Island State Crime Laboratory.

Information on homicide firearms can be used to help state and local communities understand the problems of violence and decrease injuries and deaths. However, it is difficult to collect these data. To our knowledge, in the public health arena, the National Violent Death Reporting System (NVDRS) is the only system that collects detailed firearm information. The Rhode Island State Crime Laboratory (RISCL) can provide detailed information about the firearms and cartridge cases\bullets involved in firearm deaths. With help from the RISCL, the firearm information related to homicides in Rhode Island has improved dramatically. In 2015, information on caliber/gauge increased by 80%, the firearm type by 50%, the make by 50%, and the model by 20%. By documenting the process of using information from the RISCL, it is hoped that this process can be used as a model by other states when reporting on violent deaths.

Using Plan-Do-Study-Act Cycle to Enhance Completeness of Suicide Firearm Reporting.

The Rhode Island Violent Death Reporting System (RIVDRS) collects comprehensive surveillance data on violent deaths to support violence prevention programs in Rhode Island and nationwide. Successful collection of firearm information is critical to understanding gun violence in public health. A recent quality improvement (QI) project was performed to improve gun information collection in the RIVDRS program. Our aim was to increase the presence of firearm model information for 2014 suicides from 50% to 80% by December 31, 2015. We used the 2014 RIVDRS data and the Plan-Do-Study-Act cycle for this project. Our efforts achieved a 50% increase in the number of firearm model reporting. If we work more closely with police departments, they may understand the data importance, and be more likely to include the firearm information in their reports. We describe this process and provide lessons learned that can be generalizable to other states' violent death reporting system. [Full article available at http://rimed.org/rimedicaljournal-2017-02.asp].

Pulse Oximetry Screening for Critical Congenital Heart Disease: Bringing Evidence Into Practice.

Congenital heart disease is the most common and serious type of infant birth defect. Pulse oximetry screening has been supported in the literature as a valuable tool to aid in the prompt detection of critical defects. Pulse oximetry is easily accessible, inexpensive, and noninvasive, and can be readily performed by clinical nurses at the infant's bedside; however, it remains a technology that is underutilized in newborns. Nurses can be leaders in addressing the need to translate knowledge into practice to improve the morbidity and mortality rates in the newborn population.

A case report of a low-birth-weight infant with a subcapsular liver hematoma and spontaneous bowel perforation.

This case report describes a 27-week, 1040-g infant, whose mother presented with an acute abruption and fetal distress prompting emergency cesarean birth. The birth was further complicated by fetal malposition, manual version, birth trauma, and perinatal depression requiring intubation, ventilation, and chest compressions. On day of life (DOL) 7, the infant suddenly deteriorated with cardiovascular collapse and severe coagulopathy. Coexisting spontaneous bowel perforation (SBP) and ruptured subcapsular liver hematoma (SLH) were confirmed operatively. Although survival with ruptured SLH is rarely reported, with aggressive medical and surgical management, this infant survived and was discharged home at 43 weeks postconceptual age. SBP may occur silently; pneumoperitoneum may be an incidental finding. Conversely, rupture of an SLH typically presents with a sudden clinical deterioration. The common predisposing factor for both conditions is low birth weight (LBW). A review of the known and proposed risk factors, clinical signs and symptoms, pathophysiology, and treatment of both SBP and SLH are provided. A literature review highlighting the potential impact of drug exposures (indomethacin, hydrocortisone, and low molecular weight heparin) is provided, along with a discussion of the implications for clinical practice and research.