Improving Compliance and Quality of Documentation of Cerebral Function Monitoring in a Neonatal Neurocritical Care Unit.

INTRODUCTION: Neonates admitted to neurocritical care units frequently undergo continuous bedside cerebral function monitoring (CFM). Documentation of CFM findings that are complete and accurate can augment the quality of care through improved communication. We aimed to increase the compliance with and quality of CFM documentation in the electronic medical records by 50% in our neonatal intensive care unit over 6 months. METHODS: We used the Plan-Do-Study-Act methodology, process mapping, and fishbone analysis. We implemented interventions, including the development of standardized EMR templates, face-to-face reminders at staff meetings and clinical handover sessions, and teaching on CFM interpretation. RESULTS: We evaluated 50 and 161 charts pre (August-October 2018) and postintervention (December 2018-July 2019), respectively. We improved compliance with documentation from 72% to 89% (P = 0.004); and the quality of documentation from 10% to 61% (P < 0.001). Multimodal reminders to document and educational sessions to increase familiarity with CFM interpretation effectively improved the quality of documentation. CONCLUSIONS: We improved the compliance with and the quality of CFM documentation using targeted quality improvement interventions with case-focused educational sessions, reference tools, and standardized templates. Barriers to compliance with documentation were adverse effects on the workflow that changes in the EMR system may address. A significant challenge to sustainability was the high frequency of rotating trainees. We addressed this challenge by developing mandatory electronic teaching modules that include reminders to document and a case-focused teaching curriculum; to increase awareness of the importance of CFM documentation and increase confidence in CFM interpretation.

Influence of extreme prematurity and bronchopulmonary dysplasia on cardiac function.

OBJECTIVE: Prematurity and bronchopulmonary dysplasia (BPD) are associated with poorly understood abnormalities of ventricular function. We therefore comprehensively compared biventricular function in infants with and without BPD. METHODS: Prospective observational study in extremely preterm infants with (n = 20) and without (n = 38) BPD using conventional and advanced echocardiography at 28 days (T1) and near-term (T2). RESULTS: Infants with BPD had lower birth gestational age (26.7±1.9 vs 27.4±1.1 weeks, p = 0.047) and weight (884±207 vs 1108±190 g, p = 0.0001). BPD was associated with larger right ventricles (RV) and reduced RV systolic strain rate at T1 and pulmonary hypertensive indicators at T2 (pulmonary artery acceleration time BPD 51±17 vs no BPD 63±12 ms, p = 0.017). At T1/T2, infants with BPD had lower RV tissue Doppler velocities (e', a' and s) and higher E/e' ratios (T1: BPD 10.4±2.4 vs no BPD 6.2±3.1 cm/sec, p = 0.001; T2: BPD 8.0±3.1 vs no BPD 5.6±2.6 cm/sec, p = 0.02), altered LV diastolic function (apical circumferential T1 early diastolic strain rate BPD 2.8±0.8 vs no BPD 3.6±1.0 /sec, p = 0.04; T2 late diastolic strain rate, BPD 2.29 ± 0.99 vs no BPD 1.67±0.84 /sec, p = 0.03) and LV rotational mechanics (T1: twist rate BPD 90±16 vs no BPD 130±48 deg/sec, p = 0.008; untwist rate (UTR) BPD -69±90 vs no BPD -147±68 deg/sec, p = 0.008; torsion BPD 2.78±0.56 vs no BPD 4.48±1.74 deg/cm, p = 0.009; and T2: UTR BPD -132±69 vs no BPD -179±57 deg/sec, p = 0.013). CONCLUSION: BPD is associated with altered RV diastolic function that persists near term, with elevated pulmonary vascular resistance, and with persistent alterations in LV apical strain rate and rotational mechanics.

Physiology of Low Blood Pressure During the First Day After Birth Among Extremely Preterm Neonates.

OBJECTIVE: To investigate the circulatory physiology of hypotension during the first day after birth among stable extremely preterm neonates. STUDY DESIGN: Case-control study of neonates born at ≤276/7 weeks gestational age with hypotension, defined as mean blood pressure in mmHg less than gestational age in weeks for at least 1 hour during the first 24 hours after birth, who underwent comprehensive echocardiography assessment before commencement of cardiovascular drugs. Neonates with hypotension (n = 14) were matched by gestational age and intensity of respiratory support with normotensive neonates (n = 27) who underwent serial echocardiography during the first day after birth, and relatively contemporaneous echocardiography assessments were used for comparison. RESULTS: Neonates with hypotension had a higher frequency of patent ductus arteriosus ≥1.5 mm (71% vs 15%; P < .001) and ductal size (median diameter, 1.6 mm [IQR, 1.4-2.1] vs 1.0 mm [IQR, 0-1.3]; P = .002), higher echocardiography indices of left ventricular systolic function (mean shortening fraction, 34 ± 7% vs 26 ± 4%; P < .001; mean longitudinal strain, -16 ± 5% vs -14 ± 3%; P = .04; and mean velocity of circumferential fiber shortening, 1.24 ± 0.35 circ/s vs 1.01 ± 0.28 circ/s; P = .03), lower estimates of left ventricular afterload (mean end-systolic wall stress, 20 ± 7 g/cm2 vs 30 ± 9 g/cm2; P < .001 and mean arterial elastance, 43 ± 19 mmHg/mL vs 60 ± 22 mmHg/mL; P = .01), without significant difference in stress-velocity index z-score (-0.42 ± 1.60 vs -0.88 ± 1.30; P = .33). Neonates with hypotension had higher rates of any degree of intraventricular hemorrhage (71% vs 22%; P = .006). CONCLUSIONS: Low blood pressure in otherwise well extremely low gestational age neonates was associated with low systemic afterload and larger patent ductus arteriosus, but not left ventricular dysfunction.

Patent ductus arteriosus and small for gestational age infants: Treatment approaches and outcomes.

BACKGROUND: The current treatment approach in patent ductus arteriosus suggests the identification of high-risk infants that may benefit the most from treatment. Small for gestational age infants are a high-risk population in which the treatment approach to the patent ductus arteriosus and outcomes have not been described. AIM: To compare the patent ductus arteriosus treatment approach and outcomes in small for gestational age and appropriate for gestational age infants. STUDY DESIGN: Retrospective analysis of infants born between January 1, 2011 and December 31, 2015 at <33 weeks' GA and admitted to neonatal intensive care units (NICU) part of the Canadian Neonatal Network. RESULTS: 595 of 2507 small for gestational age infants (23.7%) and 4714 of 20,002 appropriate for gestational age infants (23.6%) had a patent ductus arteriosus. The patent ductus arteriosus treatment approach (conservative, medical, surgical) was similar in both groups. Small for gestational age infants with and without a patent ductus arteriosus had increased risk of the composite outcome of death or bronchopulmonary dysplasia (aOR 3.40; 95% CI 2.73, 4.24; and aOR 2.72; 95% CI 2.24, 3.31) respectively. CONCLUSIONS: Patent ductus arteriosus management did not differ between small for gestational age and appropriate for gestational age infants. Small for gestational age infants had increased risk of death or bronchopulmonary dysplasia regardless of their patent ductus arteriosus status.

Congenital tuberculosis presenting as otorrhoea in a preterm infant.

A premature infant of 25 weeks' gestational age presented at 8 weeks after birth with otorrhoea from the left ear. Following a course of topical and systemic antibiotics, the patient deteriorated developing facial nerve paralysis and cervical lymphadenitis. Contrast-enhanced CT and MRI of the head showed a destructive process of the left temporal bone. These findings prompted the clinicians to send swabs from the purulent discharge from the ear for acid-fast bacilli stain. Furthermore, surgical exploration and debridement were undertaken. Cultures from ear discharge and biopsy-taken during surgical procedure-revealed the presence of Mycobacterium tuberculosis complex. The patient developed necrotizing otitis media, left temporal bone osteomyelitis and cervical lymphadenitis. The infant's mother was found to have an endometrial biopsy positive for M. tuberculosis suggesting the diagnosis of congenital tuberculosis.

Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis.

CONTEXT: In spontaneously breathing preterm infants with respiratory distress syndrome (RDS) receiving nasal continuous positive airway pressure, a method of less invasive surfactant administration (LISA) using a thin catheter has been described as an alternative to endotracheal intubation for surfactant delivery to reduce lung injury. OBJECTIVE: A systematic review of randomised controlled trials (RCTs) comparing LISA with the standard method of surfactant delivery for clinical outcomes. METHODS: Medline, CENTRAL and Embase databases were searched (until 29 October 2015). Additional citations were identified from trial registries, conference proceedings and the bibliographies of selected articles. The included studies were RCTs enrolling preterm infants with RDS and compared LISA technique with intubation for surfactant delivery for any of the prespecified clinical outcomes. RESULTS: Six RCTs were identified, enrolling a total of 895 infants. The use of LISA technique reduced the composite outcome of death or bronchopulmonary dysplasia (BPD) at 36 weeks (risk ratio (RR)=0.75 (95% CI 0.59 to 0.94), p=0.01), BPD36 among survivors (RR=0.72 (0.53 to 0.97), p=0.03), need for mechanical ventilation within 72 hours of birth (RR=0.71 (0.53 to 0.96), p=0.02) or need for mechanical ventilation anytime during the neonatal intensive care unit stay (RR=0.66 (0.47 to 0.93), p=0.02). There were no differences noted for the outcome of death and other neonatal morbidities. Procedure failure rate on the first attempt and the need for additional doses of surfactant were not different between the intervention groups. CONCLUSIONS: LISA technique for surfactant delivery results in a lesser need for mechanical ventilation in infants with RDS, reduction in the composite outcome of death or BPD at 36 weeks, and BPD36 among survivors.