California NICU disaster preparedness.

OBJECTIVE: NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited. STUDY DESIGN: From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster. RESULTS: Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year. CONCLUSION: We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.

Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection.

OBJECTIVES: To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection. METHODS: We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates. RESULTS: The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure. CONCLUSIONS: The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

Variations in Neonatal Antibiotic Use.

OBJECTIVES: We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens. METHODS: In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts. RESULTS: By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (ρ = 0.53; P = .01), mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%). CONCLUSIONS: Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California.

OBJECTIVE: To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS: Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS: Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION: Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity.

Importance: Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. Objectives: To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Design, Setting, and Participants: Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Exposures: Live birth at GA of 34 weeks or more. Main Outcomes and Measures: Inborn NICU admission rate. Results: Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41). Conclusions and Relevance: Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Neonatal intensive care unit antibiotic use.

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California.

OBJECTIVES: To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative. STUDY DESIGN: Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral. RESULTS: In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment. CONCLUSIONS: There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

Hospital variation in medical and surgical treatment of patent ductus arteriosus.

OBJECTIVE: This study aims to characterize population risks for diagnosis, medical treatment, and surgical ligation of patent ductus arteriosus (PDA) in very low-birth-weight infants. STUDY DESIGN: Maternal and neonatal data were collected in 40 hospitals in California during 2011 for infants with birth weight ≤ 1,500 g without any congenital malformation, with a diagnosis of PDA. Multivariable logistic regression was used to determine independent risks for PDA diagnosis and for surgical ligation. RESULTS: There were 770/1,902 (40.4%) infants diagnosed with PDA. Low birth weight, gestational age, respiratory distress syndrome, and surfactant administration were associated with PDA diagnosis. Ligation occurred in 43% of patients with birth weight ≤ 750 g, in 24% of patients weighing between 715 and 1,000 g, and in 12% of patients weighing from 1,001 to 1,500 g. Older gestational age (1 week, odds ratio 0.55, 95% confidence interval 0.48-0.63) and absence of respiratory distress syndrome (odds ratio 0.14, 95% confidence interval 0.03-0.59) were associated with lower ligation risk. The median hospital ligation rate was 14% (interquartile range 0-38%). CONCLUSION: Most patients with PDA receive treatment for closure. Practice variation may set the stage for further exploration of experimental trials.

Comparison of methods for identifying a population-based sample of Filipina women for a health survey.

This paper describes and compares 2 random-digit dialing (RDD) methods that have been used to select minority subjects for population-based research. These methods encompass the census-based method, which draws its primary sampling units from census tracts with a high proportion of minority persons, and the registry-based method, which derives its primary sampling units from a population-based cancer registry. Our study targeted Filipinos living in 10 Northern California counties, where they constitute 4% of the total population. Eligible participants (Filipina women, at least aged 20, who spoke 1 of 4 interview languages) were asked to complete a short telephone interview. Both the census and registry methods located Filipino households with comparable efficiency and with a higher yield than would be expected in a non-targeted population survey, such as the Mitofsky-Waksberg RDD method. No systematic pattern of responses was evident that would indicate that either method sampled women who were systematically less acculturated or less likely to use cancer screening tests. Although both methods offer substantial gains in efficiency, their utility is limited by generating samples that tend to over-represent high-density areas. The degree to which these methods are considered viable depends on further refinement to limit, or eliminate, their inherent selection biases without sacrificing their increased efficiency to locate minority populations.