The NICU tracheostomy team: multidisciplinary collaboration for improvement in survival of complex patients.

OBJECTIVE: Evaluate feasibility and impact of "Tracheostomy Team" on survival and length of stay (LOS) at a level IV NICU. METHODS: Plan-do-study-act cycles targeted five Global Tracheostomy Collaborative "key drivers". From January 2017 to December 2022 multidisciplinary, bimonthly bedside rounds were conducted. RESULTS: After 3 cycles, in-hospital survival among 39 patients with tracheostomy improved and sustained from 67% to 100% (baseline 18/27; 66.7%; QI 35/39, 89.7%; p = 0.03). Median LOS (days [IQR]) did not significantly differ between baseline and QI (237 [57-308] vs. 217 [130-311]; p = 0.9). Among patients with BPD, median LOS was higher after QI interventions (baseline 248 [222-308] vs. QI 332.5 [283.5-392]; p = .02). Special cause variation resulted from peak increase in LOS during the COVID19 pandemic (2021). Tracheitis/pneumonia was treated significantly more frequently in QI BPD patients. CONCLUSION: Multidisciplinary approach is feasible, resulting in improved survival without a sustained increase in LOS. Future QI efforts should address post-operative infectious complications.

Nissen Fundoplication in Infants With Severe Bronchopulmonary Dysplasia: A Propensity-Matched Analysis.

INTRODUCTION: Bronchopulmonary dysplasia (BPD) is a common respiratory morbidity among premature infants. Nissen fundoplication may be performed on infants with BPD to protect the lungs from gastroesophageal reflux-related aspiration, but the indications and benefits associated with fundoplication are not well-defined. This study evaluated associations of Nissen with clinical outcomes in infants with severe BPD (sBPD), using propensity score matching to minimize bias and confounding. METHODS: Infants ≤31 wk gestational age with sBPD (grade 2-3) admitted to a single neonatal intensive care unit (NICU) between January 2016 and October 2021 were included. Patients with sBPD who underwent Nissen fundoplication during initial NICU admission were propensity score-matched at a 1:2 ratio with control patients who did not undergo Nissen (no-Nissen). Outcomes were compared, including time to freedom from respiratory support (defined as ≤2 L nasal cannula), time to initial NICU discharge, and incidence of hospital readmission or death within 1 y postdischarge. RESULTS: After propensity score matching, 18 Nissen infants were compared with 30 no-Nissen infants. The Nissen group trended toward longer time to freedom from respiratory support (median 105 versus 70 d, P = 0.09), and had longer initial hospital stays (188 versus 111 d, P = 0.002), more 1-y hospital readmissions (83% versus 50%, P = 0.04), and more tracheostomies (28% versus 0%, P = 0.005). Mortality during first-year postdischarge was similar (6% versus 10%, P = 1.0). CONCLUSIONS: Despite adjustment for confounding variables, Nissen fundoplication was associated with prolonged support and greater resource utilization among infants with sBPD. Prospective studies are needed to clarify indications for fundoplication in this population.

Extrauterine Growth Restriction: Need for an Accurate Definition.

Neonates show considerable variation in growth that can be recognized through serial measurements of basic variables such as weight, length, and head circumference. If possible, measurement of subcutaneous and total body fat mass can also be useful. These biometric measurements at birth may be influenced by demographics, maternal and paternal anthropometrics, maternal metabolism, preconceptional nutritional status, and placental health. Subsequent growth may depend on optimal feeding, total caloric intake, total metabolic activity, genetic makeup, postnatal morbidities, medications, and environmental conditions. For premature infants, these factors become even more important; poor in utero growth can be an important reason for spontaneous or induced preterm delivery. Later, many infants who have had intrauterine growth restriction (IUGR) and are born small for gestational age (SGA) continue to show suboptimal growth below the 10th percentile, a condition that has been defined as extrauterine growth restriction (EUGR) or postnatal growth restriction (PNGR). More importantly, a subset of these growth-restricted infants may also be at high risk of abnormal neurodevelopmental outcomes. There is a need for well-defined criteria to recognize EUGR/PNGR, so that correctional steps can be instituted in a timely fashion.

Handoff standardization in the neonatal intensive care unit with an EMR-based handoff tool.

OBJECTIVE: This quality improvement project aimed to improve the accuracy and efficiency of handoff communication among NICU medical providers with an Electronic Medical Record (EMR)-based handoff tool (HT). STUDY DESIGN: Three Plan-Do-Study-Act (PDSA) cycles were utilized following the implementation of a NICU-specific EMR-based HT and a standardized handoff process. Primary measures included accuracy of demographic components: patient name, bed, age, gestational age, postmenstrual age; and medical components: active diagnoses, weight, vascular access, respiratory support, diet, total fluid goal, medications. Secondary measures included environmental components (start time, duration, location, and distractions) as indicators of efficiency. RESULTS: Accuracy of handoff components improved from 68% to 99% (p < 0.001). Efficiency of the handoff improved with time needed to complete patient handoff decreasing from 78 to 47 s per patient (p < 0.001). CONCLUSIONS: Standardizing the NICU handoff process using an EMR-based HT allowed for increased accuracy of handoff components and improved efficiency, which may promote enhanced patient safety.

Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome.

Parents of infants with neonatal abstinence syndrome (NAS) in the NICU may have questions about the long-term consequences of prenatal exposure to methadone, both asked and unasked. Although the signs of withdrawal will abate relatively quickly, parents should be aware of potential vision, motor, and behavioral/cognitive problems, as well as sleeping disturbances and ear infections so their infants can be followed closely and monitored by their pediatrician with appropriate referrals made. Furthermore, this knowledge may inspire parents to enroll their infants in an early intervention program to help optimize their outcomes. There are still many unanswered questions about epigenetic consequences, risk for child abuse/neglect, and risk of future substance abuse in this population.

Characteristics of Maternal-Infant Interaction During Treatment for Opioid Withdrawal.

PURPOSE: The purpose of this study was to describe the interactions between mothers in a methadone treatment program and their infants during a bottle feeding and compare the findings with normed data. DESIGN: A comparative-descriptive design was used. SAMPLE: Data from 12 opiate-exposed mother-infant dyads were compared with normed data. MAIN OUTCOME VARIABLE: Nursing Child Assessment Satellite-Training Scale scores. RESULTS: The opiate-exposed dyads scored significantly lower than the normed dyads in the infant subscales of clarity of cues (p < .001, 95% confidence interval [CI], 1.56-4.08) and responsiveness to caregiver (p < .01, 95% CI, 0.27-2.5), as well as the total score (p < .001, 95% CI, 2.42-6.15). Parent sensitivity to infant cues subscale (p < .01, 95% CI, 0.42-2.37) and parent contingency score (p < .01, 95% CI, 0.55-3.81) were also significantly lower. The cognitive growth fostering subscale scores were significantly higher in the neonatal abstinence syndrome (NAS) group (p < .01, 95% CI,- 2.94 to- 0.7).