Postnatal Steroids Use for Bronchopulmonary Dysplasia in a Quaternary Care NICU.

OBJECTIVE: Intercenter variation and trends in postnatal steroids (PNS) use among preterm infants for prevention or treatment of bronchopulmonary dysplasia (BPD) is known. Understanding intracenter PNS use patterns facilitate implementation of center-specific change interventions to optimize outcomes.This study aimed to (i) quantify the proportion of infants who received PNS, and describe the timing, type, trends over time, regimen used, and deviations, and (2) describe the clinical characteristics and unadjusted outcomes of infants who received PNS. STUDY DESIGN: This was a cohort study in a quaternary neonatal intensive care unit including infants born at less than 33 weeks, and who received PNS for prevention or treatment of BPD between 2011 and 2021. Following data were included: proportion of babies who received PNS; type of PNS; age at initiation and duration; trends over time; deviation from published regimen; morbidity, mortality, and cointerventions. RESULTS: One hundred and eighty four infants (8% of <33 week' infants) received PNS. The median (interquartile range [IQR]) gestational age and birth weight were 25 (24-26) weeks and 720 (625-841) grams, respectively. The median (IQR) day of initiation and duration of PNS use were 29 (19-38) and 10 (10-22) days, respectively. One hundred and fifty-seven (85%) infants received dexamethasone (DX) and 22 (12%) received hydrocortisone as the first PNS course, and 71 (39%) infants received multiple courses. The proportion of infants receiving PNS remained unchanged, but the cumulative median dose received for BPD per patient increased by 56%. Nearly one-third of cumulative PNS dose came from PNS used for non-BPD indications. Forty-six percent infants had a deviation from published regimen (±20% deviation in duration or ±10% deviation in dose). Survival, survival without major morbidity, moderate-to-severe BPD, and technology dependence at discharge were 87, 2, 91, and 67%, respectively. CONCLUSION: Increased variation in PNS use, deviation from published regimen, and concurrent PNS exposure from non-BPD indication offer insights into implementing interventions to improve processes. KEY POINTS: · In this quaternary NICU, 8% of infants born before 33 weeks were administered postnatal steroids (PNS).. · The percentage of infants given PNS remained stable; however, the cumulative dose per patient for BPD rose.. · The study identified targeted interventions to minimize clinical practice variations at the center..

Understanding what patients and physicians need to improve their decision-making about antenatal corticosteroids in late preterm gestation: a qualitative framework analysis.

BACKGROUND: It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful. METHODS: We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework. RESULTS: We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty. INTERPRETATION: Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

Care Bundle to Improve Oxygen Maintenance and Events.

Prolonged periods spent outside the target range of oxygen saturation (SpO2) in preterm infants, along with frequent desaturation events, predispose them to retinopathy of prematurity (ROP) and long-term neurodevelopmental impairment. The primary aim of this study was to increase the mean time spent within the target SpO2 range (WTR) by 10% and to reduce the frequency of desaturation events by 5 events per patient day, respectively, within 18 months of implementing a care bundle. Methods: This study was completed in a 46-bed neonatal intensive care unit (NICU), involving 246 staff members and led by a quality improvement team. The change interventions included implementing new practice guidelines, reviewing daily summaries of SpO2 maintenance, daily infant wellness assessment, standardizing workflow, and responding to SpO2 alarms. In addition, we collected staff satisfaction and compliance with change interventions, resource use, and morbidity and mortality data at discharge. Results: The mean time spent WTR increased from 65.3% to 75.3%, and the frequency of desaturation events decreased from 25.1 to 16.5 events per patient day, respectively, with a higher magnitude of benefit in infants on days with supplemental oxygen. Postimplementation, the duration of high-frequency ventilation and supplemental oxygen were lower, but morbidity and mortality rates were similar. Staff satisfaction with training workshops, coaching, use of the infant wellness assessment tool, and SpO2 alarm management algorithms were 74%, 82%, 80%, and 74%, respectively. Conclusion: Implementing a care bundle to improve oxygen maintenance and reduce desaturation events increased the time spent WTR and reduced the frequency of desaturation events.

Designing behavioral interventions using the capability-opportunity-motivation-behavior model and the theoretical domains framework to optimize oxygen saturation maintenance by NICU providers.

Objective: Despite evidence-based guidelines, SpO2 maintenance-related practices of care providers remain inconsistent. Our aim was to evaluate the impact of interprofessional learning workshops, bedside coaching, and neonatal intensive care unit (NICU) level enablers on targeted behavioral change of NICU staff, focusing on SpO2 maintenance. Methods: NICU is a specialized area of the hospital with sophisticated monitors where multidisciplinary staff provide round-the-clock care for sick and preterm infants. As a subset of a quality improvement project to improve SpO2 maintenance and reduce desaturation events, three targeted evidence-based staff behaviors were deemed as important based on established capability-opportunity-motivation-behavior and theoretical domains framework models: setting SpO2 alarm limits, using SpO2 alarm management algorithms, and reporting daily summaries of SpO2 during rounds. We conducted interprofessional workshops, provided bedside coaching, and altered unit NICU processes (guidelines, automated SpO2 histogram printouts, defined staff standard work) and measured demonstrable changes in staff reaction, learning, and behaviors by direct observation of behaviors and survey questionnaires. Results: Two hundred and seventy-five (87%) and 210 (80%) of NICU staff attended workshops and received bedside coaching, respectively. The proportion of staff expressing satisfaction with workshop and bedside coaching was 85% and 82%, respectively. The proportion of staff reporting improvement in their knowledge and confidence related to SpO2 maintenance increased significantly following the workshop. Targeted behaviors related to SpO2 maintenance like setting appropriate alarm limits, adhering to SpO2 management algorithm, and reporting daily SpO2 summaries during rounds increased from 80% to 96%, 0% to 64%, and 20% to 70%, respectively. Conclusion: Focused behavioral change interventions aimed at improving staff capability, opportunity, and motivation resulted in a demonstrable change in targeted staff behaviors related to SpO2 maintenance. Further research is needed to establish ways of optimizing intended staff behaviors while implementing care bundles in a given setting.

Variations in practices and outcomes of neonates with hypoxic ischemic encephalopathy treated with therapeutic hypothermia across tertiary NICUs in Canada.

OBJECTIVE: To characterize variations in practices and outcomes for neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) across Canadian tertiary Neonatal Intensive Care Units (NICUs). STUDY DESIGN: Retrospective study of neonates admitted for HIE and treated with TH in 24 tertiary NICUs from the Canadian Neonatal Network, 2010-2020. The two primary outcomes of mortality before discharge and MRI-detected brain injury were compared across NICUs using adjusted standardized ratios (SR) with 95% CI. RESULTS: Of the 3261 neonates that received TH, 367 (11%) died and 1033 (37%) of the 2822 with MRI results had brain injury. Overall, rates varied significantly across NICUs for mortality (range 5-17%) and brain injury (range 28-51%). Significant variations in use of inotropes, inhaled nitric oxide, blood products, and feeding during TH were identified (p values < 0.01). CONCLUSION: Significant variations exist in practices and outcomes of HIE neonates treated with hypothermia across Canada.

Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants.

OBJECTIVE: This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA). STUDY DESIGN: Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. RESULTS: Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants). CONCLUSION: 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out. KEY POINTS: · Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.

Improving Efficiency of Multidisciplinary Bedside Rounds in the NICU: A Single Centre QI Project.

INTRODUCTION: Inconsistent workflow, communication, and role clarity generate inefficiencies during bedside rounds in a neonatal intensive care unit. These inefficiencies compromise the time needed for essential activities and result in reduced staff and family satisfaction. This study's primary aim was to reduce the mean duration of bedside rounds by 25% within 3 months by redesigning the rounding processes and applying QI principles. The secondary aims were to improve staff and family experience. METHODS: We conducted this work in an academic 50-bed neonatal intensive care unit involving 350 staff members. The change interventions included: (i) reinforcing essential value-added activities like standardizing rounding time, the sequencing of patients rounded, sequencing each team member rounding presentations, team preparation, bedside presentation content, and time management; (ii) reducing non-value-added activities; and (iii) moving value-added nonessential activities outside of the rounds. RESULTS: The mean duration of rounds decreased from 229 minutes in the pre-implementation to 132 minutes in the postimplementation phase. The proportion of staff showing satisfaction regarding various components of the rounds increased from 5% to 60%, and perceived staff involvement during the rounds increased from 70% to 77%. Ninety-three percent of family experience survey respondents expressed satisfaction at being invited for bedside reporting and being involved in decision-making or care planning. The staff did not report any adverse events related to the new rounds process. CONCLUSION: Redesigning bedside rounds improved staff engagement and workflow, resulting in efficient rounds and better staff experience.

Corrigendum to: Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study.

[This corrects the article DOI: 10.1093/pch/pxz085.].

Development of a national neonatal intensive care unit-specific antimicrobial stewardship programme in Canada: protocol for a cohort study.

INTRODUCTION: Early empiric treatment with broad-spectrum antimicrobials is common in neonatal intensive care units (NICU) due to the non-specific clinical presentation of infection. However, excessive and inappropriate antimicrobial use can lead to the emergence of drug-resistant organisms and adverse neonatal outcomes. This study aims to develop and implement a nationwide NICU-specific antimicrobial stewardship programme (ASP) to promote judicious antimicrobial use and control the emergence of multidrug-resistant organisms (MDROs) in Canada. METHODS AND ANALYSIS: Our study population will include all very low-birth-weight neonates admitted to participating tertiary NICU in Canada. Based on the existing limited literature, we will develop consensus on NICU antimicrobial stewardship interventions to enhance best practices. Using an expanded Canadian Neonatal Network (CNN) platform, we will collect data on antimicrobial use and the susceptibility of organisms identified in clinical samples from blood and cerebrospinal fluid over a period of 2 years. These data will be used to provide all NICU stakeholders with benchmarked centre-adjusted antimicrobial use and MDRO prevalence reports. An ASP plan will be developed at both individual unit and national levels in the subsequent years. Knowledge translation strategies will be implemented through the well-established Evidence-based Practice for Improving Quality methodology. ETHICS AND DISSEMINATION: Ethics for the study has been granted by the University of British Columbia Children's & Women's Research Ethics Board (H19-02490) and supported by CNN Executive Committee. The study results will be disseminated through national organisations and open access peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04388293.

Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study.

PURPOSE: Retinopathy of prematurity (ROP) is a potentially blinding condition affecting premature infants for which less than 10% of babies undergoing screening require treatment. This study assessed and validated predictors of developing clinically significant ROP (type 2 or worse) and ROP requiring treatment. DESIGN: Nationwide retrospective cohort study. METHODS: This study included infants born between January 2014 and June 2016, admitted to level 3 neonatal intensive care units across Canada who underwent ROP screening. Data were derived from the Canadian Neonatal Network database. Predefined ≥ 1% risk for clinically significant retinopathy or prematurity and ROP requiring treatment was set as threshold for screening. Thirty-two potential predictors were analyzed, to identify and validate the most important ones for predicting clinically significant ROP. The predictors were determined on a derivation cohort and tested on a validation cohort. Multivariable logistic regression modeling was used for analysis. RESULTS: Using a sample of 4,888 babies and analyzing 32 potential predictors, capturing babies with ≥1% risk of developing clinically significant ROP equated to screening babies with birth weight (BW) <1,300 g or gestational age (GA) <30 weeks while capturing babies with ≥1% risk of requiring ROP treatment equated to screening babies with BW <1,200 g or GA <29 weeks. CONCLUSIONS: The Canadian ROP screening criteria can be modified to screen babies with BW <1,200 g or GA <30 weeks. Using these criteria, babies requiring treatment would be identified while reducing the number of babies screened unnecessarily.

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.

Characteristics and short-term outcomes of neonates with mild hypoxic-ischemic encephalopathy treated with hypothermia.

OBJECTIVE: To compare the characteristics and outcomes of neonates with mild hypoxic-ischemic encephalopathy (HIE) who received hypothermia versus standard care. STUDY DESIGN: We conducted a retrospective cohort study of neonates ≥35 weeks' gestation and ≥1800 g admitted with a diagnosis of Sarnat stage 1 encephalopathy. We evaluated length of hospital stay, duration of ventilation, evidence of brain injury on MRI, and neonatal morbidities. RESULTS: Of 1089 eligible neonates, 393 (36%) received hypothermia and 595 (55%) had neuroimaging. The hypothermia group was more likely to be outborn, born via C-section, had lower Apgar scores, and required extensive resuscitation. They had longer durations of stay (9 vs. 6 days, P < 0.001), respiratory support (3 vs. 2 days, P < 0.001), but lower odds of brain injury on MRI (adjusted odds ratio 0.33, 95% CI: 0.22-0.52) compared with standard care group. CONCLUSION: Despite prolongation of hospital stay, hypothermia may be potentially beneficial in neonates with mild HIE; however, selection bias cannot be ruled out.

Outcomes of Neonates With Complex Medical Needs.

BACKGROUND: Children with complex medical needs (CMN) are high healthcare resource utilizers, have varying underlying diagnoses, and experience repeated hospitalizations. Outcomes on neonatal intensive care (NICU) patients with CMN are unknown. PURPOSE: The primary aim is to describe the clinical profile, resource use, prevalence, and both in-hospital and postdischarge outcomes of neonates with CMN. The secondary aim is to assess the feasibility of sustaining the use of the neonatal complex care team (NCCT). METHODS: A retrospective cohort study was conducted after implementing a new model of care for neonates with CMN in the NICU. All neonates born between January 2013 and December 2016 and who met the criteria for CMN and were cared for by the NCCT were included. RESULTS: One hundred forty-seven neonates with a mean (standard deviation) gestational age of 34 (5) weeks were included. The major underlying diagnoses were genetic/chromosomal abnormalities (48%), extreme prematurity (26%), neurological abnormality (12%), and congenital anomalies (11%). Interventions received included mechanical ventilation (69%), parenteral nutrition (68%), and technology dependency at discharge (91%). Mortality was 3% before discharge and 17% after discharge. Postdischarge hospital attendances included emergency department visits (44%) and inpatient admissions (58%), which involved pediatric intensive care unit admissions (26%). IMPLICATIONS FOR PRACTICE: Neonates with CMN have multiple comorbidities, high resource needs, significant postdischarge mortality, and rehospitalization rates. These cohorts of NICU patients can be identified early during their NICU course and serve as targets for implementing innovative care models to meet their unique needs. IMPLICATIONS FOR RESEARCH: Future studies should explore the feasibility of implementing innovative care models and their potential impact on patient outcomes and cost-effectiveness.

Journey to mother baby care: Implementation of a combined care/couplet model in a Level 2 neonatal intensive care unit.

"Why can't I have my postpartum care in the same room as my baby?" questioned Hilary, a neonatal intensive care unit (NICU) "alumni" parent, during a design event for the new British Columbia's Women's Hospital 70 single family room NICU. This simple yet provocative question was nearly dismissed and the idea of a combined care model lost, since most members of the team thought it was simply "not possible." Hilary did not give up and continued to raise this idea throughout every design event. It was Hilary's fortitude and sharing of her NICU experience that was the inspiration for the MotherBaby Care unit. The voice of one woman has improved the birth experiences of potentially thousands of mothers and their at-risk newborns. By honoring women's voices and values in health care, positive changes that matter to women, infants, and families can be made. Mothers also shared: "I knew what was best for me was to be with my baby," "If I could stand up after my C-section, I would drag my IV pole to be with my baby!", "Teach me how to take care of my premature baby before I am ready to go home!" MotherBaby Care is a combined care or "couplet" care where one NICU nurse provides care for a postpartum mother and her at-risk newborn in the Level 2 NICU. This review describes the journey from innovation and design to the implementation of the MotherBaby Care model.

Retinopathy of prematurity practices: a national survey of Canadian Neonatal Intensive Care Units.

OBJECTIVE: To examine current level three Neonatal Intensive Care Unit (NICU) practices related to ROP screening and treatment. STUDY DESIGN: A cross-sectional survey was sent to 29 level three NICU's across Canada to survey current screening inclusion criteria, treatment options, supportive care and post-screening events for ROP. RESULT: 22/29 (76%) level three NICU's responded. Ten different ROP screening inclusion criteria were found to be in use with significant variation in gestational age and birth weight criteria. Many other national variations also exist regarding the supportive and procedural protocols surrounding ROP screening as well as mode of treatment for ROP. CONCLUSION: Despite national guidelines, significant variation in ROP screening inclusion criteria practices exist among neonatal units in Canada. Therefore, there is an urgent need for better evidence-based screening guidelines as well as a need to standardize supportive measures surrounding ROP screening and treatment.

The Canadian Preterm Birth Network: a study protocol for improving outcomes for preterm infants and their families.

BACKGROUND: Preterm birth (birth before 37 wk of gestation) occurs in about 8% of pregnancies in Canada and is associated with high mortality and morbidity rates that substantially affect infants, their families and the health care system. Our overall goal is to create a transdisciplinary platform, the Canadian Preterm Birth Network (CPTBN), where investigators, stakeholders and families will work together to improve childhood outcomes of preterm neonates. METHODS: Our national cohort will include 24 maternal-fetal/obstetrical units, 31 neonatal intensive care units and 26 neonatal follow-up programs across Canada with planned linkages to provincial health information systems. Three broad clusters of projects will be undertaken. Cluster 1 will focus on quality-improvement efforts that use the Evidence-based Practice for Improving Quality method to evaluate information from the CPTBN database and review the current literature, then identify potentially better health care practices and implement identified strategies. Cluster 2 will assess the impact of current practices and practice changes in maternal, perinatal and neonatal care on maternal, neonatal and neurodevelopmental outcomes. Cluster 3 will evaluate the effect of preterm birth on babies, their families and the health care system by integrating CPTBN data, parent feedback, and national and provincial database information in order to identify areas where more parental support is needed, and also generate robust estimates of resource use, cost and cost-effectiveness around preterm neonatal care. INTERPRETATION: These collaborative efforts will create a flexible, transdisciplinary, evaluable and informative research and quality-improvement platform that supports programs, projects and partnerships focused on improving outcomes of preterm neonates.

Neonatal outcomes of preterm twins according to mode of birth and presentation.

PURPOSE: To compare neonatal outcomes of twins delivered <33 weeks' gestation in tertiary centers in Canada according to the mode of birth and presentation. MATERIALS AND METHODS: This retrospective cohort from the Canadian Neonatal Network database studied preterm twins born from 24 + 0 to 32 + 6 weeks' gestation between 2005 and 2012. Twins were grouped by the mode of birth: both vaginal, combined vaginal/cesarean section (CS), and both CS. Additionally, twins were grouped by the mode of presentation: both vertex, vertex/breech, breech/vertex, and both breech. The primary outcome was a composite of mortality or severe neonatal morbidity (severe neurological injury [intraventricular hemorrhage grade 3/4 or periventricular leukomalacia], bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis). RESULTS: Of the 6636 twins, 1934 (29%) were delivered vaginally, 418 (6%) by combined vaginal birth/CS, and 4284 (65%) were born by CS. The composite did not differ between the groups. However, severe neurological injury was decreased (adjusted odds ratio [AOR], 0.77; 95% confidence interval [CI], 0.61-0.98) and respiratory distress syndrome (AOR, 1.34; 95%CI, 1.15-1.56) was increased when both the twins were delivered by CS. CONCLUSIONS: Preterm twin infants born via CS experienced less severe neurological injury when compared to those delivered vaginally, but had an increase in respiratory distress syndrome.

Antibiotics for neonates born through meconium-stained amniotic fluid.

BACKGROUND: Approximately 1 in 10 pregnancies is affected by meconium passage at delivery, which can result in meconium aspiration syndrome (MAS). MAS can cause respiratory complications and, very rarely, death. Antibiotics have been prescribed for neonates exposed to meconium in amniotic fluid, with the intention of preventing infection due to potential bacterial contaminants. OBJECTIVES: We conducted this review to assess the efficacy and safety of antibiotics for:1. prevention of infection, morbidity, and mortality among infants born through meconium-stained amniotic fluid (MSAF) who are asymptomatic at birth; and2. prevention of infection, morbidity, and mortality among infants born through MSAF who have signs and symptoms compatible with meconium aspiration syndrome (MAS). SEARCH METHODS: We performed a literature search using the following databases: MEDLINE (1966 to July 2016); Embase (1980 to July 2016); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to July 2016); and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 7) in the Cochrane Library. We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials that compared antibiotics administered via any route versus placebo or no treatment for prevention of infection among neonates exposed to MSAF, or who developed MAS. We excluded cohort, case control, and any other non-randomised studies and applied no language restrictions. We included studies of term and preterm infants, and we included studies examining use of any antibacterial antibiotics. We included studies that reported on any outcomes of interest. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of included trials by reviewing information provided in study reports and obtained by personal communication with study authors. We extracted data on relevant outcomes, estimated effect size, and reported values as risk ratios (RRs), risk differences (RDs), and mean differences (MDs), as appropriate. We conducted subgroup analyses for treatment of MAS and for prophylaxis (asymptomatic neonates exposed to meconium). MAIN RESULTS: Four randomised controlled studies including a total of 695 participants were eligible for inclusion. Three studies evaluated neonates with MAS, and one study assessed asymptomatic neonates exposed to meconium in amniotic fluid. These studies exhibited varying degrees of methodological rigour: Two studies were at low risk of bias, and two were at unclear risk. We graded evidence derived from these studies as low quality. We downgraded overall evidence owing to the large number of participants lost to follow-up in one trial, the small sample sizes of all trials, and unclear methodological details provided for two trials.The primary outcome was risk of early- and late-onset neonatal sepsis. Antibiotics did not decrease the risk of sepsis in neonates with a diagnosis of MAS (RR 1.54, 95% confidence interval (CI) 0.27 to 8.96; RD 0.00, 95% CI -0.02 to 0.03; 445 participants, three studies; I² = 0%) nor in asymptomatic neonates exposed to meconium in amniotic fluid (RR 0.76, 95% CI 0.25 to 2.34; RD -0.01, 95% CI -0.07 to 0.04; 250 participants, one study; I² = 0%). Results show no significant differences in mortality or duration of stay in hospital between groups given antibiotics and control groups of symptomatic and asymptomatic neonates. One study in asymptomatic neonates reported a significant reduction in duration of mechanical ventilation for the control group compared with the antibiotic group (MD 0.26, 95% CI 0.15 to 0.37; 250 participants, one study; I² = 0%). AUTHORS' CONCLUSIONS: Upon review of available evidence, we found no differences in infection rates following antibiotic treatment among neonates born through meconium-stained fluid and those with meconium aspiration syndrome. The overall quality of evidence is low owing to the small number of included studies. Well-controlled studies of adequate power are needed.

Video recording of neonatal resuscitation: A feasibility study to inform widespread adoption.

AIM: To determine the feasibility of introducing video recording (VR) of neonatal resuscitation (NR) in a perinatal centre. METHODS: This was a prospective cohort quality improvement study on preterm infants and their caregivers. Based on evidence and experience of other centers using VR intervention, a contextually relevant implementation and evaluation strategy was designed in the planning phase. The components of intervention were pre-resuscitation team huddle, VR of NR and video debriefing (VD), all occurring on the same day. Various domains of feasibility and sustainability as well as feasibility criteria were predefined. Data for analysis was collected using quantitative and qualitative methods. RESULTS: Seventy-one caregivers participated in VD of 14 NRs facilitated by six trained instructors. Ninety-one percent of caregivers perceived enhanced learning and patient safety and, 48 issues were identified related to policy, caregiver roles, and latent safety threats. Ninety percent of caregivers expressed their willingness to participate in VD activity and supported the idea of integrating it into a resuscitation team routine. Eighty-three percent and 50% of instructors expressed satisfaction with video review software and quality of audio VR. No issues about maintenance of infant or caregivers' confidentiality and erasure of videos were reported. Criteria for feasibility were met (refusal rate of < 10%, VR performed on > 50% of occasions, and < 20% caregivers' perceiving a negative impact on team performance). Necessary adaptations to enhance sustainability were identified. CONCLUSION: VR of NR as a standard of care quality assurance activity to enhance caregivers' learning and create opportunities that improve patient safety is feasible. Despite its complexity with inherent challenges in implementation, the intervention was acceptable, implementable, and potentially sustainable with adaptations.

Introduction of microsystems in a level 3 neonatal intensive care unit-an interprofessional approach.

BACKGROUND: Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care. METHODS/DESIGN: The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model. DISCUSSION: In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns. TRIAL REGISTRATION: ClinicalTrial.gov, NCT02912780 . Retrospectively registered on 22 September 2016.