Early Start: an obstetric clinic-based, perinatal substance abuse intervention program.

Maternal substance abuse is a serious problem with significant adverse effects to mothers, fetuses, and children. The Early Start Program provides pregnant women in a managed care organization with screening and early identification of substance abuse problems, early intervention, ongoing counseling, and case management by a licensed clinical social worker located in the prenatal clinic, where she is an integral part of the prenatal team. We describe the development of the Early Start Program, its administrative history, and how it has interfaced with clinicians and administrators. We also highlight two important program characteristics: the partnership with a perinatal health services research unit and the degree to which the program could be "exported" to other managed care settings.

Rapid retrieval of neonatal outcomes data: the Kaiser Permanente Neonatal Minimum Data Set.

Although neonatal intensive care units are known to be expensive, much of what happens inside such units in managed care organizations is not known. One reason for this lack of knowledge is that existing database systems were not designed to capture information in modern critical care units. This article describes the development of a dedicated outcomes database and wide area network linking six level III intensive care nurseries in the Kaiser Permanente Medical Care Program's Northern California Region. This database can be considered a hybrid, in that it combines attributes of research and operational systems.

Early discontinuation of antibiotic treatment in newborns admitted to rule out sepsis: a decision rule.

We developed a decision rule to define a group of newborns eligible for discontinuation of antibiotic treatment 24 hours after initiation. The decision rule is based on two clinical assessments, three demographic variables, four maternal risk factors and six laboratory studies. The rule was created by retrospective analysis of all admissions to rule out sepsis at 10 Kaiser Permanente Northern California Region nurseries during a 2-month period in 1990. Of the 214 study subjects, 11 (5%) had a positive bacterial or viral culture result. No deaths occurred, but three babies who had negative culture results experienced late deterioration (after 24 hours in the special care nursery). After 24 hours of antibiotic treatment, 133 (67%) of the 199 babies who had negative culture results were asymptomatic, 36 (18%) had clear signs of illness and 30 (15%) had questionable signs of illness. The rule correctly identified all babies with positive culture results as well as all persistently symptomatic babies with negative culture results. The rule also identified 57 low-risk babies eligible for only 24 hours of antibiotic treatment. We tested the rule on a second data set. The rule identified 19 of 20 newborns with positive culture results in this independent group. The 20th baby was not identified because a required test (complete blood count at 12 to 24 hours of age) was not done. Under controlled clinical conditions, this baby could have returned to the nursery to complete antibiotic treatment. We concluded that early discontinuation of antibiotic treatment in selected newborns is safe and could lead to a 1 to 2% decrease in special care nursery days in our 10 hospitals.

Investigation of a cluster of anencephaly and spina bifida.

Environmental factors remain undefined as possible causes of spina bifida and anencephaly. The authors noted a fivefold increased incidence for 1979-1980 in the Antioch-Pittsburg , California area, prompting a case-control study. They studied nine case and 27 control mothers as well as eight case and 17 control fathers to evaluate factors including residence, occupation, drug use, illnesses, and pesticide or chemical exposure. Except for fathers' smoking (p less than 0.05), no exposure was associated with neural tube defects.

Peliosis hepatis in a child.

Peliosis hepatis, which has previously only been reported in adults, occurred in a chronically ill 11-year-old boy with cystic fibrosis. As in cases in adults, chronic illness, long-term anabolic steroid therapy, and right ventricular congestive failure may well have been the causative factors in this case. Histologically, the phlebectatic and parenchymal types, which were presumed to be separate, were found conjointly in this case. This is compatible with its origin from severe right ventricular congestive failure. The rarity of peliosis, however, indicates that one or more as yet unknown factors might be operative in its development.