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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.., Competing Interests: None declared., (Thieme. All rights reserved.)

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., Competing Interests: Competing interests: JT is supported by the Investigator Grant Award Program through the British Columbia Children’s Hospital Research Institute. Dr Prakesh S Shah reported holding an Applied Research Chair in Reproductive and Child Health Services and Policy Research awarded by the Canadian Institutes of Health Research (grant APR-126340)., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

"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., (© 2019 Wiley Periodicals, Inc.)

Aim: To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs)., Methods: A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice., Results: In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes., Conclusion: There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: Our objective was to evaluate the impact of a dedicated resuscitation and stabilization (RAS) room and process changes on infant stabilization time., Study Design: A prospective quality improvement study was conducted on preterm infants in a tertiary care center. A dedicated RAS room, preresuscitation huddle, infant-isolette-ventilator pairing and improved documentation were implemented. The primary outcome was median time to stabilization and secondary outcomes were illness severity on day 1 and morbidity at discharge., Results: A sustained reduction in median time to stabilization from 90 min in the preimplementation phase to 72 min in the sustainability phase was observed. All planned and iterative process changes were integrated into the RAS team's daily routine. Time to completion of procedures decreased, illness severity and morbidity remained unchanged., Conclusion: A dedicated RAS room adjacent to the delivery suite in conjunction with process changes improves efficiency of care.

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.

Objective To determine the proportion of infants who receive inhaled nitric oxide (iNO), and to characterize the variations in its use by gestational age (GA) and center in infants <34 weeks' gestation. Design Retrospective analysis was performed in infants born at <34 weeks' gestation and admitted to neonatal intensive care units participating in the Canadian Neonatal Network between January 2010 and December 2013. Results Of 19,525 infants, 831 (4.2%) received iNO. A total of 369 infants (44%) received iNO during the first 2 days after birth. The proportion of neonates who received iNO in the 22 to 25, 26 to 29, and 30 to 33 weeks' GA groups was 16.1, 6.0, and 1.3%, respectively. Infants in whom iNO was initiated in the first 2 days of age received it for a shorter duration (median, 3 days; interquartile range [IQR], 2-5) as compared with those who started after 2 days (median, 5 days; IQR, 2-11). The use of iNO varied by center, ranging from 0 to 15.5% (p < 0.001). Conclusion Out of every 25 infants born at <34 weeks' gestation in Canada received iNO, with the highest rate of use in infants born at lower gestation. Further research to identify reasoning, efficacy, and safety of iNO in preterm infants is warranted., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Non-availability of an established validated tool to assess and monitor the severity of visible blood in a stool (VBS) specimen over time, prevents effective decision making about discontinuation of contact precautions and hospital discharge., Objective: To determine the impact of implementing a VBS investigation, parent apprisal template and Visible Blood in the Stool -Assessment Tool (VBS-AT) on standardized reporting and the evaluation of clinical improvement., Methods: A prospective quality improvement cohort study was conducted in a tertiary, neonatal unit. All infants with isolated VBS without clinical signs, radiological pneumatosis and abnormal laboratory results were included. The template and VBS-AT instrument were implemented at the bedside. Criteria for discontinuation of contact precautions and readiness for discharge home were defined apriori., Results: Eight infants developed VBS during the cluster lasting ten days. Seventy-four (78%) of the 98 episodes were graded by the VBS-AT. Five of the six infants had a maximum VBS grade of 3. The duration of VBS and contact precautions ranged from 4-38 days. All six infants with a VBS grade ≤2 for 4 consecutive days did not deteriorate beyond grade ≥3 or develop gastrointestinal complications during the ten week period following the end of the cluster. Consistent objective reporting of the severity of VBS and consistent evaluation of infants' progress over time contained the cluster effectively and facilitated discharge of stable infants., Conclusions: Implementation of a tool to standardize, investigate and objectively monitor the severity of VBS is feasible and improves effectiveness of care at no extra cost.

Background/purpose: Preterm infants needing patent ductus arteriosus (PDA) ligation are transferred to a pediatric cardiac center (CC) unless the operation can be done locally by a pediatric surgeon at a non-cardiac center (NCC). We compared infant outcomes after PDA ligation at CC and NCC., Methods: We analyzed 990 preterm infants who had PDA ligation between 2005 and 2009 using the Canadian Neonatal Network database. In-hospital mortality and major morbidities were compared between CC (n=18) and NCC (n=9)., Results: SNAP-II-adjusted mortality rates were similar (CC=8.7% vs NCC=10.7%, P=.32). Significant cranial ultrasound abnormalities (CC=24.1% vs NCC=32.1%, P<.01) and culture-proven sepsis (CC=39.7% vs NCC=54.8%, P<.01) were more frequent in infants treated at NCC. Infants transferred to CC had higher rates of cranial ultrasound abnormalities (transferred 31.6% vs non-transferred 20.4%, P<.01). NSAIDs prior to PDA ligation were used more often at NCC (CC 36.6% vs NCC 75.6%, P<.001)., Conclusions: Mortality rates after PDA ligation were similar at CC and NCC, but cranial ultrasound abnormalities and sepsis rates were higher at NCC. Higher morbidity may be associated with different PDA management strategies, including NSAID use or infant transfer. Further studies are needed to investigate the reasons for these differences in morbidity., (Copyright © 2013 Elsevier Inc. All rights reserved.)