Search

Importance: Neonates requiring surgery are often cared for in neonatal intensive care units (NICUs). Despite a breadth of surgical pathology, neonates share many perioperative priorities that allow for the development of unit-wide evidence-based Enhanced Recovery After Surgery (ERAS) recommendations., Observations: The guideline development committee included pediatric surgeons, anesthesiologists, neonatal nurses, and neonatologists in addition to ERAS content and methodology experts. The patient population was defined as neonates (first 28 days of life) undergoing a major noncardiac surgical intervention while admitted to a NICU. After the first round of a modified Delphi technique, 42 topics for potential inclusion were developed. There was consensus to develop a search strategy and working group for 21 topic areas. A total of 5763 abstracts were screened, of which 98 full-text articles, ranging from low to high quality, were included. A total of 16 recommendations in 11 topic areas were developed with a separate working group commissioned for analgesia-related recommendations. Topics included team communication, preoperative fasting, temperature regulation, antibiotic prophylaxis, surgical site skin preparation, perioperative ventilation, fluid management, perioperative glucose control, transfusion thresholds, enteral feeds, and parental care encouragement. Although clinically relevant, there were insufficient data to develop recommendations concerning the use of nasogastric tubes, Foley catheters, and central lines., Conclusions and Relevance: Despite varied pathology, neonatal perioperative care within NICUs allows for unit-based ERAS recommendations independent of the planned surgical procedure. The 16 recommendations within this ERAS guideline are intended to be implemented within NICUs to benefit all surgical neonates.

Background and Objectives: Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR)., Methods: A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation., Results: We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator., Conclusions: Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective:  It is important to determine whether the use of different quality improvement tools in neonatal resuscitation is well-received by health care teams and improves coordination and perceived quality of the stabilization of the newborn at birth. This study aimed to explore the satisfaction of personnel involved in resuscitation for infants under 32 weeks of gestational age (<32 wGA) at birth with the use of an assistance toolkit: Random Real-time Safety Audits (RRSA) of neonatal stabilization stations, the use of pre-resuscitation checklists, and the implementation of briefings and debriefings., Study Design:  A quasi-experimental, prospective, multicenter intervention study was conducted in five level III-A neonatal intensive care units in Madrid (Spain). The intervention involved conducting weekly RRSA of neonatal resuscitation stations and the systematic use of checklists, briefings, and debriefings during stabilization at birth for infants <32 wGA. The satisfaction with their use was analyzed through surveys conducted with the personnel responsible for resuscitating these newborns. These surveys were conducted both before and after the intervention phase (each lasting 1 year) and used a Likert scale response model to assess various aspects of the utility of the introduced assistance tools, team coordination, and perceived quality of the resuscitation., Results:  Comparison of data from 200 preintervention surveys and 155 postintervention surveys revealed statistically significant differences ( p  < 0.001) between the two phases. The postintervention phase scored higher in all aspects related to the effective utilization of these tools. Improvements were observed in team coordination and the perceived quality of neonatal resuscitation. These improved scores were consistent across personnel roles and years of experience., Conclusion:  Personnel attending to infants <32 wGA in the delivery room are satisfied with the application of RRSA, checklists, briefings, and debriefings in the neonatal resuscitation and perceive a higher level of quality in the stabilization of these newborns following the introduction of these tools., Key Points: · RRSA, checklists, briefings, and debriefings improve the quality of neonatal resuscitation at birth.. · These tools, when used together, are well-received and enhance perceived resuscitation quality.. · Perception of utility and quality improvement is consistent across roles and experience.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: to analyze the reliability of the items that compose the instrument for classifying newborns according to the degree of dependence on nursing care in a neonatal intensive care unit., Method: methodological study that analyzed the agreement and reliability of the instrument in a neonatal intensive care unit. Six care nurses and a research nurse assessed 35 newborns and completed the instrument, which was made up of 15 areas of care. The weighted Kappa coefficient and the Intraclass Correlation Coefficient were used for analysis., Results: the areas of: weight (92%), oxygenation (93%) and catheter control (95%) had almost perfect agreement and the area of reaction to stimuli (50%) had poor agreement. The areas of elimination and vital signs showed low reliability, due to the low variability of responses. The Intraclass Correlation Coefficient was 0.94., Conclusion: there are variations in the evaluations of some areas of care due to the imprecise description of items to which scores are assigned, however the instrument is reliable for categorizing the type of care (minimal, intermediate and intensive). Its use can contribute to measuring the quality and safety of newborn care.

Background: Neonatal acute kidney injury (AKI) is a common yet underdiagnosed condition in neonates with significant implications for long-term kidney health. Lack of timely recognition and documentation of AKI contributes to missed opportunities for nephrology consultation and follow-up, potentially leading to adverse outcomes., Methods: We conducted a quality improvement (QI) project to address this by incorporating an automated real-time electronic medical record (EMR)-AKI alert system in the Neonatal Intensive Care Unit (NICU) at Le Bonheur Children's Hospital. Our primary objective was to improve documentation of neonatal AKI (defined as serum creatinine (SCr) > 1.5 mg/dL) by 25% compared to baseline levels. The secondary goal was to increase nephrology consultations and referrals to the neonatal nephrology clinic. We designed an EMR-AKI alert system to trigger for neonates with SCr > 1.5 mg/dL, automatically adding AKI diagnosis to the problem list. This prompted physicians to consult nephrology, refer neonates to the nephrology clinic, and consider medication adjustments., Results: Our results demonstrated a significant improvement in AKI documentation after implementing the EMR-AKI alert, reaching 100% compared with 7% at baseline (p < 0.001) for neonates with SCr > 1.5 mg/dL. Although the increase in nephrology consultations was not statistically significant (p = 0.5), there was a significant increase in referrals to neonatal nephrology clinics (p = 0.005)., Conclusions: Integration of an EMR alert system with automated documentation offers an efficient and economical solution for improving neonatal AKI diagnosis and documentation. This approach enhances healthcare provider engagement, streamlines workflows, and supports QI. Widespread adoption of similar approaches can lead to improved patient outcomes and documentation accuracy in neonatal AKI care., (© 2024. The Author(s).)

Background: Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500 g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants., Purpose: For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration., Methods: The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500 g., Results: The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data., Implications for Practice and Research: Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH., Competing Interests: Competing Interests:The authors declare no conflicts of interest., (Copyright © 2024 by The National Association of Neonatal Nurses.)

Objectives: The authors sought to measure and compare practice preference variation in neonatal respiratory care within and between neonatal intensive care units (NICUs) using the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool (NSIGHT)., Study Design: Eleven NICUs completed the NSIGHT between 2019 and 2021. Net preference was measured by mean response; agreement was ranked by standard distribution of response values. Heat maps showed comparisons between NICUs and disciplines., Results: NICUs and individuals agreed most often on use of pressure support with mandatory ventilation and on use of non-invasive positive pressure ventilation for apnea. High preference variation surrounded decisions for invasive ventilation versus continuous positive airway pressure for extremely low birth weight infants. Preference difference was most frequent between neonatologists and nurses., Conclusions: Patterns of practice preference variation in neonatal respiratory care are specific to clinical scenario. Measuring preference variation may inform psychology of change and strengthen quality improvement efforts., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objective: To increase compliance with standardized safe sleep recommendations for patients in a cohort of regional level III/IV neonatal intensive care units (NICUs) in accordance with recently revised guidelines issued by the American Academy of Pediatrics (AAP)., Study Design: A regional quality improvement (QI) initiative led by a multidisciplinary task force standardized safe sleep criteria across participating NICU sites. Universal and unit-specific interventions were implemented via Plan-Do-Study-Act (PDSA) cycles with evaluation of compliance through routine crib audits, run chart completion, and Pareto chart analysis., Results: Following QI implementation, compliance with safe sleep guidelines for eligible NICU infants improved from 34% to 90% from October 2019 through September 2022., Conclusion: Compliance with early, consistent modeling of safe sleep practices nearly tripled in this cohort of regional NICUs. A standardized, timely approach to safe sleep transition demonstrated dramatic and sustained improvement in the practice and modeling of safe sleep behaviors in the NICU., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: To shorten the hospital stay in preterm infants, it is important to understand the factors extending the length of stay., Aims: To understand how different discharge criteria affect the length of stay in preterm infants., Study Design: A retrospective comparison study., Subjects: Preterm infants born at 28 to 31 gestational weeks in 2020-2021 in a Level IV NICU in Japan (n = 22) and a Level III NICU in Finland (n = 49)., Outcome Measures: We compared the most common last discharge criteria and the postmenstrual age (PMA) between the two NICUs. The potential extending effects of each discharge criterion on the length of stay were also evaluated. The discharge criteria were classified into six categories: temperature, respiration, feeding, examination, weight limit, and family readiness., Results: The PMA at discharge was significantly higher in Japan than in Finland: median 40.7 (interquartile range 39.9-41.3) vs. 37.9 (36.9-39.0) weeks; r = 0.58; p < 0.001. The most common last discharge criterion was the family criterion in Japan (n = 19; 86 %) and the respiration criterion in Finland (n = 43; 88 %). In Japan, the length of stay was extended by 7.9 (standard deviation [SD] 7.0) days due to a lack of family readiness for discharge and 8.7 (SD 8.7) days due to not having discharged home with a feeding tube as a common practice., Conclusions: The length of stay of preterm infants in Japan could be notably reduced by supporting the parents' earlier readiness for discharge and allowing tube feeding at home., Competing Interests: Declaration of competing interest The authors have no potential conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

For parenteral nutrition (PN) of newborns, the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) 2018 guidelines recommend standardized solutions over individual PN (IPN) solutions for most patients. This retrospective study assessed if a shift from IPN to standardized PN was feasible at the UZ Brussel. Using prescription data of 145 neonates, we calculated the nutrient provision for IPN and for standardized PN of the same volumes. We compared the macronutrient intakes with ESPGHAN 2018 recommendations to assess the feasibility. For neonates of a gestational age (GA) <32 or >36 weeks, standardized PN reached recommendations as least as fast as IPN. For neonates with a GA of 32 to 36 weeks, the administration protocol requires further adjustments as amino acid provision was lacking compared to IPN. Overall, the results support the feasibility of a shift from IPN to standardized PN at the UZ Brussel., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility., Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU., Methods: This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked., Results: Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt., Implications for Practice and Research: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 by The National Association of Neonatal Nurses.)

Video review (VR) of procedures in the medical environment can be used to drive quality improvement. However, first it has to be implemented in a safe and effective way. Our primary objective was to (re)define a guideline for implementing interprofessional VR in a neonatal intensive care unit (NICU). Our secondary objective was to determine the rate of acceptance by providers attending VR. For 9 months, VR sessions were evaluated with a study group, consisting of different stakeholders. A questionnaire was embedded at the end of each session to obtain feedback from providers on the session and on the safe learning environment. In consensus meetings, success factors and preconditions were identified and divided into different factors that influenced the rate of adoption of VR. The number of providers who recorded procedures and attended VR sessions was determined. A total of 18 VR sessions could be organised, with an equal distribution of medical and nursing staff. After the 9-month period, 101/125 (81%) of all providers working on the NICU attended at least 1 session and 80/125 (64%) of all providers recorded their performance of a procedure at least 1 time. In total, 179/297 (61%) providers completed the questionnaire. Almost all providers (99%) reported to have a positive opinion about the review sessions. Preconditions and success factors related to implementation were identified and addressed, including improving the pathway for obtaining consent, preparation of VR, defining the role of the chair during the session and building a safe learning environment. Different strategies were developed to ensure findings from sessions were used for quality improvement. VR was successfully implemented on our NICU and we redefined our guideline with various preconditions and success factors. The adjusted guideline can be helpful for implementation of VR in emergency care settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation., Method: Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation., Results: Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable., Conclusion: Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objectives: This study aimed to describe resuscitation practices in level-IV neonatal intensive care units (NICUs) and identify possible areas of improvement., Study Design: This study was a cross-sectional cohort survey and conducted at the Level-IV NICUs of Children's Hospital Neonatal Consortium (CHNC). The survey was developed with consensus from resuscitation and education experts in the CHNC and pilot tested. An electronic survey was sent to individual site sponsors to determine unit demographics, resuscitation team composition, and resuscitation-related clinical practices., Results: Of the sites surveyed, 33 of 34 sites responded. Unit average daily census ranged from less than 30 to greater than 100, with the majority (72%) of the sites between 30 and 75 patients. A designated code response team was utilized in 18% of NICUs, only 30% assigned roles before or during codes. The Neonatal Resuscitation Program (NRP) was the exclusive algorithm used during codes in 61% of NICUs, and 34% used a combination of NRP and the Pediatric Advanced Life Support (PALS). Most (81%) of the sites required neonatal attendings to maintain NRP training. A third of sites (36%) lacked protocols for high-acuity events. A code review process existed in 76% of participating NICUs, but only 9% of centers enter code data into a national database., Conclusion: There is variability among units regarding designated code team presence and composition, resuscitation algorithm, protocols for high-acuity events, and event review. These inconsistencies in resuscitation teams and practices provide an opportunity for standardization and, ultimately, improved resuscitation performance. Resources, education, and efforts could be directed to these areas to potentially impact future neonatal outcomes of the complex patients cared for in level-IV NICUs., Key Points: · Resuscitation practice is variable in level-IV NICUs.. · Resuscitation algorithm training is not uniform. · Standardized protocols for high-acuity low-occurrence (HALO) events are lacking., Competing Interests: None declared., (Thieme. All rights reserved.)

NICU clinicians strive to provide family-centered care and often encounter complex and ethical challenges. Emerging evidence suggests that NICU clinicians likely interact with families experiencing intimate partner violence (IPV). However, little research and training exists to guide NICU clinicians in their thinking and practice in the midst of IPV. In this review, we use a structural violence framework to engage in a critical analysis of commonly held assumptions about IPV. These assumptions include an overreliance on binaries including male-female and offender-victim, the belief that people need to be rescued, prioritization of physical safety, and the notion that mandatory reporting helps families who experience violence. By reexamining these assumptions, this review guides NICU clinicians to consider alternatives to carceral and punitive responses to IPV, such as transformative justice and reflexive engagement., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress., Study Design: Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network calculated the Triple Aim in 23 0/7 to 27 6/7 -week infants using three surrogate measures: (1) population health/x-axis-eight major morbidity rates as a composite, risk-adjusted metric; (2) cost/y-axis-total hospital length of stay; and (3) individual care/z-axis-mortality, then illustrated this relationship as a sphere within a three-dimensional cube., Results: Three thousand seven hundred six infants born between January 1, 2014 and December 31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth weight of 803 (208) grams were analyzed. Triple Aim three-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric), but moved backward in the y-axis length of stay and z-axis mortality measurements., Conclusion: Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions., Key Points: · The Triple Aim gold standard is elusive. There is no demonstration of sustained, large-scale success in healthcare and our quality improvement network has previously published benchmark extreme prematuritymorbidity improvements.. · Extreme prematurity outcomes illustrated as the Triple Aim show uneven results in relevant surrogate parameters and Triple Aim achievement, if even possible, will necessitate evidence-based methodologies that are scalable.. · Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required for Triple Aim success.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Sleep-related deaths were the fourth leading cause of infant death in Tennessee between 2014 and 2018. In response, the Tennessee Initiative for Perinatal Quality Care developed a statewide quality improvement project, which focused on the demonstration and enforcement of a safe sleep environment in participating birthing hospitals to help families learn and practice the same at home. The project's aim was to improve the percent of infants audited for safe sleep practices (0-12 mo of age, cared for in participating newborn nurseries or neonatal intensive care units) that were compliant with the practices recommended by the 2016 American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome., Study Design: Participating teams were required to develop and implement safe sleep policies in compliance with the AAP recommendations, provide safe sleep education to staff and families, and complete monthly safe sleep audits. A tool was provided to assess whether each audited infant was compliant with safe sleep recommendations and any reason(s) the infant was not compliant. Teams met virtually for monthly huddles and semiannual learning sessions to discuss the development and testing of change ideas., Results: The project teams were able to improve the percent of infants audited that were compliant with safe sleep recommendations by 22% over the course of the project. Audits revealed the main reasons for noncompliance were additional objects in the crib (49%, 329/671), unsafe bedding (27%, 181/671), and head of bed elevation (24%, 164/671)., Conclusion: This project demonstrates the positive impact that a statewide quality improvement initiative can have on identifying and addressing barriers, sharing resources and education, and monitoring local and statewide data, which led to increased compliance with safe sleep recommendations in the hospital. Safe sleep education and monitoring should be ongoing as new parents and staff always need to be educated on safe sleep principles., Key Points: · In 2020, 25% of all infant deaths in Tennessee were due to an unsafe sleep environment.. · Sleep-related deaths in infants are frequently preventable.. · State quality improvement projects are effective in increasing safe sleep compliance.. · State perinatal quality collaboratives can partner with their State Department of Health, local hospitals, and providers, to increase awareness, educate parents, and model a safe sleep environment.., Competing Interests: None declared., (Thieme. All rights reserved.)

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards., Competing Interests: Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2024. Published by Elsevier Inc.)

Background: Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs., Methods: A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up., Discussion: The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring., Trial Registration: NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1., Competing Interests: Gabriel FT Variane and Alexandre Netto are the owners of PBSF and Guilherme M Sant’Anna has no conflicts of interest and no financial relationships relevant to this article to disclose. All other authors work at PBSF.

Objective: Therapeutic hypothermia (TH) for neonatal hypoxic-ischaemic encephalopathy (HIE), delivered mainly in tertiary cooling centres (CCs), reduces mortality and neurodisability. It is unknown if birth in a non-cooling centre (non-CC), without active TH, impacts short-term outcomes., Design: Retrospective cohort study using National Neonatal Research Database and propensity score-matching., Setting: UK neonatal units., Patients: Infants ≥36 weeks gestational age with moderate or severe HIE admitted 2011-2016., Interventions: Birth in non-CC compared with CC., Main Outcome Measures: Primary outcome was survival to discharge without recorded seizures. Secondary outcomes were recorded seizures, mortality and temperature on arrival at CCs following transfer., Results: 5059 infants were included with 2364 (46.7%) born in non-CCs. Birth in a CC was associated with improved survival without seizures (35.1% vs 31.8%; OR 1.15, 95% CI 1.02 to 1.31; p=0.02), fewer seizures (60.7% vs 64.6%; OR 0.84, 95% CI 0.75 to 0.95, p=0.007) and similar mortality (15.8% vs 14.4%; OR 1.11, 95% CI 0.93 to 1.31, p=0.20) compared with birth in a non-CC. Matched infants from level 2 centres only had similar results, and birth in CCs was associated with greater seizure-free survival compared with non-CCs. Following transfer from a non-CC to a CC (n=2027), 1362 (67.1%) infants arrived with a recorded optimal therapeutic temperature but only 259 (12.7%) of these arrived within 6 hours of birth., Conclusions: Almost half of UK infants with HIE were born in a non-CC, which was associated with suboptimal hypothermic treatment and reduced seizure-free survival. Provision of active TH in non-CC hospitals prior to upward transfer warrants consideration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: Neonatal mortality in Guinea accounts for about 30% of all fatalities in children younger than five years. Countrywide, specialized neonatal intensive care is provided in one single clinic with markedly limited resources. To implement targeted measures, prospective data on patient characteristics and factors of neonatal death are needed., Objective: To determine the rates of morbidity and mortality, to describe clinical characteristics of admitted newborns requiring intensive care, to assess the quality of disease management, and to identify factors contributing to neonatal mortality., Methods: Prospective observational cohort study of newborns admitted to the hospital between mid-February and mid-March 2019 after birth in other institutions. Data were collected on maternal/prenatal history, delivery, and in-hospital care via convenience sampling. Associations of patient characteristics with in-hospital death were assessed using cause-specific Cox proportional-hazards models., Results: Half of the 168 admitted newborns underwent postnatal cardiopulmonary resuscitation. Reasons for admission included respiratory distress (49.4%), poor postnatal adaptation (45.8%), prematurity (46.2%), and infections (37.1%). 101 newborns (61.2%) arrived in serious/critical general condition; 90 children (53.9%) showed clinical signs of neurological damage. Quality of care was poor: Only 59.4% of the 64 newborns admitted with hypothermia were externally heated; likewise, 57.1% of 45 jaundiced infants did not receive phototherapy. Death occurred in 56 children (33.3%) due to birth asphyxia (42.9%), prematurity (33.9%), and sepsis (12.5%). Newborns in serious/critical general condition at admission had about a fivefold higher hazard to die than those admitted in good condition (HR 5.21 95%-CI 2.42-11.25, p = <0.0001). Hypothermia at admission was also associated with a higher hazard of death (HR 2.00, 95%-CI 1.10-3.65, p = 0.023)., Conclusion: Neonatal mortality was strikingly high. Birth asphyxia, prematurity, and infection accounted for 89.3% of death, aggravated by poor quality of in-hospital care. Children with serious general condition at admission had poor chances of survival. The whole concept of perinatal care in Guinea requires reconsideration., Competing Interests: The authors have declared that no competing interests exist.

Background: Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States., Methods: Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants., Results: This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average., Conclusions: With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Edwards receives salary support from the Vermont Oxford Network. Ms Greenberg is an employee of the Vermont Oxford Network. Dr Horbar is chief executive officer, president, and chief scientific officer of the Vermont Oxford Network and an unpaid member of the Vermont Oxford Network Board of Trustees. The other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objective: Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations., Methods: A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen)., Results: In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions., Conclusions: There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Neonatal intensive care unit (NICU) discharge readiness is the primary caregivers' masterful attainment of technical care skills and knowledge, emotional comfort and confidence with infant care by the time of discharge. NICU discharge preparation is the process of facilitating discharge readiness. Discharge preparation is the process with discharge readiness as the goal. Our previous work described the importance of NICU discharge readiness and strategies for discharge preparation from an American medical system perspective. NICU discharge planning is, however, of international relevance as challenges in relation to hospital discharge are a recurring global theme. In this manuscript, we conceptualise NICU discharge preparation with international perspective., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period., Methods: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time., Results: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months., Conclusions: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Family-centered care contributes to improved outcomes for preterm and ill infants. Little is known about the perceptions of neonatal intensive care unit (NICU) healthcare professionals regarding the degree to which their NICU practices or values family-centered care., Purpose: The aims of this study were to describe attitudes and beliefs of NICU healthcare professionals about family-centered care and to explore professional characteristics that might influence those views., Methods: Data were derived from the baseline phase of a multicenter quasi-experimental study comparing usual family-centered NICU care with mobile-enhanced family-integrated care. Neonatal intensive care unit healthcare professionals completed the Family-Centered Care Questionnaire-Revised (FCCQ-R), a 45-item measure of 9 core dimensions of Current Practice and Necessary Practice for family-centered care., Results: A total of 382 (43%) NICU healthcare professionals from 6 NICUs completed 1 or more of the FCCQ-R subscales, 83% were registered nurses. Total and subscale scores on the Necessary Practice scale were consistently higher than those on the Current Practice scale for all dimensions of family-centered care (mean: 4.40 [0.46] vs 3.61 [0.53], P < .001). Only years of hospital experience and NICU site were significantly associated with Current Practice and Necessary Practice total scores., Implications for Practice: Ongoing assessment of the perceptions of NICU healthcare professionals regarding their current practice and beliefs about what is necessary for the delivery of high-quality family-centered care can inform NICU education, quality improvement, and maintenance of family-centered care during the COVID-19 pandemic., Implications for Research: Further research is needed to identify additional factors that predict family-centered care perceptions and behaviors., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 by The National Association of Neonatal Nurses.)

Importance: Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade., Objective: To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD., Design, Setting, and Participants: This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019)., Interventions: A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable., Main Outcomes and Measures: The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities., Results: The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly., Conclusions and Relevance: A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.

Background: We investigated the impact of policy change in delivery room resuscitation from routine endotracheal (ET) suctioning of non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) to immediate non-invasive respiratory support., Design: Single-centre cohort study. Prospective group (October 2016-September 2017)-non-vigorous neonates born through MSAF managed according to the current (2015) guidance of commencing respiratory support without prior suctioning. Retrospective group (August 2015-July 2016)-non-vigorous neonates born through MSAF who underwent routine ET suctioning., Results: 1138 neonates born through MSAF were analysed. No differences in the incidence of meconium aspiration syndrome (MAS), requirement of mechanical ventilation, inhaled nitric oxide or surfactant therapy were found between groups. Less neonatal intensive care unit (NICU) admissions were necessary in the prospective cohort compared with the retrospective group (19.1% vs 55.6%, respectively; p<0.05)., Conclusion: The policy change towards not routinely suctioning non-vigorous neonates born through MSAF at birth was not associated with an increase in the local incidence of MAS and was associated with fewer NICU admissions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

COVID-19's first wave created chaos for new NICU families as they struggled to cope with the challenge of a fragile infant along with a pandemic. Safety was paramount due to a lack of understanding around how the virus transmits, but much has been learned since then. The next wave of the virus needs to have a rethink around family separation. World leader organization European Foundation for the Care of Newborn Infants (EFCNI) provides insight into the challenges with the first wave and suggests ideas around rethinking how families interact with their baby in the subsequent waves., (© Copyright 2021 Springer Publishing Company, LLC.)

Objective: Provide a progress report updating our long-term quality improvement collaboration focused on major morbidity reduction in extremely premature infants 23-27 weeks., Methods: 10 Vermont Oxford Network (VON) neonatal intensive care units (NICUs) (the POD) sustained a structured alliance: (A) face-to-face meetings, site visits and teleconferences, (B) transparent process and outcomes sharing, (C) utilisation of evidence-based potentially better practice toolkits, (D) family integration and (E) benchmarking via a composite mortality-morbidity score (Benefit Metric). Morbidity-specific toolkits were employed variably by each NICU according to local priorities. The eight major VON morbidities and the risk-adjusted Benefit Metric were compared in two epochs 2010-2013 versus 2014-2018., Results: 5888 infants, mean (SD) gestational age 25.8 (1.4) weeks, were tracked. The POD Benefit Metric significantly improved (p=0.03) and remained superior to the aggregate VON both epochs (p<0.001). Four POD morbidities significantly improved through 2018 - chronic lung disease (48%-40%), discharge weight <10th percentile (32%-22%), any late infection (19%-17%) and periventricular leukomalacia (4%-2%). In epoch 2, 34% of survivors had none of the eight major morbidities, while 36% had just one. Mortality did not change., Conclusions: Inter-NICU collaboration, process and outcomes sharing and potentially better practice toolkits sustain improvement in 23-27 week morbidity rates, notably chronic lung disease, extrauterine growth restriction and the lowest zero-or-one major morbidity rate reported by a quality improvement collaboration. Unrevealed biological and cultural variables affect morbidity rates, countless remain unmeasured, thus duplication to other quality improvement groups is challenging. Understanding intensive care as innumerable interactions and constant flux that defy convenient linear constructs is fundamental., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The health of the hospital associated persons, particularly those dealing directly with insertion of devices, are serious cause of concern for hospitals. In this study, the most prevalent organism on the surface of medical devices in PICU were CoNS (16.66%) and Staphylococcus aureus (16.66%), while in NICU the most prevalent organism was Klebsiella spp. (11.25%) among Entero-bacteriaceae group followed by Acinetobacter baumannii (10%), Escherichia coli (2.5%), CoNS (6.25%), S. aureus (6.25%) and Enterococcus faecalis (6.25%). The most common species identified from blood specimen of clinical samples shows the maximum presence of Candida sp. (60/135) followed by A. baumannii (21/135), Klebsiella Pneumoniae (20/135), Enterococci (12/135), Burkholderia cepacia complex (8/135), S. aureus (6/135), E. coli (5/135), Pseudomonas aeruginosa (3/135). Different antibiotics have been used against these micro-organisms; but Cotrimoxazole, Vancomycin have been found more effective against CoNS bacteria, Clindamycin, Tetracycline for S. aureus, Nitofurantoin for Acinetobacter, and for E. faecalis, A. baumanii, and Klebsiella, erythromycin, Colistin, and Ceftriaxone have been found more effective respectively.

Objectives: To find out if the expressed breast milk delivery rate to neonatal intensive care unit (NICU) for babies who were hospitalized for any reason other than COVID-19, and exclusive breastfeeding (EB) rates between discharge date and 30th day of life of those babies were affected by COVID-19 pandemic., Methods: Babies who were hospitalized before the date first coronavirus case was detected in our country were included as control group (CG). The study group was divided into two groups; study group 1 (SG1): the mothers whose babies were hospitalized in the period when mother were asked not to bring breast milk to NICU, study group 2 (SG2): the mothers whose babies were hospitalized after the date we started to use the informed consent form for feeding options. The breast milk delivery rates to NICU during hospitalization and EB rates between discharge and 30th day of life were compared between groups., Results: Among 154 mother-baby dyads (CG, n=50; SG1, n=46; SG2, n=58), the percentage of breast milk delivery to NICU was 100%, 79% for CG, SG2, respectively (p<0.001). The EB rate between discharge and 30th day of life did not change between groups (CG:90%, SG1:89%, SG2:75.9; p=0.075)., Conclusions: If the mothers are informed about the importance of breast milk, the EB rates are not affected by the COVID-19 pandemic in short term, even if the mothers are obligatorily separated from their babies. The breast milk intake rate of the babies was lowest while our NICU protocol was uncertain, and after we prepared a protocol this rate increased., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Background: Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited., Objective: This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period., Methods: The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age., Results: Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time., Conclusions: While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient's individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed., (©Katarina Braune, Mandy Wäldchen, Klemens Raile, Sigrid Hahn, Tebbe Ubben, Susanne Römer, Daniela Hoeber, Nora Johanna Reibel, Michael Launspach, Oliver Blankenstein, Christoph Bührer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.12.2020.)

Objectives: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture., Study Design: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions., Results: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate., Conclusions: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.

Purpose: Mothers of infants hospitalized in neonatal intensive care units (NICUs) need to be recognized as essential partners of the care team as their presence and involvement are key to infants' health and developmental outcomes. Addressing mothers' perceived needs is beneficial for the improvement of supportive nursing care; however, little qualitative research on their unmet needs has been conducted in South Korea. This study assessed mothers' perspectives on their NICU experiences and their unmet needs within the South Korean cultural context., Method: A cross-sectional, multicentered, secondary analysis study was conducted using the written responses to an open-ended questionnaire. Of the 344 NICU-experienced mothers, 232 throughout South Korea (seven cities and five provinces) voluntarily completed the questionnaire via smartphone-based or web-based surveys. Their narrative responses were analyzed using thematic content analysis guided by the critical incident technique., Results: Four themes emerged. NICU-experienced mothers of preterm infants referred to the "family-friendly environment" (16.4%) as a positive experience. The greatest unmet need was "relationship-based support" (58.2%), followed by "information and education-based support" (20.0%) and "system-level challenges" (5.4%)., Conclusion: The importance of creating a family-friendly NICU environment should be emphasized by ensuring 24-hour unrestricted access and encouraging active parental involvement in infant care, as well as actively supporting NICU families through supportive words and actions. The assurance of antiinfection management and better staffing levels should be fundamentally guaranteed to NICU staff., Competing Interests: Conflicts of interest None declared., (Copyright © 2020. Published by Elsevier B.V.)

Objectives: Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines., Methods: A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied., Results: We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score., Conclusions: Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To characterise the association between weekend (Saturday and Sunday) deliveries of very low birthweight (VLBW) infants and delivery room outcomes in the 'golden hour' after birth., Design and Setting: A retrospective cohort study using California Perinatal Quality Care Collaborative data from participating neonatal intensive care units., Patients: The study population after exclusions was 26 515 VLBW infants born in California from 2010 to 2016., Main Outcome Measures: Delivery room outcomes assessed included: chest compressions, epinephrine, intubation prior to continuous positive airway pressure ventilation, 5 min Apgar <4, admission hypothermia and death within 12 hours. To adjust for potential confounders, we fit multivariate regression models controlling for two sets of infant, maternal and hospital characteristics., Results: Infants delivered on weekends were less likely to have been prenatally diagnosed with intrauterine growth restriction but were otherwise not significantly different in gestational age, ethnicity, sex or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends, while vaginal deliveries were consistent across all days. After adjusting for sex and race, weekend delivery was associated with delivery room chest compressions (OR: 1.12, 95% CI 1.02 to 1.24) and lower 5 min Apgar (OR: 1.11, 95% CI 1.01 to 1.21)., Conclusion: In this population-based study of VLBW infants, there was an increase in chest compressions for infants born on the weekend. More research is needed on the differences between populations born on weekdays versus weekends, and how these may contribute to observed associations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the prevalence of symptoms of postpartum depression (PPD) and examine how fathers' presence and involvement in the care of their newborns affect symptoms of PPD within the first 2 weeks after birth among mothers with newborns in the NICU., Design: Observational cohort study., Setting: Open-bay, 40-bed, tertiary level NICU in Eastern Canada., Participants: Mothers (N = 105) of newborns who were anticipated to survive and required more than 5 days of hospitalization in the NICU., Methods: Participants completed the Postpartum Depression Screening Scale (PDSS) 14 days after they gave birth. They kept daily diaries to record the amount of time that fathers spent by the newborns' bedsides (i.e., presence) and actively caring for their newborns (i.e., involvement such as skin to skin). Participants completed daily diaries from the time of enrollment in the study until their newborns were discharged home. We analyzed the data using linear regression; score on the PDSS was the dependent variable, and fathers' presence and involvement were the independent variables. We adjusted for covariates., Results: The prevalence of positive screening for symptoms of major PPD was 24.1% (n = 20), and the prevalence of significant symptoms of PPD was 27.7% (n = 23). Participants reported that fathers were present in the NICU an average of 3.8 hours per day and were actively involved with their newborns 53% of the time. Fathers' involvement was significantly associated with lower scores on the PDSS (adjusted β = -3.85; 95% confidence interval [CI] [-6.10, -1.60]). A history of anxiety was significantly associated with greater scores on the PDSS (adjusted β = 12.06, 95% CI [2.07, 22.05]). Maternal age and income less than $50,000 CAD were marginally associated with greater scores on the PDSS (adjusted β = -0.86, 95% CI [-1.77, 0.05] and adjusted β = 10.69, 95% CI [-0.73, 22.11], respectively). The overall explained variance in the PDSS scores with the independent variables was R 2  = 0.35., Conclusion: Fathers' involvement in the care of their newborns in the NICU was significantly associated with fewer symptoms of PPD among mothers. We recommend research with targeted interventions to promote fathers' involvement in the NICU to potentially mitigate the symptoms of PPD among mothers of newborns in the NICU., (Copyright © 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Before the initiation of a standardized feeding roadmap in our regional, level IV academic neonatal intensive care unit, utilization of central lines was high, and initiation of enteral feeds delayed in the very low-birth-weight population (<1500 g). Given our review of the literature, it appeared that the standardization of feeding advancement would likely result in improved performance in both issues., Methods: This was a retrospective cohort comparison of very low-birth-weight patients before initiation of any feeding roadmap with a second cohort following completion of the final roadmap. Infants were examined retrospectively in 2 historical cohorts: Phase 1, infants fed before roadmap development and rollout, October 1, 2012-March 31, 2013; and Phase 2, following promulgation of the final feeding roadmap, January 1, 2017-June 30, 2017., Results: During Phase 2, we observed a significant reduction in median (interquartile range) days to first feed (3 [1] vs 1 [1] [P < 0.0001]) and utilization of a second central line (35% vs 12% [P < 0.01]). Weight gain was significantly improved from before roadmap implementation to final, mean (SD) (g/d, 21 [5] vs 24 [4]; [P < .0001]). Percentage of first enteral feedings that were human milk also increased significantly from 71% to 91% (P = 0.0007)., Conclusion: Implementation of a standardized feeding roadmap was associated with a reduction in days to first enteral feeds, an increase in the primary use of human milk for initiation of enteral feeds, and a decrease in the utilization of central lines while improving weight gain in very low-birth-weight infants., (© 2019 American Society for Parenteral and Enteral Nutrition.)