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To the Editor.-- Kaempf et al (1) have presented a hospital-based guideline designed to reduce "variability by call schedule" in counseling and decision-making practices for resuscitation of extremely preterm infants. [...]

OBJECTIVES. The goal of this report is to describe the collaborative formation of rational, practical, medical staff guidelines for the counseling and subsequent care of extremely early-gestation pregnancies and premature infants between 22 and 26 weeks. The purposes of the guidelines were to improve knowledge regarding neonatal outcomes, to provide consistency in periviability counseling, and to promote informed, supportive, responsible choices. METHODS. To formulate the guidelines, a 5-step process was conducted; it began with a series of multidisciplinary meetings among maternal-fetal medicine specialists (MFMs), obstetricians, neonatologists, neonatal nurse practitioners, and nurses from both the labor and delivery unit and the NICU at Providence St Vincent Medical Center (Portland, OR). First, our discussions reviewed mortality rates, morbidity rates, and long-term neurodevelopmental outcomes for extremely premature infants. Second, we explored the variations in counseling that pregnant women received, based on providers' individual beliefs and disparate knowledge of neonatal outcomes. Third, we asked participants to complete a survey that focused on the theoretical impending delivery of a premature infant, presenting at each week between 22 and 26 weeks of gestation. Participants indicated their recommendations for NICU care at each gestational age by using a numeric scale. Fourth, the survey results were tabulated and used as a basis for the formation of guidelines related to the recommended obstetric and neonatal care at each week of gestation. MFMs and neonatologists were urged to use these specific guidelines as a framework for counseling pregnant women between 22 and 26 weeks of gestation. Fifth, we surveyed women ~3 days after they were counseled by their MFM and neonatologist, to assess comprehension, utility, consistency, and comfort with the periviability counseling. RESULTS. Twenty pregnant women with the possibility of delivery between 22% and 266/7 weeks of gestation (mean: 24 6/7 weeks) received periviability counseling with our consensus medical staff guidelines. The respondents rated the counseling process as highly understandable (80%), useful (95%), consistent (89%), and performed in a comfortable manner (100%). All (100%) of the pregnant women thought they were given enough information to make critical decisions related to the potential level of care of their infant. CONCLUSIONS. Informative, supportive, clear, medical staff guidelines developed to assist in the counseling of women delivering extremely premature infants have been designed and implemented successfully at our hospital. These guidelines form the basis of periviability counseling, which is appreciated by our at-risk pregnant patients. We recommend that all hospitals that provide high-risk obstetric and neonatal intensive care develop similar consensus guidelines based on published outcomes and local provider experience. www.pediatrics.org/cgi/doi/10.1542/ peds.2004-2547 doi:10.1542/peds.2004-2547 Key Words prematurity, extremely early-gestation pregnancy, very low birth weight infants, viability, periviability, premature labor, medical counseling, medical staff guidelines Abbreviation MFM--maternal-fetal medicine specialist PSVMC--Providence St Vincent Medical Center, THE APPLICATION OF neonatal intensive care to extremely premature infants ( Recently, 2 commentaries in this journal highlighted the controversies that surround the resuscitation decision-making process related to extremely premature [...]

To the Editor.-- As students of bioethical decision-making, we always look forward to Dr Saigal's sequential follow-up studies that focus on the long-term health and social welfare of the 166 [...]

Not only is the neurodevelopmental impairment (NDI) rate disturbingly high after extreme prematurity survival, it is largely not improving in diverse settings. Scarcity is Nature's creative provenance, the wellspring of human conflict and subsequent adaptation. Our point is that COVID-19 and adult-medicine triage controversies are not creating scarcity or new ethical issues in neonatology; palliative vs. [Extracted from the article]

Objective. The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially petter practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD). Methods. This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia. Results. The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay. Conclusion. Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks' postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented. Pediatrics 2003;111:e534-e541. URL: http://www.pediatrics.org/cgi/content/full/111/4/e534; chronic lung disease, dexamethasone, extremely low birth weight infants, nasal continuous positive airway pressure, permissive hypercarbia, Vermont Oxford Network, collaborative quality improvement, NIC/Q 2000.

Objective. Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants. Methods. The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based. Results. The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators. Conclusions. Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective. Pediatrics 2003;111:e432--e436. URL: http://www.pediatrics.org/cgi/ content/full/111/4/e432; collaborative quality improvement, chronic lung disease, extremely low birth weight infants, best practice, NIC/Q 2000.

Purpose: Because early closure therapies of the patent ductus arteriosus (PDA) have not been shown to confer benefit to premature infants, the authors' four neonatal intensive care units adopted a less aggressive PDA management protocol. Study design: A before-after investigation in infants with PDAs born 501-1500 g. Era 1 (January 2005 to December 2007) featured traditional management with indomethacin and/or surgical ligation used early to close PDAs; Era 2 (January 2008 to June 2009) featured fluid restriction and watchful waiting for PDA closure, limiting indomethacin or surgical ligation to only those infants with large PDAs needing significant respiratory support. Results: Era 2 infants (n = 129, mean ± standard deviation 27 ± 2 weeks) received less and later indomethacin and less Day 1-28 total fluids as compared to Era 1 infants (n = 240, mean ± standard deviation 27 ± 2 weeks). The Chronic Lung Disease (CLD) rate was higher in Era 2 (48% versus 34%, P <<0.01) as was the combined outcome of Death after Day 7 or CLD (57% versus 42%, P<0.01). Multiple regression analysis showed Era 2 birth was a predictor of CLD. However, Poisson regression analysis determined the predictors of all seven major Vermont Oxford Network morbidities were earlier gestational age, lower birth weight, and male gender, not the era of birth. Significantly more infants were discharged home with PDAs in Era 2. Conclusion: Permissive tolerance of PDAs may increase the risk of CLD and Death after Day 7 or CLD but is not associated with significant changes in other Vermont Oxford Network morbidities. [ABSTRACT FROM AUTHOR]

The article discusses the development of medical staff guidelines for the care of extremely early gestation pregnancies and premature infants. Topics covered include the goal of promoting a paradigm based on sound principles and practice, the purpose of the perinatal ethics consultation and the concern raised over the omission of any mention of an antenatal/periviability counseling dialogue.

A response to a letter to the editor about a hospital-based guideline designed to reduce variability by call schedule in counseling and decision-making practices for resuscitation of extremely preterm infants is presented.

Background: Continuous quality improvement (CQI) collaboration has not eliminated the morbidity variability seen among neonatal intensive care units (NICUs). Factors other than inconstant application of potentially better practices (PBPs) might explain divergent proficiency.Objective: Measure a composite morbidity score and determine whether cultural, environmental and cognitive factors distinguish high proficiency from lower proficiency NICUs.Design/methods: Retrospective analysis using a risk-adjusted composite morbidity score (Benefit Metric) and cultural survey focusing on very low birth weight (VLBW) infants from 39 NICUs, years 2000-2014. The Benefit Metric and yearly variance from the group mean was rank-ordered by NICU. A comprehensive survey was completed by each NICU exploring whether morbidity variance correlated with CQI methodology, cultural, environmental and/or cognitive characteristics.Results: 58 272 VLBW infants were included, mean (SD) age 28.2 (3.0) weeks, birth weight 1031 (301) g. The 39 NICU groups' Benefit Metric improved 40%, from 80 in 2000 to 112 in 2014 (P<0.001). 14 NICUs had composite morbidity scores significantly better than the group, 16 did not differ and 9 scored below the group mean. The 14 highest performing NICUs were characterised by more effective team work, superior morale, greater problem-solving expectations of providers, enhanced learning opportunities, knowledge of CQI fundamentals and more generous staffing.Conclusion: Cultural, environmental and cognitive characteristics vary among NICUs perhaps more than traditional CQI methodology and PBPs, possibly explaining the inconstancy of VLBW infant morbidity reduction efforts. High proficiency NICUs foster spirited team work and camaraderie, sustained learning opportunities and support of favourable staffing that allows problem solving and widespread involvement in CQI activities. [ABSTRACT FROM AUTHOR]

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.)