James E. Gray

Occurrence of nosocomial bloodstream infections in six neonatal intensive care units.

BACKGROUND Nosocomial bloodstream infections (NBSIs) occur frequently in neonatal intensive care units (NICUs) and are associated with substantial morbidity and mortality. Little has been published regarding variation in NBSI among institutions. OBJECTIVE To determine NBSI incidence among six NICUs and to explore how much variation is explained by patient characteristics and NICU practice patterns. METHODS From October, 1994, to June, 1996, six regional NICUs prospectively abstracted clinical records of all neonates weighing <1,500 g. Occurrence of NBSI, defined as first positive culture occurring >48 h after admission, was analyzed in relation to baseline patient characteristics and several common therapeutic interventions. Variables significant in univariate analyses were analyzed by Cox proportional hazards regression. RESULTS There were 258 NBSIs (incidence, 19.1%) among 1,354 inborn first admissions. Incidence varied significantly by site, from 8.5 to 42%. Birth weight, Broviac catheter use and parenteral nutrition were significantly associated with NBSI (P < 0.05). When controlling for these variables interinstitutional variation in NBSI occurrence decreased but remained significant. CONCLUSIONS Neonatal NBSI incidence varies substantially among institutions despite adjustment for length of stay and some known risk factors. The uses of Broviac catheters and especially intravenous nutrition supplements were significant determinants of NBSI risk.

Declining severity adjusted mortality: evidence of improving neonatal intensive care.

Objectives. Declines in neonatal mortality have been attributed to neonatal intensive care. An alternative to the “better care” hypothesis is the “better babies” hypothesis; ie, very low birth weight infants are delivered less ill and therefore have better survival. Design. We ascertained outcomes of all live births <1500 g in two prospective inception cohorts. We estimated mortality risk from birth weight and illness severity on admission and measured therapeutic intensity. We calculated logistic regression models to estimate the changing odds of mortality between cohorts. Patients and Setting. Two cohorts in the same two hospitals, 5 years apart (1989–1990 and 1994–1995) (totaln = 739). Results. Neonatal intensive care unit mortality declined from 17.1% to 9.5%, and total mortality declined from 31.6% to 18.4%. Cohort 2 had lower risk (higher birth weight, gestational age, and Apgar scores and lower admission illness severity for newborns ≥750 g). Risk-adjusted mortality declined (odds ratio, 0.52; confidence interval, 0.29–0.96). One third of the decline was attributable to “better babies” and two thirds to “better care.” Use of surfactant, mechanical ventilation, and pressors became more aggressive, but decreases in monitoring, procedures, and transfusions resulted in little change in therapeutic intensity. Conclusions. Mortality decreased nearly 50% for infants <1500 g in 5 years. One third of this decline is attributable to improved condition on admission that reflects improving obstetric and delivery room care. Two thirds of the decline is attributable to more effective newborn intensive care, which was associated with greater aggressiveness of respiratory and cardiovascular treatments. Attribution of improved birth weight specific mortality solely to neonatal intensive care may underestimate the contribution of high-risk obstetric care in providing “better babies.”

Intravenous lipid emulsions are the major determinant of coagulase-negative staphylococcal bacteremia in very low birth weight newborns

BACKGROUND Intravenous lipid emulsions and the i.v. catheters through which they were administered were the major risk factors for nosocomial coagulase-negative staphylococcal (CONS) bacteremia among newborns in our neonatal intensive care units a decade ago. However, medical practice is changing, and these and other interventions may have different effects in the current setting. OBJECTIVES We determined the independent risk factors for CONS bacteremia in current very low birth weight newborns after adjusting for severity of underlying illness. METHODS We surveyed 590 consecutively admitted newborns with birth weights < 1500 g hospitalized in 2 neonatal intensive care units and conducted a case-control study in a sample of 74 cases of CONS bacteremia and 74 pairs of matched controls. Adjusted relative odds of bacteremia were estimated for a number of attributes and therapeutic interventions in 2 time intervals before CONS bacteremia: any time before bacteremia and the week before bacteremia. RESULTS Using conditional logistic regression to adjust for indicators of severity of illness, two procedures were independently associated with subsequent risk of CONS bacteremia at any time during hospitalization: i.v. lipids, odds ratio (OR) = 9.4 [95% confidence interval (CI) 1.2 to 74.2]; and any surgical or percutaneously placed central venous catheter, OR = 2.0 (95% CI 1.1 to 3.9). Considering only the week immediately preceding bacteremia, the independent risk factors were: mechanical ventilation, OR = 3.2 (95% CI 1.3 to 7.6); and short peripheral venous catheters, OR = 2.6 (95% CI 1.0 to 6.5). CONCLUSIONS During the last decade exposure to i.v. lipids any time during hospitalization has become an even more important risk factor for CONS bacteremia (OR = 9.4). Of these bacteremias 85% are now attributable to lipid therapy. In contrast the relative importance of intravenous catheters as independent risk factors has declined. Mechanical ventilation in the week before bacteremia has emerged as a risk factor for bacteremia.

Real time patient safety audits: improving safety every day

Background: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. Objective: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). Methods: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. Results: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected ⩾1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4). Conclusions: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free “culture of patient safety” involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk

OBJECTIVE. To quantify the potential for misidentification among NICU patients resulting from similarities in patient names or hospital medical record numbers (MRNs). METHODS. A listing of all patients who received care in 1 NICU during 1 calendar year was obtained from the units electronic medical record system. A patient day was considered at risk for misidentification when the index patient shared a surname, similar-sounding surname, or similar MRN with another patient who was cared for in the NICU on that day. RESULTS. During the 1-year study period, 12186 days of patient care were provided to 1260 patients. The units average daily census was 33.4; the maximum census was 48. Not a single day was free of risk for patient misidentification. The mean number of patients who were at risk on any given day was 17 (range: 5–35), representing just over 50% of the average daily census. During the entire calendar year, the risk ranged from 20.6% to a high of 72.9% of the average daily census. The most common causes of misidentification risk were similar-appearing MRNs (44% of patient days). Identical surnames were present in 34% of patient days, and similar-sounding names were present in 9.7% of days. Twins and triplets contributed one third of patient days in the NICU. After these multiple births were excluded from analysis, 26.3% of patient days remained at risk for misidentification. Among singletons, the contribution to misidentification risk of similar-sounding surnames was relatively unchanged (9.1% of patient days), whereas that of similar MRNs and identical surnames decreased (17.6% and 1.0%, respectively). CONCLUSIONS. NICU patients are frequently at risk for misidentification errors as a result of similarities in standard identifiers. This risk persists even after exclusion of multiple births and is substantially higher than has been reported in other hospitalized populations.

Medication errors in the neonatal intensive care unit: special patients, unique issues

Medication errors are quite common in the neonatal intensive care unit Medical errors are a common occurrence in the neonatal intensive care unit (NICU). Although this high risk, fragile patient population is prone to a wide array of errors, medication errors are particularly common. Medication errors were the most common error type submitted to the Vermont Oxford Network’s NICQ.org voluntary reporting system.1 Kaushal and colleagues2 identified errors in 5.5% of NICU medication orders. Of note, potential adverse drug events (errors that had the potential to harm the patient but were intercepted, or potentially harmful errors that reached the patient but fortuitously did not result in injury) occurred eight times more often in NICU patients than in adults in hospital. Neonates, especially very low birthweight babies, are particularly vulnerable to adverse sequelae of medication errors as they have a limited ability to “buffer” such mistakes. Nursing practice has long recognised the need for extreme vigilance and a structured approach to preventing medication errors. The five “Rights” provide a framework for improving medication safety in nursing. These basic principles of standard operating procedure try to address all of the steps in the medication process: ordering, dispensing, administering, and monitoring drugs. Nurses attempt to ensure that the Right drug is given in the Right dose at the Right interval via the Right route to the Right patient. Although nurses focus on providing error-free care, research into human factors teaches us that dedication, training, and vigilance are not enough to prevent errors in complex systems.3,4 Error prevention must be a multidisciplinary process, involving doctors, pharmacists, and nurses working as a team. The team must be backed up by robust healthcare delivery systems operating in a “culture of safety”, providing staff with a working environment that provides safeguards against human fallibility. …

Network Analysis of Team Structure in the Neonatal Intensive Care Unit

OBJECTIVE: The goal was to examine nursing team structure and its relationship with family satisfaction. METHODS: We used electronic health records to create patient-based, 1-mode networks of nursing handoffs. In these networks, nurses were represented as nodes and handoffs as edges. For each patient, we calculated network statistics including team size and diameter, network centrality index, proportion of newcomers to care teams according to day of hospitalization, and a novel measure of the average number of shifts between repeat caregivers, which was meant to quantify nursing continuity. We assessed parental satisfaction by using a standardized survey. RESULTS: Team size increased with increasing length of stay. At 2 weeks of age, 50% of shifts were staffed by a newcomer nurse who had not previously cared for the index patient. The patterns of newcomers to teams did not differ according to birth weight. When the population was dichotomized according to median mean repeat caregiver interval value, increased reports of problems with nursing care were seen with less-consistent staffing by familiar nurses. This relationship persisted after controlling for factors including birth weight, length of stay, and team size. CONCLUSIONS: Family perceptions of nursing care quality are more strongly associated with team structure and the sequence of nursing participation than with team size. Objective measures of health care team structure and function can be examined by applying network analytic techniques to information contained in electronic health records.

Spread of Methicillin-Resistant Staphylococcus aureus in a Large Tertiary NICU: Network Analysis

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) colonization in NICUs increases the risk of nosocomial infection. Network analysis provides tools to examine the interactions among patients and staff members that put patients at risk of colonization. METHODS: Data from MRSA surveillance cultures were combined with patient room locations, nursing assignments, and sibship information to create patient- and unit-based networks. Multivariate models were constructed to quantify the risk of incident MRSA colonization as a function of exposure to MRSA-colonized infants in these networks. RESULTS: A MRSA-negative infant in the NICU simultaneously with a MRSA-positive infant had higher odds of becoming colonized when the colonized infant was a sibling, compared with an unrelated patient (odds ratio: 8.8 [95% confidence interval [CI]: 5.3–14.8]). Although knowing that a patient was MRSA-positive and was placed on contact precautions reduced the overall odds of another patient becoming colonized by 35% (95% CI: 20%–47%), having a nurse in common with that patient still increased the odds of colonization by 43% (95% CI: 14%–80%). Normalized group degree centrality, a unitwide network measure of connectedness between colonized and uncolonized patients, was a significant predictor of incident MRSA cases (odds ratio: 18.1 [95% CI: 3.6–90.0]). CONCLUSIONS: Despite current infection-control strategies, patients remain at significant risk of MRSA colonization from MRSA-positive siblings and from other patients with whom they share nursing care. Strategies that minimize the frequency of staff members caring for both colonized and uncolonized infants may be beneficial in reducing the spread of MRSA colonization.

Failure to screen newborns for inborn disorders: a potential consequence of changes in newborn care

OBJECTIVES To determine how changes in the structure of the hospital care of infants, such as shortened post-natal stays, affect the completeness of newborn screening. DESIGN Cohort. SETTING Two large maternity hospitals. PARTICIPANTS 8751 consecutive births at the study hospitals during 1993. MAIN OUTCOME MEASURE The completeness of initial specimen collection and processing as determined by matching of birth and screening records. RESULTS At least one specimen was received by the screening program for 8675 (99.1%) of the births. Most non-screened patients (71/76, 93%) had been admitted to the neonatal intensive care unit (NICU). Of these, 53/71 (75%) were low birth weight infants who died within 48 h of birth. Even after excluding these non-survivors, NICU patients were 37 times more likely to be unscreened than their healthy counterparts (22 vs. 0.6 per 1000 infants, 95% C.I. 12.8, 92.8 P < 0.01). A common characteristic of non-screened NICU survivors, (12/18) was interhospital transfer for sub-specialty care. Among patients in the healthy-baby nursery, early discharge (i.e. < 24 h of age) accounted for 2/5 (40%) of the cases of non-screening. The non-screening rate among patients discharged early was 25 times higher than for those discharged after 24 h (9.8 vs. 0.4 per 1000 infants, 95% C.I. 4.2, 149 P < 0.01). CONCLUSIONS Although the overall rate of screening was high, NICU patients, especially those requiring transfer, are disproportionately at risk for non-screening. Early discharge of healthy newborns was also significantly associated with non-screening. This latter finding is of special importance given the current trend toward shorter hospital stays for newborns. Increased attention to ensuring the collection of specimens from these two high-risk populations is warranted.

Characterizing Practice Style in Neonatal Intensive Care |[dagger]| 1321

Background: Outcomes and resource uses differ among NICUs. While this depends on case mix, institutional practice styles may also differ. We characterized practice style, adjusting for case mix, in a cohort of premature infants. Outcomes are reported elsewhere.