Jeffrey D. Horbar

Mortality and Neonatal Morbidity Among Infants 501 to 1500 Grams From 2000 to 2009

OBJECTIVE: To identify changes in mortality and neonatal morbidities for infants with birth weight 501 to 1500 g born from 2000 to 2009. METHODS: There were 355 806 infants weighing 501 to 1500 g who were born in 2000–2009. Mortality during initial hospitalization and major neonatal morbidity in survivors (early and late infection, chronic lung disease, necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, and periventricular leukomalacia) were assessed by using data from 669 North American hospitals in the Vermont Oxford Network. RESULTS: From 2000 to 2009, mortality for infants weighing 501 to 1500 g decreased from 14.3% to 12.4% (difference, −1.9%; 95% confidence interval, −2.3% to −1.5%). Major morbidity in survivors decreased from 46.4% to 41.4% (difference, −4.9%; 95% confidence interval, −5.6% to −4.2%). In 2009, mortality ranged from 36.6% for infants 501 to 750 g to 3.5% for infants 1251 to 1500 g, whereas major morbidity in survivors ranged from 82.7% to 18.7%. In 2009, 49.2% of all very low birth weight infants and 89.2% of infants 501 to 750 g either died or survived with a major neonatal morbidity. CONCLUSIONS: Mortality and major neonatal morbidity in survivors decreased for infants with birth weight 501 to 1500 g between 2000 and 2009. However, at the end of the decade, a high proportion of these infants still either died or survived after experiencing ≥1 major neonatal morbidity known to be associated with both short- and long-term adverse consequences.

Mortality of necrotizing enterocolitis expressed by birth weight categories

PURPOSE Low birth weight is the most important risk factor for developing necrotizing enterocolitis (NEC). We aimed to establish birth weight-based benchmarks for in-hospital mortality in neonates with NEC. METHODS Five hundred eleven centers belonging to the Vermont Oxford Network prospectively evaluated 71,808 neonates with birth weight of 501 to 1500 g between January 2005 and December 2006. The primary outcome variable was in-hospital mortality. RESULTS Birth weight was divided into 4 categories by 250-g increments. The NEC risk (P < .001) and mortality (P < .001) decreased with higher birth weight category. Necrotizing enterocolitis was associated with a significant odds ratio for death for each category (P < .001). Across groups, the odds ratio for NEC mortality increased with higher birth weight category (category 1 = 1.6 vs category 4 = 9.9; P < .001). CONCLUSION The in-hospital mortality rate of neonates with NEC remains high and is significantly related to birth weight category. Although the risk and absolute mortality of NEC decrease with higher birth weight, the odds ratios indicate that NEC has a relatively greater impact upon mortality at higher birth weight. These data afford birth weight-based mortality benchmarks that may be useful in assessing single center NEC outcomes and facilitating comparisons between centers.

The Vermont Oxford Network: a community of practice.

The Vermont Oxford Network is a not-for-profit organization established in the late 1980s with the goals of improving the quality and safety of medical care for newborn infants and their families through a coordinated program of research, education, and quality improvement. In this paper the authors discuss the activities and programs sponsored by the Network to achieve those goals.

Cardiopulmonary resuscitation in the very low birth weight infant : The Vermont Oxford Network Experience

Objective. The limited literature available to date suggests that the use of delivery room cardiopulmonary resuscitation (DR-CPR) is associated with very poor outcomes, especially for extremely low birth weight infants. We reviewed the cumulative experience of the Vermont Oxford Network to determine the actual utilization of DR-CPR and the neonatal outcomes of such infants. Methods. A retrospective review of information available in the Vermont Oxford Network Database for the years 1994 to 1996. The data set was collected from 196 neonatal units who participate in the Network (data for infants 401 to 500 g were from 1996 only). Infants were eligible for study if they received DR-CPR defined as the administration of chest compressions and/or epinephrine in the delivery room as noted on the Vermont Oxford Network Database record. Results. Information regarding survival was available for 27 707 newborns with birth weights from 501 to 1500 g, and 497 infants with birth weights from 401 to 500 g. There were 24 001 (86.6%) survivors. Overall DR-CPR was given to 9.3% of infants from 401 to 500 g and 6% of infants from 501 to 1500 g, 82.1% receiving chest compressions, and 66.7% receiving epinephrine. Survival of infants receiving DR-CPR was 23.9% for infants of 401 to 500 g, and 63.3% for infants of 501 to 1500 g, compared with 16.7% and 87.9% for infants in these weight groups not receiving DR-CPR. Survival was greater for infants of 501 g or greater without DR-CPR compared with those who received this intervention within each 250-g birth weight subgroup. For infants of <1000 g, survival was 53.8% with DR-CPR compared with 74.9% without. Head ultrasounds were available for 95.5% of all surviving infants and 96.7% of infants who received DR-CPR. Overall, any grade of intraventricular hemorrhage (IVH) occurred more frequently in infants who received DR-CPR (38%) than in those who did not (21%). Grade 3 or 4 (severe) IVH was seen in 15.3% of infants who received DR-CPR compared with 4.9% of the infants who did not. Overall, survival without severe IVH occurred in 52.2% of DR-CPR infants compared with 81.3% of infants who did not require this intervention. Conclusion. The majority of very low birth weight and extremely low birth weight infants who receive DR-CPR survive, and at least half of such infants who survive do not have evidence of severe IVH. Further follow-up studies are required to determine the long-term neurodevelopmental outcome of such infants. The current study does not support the previously noted poor outcome in extremely low birth weight infants who receive DR-CPR.

Changes in the Use of Postnatal Steroids for Bronchopulmonary Dysplasia in 3 Large Neonatal Networks

BACKGROUND. Postnatal corticosteroids were widely used in the 1990s in an attempt to reduce the incidence of bronchopulmonary dysplasia. However, high rates of short-term adverse effects and impaired neurodevelopmental outcomes were seen. In early 2002, a joint statement of the American Academy of Pediatrics and Canadian Paediatric Society called for limitation in the use of postnatal corticosteroids. The impact of this statement is not known. OBJECTIVES. The purpose of this work was to determine the frequency of postnatal corticosteroid use and mortality and morbidities over time, particularly before and after the joint statement. DESIGN/METHODS. We conducted a retrospective analysis of cohort data within 3 large network registries (the National Institute of Child Health and Development Neonatal Research Network [18 centers], the Vermont Oxford Network [444 centers], and the Canadian Neonatal Network [10 centers]) for the following 3 periods: prestatement (2001), statement (2002), and poststatement (2003) of very low birth-weight infants (501–1500 g). The National Institute of Child Health and Development Neonatal Research Network and the Vermont Oxford Network were also analyzed for longer-term trends from 1990 to 2003. Postnatal corticosteroid use, mortality at discharge, and neonatal morbidities (bronchopulmonary dysplasia at 36 weeks, late-onset infection >72 hours of age, necrotizing enterocolitis treated with surgery, and length of stay) between periods were compared. RESULTS. Mean birth weight (range: 1022–1060 g), postmenstrual age (28 weeks), and gender (51% male) were similar between the networks. Race differed with more black infants in the National Institute of Child Health and Development Neonatal Research Network than the Vermont Oxford Network (38% vs 24%). Antenatal steroid use was similar (range: 61%–75%). Postnatal corticosteroid use rose from 1990 (8%–16%), peaked in 1996–1998 (24%–28%), and began to decline in 1999. Use in 2003 was significantly less than in 2001. Mortality and major morbidities were similar. CONCLUSIONS. Postnatal corticosteroid use had decreased significantly in 3 large neonatal networks before the joint statement with further decreases after the statement with no apparent impact on mortality and short-term morbidity. Despite substantial decreases, ∼8% of very low birth-weight infants continue to be treated with postnatal corticosteroid.

Evidence from multicenter neworks on the current use and effectiveness of antenatal corticosteroids in low birth weight infants

Corticosteroid treatment of pregnant women at risk for preterm delivery enhances fetal lung maturity and improves neonatal outcomes.’ Despite convincing evidence of these effects, a consensus has not been reached about the indications for antenatal steroids, and the frequency with which they are used remains low in some countries, including the United States. In response to this situation, the National Institutes of Health (NIH) convened a Consensus Development Conference on the Effects of Corticosteroids for Fetal Maturation on Perinatal Outcomes.’ The following reports were prepared at the request of the panel; they describe the effects of antenatal steroid treatment on neonatal outcome from five current observational databases: those of the National Institute of Child Health and Development (NICHD) Neonatal Research Network, the Vermont-Oxford Trials Network, Ross Laboratories, and Burroughs Wellcome (BW) Co. The purpose of this article is to present an overview of the findings of these five large databases.

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.

Predicting mortality risk for infants weighing 501 to 1500 grams at birth: A National Institutes of Health Neonatal Research Network report

ObjectivesTo develop and evaluate a model that predicts mortality risk based on admission data for infants weighing 501 to 1500 grams at birth, and to use the model to identify neonatal ICUs where the observed mortality rate differs significantly from the predicted rate. DesignValidation cohort study. SettingUniversity-based, tertiary care neonatal ICUs. PatientsSample of 3,603 infants with birth weights of 501 to 1500 grams who were born at seven National Institute of Child Health and Human Development (NICHHD) Neonatal Research Network Centers, over a 2-yr period of time. InterventionsNone. Measurements and Main ResultsBased on logistic regression analysis, admission factrs associated with mortality risk for inborn infan were: decreasing birth weight, appropriate size for gestational age, male gender, non-black race, and 1-min Apgar score of ≤3. The mortality prediction model based on these factors had a sensitivity of 0.50, a specificity of 0.92, a correct classification rate of 0.82, and an ar under the receiver operating characteristis curve of 0.82 when applied to a validation sam ple. Goodness-of-fit testing showed that then was a marginal degree of fit between the obses vations and model predictions (X2 = 15.4, p = .05 The observed mortality rate for 3,603 infa at the seven centers was 24.7%, ranging from 21.8% to 27.7% at individual centers. These were no statistically significant difference between observed and predicted mortality rats at any of the centers. One center had an of served mortality rate that was 2.8% lower the predicted by the model (95% confidence inte −6.0% to 0.5%), and another center had as observed rate that was 3% higher than expects (95% confidence interval −0.3% to 6.2%). ConclusionsMortality risk for infants weiing 501 to 1500 grams can be predicted based admission factors. However, until more ace rate predictive models are developed and dated and the relationships between care p tices and outcomes are better understood, su models should not be relied on for evaluat the quality of care provided in different neo tal ICUs. (Crit Care Med 1993; 21:12–18)

Nurse Staffing and NICU Infection Rates

IMPORTANCE There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. OBJECTIVE To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes. DESIGN Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). SETTING Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs. PARTICIPANTS All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments. EXPOSURES We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. MAIN OUTCOMES AND MEASURES An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. RESULTS Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation-higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009. CONCLUSIONS AND RELEVANCE Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

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.