John S. Curran

Educational Disabilities of Neonatal Intensive Care Graduates

Objective. To determine the relationship between perinatal and sociodemographic factors in low birth weight and sick infants hospitalized at regional neonatal intensive care units (NICUs) and subsequent educational disabilities. Method. NICU graduates born between 1980 and 1987 at nine statewide regionalized level III centers were located in Florida elementary schools (kindergarten through third grade) during academic year 1992–1993 (n = 9943). Educational disability was operationalized as placement into eight mutually exclusive types of special education (SE) classifications determined by statewide standardized eligibility criteria: physically impaired, sensory impaired (SI), profoundly mentally handicapped, trainable mentally handicapped, educable mentally handicapped, specific learning disabilities, emotionally handicapped, and speech and language impaired (SLI). Logistic regression was used to estimate the odds of placement in SE for selected perinatal and sociodemographic variables. Results. Placement into SE ranged from .8% for SI to 9.9% for SLI. Placement was related to four perinatal factors (birth weight, transport, medical conditions [congenital anomalies, seizures or intraventricular hemorrhage] and ventilation), and five sociodemographic factors (childs sex, mothers marital status, mothers race, mothers educational level, and family income). Perinatal factors primarily were associated with placement in physically impaired, SI, profoundly mentally handicapped, and trainable mentally handicapped. Perinatal and sociodemographic factors both were associated with placement in educable mentally handicapped and specific learning disabilities whereas sociodemographic factors primarily were associated with placement in emotionally handicapped and SLI. Conclusions. Educational disabilities of NICU graduates are influenced differently by perinatal and sociodemographic variables. Researchers must take into account both sets of these variables to ascertain the long-term risk of educational disability for NICU graduates. Birth weight alone should not be used to assess NICU morbidity outcomes.

A multistate quality improvement program to decrease elective deliveries before 39 weeks of gestation.

OBJECTIVE: Nonmedically indicated (elective) deliveries before 39 weeks of gestation result in unnecessary neonatal morbidity. We sought to determine whether implementation of a process improvement program will decrease the rate of elective scheduled singleton early-term deliveries (37 0/7–38 6/7 weeks of gestation) in a group of diverse community and academic hospitals. METHODS: Policies and procedures for scheduling inductions and cesarean deliveries were implemented and patient and health care provider education was provided. Outcomes for scheduled singleton deliveries at 34 weeks of gestation or higher were submitted through a web-based data entry system. The rate of scheduled singleton elective early-term deliveries as well as the rates of early-term medically indicated and unscheduled deliveries, neonatal intensive care unit admissions, and singleton term fetal mortality rate were evaluated. RESULTS: A total of 29,030 scheduled singletons at 34 weeks of gestation or higher were delivered in 26 participating hospitals between January 2011 and December 2011. Elective scheduled early-term deliveries decreased from 27.8% in the first month to 4.8% in the 12th month (P<.001); rates of elective scheduled singleton early-term inductions (72%, P=.029) and cesarean deliveries (84%; P<.001) decreased significantly. There was no change in medically indicated or unscheduled early-term deliveries. Neonatal intensive care unit admissions among scheduled early-term singletons decreased nonsignificantly from 1.5% to 1.2% (P=.24). There was no increase in the term fetal mortality rate. CONCLUSION: A rapid-cycle process improvement program substantially decreased elective scheduled early-term deliveries to less than 5% in a group of diverse hospitals across multiple states. LEVEL OF EVIDENCE: III

Effects of birth weight and sociodemographic variables on mental development of neonatal intensive care unit survivors

Neonatal intensive care unit survivors (N = 494) from 10 tertiary care centers were evaluated over the first 4 to 5 years of life to determine the relative contributions of birth weight and sociodemographic factors to mental development. Six sociodemographic factors were studied: sex, race, family income, and mothers marital status, age, and educational level; the last five factors also are known to be associated with premature birth. Mental development was measured with the Bayley Scales of Infant Development (12 to 24 months) and the Stanford Binet Intelligence Test (4 to 5 years). Each factors influence was assessed by multivariate analysis. Birth weight had limited long-term implications; at 4 to 5 years, only infants with birth weights less than 1000 gm had significantly lower scores than those in other birth weight categories. Sociodemographic variables had a greater impact on mental development, with age-dependent differences found between nonwhite and white children and between children with mothers of low, medium, and high educational levels.

Effect of Catheter Dwell Time on Risk of Central Line–Associated Bloodstream Infection in Infants

BACKGROUND AND OBJECTIVE: Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line–associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI. METHODS: Retrospective cohort study of 13 327 infants with 15 567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256 088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type. RESULTS: Median postmenstrual age was 29 weeks (interquartile range 26–33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1. CONCLUSIONS: Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

Effect of birth weight, race, and sex on survival of low-birth-weight infants in neonatal intensive care

Survival for low-birth-weight infants has traditionally been analyzed by birth weight categories spanning considerable ranges of weight. We developed a finer description of survival rates to allow estimation of survival percentages for infants of any specific birth weight between 500 and 2500 gm. Our sample consisted of 16,183 infants treated in tertiary neonatal intensive care between 1980 and 1987. Their survival data were analyzed by 50 gm increments between 500 and 2500 gm, and a continuous survival curve was constructed by log linear regression methods. Mortality differences between males and females and blacks and whites were analyzed. Survival for females was higher than males between 500 and 1500 gm and higher for blacks than whites between 650 and 1500 gm. Between 1500 and 2500 gm, no significant effects of birth weight, race, or sex were observed, with survival remaining stable at approximately 95% across all combinations of variables.

Prospective pricing system by diagnosis-related groups: comparison of federal diagnosis-related groups with high-risk obstetric care groups.

Of 468 diagnosis-related groups identified by the federal government for Medicaid reimbursement, 15 are related to obstetric hospital care. Each diagnosis-related group is considered a distinct group in which cases are homogeneous with respect to resource consumption. Because the diagnosis-related group system is based primarily on data from community and secondary care hospitals, it does not differentiate sufficiently among high-risk obstetric patients seen at tertiary care institutions, such as Floridas Regional Perinatal Intensive Care Centers. We developed an alternative scheme for diagnosis-related groups, called obstetric care groups, using the federal diagnosis-related groups as the model from which to depart. Data collected for 4192 women during a 2 1/2-year period indicate that obstetric care groups provide more homogeneous groups than diagnosis-related groups for our population of high-risk patients. The obstetric care groups differentiate between no complications, one complication, and two or more complications, while the diagnosis-related groups differentiate only between no complications and one or more complications. Also, complications for obstetric care groups are based on only 19 diagnoses that contribute significantly to resource consumption, while the list of possible complications exceeds 200 for diagnosis-related groups. Although the obstetric care group classification system is simpler than that for diagnosis-related groups, it results in a more accurate reimbursement of hospitalization charges for high-risk obstetric care.

Results of feeding a special formula to very low birth weight infants.

Fifty-eight premature infants weighing less than 1,600 g at birth were fed a special formula. The formula contained nutrients in amounts recommended by the Committee ono Nutrition of the American Academy of Pediatrics for very low birth weight (VLBW) infants. The feeding studies were carried out at newborn nurseries in Tampa, Florida (study A, n = 25), Pittsburgh, Pennsylvania (study B, n = 20), and Oaklawn, Illinois (study C, n = 13). Study subjects were comparable in birth weight, gestational age, and in the duration of follow-up in the nurseries. All study subjects grew at rates of weight acquisition equivalent to the comparative fetal counterpart. Routine anthropometric measurements were similar to those of fetal development curves. Mean protein intake ranged from 2.3 to 3.7 g/kg/day and mean caloric intake from 105 to 150 kcal/kg/day. Late metabolic acidosis in association with prematurity was absent in all subjects studied as demonstrated by normal pH values, bicarbonate, and partial pressure of carbon dioxide. Serum sodium and serum chloride levels were normal. Serum calcium ranged from 8.3 to 10.1 mg/dl and serum phosphorus from 6.0 to 7.5 mg/dl. Total serum protein levels ranged from 4.5 to 5.1 g/dl. Blood urea nitrogen diminished progressively from 5.1 to 2 mg/dl in the course of the study. Serum glucose levels in samples taken prior to and 2 h after feeding did not demonstrate any evidence of reactive hypoglycemia.

Hospital Variations in Unexpected Complications Among Term Newborns.

We examined contributing factors and reasons for the large variation in hospital rates of unexpected complications among low-risk term newborns in Florida. OBJECTIVES: To examine contributing factors and potential reasons for hospital differences in unexpected newborn complication rates in Florida. METHODS: We conducted a population-based retrospective cohort study of linked birth certificate and hospital discharge records from 2004 to 2013. The study population included 1 604 774 term, singleton live births in 124 hospitals. Severe and moderate complications were identified via a published algorithm. Logistic mixed-effects models were used to examine risk factors for complications and to estimate the percentage of hospital variation explained by factors. Descriptive analyses were performed to explore reasons for the differences. RESULTS: Hospital total complication rates varied from 6.7 to 98.6 per 1000 births. No correlation between severe and moderate complication rates by hospital was identified. Leading risk factors for complications included medically indicated early-term delivery, no prenatal care, nulliparity, prepregnancy obesity, tobacco use, and delivery in southern Florida hospitals. Hospital factors such as geographic location, level of care or birth volume, and Medicaid births percentage explained 35% and 27.8% of variation in severe and moderate complication rates, respectively. Individual factors explained an additional 6% of variation in severe complication rates. Different complication subcategories (eg, infections, hospital transfers) drove the hospital factors that contributed to severe and moderate complications. CONCLUSIONS: Variation in unexpected complication rates is more likely to be related to hospital rather than patient characteristics in Florida. The high proportion of variation explained by hospital factors suggests potential opportunities for improvement, and identifying specific complication categories may provide focus areas. Some of the opportunities may be related to differences in hospital coding practice.

Contextual factors influencing the implementation of the obstetrics hemorrhage initiative in Florida

Objective:The purpose of this study was to explore the multilevel contextual factors that influenced the implementation of the Obstetric Hemorrhage Initiative (OHI) among hospitals in Florida.Study Design:A qualitative evaluation was conducted via in-depth interviews with multidisciplinary hospital staff (n=50) across 12 hospitals. Interviews were guided by the Consolidated Framework for Implementation Research and analyzed in Atlas.ti using rigorous qualitative analysis procedures.Result:Factors influencing OHI implementation were present across process (leadership engagement; engaging people; planning; reflecting), inner setting (for example, knowledge/beliefs; resources; communication; culture) and outer setting (for example, cosmopolitanism) levels. Moreover, factors interacted across levels and were not mutually exclusive. Leadership and staff buy-in emerged as important components influencing OHI implementation across disciplines.Conclusion:Key contextual factors found to influence OHI implementation experiences can be useful in informing future quality improvement interventions given the institutional and provider-level behavioral changes needed to account for evolving the best practices in perinatology.

SERUM THYROXINE (T4), FREE T4 (FT4) AND TSH IN PREMATURE INFANTS LESS THAN 1000 GRAMS DURING THE FIRST THREE MONTHS OF LIFE

The incidence of transient hypothyroidism in very low birth weight infants has not been delineated. We studied 22 premature infants <1000 grams and <30 weeks gestation. Eight infants died within four days and their data excluded.The nadir of T4 and FT4 and the peak TSH levels occurred at 2 weeks. Eight of 10 babies had T4s <6μg/dl and 7 had FT4s <0.8ng/dl (below accepted normal values). No TSH value was >20μU/ml. The FT4s were lower than anticipated. These data are compatible with transient hypothyroxinemia. However, it is possible that these babies had transient hypothyroidism with a blunted TSH response secondary to immaturity of the hypothalamo-pituitary-thyroid axis.