Joseph Schulman

Statewide NICU Central-Line-Associated Bloodstream Infection Rates Decline After Bundles and Checklists

OBJECTIVE: In 2008, all 18 regional referral NICUs in New York state adopted central-line insertion and maintenance bundles and agreed to use checklists to monitor maintenance-bundle adherence and report checklist use. We sought to confirm whether adopting standardized bundles and using central-line maintenance checklists reduced central-line–associated bloodstream infections (CLABSI). METHODS: This was a prospective cohort study that enrolled all neonates with a central line who were hospitalized in any of 18 NICUs. Each NICU reported CLABSI and central-line utilization data and checklist use. We used χ2 to compare CLABSI rates in the preintervention (January to December 2007) versus the postintervention (March to December 2009) periods and Poisson regression to model adjusted CLABSI rates. RESULTS: Each study period included more than 55 000 central-line days and more than 200 000 patient-days. CLABSI rates decreased 67% statewide (risk ratio: 0.33 [95% confidence interval: 0.27–0.41]; P < .0005); after adjusting for the altered central-line–associated bloodstream infection definition in 2008, by 40% (risk ratio: 0.60 [95% confidence interval: 0.48–0.75]; P < .0005). A total of 13 of 18 NICUs reported using maintenance checklists for 10% to 100% of central-line days. The checklist-use rate was associated with the CLABSI rate (coefficient: −0.57, P = .04). A total of 10 of 18 NICUs were independent CLABSI rate predictors, ranging from 1 site with greatly reduced risk (incidence rate ratio: 0.04, P < .0005) to 1 site with greatly increased risk (incidence rate ratio: 2.87, P < .0005). CONCLUSIONS: Although standardizing central-line care elements led to a significant statewide decline in NICU CLABSIs, site of care remains an independent risk factor. Using maintenance checklists reduced CLABSIs.

Changes in total, nondiffusible, and diffusibleplasma zinc and copper during infancy

Concentrations of total, nondiffusible, and diffusible zinc and copper in plasma werestudied in 130 normal infants. Total plasma zinc concentration in the newborn infant was at adult levels, fell to values just below adult levels within the first week of life, fell further to values significantly below adult levels at two and three months of age, returned toward adult values at four months of age, and, except for a fall to levels significantly below adult levels at about one year of age, remained at adult levels throughout the remainder of infancy. On the other hand, total plasma copper concentration in the neonate was at levels significantly below adult levels, gradually rose during the first week of life, fell to levels significantly below adult levels at two months of age, rose to levels within the adult range at three months of age, and rose still higher to levels above the adult range at eight months of age, at which level values persisted throughout the remainder of infancy. Changes in total plasma zinc and copper during this period of time were related mainly to changes in nondiffusible or macromolecular liganded zinc and copper.

Development of a statewide collaborative to decrease NICU central line-associated bloodstream infections

Objective:To characterize hospital-acquired bloodstream infection rates among New York States 19 regional referral NICUs (at regional perinatal centers; RPCs) and develop strategies to promote best practices to reduce central line-associated bloodstream infections (CLABSIs).Study Design:During 2006 and 2007, RPC NICUs reported bloodstream infections, patient-days and central line-days to the Department of Health, and shared their results. Aiming to improve, participants created a central line-care bundle based on visiting a potentially best performing NICU and reviewing the literature.Result:All 19 RPCs participated in this quality initiative, contributing 218 096 patient-days and 56 911 central line-days of observation. Individual RPC nosocomial sepsis infection (NI) rates ranged from 1.0 to 5.8 NIs per 1000 patient-days (2006), and CLABSI rates ranged from 2.6 to 15.1 CLABSIs per 1000 central line-days (2007). A six-fold rate variation among RPC NICUs was observed. Participants unanimously approved a level-1 evidence-based central line-care bundle.Conclusion:Individual RPC rates and consequent morbidity and resource use attributable to these infections were substantial and varied greatly. No center was without infections. It is hoped that the cooperation and accountability exhibited by the RPCs will result in a major network for characterizing performance and improving outcomes.

Neonatal Intensive Care Unit Antibiotic Use

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52 061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

Evidence-based approach to preventing central line-associated bloodstream infection in the NICU

Aim:  To review care practices and methods of implementation that reduce the risk of central line‐associated bloodstream infection (CLABSI).

Neonatal Intensive Care Unit Collaboration to Decrease Hospital-Acquired Bloodstream Infections: From Comparative Performance Reports to Improvement Networks

This two-part article provides a general guide to thinking about data-driven clinical performance evaluation and describes two statewide improvement networks anchored in such comparisons. Part 1 examines key ideas for making fair comparisons among providers. Part 2 describes the development of a data-driven collaborative that aims to reduce central line associated bloodstream infections in neonatal ICUs across New York State, and a more mature collaborative in California that has already succeeded in reducing these infections; it provides sufficient detail and tools to be of practical help to others seeking to create such networks. The content illustrates concepts with broad applicability for pediatric quality improvement.

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.

Accounting for variation in length of NICU stay for extremely low birth weight infants

Objective:To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.Study Design:We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000 g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.Results:There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).Conclusion:Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

Discovering How to Think about a Hospital Patient Information System by Struggling to Evaluate It: A Committee’s Journal

Parallel to the monumental problem of replacing paper-and-pen-based patient information management systems with electronic ones is the problem of evaluating the extent to which the change represents an improvement. All clinicians must grapple with this daunting challenge; those with little or no informatics expertise may be particularly surprised by the attendant difficulties. To do so successfully, they must be able to explicitly conceptualize the daily clinical work-a prerequisite for appreciating and reasonably evaluating it. Further, few of these evaluators may have reflected on the dynamic interaction between their work and their tools-how changing a tool necessarily changes the work. This article illuminates these problems by telling the story of how one patient care information systems committee first learned to think about the purpose of a patient information management system, and second, how to evaluate the impact of its implementation.

The effect of hypoglycemia on fetal brain function and metabolism

Abstract The effect of hypoglycemia on brain function in terms of the electroencephalogram (EEG) and on brain metabolism in terms of arteriovenous differences in substrate concentrations was studied in 11 in utero fetal sheep experiments. Fetal hypoglycemia was induced by an infusion of insulin to the ewe that resulted in maternal hypoglycemia. Carotid artery glucose concentration decreased to values that were 25 per cent of base line and as low as 3 mg. per 100 ml. The peak effect occurred 30 to 50 minutes following insulin infusion. The fetal EEG showed only minimal changes that consisted of a decrease in voltage and slowing on occasion. A significant decrease in heart rate occurred during the hypoglycemia. There was no significant change in oxygen consumption, blood flow, pH, or P CO 2 . A significant reduction (p