Robert Angert

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.

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.

Use of Temporary Names for Newborns and Associated Risks

BACKGROUND: Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors. METHODS: We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes. RESULTS: The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42–0.97). CONCLUSIONS: The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.

Simulation as a tool for improving acquisition of neonatal resuscitation skills for obstetric residents

Abstract Objective: Our goal was to compare the confidence, knowledge, and performance of obstetric residents taught initial neonatal resuscitation steps in a simulation-based versus lecture-based format. Methods: Our study was a prospective randomized controlled trial of 33 obstetric residents. Baseline confidence, knowledge, and clinical skills assessments were performed. Subjects were randomized to traditional lecture (n = 14) or simulation-based (n = 19) neonatal resuscitation curriculum with a focus on initial steps. Follow-up assessments were performed at 3 and 6 months. Total confidence, knowledge, and clinical performance scores and change from baseline in these scores were calculated and compared between groups. Results: Both the lecture-based and simulated-based groups demonstrated significant improvement in confidence, knowledge, and performance over time. However, compared with the lecture group, the magnitude of the mean change from baseline in performance scores was significantly greater in the simulation group at 3 months (2.9 versus 10.1; p < 0.001), but not at 6 months (7.0 versus 9.3; p = 0.11). Conclusions: Our study demonstrates the superiority of simulation in teaching obstetric residents initial neonatal resuscitation steps compared with a traditional lecture format. Skills are retained for upwards of 3–6 months. Refresher instruction by 6 months post-instruction may be beneficial.

Evaluating serial strategies for preventing wrong-patient orders in the NICU

The risk of wrong-patient orders was significantly higher in the NICU compared with non-NICU pediatric units. Combined ID reentry and distinct naming interventions dramatically reduced this risk. BACKGROUND: NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, “Wendysgirl”) for reducing these errors, using non-NICU pediatric units as a comparator. METHODS: Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns). RESULTS: We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34–1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; P < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; P < .001). CONCLUSIONS: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.

Universal Cervical Length Screening and Antenatal Corticosteroid Timing

OBJECTIVE To evaluate the relationship between universal transvaginal screening for short cervical length in the second trimester and the timing of antenatal corticosteroids. METHODS We performed a retrospective cohort study of patients with nonanomalous singleton gestations and spontaneous preterm birth between 24 and 34 weeks of gestation after the initiation of a universal transvaginal cervical length screening program between October 2012 and August 2015. Our primary outcome was antenatal corticosteroid administration to a delivery interval of fewer than 7 days. Secondary outcomes were delivery 24 hours to 7 days after the initial steroid injection, steroid administration to delivery interval, neonatal survival, neonatal intensive care unit length of stay, and respiratory distress syndrome. Multivariable logistic regression was used to estimate the association between antenatal corticosteroid timing and the diagnosis of a short cervix adjusted for potential confounders. RESULTS Among 266 eligible patients, 69 with a short cervical length and 197 without a short cervical length were identified. There were no statistically significant differences in baseline characteristics between the groups. During the study period, 64 of 69 (92.8%) of patients with a short cervix and 176 of 197 (89.3%) without a short cervix received at least one steroid injection before delivery (P=.411). Steroids were given within 7 days of delivery in 33 of 69 (47.8) patients with a short cervix compared with 126 of 197 (64%) patients in the no short cervix group (P=.015; adjusted odds ratio 0.51, 95% confidence interval 0.29-0.9). Median interval between steroid administration and delivery was 8 days in patients diagnosed with a short cervix compared with 3 days for those without a short cervical length (P<.001). CONCLUSION Patients identified as having a short cervical length by universal transvaginal ultrasound screening were at greater risk of delivering more than 7 days after the initiation of corticosteroids for fetal lung maturation compared with women without a short cervical length.

Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist

Objective Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. Methods Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. Results Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. Conclusions Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.

Meningomyelocele Simulation Model: Pre-surgical Management–Technical Report

This technical report describes the creation of a myelomeningocele model of a newborn baby. This is a simple, low-cost, and easy-to-assemble model that allows the medical team to practice the delivery room management of a newborn with myelomeningocele. The report includes scenarios and a suggested checklist with which the model can be employed.

Board 314 - Research Abstract Simulation as a Tool for Improving Acquisition of Neonatal Resuscitation Skills (Submission #946)

Introduction/Background The first few minutes after birth are most critical for a newborn. Although most infants transition with ease, some require delivery room resuscitation.1 The quality of initial resuscitation may impact the infant’s short- and long-term outcome.2 Traditionally, neonatal providers are present at deliveries as soon as the need is recognized and delivery of the infant is imminent. However, in the event that the neonatal resuscitation team is not present, the obstetric team must initiate resuscitation. While obstetric nurses complete resuscitation training, obstetric physicians are often not required to complete neonatal resuscitation training. In order to fulfill this educational need we hypothesize that a short instructional session that teaches initial neonatal resuscitation steps with a simulation based curriculum will increase obstetric physician confidence, knowledge, performance and retention of neonatal resuscitation skills. Methods This was a prospective randomized, controlled trial of 33 obstetric residents. Subjects received baseline confidence, knowledge and clinical skills assessments. Subjects were then randomized to traditional lecture (n=14) or simulation-based (n=19) neonatal resuscitation education with a focus on initial steps. All instructional sessions were less than one hour in duration and both lecture and simulation interventions contained the same content. The simulation session required that the subject learn how to resuscitate a depressed neonate “hands on” with expert coaching. Follow-up assessments of confidence, knowledge and clinical skills occurred at intervals of three and six months post initial instruction. Confidence was reported based on a Likert scale of 1 (least confident) to 5 (most confident). Knowledge was assessed using seven multiple choice questions at the three intervals. Clinical assessments were performed in a simulated environment and were graded as yes/no if the subject completed individual tasks successfully in the following areas: preparation, initial resuscitation, ventilation, cardiovascular resuscitation. Total knowledge and clinical assessment scores were calculated. Statistical analysis was performed with paired T-tests to test individuals improvement and Student T-test for comparisons between groups. Results For both the lecture and simulation-based groups, confidence increased significantly at three and six months post instruction when compared to baseline (p<0.01). This increase in confidence was sustained as there were no significant differences between confidence at three and six months in both groups. Performance on knowledge assessment questions also improved significantly from baseline at three and six months post instruction for both groups when compared to baseline (p<0.01). Knowledge was maintained as there were no significant differences between knowledge scores at three and six months in both groups. Clinical assessments for the lecture group revealed no significant difference in successfully completed tasks between baseline and three months. However, significant improvement was demonstrated when six month performance was compared to baseline and 3 months (P<0.01). For the simulation group, clinical assessment performance was significantly improved at three and six months versus baseline (p<0.01) and this improvement was sustained with no significant difference between three and six month scores. Although there was an overall improvement in both groups, analysis with Student T-tests demonstrated that simulation performance scores were significantly higher than the lecture group at both three months (19.8 vs. 13.4) (p<0.01) and 6 months (19.1 vs. 17.2) (p<0.05). Conclusion A short, focused curriculum that teaches initial neonatal resuscitation steps via lecture or simulation enhances subject confidence, knowledge and skills. However, education that incorporates simulation is superior to lecture, resulting in more rapid acquisition of clinical skills and sustained improvements in overall clinical performance. Fortunately, an unanticipated depressed neonate is a relatively infrequent event; however, improved ability for obstetric providers to initiate a prompt and effective neonatal resuscitation after a brief simulation intervention, has the potential to greatly impact outcomes for these vulnerable newborns. References 1. Perlman JM, Risser R: Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med 1995; 149:20-25. 2. Casalaz DM, Marlow N, Speidel BD: Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Ed 1998;78:F112-F115. Disclosures None.