Susan A. Furdon

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.

Decreasing hypothermia during delivery room stabilization of preterm neonates.

BACKGROUND AND OBJECTIVE: Hypothermia during delivery room stabilization of very low birth weight (VLBW) newborns is independently associated with mortality, yet it occurred frequently both in collaborative networks and at our institution. We aimed to attain admission temperatures in the target range of 36°C to 38°C in ≥90% of inborn VLBW neonates through implementation of a thermoregulation bundle. METHODS: This quality improvement project extended over 60 consecutive months, using sequential plan–do–check–act cycles. During the 14 baseline months, we standardized temperature measurements and developed the Operation Toasty Tot thermoregulation bundle (including consistent head and torso wrapping with plastic, warmed blankets, and a closed stabilization room). We introduced this bundle in month 15 and added servo-controlled, battery-powered radiant warmers for stabilization and transfer in month 21. We provided results and feedback to staff throughout, using simple graphics and control charts. RESULTS: There were 164 inborn VLBW babies before and 477 after bundle implementation. Introduction and optimization of the bundle decreased the incidence of hypothermia, with rates remaining in the target range for the last 13 study months. The incidence of temperatures >38°C was ∼2% both before and after bundle implementation. CONCLUSIONS: This thermoregulation bundle resulted in sustained improvement in normothermia rates during delivery room stabilization of VLBW newborns. Our benchmark goal of ≥90% admission temperatures above 36°C was met without increasing hyperthermia rates. Because these results compare favorably with those of recently published research or improvement collaboratives, we aim to maintain our performance through routine surveillance of admission temperatures.

Outcome measures after standardized pain management strategies in postoperative patients in the neonatal intensive care unit.

Written guidelines based on current research on infant pain assessment and management were developed by an interdisciplinary team in a neonatal intensive care unit of a regional medical center. Charts for infants who had undergone abdominal surgery were reviewed to compare patient outcomes before and after use of this pain management protocol. With the standardization of pain management strategies, the following improvements were noted: decreased length of time to extubation, decreased length of stay, better fluid management, and reduced side effects of narcotics. Additional benefits included improved pain management documentation, decreased cost, and decreased nursing time.

Recognizing the clinical features of Trisomy 13 syndrome.

Recognition of the clinical features of Trisomy 13 syndrome, a common autosomal trisomy, provides the basis for diagnostic testing and counseling of families. This article provides a systematic guide to physical assessment and photographs to enhance recognition of this genetic disorder. The principles of numerical chromosomal abnormalities as related to trisomies are reviewed. An abnormal development of the forebrain, holoprosencephaly, is the most common cranial abnormality in infants with Trisomy 13. The embryology and implications of holoprosencephaly are described. A discussion of antenatal diagnosis of Trisomy 13 and delivery room management is also provided. The diagnosis of Trisomy 13 is confirmed antenatally or after delivery with genetic testing. Prognosis of infants with Trisomy 13 and implications for the infants development are described.

Use of chemical warming packs during delivery room resuscitation is associated with decreased rates of hypothermia in very low-birth-weight neonates.

BACKGROUND:Hypothermia is an independent contributor to neonatal mortality. All very low-birth-weight (VLBW) newborns have the potential to undergo cold stress or frank hypothermia during delivery room stabilization. Thus, clinicians aiming to maintain normothermia in VLBW neonates are compelled to use multiple adjuncts of unknown efficacy or safety. OBJECTIVE:To evaluate the effectiveness of thermoregulation procedures in maintaining normothermia during delivery room resuscitation and to assess the impact of an unanticipated change in equipment at our institution on the admission temperatures of VLBW newborns. DESIGN/METHODS:Institutional review board—approved, retrospective analysis of quality assurance data submitted to the Vermont-Oxford Network (VON) for 24 consecutive months starting January 2006. We compared the rate of hypothermia (admission temperature < 36.5°C) in our NICU during 2006 with the aggregate rates reported by VON. We then compared the rates of hypothermia and mean admission temperatures in our NICU during period 1 (when chemical warming packs were used routinely, in addition to plastic wrapping and warm blankets) and period 2 (after packs were discontinued owing to an incident of focal skin injury). RESULTS:In 2006, 42% of VLBW babies in our NICU had an admission temperature of less than 36.5°C compared with the VON rate of 61% (interquartile range 48%, 76%). During period 1, 39% of 183 VLBW neonates were hypothermic compared with 68% of 103 during period 2 (P < .001). Mean admission temperatures during periods 1 and 2 were 36.5°C and 36.1°C, respectively (P < .001). A control chart showed the shift in temperatures occurring as period 2 began. No change in practice other than discontinuation of the warming packs was instituted during period 2. The incidence of temperatures greater than 38°C (hyperthermia) was 1.6% during period 1 and 1.0% during period 2. CONCLUSIONS:The results associated with this isolated change in practice at our institution suggest that chemical warming packs were a useful adjunct in achieving above-average rates of normothermia during delivery room resuscitation of VLBW newborns. Their potential adverse effects should be weighed against the increased risk of mortality associated with hypothermia in this population.

Change in Blood Banking Procedures Decreases Donor Exposure in a High Risk Neonatal Population † 1027

Change in Blood Banking Procedures Decreases Donor Exposure in a High Risk Neonatal Population † 1027