Yvonne Freer

Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial

Background: Screening is necessary for infants at risk of retinopathy of prematurity. Despite local anaesthetic drops, infants find eye examinations distressing, displaying behavioural and physiological changes indicating acute pain. Oral sucrose and non-nutritive sucking reduce pain responses associated with invasive procedures. Objective: To evaluate the use of oral sucrose and/or pacifier for reducing pain responses during eye examinations. Methods: Forty infants <32 weeks gestation or <1500 g birth weight, in two neonatal units, were randomised to one of four interventions administered two minutes before their first screening examination: 1 ml sterile water as placebo (group 1, n  =  10), 1 ml 33% sucrose solution (group 2, n  =  10), 1 ml sterile water with pacifier (group 3, n  =  9), or 1 ml 33% sucrose solution with pacifier (group 4, n  =  11). Examinations were videotaped. Two observers, blind to the intervention, assessed recordings. Pain responses were scored using the premature infant pain profile (PIPP). Results: The groups were similar in gestation, birth weight, and age at examination. Mean PIPP scores were 15.3, 14.3, 12.3, and 12.1 for groups 1, 2, 3, and 4 respectively. Analysis of variance showed a significant difference in PIPP score between groups (p  =  0.023). Infants randomised to pacifiers scored lower than those without pacifiers (p  =  0.003). There was no difference between groups receiving sucrose and those receiving water (p  =  0.321). Conclusions: Non-nutritive sucking reduced distress responses in infants undergoing screening for retinopathy of prematurity. The difference in response was large enough to be detected by a validated assessment tool. No synergistic effect of sucrose and pacifier was apparent in this group.

Assessment of persistent pain or distress and adequacy of analgesia in preterm ventilated infants

Abstract Indicators of persistent pain in preterm neonates are poorly defined. In the setting of a double blind, placebo‐controlled trial investigating morphine use in ventilated preterm infants (NEOPAIN Trial) we aimed to identify factors that may be useful in assessing persistent pain. Twenty‐two babies (morphine 12; placebo 10) were assessed for comfort, pain or distress and clinical staff described the factors they had considered. This assessment was performed during the first period of duty with the baby. Based on this, they stated which study drug they believed the infant was receiving. Eighty‐nine assessments were made in total (1–14 per baby). The drug was correctly identified on 71% of occasions. Staff considered one or more of the following factors: infant activity; response to routine care; known pain‐related behaviours; posture/quality of movements; respiratory effort; synchrony with ventilator; blood pressure and heart rate. Four factors most frequently identified babies receiving placebo: facial expressions of pain, high activity levels, poor response to handling and poor synchrony with ventilation. Absence of pain‐related behaviour was less discriminating. Observation of a good response to handling, good synchrony with ventilation, a “settled” baby, normal blood pressure and heart rate were poor discriminators. Hypotension and poor respiratory drive were noted exclusively in babies receiving morphine infusions. Facial expressions of pain, high activity levels, poor response to routine care, and poor ventilator synchrony were associated with placebo versus morphine therapy, and may be considered useful markers for persistent pain in preterm infants.

A comparison of graphical and textual presentations of time series data to support medical decision making in the neonatal intensive care unit.

Objective. To compare expert-generated textual summaries of physiological data with trend graphs, in terms of their ability to support neonatal Intensive Care Unit (ICU) staff in making decisions when presented with medical scenarios. Methods. Forty neonatal ICU staff were recruited for the experiment, eight from each of five groups – junior, intermediate and senior nurses, junior and senior doctors. The participants were presented with medical scenarios on a computer screen, and asked to choose from a list of 18 possible actions those they thought were appropriate. Half of the scenarios were presented as trend graphs, while the other half were presented as passages of text. The textual summaries had been generated by two human experts and were intended to describe the physiological state of the patient over a short period of time (around 40 minutes) but not to interpret it. Results. In terms of the content of responses there was a clear advantage for the Text condition, with participants tending to choose more of the appropriate actions when the information was presented as text rather than as graphs. In terms of the speed of response there was no difference between the Graphs and Text conditions. There was no significant difference between the staff groups in terms of speed or content of responses. In contrast to the objective measures of performance, the majority of participants reported a subjective preference for the Graphs condition. Conclusions. In this experimental task, participants performed better when presented with a textual summary of the medical scenario than when it was presented as a set of trend graphs. If the necessary algorithms could be developed that would allow computers automatically to generate descriptive summaries of physiological data, this could potentially be a useful feature of decision support tools in the intensive care unit.

Automatic generation of natural language nursing shift summaries in neonatal intensive care: BT-Nurse

INTRODUCTION Our objective was to determine whether and how a computer system could automatically generate helpful natural language nursing shift summaries solely from an electronic patient record system, in a neonatal intensive care unit (NICU). METHODS A system was developed which automatically generates partial NICU shift summaries (for the respiratory and cardiovascular systems), using data-to-text technology. It was evaluated for 2 months in the NICU at the Royal Infirmary of Edinburgh, under supervision. RESULTS In an on-ward evaluation, a substantial majority of the summaries was found by outgoing and incoming nurses to be understandable (90%), and a majority was found to be accurate (70%), and helpful (59%). The evaluation also served to identify some outstanding issues, especially with regard to extra content the nurses wanted to see in the computer-generated summaries. CONCLUSIONS It is technically possible automatically to generate limited natural language NICU shift summaries from an electronic patient record. However, it proved difficult to handle electronic data that was intended primarily for display to the medical staff, and considerable engineering effort would be required to create a deployable system from our proof-of-concept software.

BT-Nurse: computer generation of natural language shift summaries from complex heterogeneous medical data

The BT-Nurse system uses data-to-text technology to automatically generate a natural language nursing shift summary in a neonatal intensive care unit (NICU). The summary is solely based on data held in an electronic patient record system, no additional data-entry is required. BT-Nurse was tested for two months in the Royal Infirmary of Edinburgh NICU. Nurses were asked to rate the understandability, accuracy, and helpfulness of the computer-generated summaries; they were also asked for free-text comments about the summaries. The nurses found the majority of the summaries to be understandable, accurate, and helpful (p<0.001 for all measures). However, nurses also pointed out many deficiencies, especially with regard to extra content they wanted to see in the computer-generated summaries. In conclusion, natural language NICU shift summaries can be automatically generated from an electronic patient record, but our proof-of-concept software needs considerable additional development work before it can be deployed.

Autoregressive Hidden Markov Models for the Early Detection of Neonatal Sepsis

Late onset neonatal sepsis is one of the major clinical concerns when premature babies receive intensive care. Current practice relies on slow laboratory testing of blood cultures for diagnosis. A valuable research question is whether sepsis can be reliably detected before the blood sample is taken. This paper investigates the extent to which physiological events observed in the patients monitoring traces could be used for the early detection of neonatal sepsis. We model the distribution of these events with an autoregressive hidden Markov model (AR-HMM). Both learning and inference carefully use domain knowledge to extract the babys true physiology from the monitoring data. Our model can produce real-time predictions about the onset of the infection and also handles missing data. We evaluate the effectiveness of the AR-HMM for sepsis detection on a dataset collected from the Neonatal Intensive Care Unit at the Royal Infirmary of Edinburgh.

NEONATE: Decision Support in the Neonatal Intensive Care Unit – A Preliminary Report

The aim of the NEONATE project is to investigate sub-optimal decision making in the neonatal intensive care unit and to implement decision support tools which will draw the attention of nursing and clinical staff to situations where specific actions should be taken or avoided. We have collected over 400 patient-hours of data on 31 separate babies, including physiological parameters sampled every second, observations made by a research nurse of all the actions performed on the baby with an accuracy of a few seconds, occasional descriptions of the appearance, mobility, sleep patterns, etc of the baby. We describe our attempts to use this data to discover examples of sub- optimal behaviour.

Risk management, or just a different risk?

Background: National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement to alter practice. There is likely to be clinician resistance to such a method of change management, particularly where evidence of safety is missing. Aim: To determine the level of implementation within neonatal units of an alert requiring the change from litmus to pH paper to test nasogastric tube position. Method: A questionnaire sent to all neonatal units in the United Kingdom with more than 12 cots. Results: From the 207 questionnaires sent, there were 165 (80%) responses. Fifty five percent of units were still using litmus. All continued to use supplementary tests not recommended in best practice statements issued at the time of the alert. There was considerable variation in the pH value at which it was considered safe to feed. Conclusions: Nine months after the alert, more than half the units had not changed to pH paper, and supplementary methods of testing were still being used. The wide range of pH values highlights the uncertainty about the “normal” gastric pH in the newborn. The evidence that, in neonatal units, changing to pH paper is safer than the long established use of litmus is lacking. Recommendations for change in practice must be based on good information and not seen just as a “knee jerk” response to adverse incidents.

Mismatched concepts in a neonatal intensive care unit (NICU): further issues for computer decision support?

Background.Common concepts and definitions are important for the effective practice of medicine. In an intensive care unit clear understanding of terminology and communication between different staff groups may be critical for optimal care. If computerised decision support tools are to be successfully deployed in these high intensity environments, all staff must understand the concepts and information that is to be portrayed. Objective.To examine the similarity of language and concepts related to newborn infants and their care in staff groups with different experience. Methods.An experimental study in a tertiary regional neonatal intensive care unit involved 32 staff in 4 groups with varying experience (junior and senior / nurses and doctors). A psychologist developed a lexicon of clinical actions and a second lexicon of possible patient descriptors applicable to newborn infants receiving all degrees of neonatal care by conducting interviews with staff on the unit. Card sorting experiments were performed on the terms in the action and descriptor lexicons, the staff being asked to group words that were related to the same or similar concepts. The card sort data were analysed using conventional cluster analysis to produce tree-diagrams or dendrograms and then by distance matrix analysis to give cumulative probability plots. Results.Differences were shown in the way various classes of staff and staff with different experience mentally map clinical concepts. Clinical actions were grouped more randomly by nurses and by those with less experience with a polarisation between senior doctors and junior nurses. Descriptors were classed more definitively and similarly by junior and senior nurses and senior doctors but more randomly and quite differently by junior doctors. Thus there were differences seen between nurses and doctors with different roles within the unit and differences related to experience. Conclusions.Concepts are used differently by various staff groups in a neonatal unit: this may have an impact on the effectiveness of computerised decision aids unless it is taken into account during their development.

Effect of suckling on the peripheral sensitivity of full-term newborn infants

Background: Sucking may reduce the manifestations of pain in newborn infants. Objective: To examine the effect of suckling on the threshold for peripheral somatosensory responses. Subjects and methods: Graded Von Frey filaments were applied to the heel to initiate peripheral somatosensory responses (withdrawal reflex and gross body movements) in term infants. Results: Dummy sucking increases the somatosensory threshold, but breast feeding had a more marked effect, increasing the threshold of the flexion withdrawal reflex (p⩽0.002) and the threshold for gross body movements (p⩽0.002). Conclusion: Peripheral sensitivity of newborn infants is considerably reduced during sucking, particularly at the breast.