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PubMed2006

Initial audiologic assessment of infants referred from well baby, special care, and neonatal intensive care unit nurseries.

PURPOSE: The purpose of the study was to evaluate the effectiveness of a 2-hr initial audiologic assessment appointment for infants referred from area universal newborn hearing screening (UNHS) programs to a clinical audiology department in an urban hospital. METHOD: A prospective auditory brainstem response (ABR)-based protocol, including clicks, frequency-specific tone bursts, and bone-conducted stimuli, was administered by 10 audiologists to 375 infants. Depending on the ABR findings, additional test options included distortion product otoacoustic emissions (DPOAEs), high-frequency tympanometry, and/or otologic examination. RESULTS: In 88% of the 2-hr test sessions, at least 4 ABR threshold estimates were obtained (i.e., bilateral clicks and either a 500- or 1000-Hz tone burst and a 4000-Hz frequency tone burst for the better ear). The incidence of hearing loss was significantly different across nursery levels: 18% for Level I (well baby), 29% for Level II (special care), and 52% for Level III (neonatal intensive care unit). Hearing loss type was defined at the initial assessment for 35 of the 51 infants with bilateral hearing loss based on bone-conduction ABR, latency measures, DPOAEs, high-frequency tympanometry, and/or otologic examination. CONCLUSIONS: Our findings indicate that a 2-hr test appointment is appropriate for all nursery levels to diagnose severity and type of hearing loss in the majority of infants referred from UNHS. Examination by an otolaryngologist within 24-48 hr further defines the hearing loss and facilitates treatment plans.

Acoustic Impedance Tests↗
PubMed2004

Planning a developmentally appropriate neonatal intensive care unit.

Neonatal intensive care units (NICUs) are now being redesigned in the wake of growing evidence that the physical environment of the NICU has a profound impact on all who live and work there. These new units reflect the universal trend of bringing families directly into the center of the medical care team. More than ever,such projects are bound to change how staff care for babies, how families interact with babies, how staff and families interact with one another, and how staff interact among themselves. When a NICU decides that a more developmentally appropriate environment should be initiated, the question of funding and obtaining other resources inevitably arises. This chapter identifies the essential components that should be included when planning to seek investments in NICU facilities.

Child Development↗
PubMed2003

Evaluation and development of potentially better practices for improving family-centered care in neonatal intensive care units.

OBJECTIVE: Technological and scientific advances have progressively decreased neonatal morbidity and mortality. Less attention has been given to meeting the psychosocial needs of the infant and family than on meeting the infant's physical needs. Parents' participation in making decisions and caring for their child has often been limited. Environments designed for efficient technological care may not be optimal for nurturing the growth and development of sick neonates or their families. Eleven centers collaborating on quality improvement tried to make the care of families better by focusing on understanding and improving family-centered care. METHODS: Through internal process analysis, review of the evidence, collaborative learning, and benchmarking site visits to centers of excellence in family-centered care, a list of potentially better practices was developed. Choice of which practices to implement and methods of implementation were center specific. Improvement goals were in 3 areas: parent-reported outcomes, staff beliefs and practices, and clinical outcomes in length of stay and feeding practices. Measurement tools for the first 2 areas were developed and pilots were conducted. RESULTS: Length of stay and feeding outcomes were not different before the collaboration (1998) and at the formal end of the collaboration (2000). CONCLUSIONS: Prospective parent-reported outcomes are being collected, and the staff beliefs and practices questionnaire will be repeated in all centers to determine the impact of the project in those areas.

Benchmarking↗
PubMed2005

Health care-associated infections in the neonatal intensive care unit.

Neonates represent a unique and highly vulnerable patient population. Advances in medical technology that have occurred over the last few decades have improved the survival and quality of life for neonates, particularly those infants born with extreme prematurity or with congenital defects. Although immunologic immaturity and altered cutaneous barriers play some role in the vulnerability of neonates to nosocomial infections, clearly, therapeutic interventions that have proven to be lifesaving for these fragile infants also appear to be associated with the majority of infectious complications resulting in neonatal morbidity and mortality. Rates of infections in neonatal intensive care units (NICUs) have varied from 6% to 40% of neonatal patients, with the highest rates in those facilities having larger proportions of very low-birth-weight infants (birthweight < or =1000 grams) or neonates requiring surgery. Efforts to protect the vulnerable NICU infants include the following: (1) optimal infection control practices, especially good hand hygiene and good nursery design; (2) prudent use of invasive interventions with particular attention to early removal of invasive devices after they are no longer essential; and (3) judicious use of antimicrobial agents, with an emphasis on targeted (narrow spectrum) rather than broad-spectrum antibiotics and appropriate indications (proven or suspected bacterial infections).

Cross Infection↗
PubMed2000

Nurse/parent role perceptions in care of neonatal intensive care unit infants: implications for the advanced practice nurse.

This study compared parent and nurse perceptions of the nurse's roles regarding responsibilities toward infants in the neonatal intensive care unit (NICU). It also examined the attitudes of nurses and parents regarding the extent to which parents should participate in the care of their infants in the NICU, as well as the role of the advanced practice nurse (APN). The convenience sample of 25 parents of infants in the NICU and 35 nurses who cared for the infants was surveyed regarding perceptions of nurses and parents about nurse responsibilities and parent roles in the NICU. Results suggest parents and nurses have different perceptions about role expectations and that nurses perceive themselves to lack comfort and knowledge in providing support to parents. The findings support a role of the APN as fostering a nursing NICU philosophy to facilitate role transition for parents of infants in the NICU.

Attitude of Health Personnel↗
PubMedDate not supplied

Adapting the neonatal intensive care environment to decrease noise.

A protocol of environmental noise reduction was developed and tested over a 14-month period in a 70-bed tertiary care neonatal intensive care unit (NICU). Evidence-based research and a detailed sound assessment guided the development of the protocol. Modifications of caregiving activities and categorized changes in the physical environment were specific to the NICU tested; however, guidelines for adapting the protocol to other NICUs are explained as well as methods for implementation to promote staff awareness and cooperation are reviewed.

Case Management↗
PubMed1999

National epidemiology of mycoses survey (NEMIS): variations in rates of bloodstream infections due to Candida species in seven surgical intensive care units and six neonatal intensive care units.

Candida species are the fourth most frequent cause of nosocomial bloodstream infections, and 25%-50% occur in critical care units. During an 18-month prospective study period, all patients admitted for > or = 72 hours to the surgical (SICUs) or neonatal intensive care units (NICUs) at each of the participant institutions were followed daily. Among 4,276 patients admitted to the seven SICUs in six centers, there were 42 nosocomial bloodstream infections due to Candida species (9.8/1,000 admissions; 0.99/1,000 patient-days). Of 2,847 babies admitted to the six NICUs, 35 acquired a nosocomial bloodstream infection due to Candida species (12.3/1,000 admissions; 0.64/1,000 patient-days). The following were the most commonly isolated Candida species causing bloodstream infections in the SICU: Candida albicans, 48%; Candida glabrata, 24%; Candida tropicalis, 19%; Candida parapsilosis, 7%; Candida species not otherwise specified, 2%. In the NICU the distribution was as follows: C. albicans, 63%; C. glabrata, 6%; C. parapsilosis, 29%; other, 3%. Of the patients, 30%-50% developed incidental stool colonization, 23% of SICU patients developed incidental urine colonization, and one-third of SICU health care workers' hands were positive for Candida species.

Candidiasis↗
PubMed2000

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit.

BACKGROUND: The need for sedation for neonates undergoing uncomfortable procedures in the neonatal intensive care unit (NICU) has often been overlooked. Proper sedation may reduce stress and avoid complications during procedures such as mechanical ventilation. Midazolam is a short acting benzodiazepine that has been increasingly used in the NICU. However, the effectiveness of intravenous midazolam as a sedative in neonates has not been systematically evaluated. OBJECTIVES: To determine whether intravenous midazolam infusion is an effective sedative, as evaluated by behavioural and/or physiologic measurements, for critically ill neonates undergoing intensive care, and to assess clinically significant short and long term adverse effects associated with its use. SEARCH STRATEGY: Literature search according to the Cochrane Neonatal Collaborative Review Group search strategy. Randomized and quasi-randomized controlled trials of intravenous midazolam use in neonates were identified by searching MEDLINE, EMBASE, the Cochrane Controlled Trials Register, reference lists of published studies, personal files, and abstracts published in Pediatric Research from 1990-1999. SELECTION CRITERIA: Randomized controlled trials of intravenous midazolam infusion in infants </= 28 days of age for sedation during mechanical ventilation or radiologic investigations were selected for review. Studies on midazolam use as an anesthetic or an anticonvulsant were excluded. Studies involving neonates and older infants and children were excluded if data for neonates could not be extracted. DATA COLLECTION AND ANALYSIS: Data regarding the primary outcome of level of sedation (as evaluated by behavioural scales or physiologic parameters) were abstracted. Secondary outcomes including intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), death within 28 days of age, adverse effects associated with midazolam (hemodynamic and neurologic), days of ventilation, days of supplemental oxygen use, pneumothorax, length of NICU stay, and long term neurodevelopmental outcome were assessed. When appropriate, meta-analyses were performed using relative risk (RR), risk difference (RD), along with their 95% confidence intervals (95% CI) for categorical variables and weighted mean difference (WMD) for continuous variables. MAIN RESULTS: Two trials were eligible for inclusion in the review. Data on level of sedation from the two trials could not be combined because of differences in tools used to measure sedation levels. One study (Jacqz-Aigrain 1994) showed statistically a significant higher level of sedation in the midazolam group compared to the placebo group. The other study (Anand 1999) comparing midazolam to morphine and placebo found no statistically significant difference in sedation level among the three groups, but statistically significantly higher level of sedation was found in the midazolam group compared with the placebo group during the treatment infusion. However, since the sedation scales used in both studies have not been validated in preterm infants, the effectiveness of midazolam as a sedative in this population could not be ascertained based on the findings of these two studies. In the study by Jacqz-Aigrain (1994), blood pressures were statistically significantly lower in the midazolam group than in the placebo group on days 1 and 2, although there was no statistically significant difference in the incidence of hypotension requiring albumin or vasoactive drugs between groups. The study by Anand (1999) showed a statistically significant higher incidence of adverse neurologic events (death, grade III-IV IVH, PVL) in the midazolam group compared with the other groups. In addition, the midazolam group had a statistically significantly longer duration of NICU stay compared to the placebo group (WMD 5.4 days, 95%CI 0.4, 10.5). (ABSTRACT TRUNCATED)

Humans↗
PubMed1991

Predicting outcome of care in the neonatal intensive care unit.

The accuracy of a neonatal intensive care unit (NICU) staff in predicting the outcome and length of stay of infants admitted to the NICU, and the factors they felt were important in making these predictions, were evaluated. This prospective study used a questionnaire to survey 44 nurses, residents, and attending neonatologists working in the NICU about the predicted outcomes of 52 infants admitted to the NICU at the University of Nebraska Medical Center over a 1-month period. Factors previously identified by the staff as important indicators of infant outcome were assigned points of importance by the respondents, and specific values for these factors were recorded for each infant. The NICU staff indicated that gestational age was the most important indicator of infant outcome. The attending neonatologists placed more value on gestational age (analysis of variance [ANOVA] P less than .0001) than did the nurses or residents. Among the staff groups, there were significant differences in the weight or points assigned to a given factor for pulmonary function, renal function, number of resuscitations, and the "other" category (ANOVA P less than .05). The nurses ranked pulmonary function criteria lower than the residents did (P less than .04), but considered renal function more important than either the residents (P = .005) or the attending neonatologists considered it to be (P = .01). The number of resuscitations was ranked higher by the nursing staff than by other groups, whereas the attending neonatologists assigned less importance to the "other" category.(ABSTRACT TRUNCATED AT 250 WORDS)

Forecasting↗
PubMed1993

The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units. The International Neonatal Network.

Assessment of different hospitals' performance in neonatal intensive care has tended to rely on risk of mortality adjusted only for birthweight. We have developed a neonatal scoring system, CRIB (clinical risk index for babies), to take account of other factors. Scores are given for birthweight, gestational age, maximum and minimum fraction of inspired oxygen and maximum base excess during the first 12 h, and presence of congenital malformations. CRIB was developed retrospectively in a cohort of 812 infants of birthweight 1500 g or less or gestational age less than 31 weeks treated in four UK tertiary hospitals between 1988 and 1990. The scoring system was then validated by comparing its value as a predictor of hospital death with that of birthweight in a separate cohort of 488 similar infants. The area under the receiver operating characteristic (ROC) curve for predicting death in this validation cohort (a measure of the predictor's accuracy) was significantly greater for CRIB than for birthweight alone (0.90 [SE 0.05] vs 0.78 [0.03], p = 0.03). Both indices of initial risk were used to assess the performance of nine tertiary and four non-tertiary hospitals in the UK. We looked at hospital mortality among the 1198 infants in the development and validation cohorts plus 350 other infants of birthweight 1500 g or less or gestational age less than 31 weeks [corrected]. Without adjustment for initial risk, there was no clear difference in group mortality between the tertiary and non-tertiary hospitals. However, calculation of risk-adjusted mortality by means of CRIB showed that babies were twice as likely to die in the non-tertiary hospitals as in the tertiary hospitals (odds ratio 2.12 [95% CI 1.39-3.24]). Adjustment for birthweight alone also showed higher odds of death in non-tertiary hospitals (1.45 [1.01-2.11]). CRIB is a robust index of initial neonatal risk that is more accurate than birthweight and simple enough for routine use. International comparisons of staffing policy and organisation of neonatal intensive care units are needed to investigate the reasons for variations in performance.

Acid-Base Equilibrium↗
PubMed2006

Patterns of drug utilization in a neonatal intensive care unit.

The objective of this study was to determine drug use in newborns at an inborn tertiary care neonatal intensive care unit, serving a predominantly African American population, to identify educational/research priorities in neonatal drug therapy. Data on demographics and exposure rates to all drugs from 6839 neonates born between January 1997 and June 2004 were analyzed. Number of drugs used was correlated with race, gender, gestational age, birthweight, and survival status. The contribution of these factors to mean drug use was predicted by multivariate regression analysis. In this population of 80% African Americans, mean drug use was 3.6/infant, with the highest use in the 24- to 27-week gestational age group (11.7/infant). Ampicillin and cefotaxime had the highest exposure rates. Premature infants had high use of surfactant, pressor agents, and diuretics. Caucasians, males, gestational age<28 weeks, and birthweight<1000 g were the risk factors for higher drug exposure. Future research/education must emphasize these therapeutic areas with priority assigned to low-birthweight infants.

Black or African American↗
PubMed1990

Defining quality of care indicators for neonatal intensive care units independent of maternal risk factors.

Observed and birthweight-specific neonatal mortality rates have been used for assessing quality of neonatal care, but these are crude and affected by risk characteristics of the population served. Even when neonatal mortality rate is corrected for four risk factors, race, sex, birthweight, and multiple births, (California Data Research Facility, Santa Barbara, CA) it is possible that the corrected neonatal mortality rate is not comparable among institutions because of population differences not corrected for, eg, prenatal care. To analyze whether our high neonatal mortality rate is primarily dependent on population risk or quality of neonatal care, we used contemporaneous data collection by senior physicians and a microcomputer database system to construct indices of quality of care that are based on diagnoses graded according to disease severity. For the 1987/1988 academic year, we found: neonatal intensive care unit nosocomial infection rate, 20%; severe intraventricular hemorrhage per 100 very low birthweight infants (1500 g), 20%; bronchopulmonary dysplasia per 100 cases of severe respiratory distress syndrome, 27%; necrotizing enterocolitis per 100 neonatal intensive care unit discharges, 5%; air leak per 100 cases of severe respiratory distress syndrome, 21%; and neonatal mortality rate per very low birthweight delivery rate, 0.4. We propose that microcomputer, hospital-based analyses will improve comparisons of neonatal intensive care unit quality of care if appropriate indices can be sufficiently well-defined and shared.

Black or African American↗
PubMed2003

Technical skills in paediatrics: a qualitative study of acquisition, attitudes and assumptions in the neonatal intensive care unit.

PURPOSE: While the effective acquisition of technical skills is essential for excellent paediatric care, little is known about how technical skills are learned in the paediatric setting. This study sought to describe and theorise the variables influencing technical skills acquisition in a tertiary care neonatal intensive care unit (NICU) inpatient setting. METHODOLOGY: Using non-participant field methodology, paediatric residents and their teachers (nurses, respiratory therapists, neonatal staff and fellows) were observed at various times in the NICU for 8 weeks. Thirteen semistructured interviews with these teachers and learners and 1 focus group of additional learners were conducted and used to triangulate observational findings. Using a constant comparative process, field notes, interview and focus group transcripts were analysed by 2 researchers for emergent themes in the grounded theory tradition. RESULTS: Data sourced from over 90 hours of observation and 21 observed technical procedures, and both individual and group interviews are presented thematically. Dominant themes include: the nature, timing and purpose of feedback about technical procedures; opportunities to learn technical skills; multiple demands that intersect with technical procedure attempts; competing priorities, and teachers' and learners' differing perceptions. These themes interact to affect the learning environment. CONCLUSION: The NICU learning environment represents a complex interplay between competing priorities, learning opportunities and attributions about learners. This interplay must be understood if improvements to technical skills training in this domain are to be developed.

Attitude of Health Personnel↗
PubMed1999

Staphylococcus capitis bacteremia of very low birth weight premature infants at neonatal intensive care units: clinical significance and antimicrobial susceptibility.

Coagulase-negative staphylococci (CNS) are frequently isolated from blood cultures in critically ill neonates. However, Staphylococcus capitis is rarely reported as a pathogen in human beings. From January, 1995 to December, 1997 at a tertiary care neonatal intensive care unit (NICU), a total of 147 (62%) CNS isolates were detected from 236 positive blood cultures, including 27 isolates of S. capitis. Among the S. capitis bacteremia, 17 isolates were judged to be infections as opposed to 10 of the noninfection cultures. The occurrence of S. capitis infection was correlated with long hospital stay (52 +/- 17.6 days vs. 28 +/- 18.5 days, p=0.003) and total parenteral nutrition administration (46 +/- 17.4 days vs. 22 +/- 19.1 days, p=0.006). Apnea, bradycardia, temperature instability and poor activity were the predominant clinical features. Among the 17 episodes of bacteremia, one patient had complicated septic meningitis. There is no statistical significance between S. capitis infection and the duration of a central venous catheter placement (37 +/- 17.5 days vs. 26 +/- 19.5 days, p=0.165). No catheter related infection was proven. Removal of a percutaneous central venous catheter routinely in patients with S. capitis bacteremia is not recommended. All the patients survived after antibiotic treatment. The prevalence rate of multiple resistant S. capitis was 94%. All isolates were resistant to oxacillin, erythromycin and clindamycin but susceptible to ampicillin/sulbactam, vancomycin and teicoplanin. Empiric therapy for S. capitis infection in NICU with ampicillin/sulbactam is therefore recommended. It is important to detect S. capitis which has a high degree of antibiotic resistance in order to treat the patient correctly. S. capitis should be included as etiology and the possibility of nosocomial outbreak in very low birth weight (VLBW) premature infants at NICU.

Bacteremia↗