Background Data regarding the effects of antenatal corticosteroids in twin pregnancies are limited because of the insufficient number of women with twins enrolled in randomized controlled trials on ...antenatal corticosteroids. Furthermore, the interpretation of available data is limited by the fact that the interval from the administration of antenatal corticosteroids to delivery is greater than 7 days in a large proportion of twins, a factor that has been shown to affect the efficacy of antenatal corticosteroids and has not been controlled for in previous studies. Objective The objective of the study was to compare neonatal mortality and morbidity in preterm twins receiving a complete course of antenatal corticosteroids 1–7 days before birth to those who did not receive antenatal corticosteroids and to compare these outcome effects with those observed in singletons. Study Design We performed a retrospective cohort study using data collected on singleton and twin neonates born between 240/7 and 336/7 weeks’ gestational age and were admitted to tertiary neonatal units in Canada between 2010 and 2014. A comparison of neonatal outcomes between twin neonates who received a complete course of antenatal corticosteroids 1–7 days before birth (n = 1758) and those who did not receive antenatal corticosteroids (n = 758) and between singleton neonates who received a complete course of antenatal corticosteroids 1–7 days before birth (n = 4638) and those did not receive antenatal corticosteroids (n = 2312) was conducted after adjusting for gestational age, sex, hypertension, outborn status, small for gestational age, parity, and cesarean birth. Adjusted odds ratios and 95% confidence intervals for various neonatal outcomes were calculated. Results Administration of a complete course of antenatal corticosteroids within 1–7 days before birth in both twins and singletons was associated with similar reduced odds of neonatal death (for twins adjusted odds ratio 0.42 95% confidence interval, 0.24–0.76 and for singletons adjusted odds ratios, 0.38 95% confidence interval, 0.28–0.50; P = .7 for comparison of twins vs singletons), mechanical ventilation (for twins adjusted odds ratio, 0.47 95% confidence interval, 0.35–0.63 and for singletons adjusted odds ratio, 0.47 95% confidence interval, 0.41–0.55; P = .9), respiratory distress syndrome (for twins adjusted odds ratio, 0.53 95% confidence interval, 0.40–0.69, and for singletons adjusted odds ratio, 0.54 95% confidence interval, 0.47–0.62; P = .9) and severe neurological injury (for twins adjusted odds ratio, 0.50 95% confidence interval, 0.30–0.83 and for singletons adjusted odds ratio, 0.45 95% confidence interval, 0.34–0.59; P = .7). Administration of a complete course of antenatal corticosteroids was not associated with a reduced odds of bronchopulmonary dysplasia, severe retinopathy of prematurity, or necrotizing enterocolitis in both twins and singletons. Conclusion Administration of a complete course of antenatal corticosteroids 1–7 days before birth in twin pregnancies is associated with a clinically significant decrease in neonatal mortality, short-term respiratory morbidity, and severe neurological injury that is similar in magnitude to that observed among singletons.
Abstract Neonatal intensive care unit networks that encompass regions, states, and even entire countries offer the perfect platform for implementing continuous quality improvement initiatives to ...advance the health care provided to vulnerable neonates. Through cycles of identification and implementation of best available evidence, benchmarking, and feedback of outcomes, combined with mutual collaborative learning through a network of providers, the performance of health care systems and neonatal outcomes can be improved. We use examples of successful neonatal networks from across North America to explore continuous quality improvement in the neonatal intensive care unit, including the rationale for the formation of neonatal networks, the role of networks in continuous quality improvement, quality improvement methods and outcomes, and barriers to and facilitators of quality improvement.
Preterm birth is the leading cause of morbidity and mortality in children younger than 5 years. We report the changes in neonatal outcomes and care practices among very preterm infants in Canada over ...14 years within a national, collaborative, continuous quality-improvement program.
We retrospectively studied infants born at 23-32 weeks' gestation who were admitted to tertiary neonatal intensive care units that participated in the Evidence-based Practice for Improving Quality program in the Canadian Neonatal Network from 2004 to 2017. The primary outcome was survival without major morbidity during the initial hospital admission. We quantified changes using process-control charts in 6-month intervals to identify special-cause variations, adjusted regression models for yearly changes, and interrupted time series analyses.
The final study population included 50 831 infants. As a result of practice changes, survival without major morbidity increased significantly (56.6% 669/1183 to 70.9% 1424/2009; adjusted odds ratio OR 1.08, 95% confidence interval CI 1.06-1.10, per year) across all gestational ages. Survival of infants born at 23-25 weeks' gestation increased (70.8% 97/137 to 74.5% 219/294; adjusted OR 1.03, 95% CI 1.02-1.05, per year). Changes in care practices included increased use of antenatal steroids (83.6% 904/1081 to 88.1% 1747/1983), increased rates of normothermia at admission (44.8% 520/1160 to 67.5% 1316/1951) and reduced use of pulmonary surfactant (52.8% 625/1183 to 42.7% 857/2009).
Network-wide quality-improvement activities that include better implementation of optimal care practices can yield sustained improvement in survival without morbidity in very preterm infants.
Background Few data are available on central–line associated bloodstream infections (CLABSIs) in Chinese neonatal intensive care units (NICUs). The aims of this study were to characterize CLABSIs ...among neonates in a Chinese NICU and evaluate the impact of a multifaceted evidence-based practice for improving quality program to decrease CLABSI. Methods We conducted a prospective before-after intervention study with a 1-year follow-up among patients with central lines at the NICU of the Children's Hospital of Fudan University between January 2008 and December 2010. The study was conducted in 3 phases: before, during, and after the intervention. A multifaceted infection control program was introduced in phase 2 with successive surveillance. CLABSIs were prospectively monitored and compared. Results A total of 171 patients with central lines (CLs) were observed; 29 of them developed CLABSI corresponding to 7.35 per 1,000 catheter days, with a CL utilization ratio of 37.9%. Overall CLABSI rate decreased gradually from 16.7 per 1,000 CL days in phase 1 to 7.6 per 1,000 CL days in phase 2 ( P = .08) to 5.2 per 1,000 CL days in phase 3 ( P < .01). Gram-negative bacterium (54.5%) was the predominant pathogen in CLABSIs. Conclusion A multifaceted infection control program is effective in reducing the CLABSI rate among neonates. Such interventions could be extended to other resource-limited countries.
Objective To assess the biophysical properties of the aorta in children born small for gestational age (SGA) with an echo-Doppler method and to determine associations with known perinatal risk ...factors. Study design In this cross-sectional study, 39 SGA and 41 control subjects aged 8 to 13 years were recruited. Perinatal risk factors were recorded. The aortic diameters and pulse wave transit time around the aortic arch were measured with echo-Doppler and the blood pressure recorded. Pulse wave velocity, aortic input impedance (Zi), characteristic impedance (Zc), arterial pressure-strain elastic modulus (Ep), and arterial wall stiffness index (β-index) were calculated. Results Pulse wave velocity (374 ± 46 vs 348 ± 47cm/sec, P < .02); Zi (177 ± 39 vs 142 ± 27 dynes · sec/cm5 , P < .0001); Zc (185 ± 29 vs 152 ± 37 dynes · sec/cm5 , P < .0001); Ep (286 ± 101 vs 216 ± 41 mm Hg, P < .0001); and β-index (2.43 ± 0.32 vs 2.17 ± 0.15, P < .0001) were all higher in SGA. We found negative associations between the following: birth weight and Zi, Zc, Ep, and β-index; as well as body mass index and Zi, Zc. Conclusion This simple echo-Doppler method demonstrated abnormal biophysical properties of the aorta in a cohort of pre-adolescent patients born SGA who remain small in stature and continue to have normal blood pressure.
Abstract Introduction Studies of adult patient populations suggest that organizational culture is associated with quality improvement (QI) implementation, as well as patient outcomes. However, very ...little research on organizational culture has been performed in neonatal patient populations. Method This combined cross-sectional survey and retrospective cohort study assessed employee perceptions of organizational culture and QI implementation within 18 Canadian neonatal intensive care units. The associations between these data and neonatal outcomes in extremely preterm infants (born at < 29 weeks' gestation) were then assessed using multivariable analyses. Results Perceptions of unit culture and QI implementation varied according to occupation and age. Higher hierarchical culture was associated with increased survival without major morbidities (odds ratio, 1.04; 95% confidence interval, 1.01-1.06), as were higher QI implementation scores (odds ratio range, 1.20-1.36 by culture type). Discussion Our data suggest that organizational culture, particularly hierarchical culture, and level of QI implementation may play a role in neonatal outcomes.
Background Measures employed in preventing ventilator-associated pneumonia (VAP) in developing countries are rarely reported. This study evaluates the efficacy of an infection control program in ...reducing VAP in a neonatal intensive care unit (NICU) in China. Methods All neonates who received mechanical ventilation for at least 48 hours and were hospitalized in the NICU for ≥5 days during 3 epochs were included. The hospital relocated to a new site during phase 2 and a bundle of comprehensive preventive measures against VAP were gradually implemented using the evidence-based practice for improving quality method. Research physicians recorded associated information of patients diagnosed with VAP. Results Of 491 patients receiving mechanical ventilation, 92 (18.7%) developed VAP corresponding to 27.33 per 1,000 ventilator-days. The rate decreased from 48.84 per 1,000 ventilator-days in phase 1 to 25.73 per 1,000 ventilator-days in phase 2 and further diminished to 18.50 per 1,000 ventilator-days in phase 3 ( P < .001). Overall mortality rate of admitted neonates significantly decreased from 14.0% in phase 1 to 2.9% in phase 2 and 2.7% in phase 3 ( P = .000). Gram-negative bacteria (95.5%) were the predominant organisms in VAP and Acinetobacter baumannii (65.2%) was the most frequently isolated microorganism. Conclusions Implementing a multifaceted infection control program resulted in a significant reduction in VAP rate with long-term effects. Such interventions could be extended to other low-income countries.
Objectives: Illness severity scores for newborns are complex and restricted by birth weight and have dated validations and calibrations. We developed and validated simplified neonatal illness ...severity and mortality risk scores. The primary outcome was in-hospital mortality. Study design: Thirty neonatal intensive care units in Canada, California, and New England collected data on all admissions during the mid 1990s; patients moribund at birth or discharged to normal newborn care in <24 hours were excluded. Starting with the 34 data elements of the Score for Neonatal Acute Physiology (SNAP), we derived the most parsimonious logistic model for in-hospital mortality using 10,819 randomly selected Canadian cases. SNAP-II includes 6 physiologic items; to this are added points for birth weight, low Apgar score, and small for gestational age to create a 9-item SNAP-Perinatal Extension-II (SNAPPE-II). We validated SNAPPE-II on the remaining 14,610 cases and optimized the calibration. Results: In all birth weights, SNAPPE-II had excellent discrimination and goodness of fit. Area under the receiver operator characteristic curve was.91 ± 0.01. Goodness of fit (Hosmer-Lemeshow) was 0.90. Conclusions: SNAP-II and SNAPPE-II are empirically validated illness severity and mortality risk scores for newborn intensive care. They are simple, accurate, and robust across populations. (J Pediatr 2001;138:92-100)
Objectives:To determine the impact of neighbourhood income and maternal residence population density on mortality and various morbidities at discharge or transfer from the NICU among extremely ...preterm neonates (<27 weeks gestation) in Canada.
Methods:Neighbourhood income level and residential status was derived using a postal code conversion file and census data. Multivariable logistic regression analysis was used to estimate the risk-adjusted odds ratio (AOR) of mortality and survival without major morbidities (chronic lung disease, necrotizing enterocolitis, severe intraventricular hemorrhage, and retinopathy of prematurity) among 2,752 extremely preterm infants admitted to 25 tertiary level neonatal intensive care units in Canada between 2007 and 2008.
Results:There were no significant differences between mothers from different neighbourhood income quintiles (Q1 = low; Q5 = high) and neonatal mortality AOR (95% confidence interval): Q1: 1.10 (0.74–1.62), Q2: 1.00 (0.67–1.49), Q3: 1.39 (0.93–2.07), Q4: 1.01 (0.67–1.52), Q5: 1 (reference); or survival without major morbidity: Q1: 1.01 (0.70–1.44), Q2: 0.84 (0.58–1.23), Q3: 0.85 (0.58–1.24), Q4: 0.92 (0.63–1.35), Q5: 1 (reference). There were no significant differences in mortality (AOR 1.14 0.83–1.57) or in survival without major morbidity (AOR 0.92 0.67–1.26) between infants of mothers residing in sparsely populated areas compared to densely populated areas.
Conclusion:Maternal residence in a low-income neighbourhood or sparsely populated area was not associated with higher odds of mortality or survival free of major morbidities in extremely preterm infants.
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