The neonatal preventable harm index: a high reliability tool

Midline Catheter Use in the Neonatal Intensive Care Unit

Neonates admitted to the neonatal intensive care unit (NICU) are a unique population who most often begin life acutely or critically ill. Venous access is required by most acutely/critically ill neonates, especially those born preterm. Access is required for implementing management strategies such as stabilization, medications, fluids, nutrition, and transfusion of blood products. However, achieving and maintaining venous access in these neonates can be difficult, especially in preterm infants due to a myriad of contributing factors. Peripheral intravenous (PIV) catheters and peripherally inserted central catheters (PICC) are 2 common vascular access approaches used in the NICU and have traditionally been the most studied in the neonatal literature. Both options offer advantages and disadvantages. An alternative to PIVs and PICCs is the midline peripheral catheter (MPC), which in the literature may also be referred to as extended dwell peripheral intravenous catheters. Depending on the intended use, the MPC offers a venous access approach between a PIV and PICC. Usage of MPCs in the NICU is slowly increasing with the limited published evidence suggesting they are viable option when considering the need for vascular access. The purpose of this article is to present the advantages and disadvantages of MPCs as an alternative approach for venous access in neonates when appropriate.

Associations between safety perceptions and medical error reporting among neonatal intensive care unit staff

INTRODUCTION

Critically ill neonates are particularly susceptible to medical errors; however, few studies have evaluated NICU safety climate in the context of medical error reporting. This study aims to identify the association between perceptions of safety and culture among NICU staff with medical error reporting behaviours.

METHODS

This study used a convenience sample of 79 NICU staff members (38 Nurses and 41 Respiratory Therapists). Questionnaires consisted of demographic factors (years of experience, sex and education), the Safety Attitudes Questionnaire (SAQ) and hypothetical medical error reporting scenarios (categorized into minor harm or major harm). The SAQ consists of six domains: job satisfaction, teamwork climate, safety climate, perceptions of management, working conditions and stress recognition. Scores ranged from 0-5, with a 5 indicating a more positive perception. Logistic regression was used to determine statistically significant predictors for each individual harm scenario (odds of being very likely/likely to report vs. all other responses).

RESULTS

Among those who completed the study, approximately 84.8% were female. Safety attitude domain scores were similar for both NICU respiratory therapists and nurses across all domains except for job satisfaction and stress. Respiratory therapists reported higher levels of job satisfaction compared to nurses (24 vs. 23, respectively, p = 0.01). However, nurses reported higher levels of stress management compared to respiratory therapists (12 vs. 9, respectively, p < 0.01). While we did not find a significant association between safety attitudes and hypothetical medical error reporting, NICU staff overall were more likely to report major medical errors compared to minor medical errors.

CONCLUSIONS

This study suggests that safety climate may not play a significant role in promoting medical error reporting in the NICU setting.

RELEVANCE TO CLINICAL PRACTICE

Interventions aimed at increasing medical error reporting should also incorporate established employees rather than targeting new employees only.

Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System

IMPORTANCE

There are few population-based studies addressing trends in neonatal intensive care unit (NICU) admission and NICU patient-days, especially in the subpopulation that, by gestational age (GA) and birth weight (BW), might otherwise be able to stay in the room with their mothers.

OBJECTIVE

To describe population-based trends in NICU admissions, NICU patient-days, readmissions, and mortality in the birth population of a large integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data extracted from electronic medical records at Kaiser Permanente Southern California (KPSC) health care system. Participants included all women who gave birth at KPSC hospitals and their newborns from January 1, 2010, through December 31, 2018. Data extraction was limited to data entry fields whose contents were either numbers or fixed categorical choices. Rates of NICU admission, NICU patient-days, readmission rates, and mortality rates were measured in the total population, in newborns with GA 35 weeks or greater and BW 2000 g or more (high GA and BW group), and in the remaining newborns (low GA and BW group). Admissions to the NICU and NICU patient-days were risk adjusted with a machine learning model based on demographic and clinical characteristics before NICU admission. Changes in the trends were assessed with 2-sided correlated seasonal Mann-Kendall test. Data analysis was performed in August 2019.

EXPOSURES

Admission to the NICU and NICU patient-days among the birth cohort.

MAIN OUTCOMES AND MEASURES

The primary outcomes were NICU admission and NICU patient-days in the total neonatal population and GA and BW subgroups. The secondary outcomes were readmission and mortality rates.

RESULTS

Over the study period there were 320 340 births (mean [SD] age of mothers, 30.1 [5.7] years; mean [SD] gestational age, 38.6 [1.97] weeks; mean [SD] birth weight, 3302 [573] g). The risk-adjusted NICU admission rate decreased from a mean of 14.5% (95% CI, 14.2%-14.7%) to 10.9% (95% CI, 10.7%-11.7%) (P for trend = .002); 92% of the change was associated with changes in the care of newborns in the high GA and BW group. The number of risk-adjusted NICU patient-days per birth decreased from a mean of 1.50 patient-days (95% CI, 1.43-1.54 patient-days) to 1.40 patient-days (95% CI, 1.36-1.48 patient-days) (P for trend = .03); 70% of the change was associated with newborns in the high GA and BW group. The unadjusted 30-day readmission rates and mortality rates did not change.

CONCLUSIONS AND RELEVANCE

Admission rates to the NICU and numbers of NICU patient-days decreased over the study period without an increase in readmissions or mortality. The observed decrease was associated with the high GA and BW newborn population. How much of this decrease is attributable to intercurrent health care systemwide quality improvement initiatives would require further investigation. The remaining unexplained variation suggests that further changes are also possible.

A New Model for Non-Lipid Compounded Neonatal Parenteral Nutrition Solution Osmolality

BACKGROUND

Osmotic stress is a physical risk factor for adverse events related to peripheral parenteral nutrition (PN) administration, such as infiltration. We sought to improve prediction of compounded PN osmolality utilizing basic nutrient solutions available to North American neonatal intensive care units. This study tested the hypothesis that calculated osmolarity underestimates osmolality in compounded PN.

METHODS

Osmolarity (mOsm/L) was calculated utilizing commercial software. Osmolality (mOsm/kg) was determined by a freezing-point depression micro-osmometer. The relationship between calculated osmolarity and measured osmolality was modeled from linear or polynomial regression analysis using the least squares method. Regression models were based upon calculated osmolarity and included various combinations of PN components.

RESULTS

Calculated osmolarity significantly underestimated measured osmolality in all PN samples (n = 363). Based upon the osmolality of PN and the basic nutrient solutions, we determined a polynomial regression that effectively corrects for the osmolal gap (measured osmolality-calculated osmolarity) in the validation set (R² = 0.99367). The unbiased analysis corrected for the osmolal gap based on individual solute behaviors, as well as the solute-solute interactions in compounded solutions.

CONCLUSIONS

Calculated osmolarity (mOsm/L) significantly underestimates the osmolality (mOsm/kg) in compounded PN. We developed a new algorithm to more accurately predict PN osmolality based upon calculated osmolarity from commercial software and composition of neonatal basic nutrient solutions used in North America. We propose that use of this PN algorithm will facilitate future studies to determine whether a causal association exists between PN osmolality and adverse events, and to establish safe thresholds for PN concentration in neonates.