Prioritizing a research agenda: a Delphi study of the better outcomes through research for newborns (BORN) network

Research priorities for maternal and perinatal health clinical trials and methods used to identify them: A systematic review

OBJECTIVE

Research prioritisation helps to target research resources to the most pressing health and healthcare needs of a population. This systematic review aimed to report research priorities in maternal and perinatal health and to assess the methods that were used to identify them.

METHODS

A systematic review was undertaken. Projects that aimed to identify research priorities that were considered to be amenable to clinical trials research were eligible for inclusion. The search, limited to the last decade and publications in English, included MEDLINE, EMBASE, CINHAL, relevant Cochrane priority lists, Cochrane Priority Setting Methods Group homepage, James Lind Alliance homepage, Joanna Brigg's register, PROSPERO register, reference lists of all included articles, grey literature, and the websites of relevant professional bodies, until 13 October 2020. The methods used for prioritisation were appraised using the Reporting Guideline for Priority Setting of Health Research (REPRISE).

FINDINGS

From the 62 included projects, 757 research priorities of relevance to maternal and perinatal health were identified. The most common priorities related to healthcare systems and services, pregnancy care and complications, and newborn care and complications. The least common priorities related to preconception and postpartum health, maternal mental health, contraception and pregnancy termination, and fetal medicine and surveillance. The most commonly used prioritisation methods were Delphi (20, 32%), Child Health Nutrition Research Initiative (17, 27%) and the James Lind Alliance (10, 16%). The fourteen projects (23%) that reported on at least 80% of the items included in the REPRISE guideline all used an established research prioritisation method.

CONCLUSIONS

There are a large number of diverse research priorities in maternal and perinatal health that are amenable to future clinical trials research. These have been identified by a variety of research prioritisation methods.

Assessing and Validating a Model of Study Completion for a Prospective Cohort of Healthy Newborns

OBJECTIVES

To identify potentially modifiable or actionable factors related to study completion among healthy mother-infant dyads participating in prospective research.

PATIENTS/METHODS

We conducted a secondary analysis of completion data from a prospective study on newborn jaundice in the first week of life at a tertiary-care hospital in Philadelphia, PA, from 2015 to 2019. Participation in the original study involved enrollment before newborn discharge and subsequent follow-up for a jaundice assessment between 2 and 6 days of life. For this study, our primary outcome was completion of all study procedures. Associations between predictor variables and the outcome were assessed using bivariate and multivariable analyses. We fit a predictive model of study completion using logistic regression and validated the model using 5-fold cross-validation.

RESULTS

Of 501 mother-infant dyads enrolled in the original study, 304 completed the study. Median maternal age was 28 years and 81.8% of mothers delivered via vaginal birth. Study completion was associated with colocation of the study visit with the initial well-child visit (adjusted odds ratio [aOR], 2.99, 95% confidence interval [CI], 2.01-4.46) and provision of an alternate phone number by the participant (aOR, 1.99; 95% CI, 1.34-2.96). The cross-validated model performed similarly to our final predictive model and had an average area under the receiver operating characteristic curve of 0.67 (range, 0.59-0.72), with a sensitivity of 68% and specificity of 60%.

CONCLUSIONS

Findings demonstrate the importance of communication and patient-centric approaches for recruitment and retention in newborn research. Future work should incorporate these approaches while continuing to evaluate study retention strategies.

Hospital Readmission Among Late Preterm Infants: New Insights and Remaining Questions

Late preterm infants (LPIs), those born at 34 to 36 6/7 weeks' gestation, account for the majority of preterm births (73%).1 Given their physiologic immaturity, LPIs are at increased risk of respiratory distress, hyperbilirubinemia, hypoglycemia, and other complications in the neonatal period, and are at increased risk of hospital readmission in the first month of life.2 As Amsalu and colleagues describe in this month's issue of Hospital Pediatrics,3 identification of a predictive model to differentiate LPI at higher risk of complications would help inform tailored discharge plans and prevent readmissions.

Child Protective Services Reports in the Context of Intimate Partner Violence: A Delphi Process Examining Best Practices

OBJECTIVES

Child protective services (CPS) reporting for families experiencing intimate partner violence (IPV) is complex. The goal of this study was to develop expert-driven best practices for pediatric providers filing CPS reports in the context of IPV.

METHODS

We conducted a Delphi study with experts in IPV and child abuse and neglect (CAN) through 3 rounds of surveys. In Round 1, participants selected clinical scenarios for which they would file, as well as best practices when CPS reporting is indicating. In Round 2, participants described how strongly they agreed that a provider should file for each clinical scenario and how important each best practice was on a 5-point Likert scale. Finally, in Round 3 participants reviewed Round 1 and 2 results, then reported their final determination by selecting yes or no for each option. Consensus was achieved in Round 3 if >80% of participants agreed. In each round, participants could provide further detail via free-text answers.

RESULTS

Twenty-three (40%) of the invited experts participated. Consensus was not achieved for children directly witnessing IPV or experiencing health symptoms due to IPV exposure. Participants were in consensus regarding need for CPS reporting when CAN was present and that reporting should not occur for exposure to IPV only. Best practices included supporting IPV survivors, developing healthcare-based IPV advocacy programs, and optimizing the child welfare system.

CONCLUSION

This study provides expert-driven recommendations for filing CPS reports in the context of IPV and highlights the inherent complexity of filing and the need for further guidelines.

The updated national research agenda 2021-2026 for prehospital emergency medical services in the Netherlands: a Delphi study

Background

In 2015, a national research agenda was established for Dutch prehospital EMS to underpin the evidence base of care delivery and inform policymakers and funders. The continuously increasing demand for ambulance care and the reorientation towards the role of EMS in recent years may have changed research priorities. Therefore, this study aimed to update the Dutch national EMS research agenda.

Methods

A three-round online Delphi survey was used to explore and discuss different viewpoints and to reach consensus on research priorities (i.e., themes and special interest groups, e.g. patient types who require specific research attention). A multidisciplinary expert panel (n = 62) was recruited in the field of prehospital EMS and delegates of relevant professional organizations and stakeholders participated. In round one, fifty-nine research themes and six special interest groups (derived from several resources) were rated on importance on a 5-point scale by the panel members. In round two, the panel selected their priority themes and special interest groups (yes/no), and those with a positive difference score were further assessed in round three. In this final round, appropriateness of the remaining themes and agreement within the panel was taken into account, following the RAND/UCLA appropriateness method, which resulted in the final list of research priorities.

Results

The survey response per round varied between 94 and 100 percent. In round one, a reduction from 59 to 25 themes and the selection of three special interest groups was realized. Round two resulted in the prioritization of six themes and one special interest group ('Vulnerable elderly'). Round three showed an adequate level of agreement regarding all six themes: 'Registration and (digital) exchange of patient data in the chain of emergency care'; 'Mobile care consultation/Non conveyance'; 'Care coordination'; 'Cooperation with professional partners within the care domain'; 'Care differentiation' and 'Triage and urgency classification'.

Conclusions

The updated Dutch national EMS research agenda builds further on the previous version and introduces new EMS research priorities that correspond with the future challenges prehospital EMS care is faced with. This agenda will guide researchers, policymakers and funding bodies in prioritizing future research projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00971-6.

Variation in Newborn Skincare Policies Across United States Maternity Hospitals

OBJECTIVE

Newborn skincare influences levels of beneficial factors from vernix and vaginal secretions but also the emergence of potential skin pathogens. However, evidence-based national guidelines for newborn skincare do not exist, and actual hospital practices for newborn skincare have not been described. In this study, we test the hypothesis that US maternity hospitals follow differing policies with regard to newborn skincare.

METHODS

A 16-question survey querying skin care practices was distributed to nursery medical directors at the 109 US hospital members of the Better Outcomes through Research for Newborns network. Data from free text responses were coded by 2 study personnel. Survey responses were analyzed by using descriptive statistics and compared by region of the United States.

RESULTS

Delaying the first newborn bath by at least 6 hours is a practice followed by 87% of US hospitals surveyed. Discharging newborns without a bath was reported in 10% of hospitals and was more common for newborns born in nonacademic centers and on the West Coast. Procedures and products used for newborn skincare varied significantly. Parental education on tub immersion and soap use was also inconsistent and potentially contradictory between providers. Evidence cited by hospitals in forming their policies is scant.

CONCLUSION

In this study, we identify similar and strikingly different newborn skincare policies across a national network of US maternity hospitals. Research is needed to identify effects of differing skincare routines on skin integrity, infection rates, and childhood health outcomes to improve the evidence base for the care of newborn skin.

Practice Variations in Diagnosis and Treatment of Hypoglycemia in Asymptomatic Newborns

OBJECTIVES

To describe variations in the practice of hypoglycemia screening and treatment in asymptomatic infants in the United States.

METHODS

During the time period from February 2018 to June 2018, we surveyed representatives of hospitals participating in the Better Outcomes through Research for Newborns Network, a national research network of clinicians providing hospital care to term and late-preterm newborns. The survey included 22 questions evaluating practices related to hypoglycemia screening and management of asymptomatic infants.

RESULTS

Of 108 network sites, 84 (78%) responded to the survey; 100% had a hypoglycemia protocol for screening at-risk infants in the well-baby nursery. There were wide variations between sites regarding the definition of hypoglycemia (mg/dL) (<45 [24%]; <40 [23%]; <40 [0-4 hours] and <45 [4-24 hours] [27%]; <25 [0-4 hours] and <35 [4-24 hours] [8%]), timing of first glucose check (<1 hour [18%], 1-2 hours [30%], 30 minutes post feed [48%]), and threshold glucose level for treatment (<45 [19%]; <40 [18%]; <40 [0-4 hours] and <45 [4-24 hours] [20%]; <25 [0-4 hours] and <35 [4-24 hours] [15%]). All respondents used breast milk as a component of initial therapy. Criteria for admission to the NICU for hypoglycemia included the need for dextrose containing intravenous fluids (52%), persistent hypoglycemia despite treatment (49%), and hypoglycemia below a certain value (37%).

CONCLUSIONS

There is a significant practice variation in hypoglycemia screening and management across the United States.

Morbidity and Mortality in Critically Ill Children. I. Pathophysiologies and Potential Therapeutic Solutions

OBJECTIVES

Developing effective therapies to reduce morbidity and mortality requires knowing the responsible pathophysiologies and the therapeutic advances that are likely to be impactful. Our objective was to determine at the individual patient level the important pathophysiological processes and needed therapeutic additions and advances that could prevent or ameliorate morbidities and mortalities.

DESIGN

Structured chart review by pediatric intensivists of PICU children discharged with significant new morbidity or mortality to determine the pathophysiologies responsible for poor outcomes and needed therapeutic advances.

SETTING

Multicenter study (eight sites) from the Collaborative Pediatric Critical Care Research Network of general and cardiac PICUs.

PATIENTS

First PICU admission of patients from December 2011 to April 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two-hundred ninety-two patients were randomly selected from 681 patients discharged with significant new morbidity or mortality. The median age was 2.4 years, 233 (79.8%) were in medical/surgical ICUs, 59 (20.2%) were in cardiac ICUs. Sixty-five (22.3%) were surgical admissions. The outcomes included 117 deaths and 175 significant new morbidities. The most common pathophysiologies contributing to the poor outcomes were impaired substrate delivery (n = 158, 54.1%) and inflammation (n = 104, 35.6%). There were no strong correlations between the pathophysiologies and no remarkable clusters among them. The most common therapeutic needs involved new drugs (n = 149, 51.0%), cell regeneration (n = 115, 39.4%), and immune and inflammatory modulation (n = 79, 27.1%). As with the pathophysiologies, there was a lack of strong correlations or meaningful clusters in the suggested therapeutic needs.

CONCLUSIONS

There was no single dominant pathophysiology or cluster of pathophysiologies responsible for poor pediatric critical care outcomes. Therapeutic needs often involved therapies that are not close to implementation such as cell regeneration, improved organ transplant, improved extracorporeal support and artificial organs, and improved drugs.

Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and Potential Therapeutic Solutions

OBJECTIVES

To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality.

DESIGN

Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review.

SETTING

Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.

PATIENTS

A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%).

CONCLUSIONS

Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.

Priorities for collaborative research using very preterm birth cohorts

OBJECTIVES

To develop research priorities on the consequences of very preterm (VPT) birth for the RECAP Preterm platform which brings together data from 23 European VPT birth cohorts.

DESIGN AND SETTING

This study used a two-round modified Delphi consensus process. Round 1 was based on 28 research themes related to childhood outcomes (<12 years) derived from consultations with cohort researchers. An external panel of multidisciplinary stakeholders then ranked their top 10 themes and provided comments. In round 2, panel members provided feedback on rankings and on new themes suggested in round 1.

RESULTS

Of 71 individuals contacted, 64 (90%) participated as panel members comprising obstetricians, neonatologists, nurses, general and specialist paediatricians, psychologists, physiotherapists, parents, adults born preterm, policy makers and epidemiologists from 17 countries. All 28 initial themes were ranked in the top 10 by at least six panel members. Highest ranking themes were: education (73% of panel members' top 10 choices); care and outcomes of extremely preterm births, including ethical decisions (63%); growth and nutrition (60%); emotional well-being and social inclusion (55%); parental stress (55%) and impact of social circumstances on outcomes (52%). Highest ranking themes were robust across panel members classified by background. 15 new themes had at least 6 top 10 endorsements in round 2.

CONCLUSIONS

This study elicited a broad range of research priorities on the consequences of VPT birth, with good consensus on highest ranks between stakeholder groups. Several highly ranked themes focused on the socioemotional needs of children and parents, which have been less studied.

Determinants of excessive weight loss in breastfed full-term newborns at a baby-friendly hospital: a retrospective cohort study

Background

Excessive weight loss in newborns is associated with neonatal complications such as jaundice and dehydration, which cause renal failure, thrombosis, hypovolemic shock, and seizures. The identification of the risk factors for excessive weight loss will help to discover preventive measures. The aim of this study was to determine the factors associated with excessive weight loss, defined as weight loss of ≥10%, in breastfed full-term newborns in Japan.

Methods

The present retrospective study, which was performed in a tertiary perinatal center accredited as a Baby-Friendly Hospital, included neonates who were born alive with a gestational age of ≥37 weeks. Cases of multiple births, admission to the neonatal intensive care unit (NICU), referral to another facility, or exclusive formula feeding were excluded. Multivariate logistic regression analyses were performed to assess the association between maternal or neonatal characteristics and excessive weight loss.

Results

We studied 399 newborns, of whom 164 (41%) had excessive weight loss. According to the adjusted multiple regression analysis, the factors associated with excessive weight loss were an older maternal age, primiparity, and antepartum Caesarean section, with adjusted odds ratios (95% Confidence Intervals [CIs]) of 1.07 (1.02, 1.11), 2.72 (1.69, 4.38), and 2.00 (1.09, 3.65), respectively.

Conclusions

Close monitoring of infants born to older mothers, primiparous mothers, or infants delivered by antepartum Cesarean section is recommended, and earlier supplementation with artificial milk may be considered.

The North East Multispecialty Delphi Project - Collaboration Between Trainee Research Networks

Trainee research collaborative networks have revolutionized how trainees participate in clinical research. Three North East of England trainee-led research groups, the Intensive Care and Anesthesia Research Network of North East Trainees (INCARNNET), the Northern Surgical Trainees Research Association (NOSTRA) in General Surgery and the Collaborative Orthopedic Research Network (CORNET) in Trauma and Orthopedics have joined, creating a multispecialty collaborative. This multispecialty collaborative undertook a two-phase research Delphi, between November 2017 and June 2018, to identify key research questions. This Delphi identified three high priority research questions common to the three specialties: what is the impact of diabetes control on perioperative outcomes, what factors affect theater efficiency, and how to prevent postoperative chest infection following emergency surgery? These research questions will be developed into collaborative projects. The Delphi also identified specialty-specific questions to be taken forward as research projects by each network.

Wide Variation Found in Care of Opioid-Exposed Newborns

OBJECTIVE

Standardized practices for the management of neonatal abstinence syndrome (NAS) are associated with shorter lengths of stay, but optimal protocols are not established. We sought to identify practice variations for newborns with in utero chronic opioid exposure among hospitals in the Better Outcomes Through Research for Newborns (BORN) network.

METHODS

Nursery site leaders completed a survey about hospitals' policies and practices regarding care for infants with chronic opioid exposure (≥3 weeks).

RESULTS

The 76 (80%) of 95 respondent hospitals were in 34 states, varied in size (<500 to >8000 births and <10 to >200 opioid-exposed infants per year), with most affiliated with academic centers (89%). Most (80%) had protocols for newborn drug exposure screening; 90% used risk-based approaches. Specimens included urine (85%), meconium (76%), and umbilical cords (10%). Of sites (88%) with NAS management protocols, 77% addressed medical management, 72% nursing care, 72% pharmacologic treatment, and 58% supportive care. Morphine was the most common first-line pharmacotherapy followed by methadone. Observation periods for opioid-exposed newborns varied; 57% observed short-acting opioid exposure for 2 to 3 days, while 30% observed for ≥5 days. For long-acting opioids, 71% observed for 4 to 5 days, 19% for 2 to 3 days, and 8% for ≥7 days. Observation for NAS occurred mostly in level 1 nurseries (86%); however, most (87%) transferred to NICUs when pharmacologic treatment was indicated.

CONCLUSIONS

Most BORN hospitals had protocols for the care of opioid-exposed infants, but policies varied widely and characterized areas of needed research. Identification of variation is the first step toward establishing best practice standards to improve care for this rapidly growing population.

Variation in Sepsis Evaluation Across a National Network of Nurseries

BACKGROUND AND OBJECTIVES

The extent to which clinicians use currently available guidelines for early-onset sepsis (EOS) screening has not been described. The Better Outcomes through Research for Newborns network represents 97 nurseries in 34 states across the United States. The objective of this study was to describe EOS risk management strategies across a national sample of newborn nurseries.

METHODS

A Web-based survey was sent to each Better Outcomes through Research for Newborns network nursery site representative. Nineteen questions addressed specific practices for assessing and managing well-appearing term newborns identified at risk for EOS.

RESULTS

Responses were received from 81 (83%) of 97 nurseries located in 33 states. Obstetric diagnosis of chorioamnionitis was the most common factor used to identify risk for EOS (79 of 81). Among well-appearing term infants with concern for maternal chorioamnionitis, 51 of 79 sites used American Academy of Pediatrics or Centers for Disease Control and Prevention guidelines to inform clinical care; 11 used a published sepsis risk calculator; and 2 used clinical observation alone. Complete blood cell count (94.8%) and C-reactive protein (36.4%) were the most common laboratory tests obtained and influenced duration of empirical antibiotics at 13% of the sites. Some degree of mother-infant separation was required for EOS evaluation at 95% of centers, and separation for the entire duration of antibiotic therapy was required in 40% of the sites.

CONCLUSIONS

Substantial variation exists in newborn EOS risk assessment, affecting the definition of risk, the level of medical intervention, and ultimately mother-infant separation. Identification of the optimal approach to EOS risk assessment and standardized implementation of such an approach could affect care of a large proportion of newborns.

Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial

BACKGROUND

For evaluation of jaundiced neonates, serum bilirubin (SB) or transcutaneous bilirubinometry (TcB) is used. Few data are available on the quantitative reduction of blood sampling by using TcB.

METHODS

We conducted a randomized controlled trial in hospitalized jaundiced neonates ≥32 weeks' gestational age. In the intervention group, TcB was used and in the control group the decision to obtain a blood sample for SB was based on visual and clinical assessment. Outcome measure was the number of blood samples before phototherapy. When TcB was <50 µmol/L below the threshold for phototherapy, SB was obtained. The decision to start treatment was always based on an SB value.

RESULTS

A total of 430 were randomized and included in the intention-to-treat analysis: 213 in the TcB group and 217 in the control group. In the TcB group, 104 (48.4%) had at least 1 blood sample taken for SB, versus 172 (79.3%) in the control group (difference 30.5%, 95% confidence interval 21.5-38.7, P < .001). The number of blood draws was significantly reduced by 38.5% (0.9 ± 1.1 vs 1.3 ± 1.0, difference -0.5, 95% confidence interval -0.7 to -0.3, P < .001). Peak of bilirubin value, indications for phototherapy, or exchange transfusion and hospitalization length were not different between groups.

CONCLUSIONS

The use of TcB in jaundiced neonates is feasible and safe, resulting in a reduction of more than one-third in blood draws.

Excessive weight loss in exclusively breastfed full-term newborns in a Baby-Friendly Hospital

OBJECTIVE

To determine the risk factors for weight loss over 8% in full-term newborns at postpartum discharge from a Baby Friendly Hospital.

METHODS

The cases were selected from a cohort of infants belonging to a previous study. Healthy full-term newborns with birth weight ≥2.000g, who were exclusively breastfed, and excluding twins and those undergoing phototherapy as well as those discharged after 96 hours of life, were included. The analyzed maternal variables were maternal age, parity, ethnicity, type of delivery, maternal diabetes, gender, gestational age and appropriate weight for age. Adjusted multiple and univariate Cox regression analyses were used, considering as significant p<0.05.

RESULTS

We studied 414 newborns, of whom 107 (25.8%) had excessive weight loss. Through the univariate regression, risk factors associated with weight loss >8% were caesarean delivery and older maternal age. At the adjusted multiple regression analysis, the model to explain the weight loss was cesarean delivery (relative risk: 2.27 and 95% of confidence interval: 1.54 to 3.35).

CONCLUSIONS

The independent predictor for weight loss >8% in exclusively breastfed full-term newborns in a Baby-Friendly Hospital was the cesarean delivery. It is possible to reduce the number of cesarean sections to minimize neonatal excessive weight loss and the resulting use of infant formula during the first week of life.

A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study

BACKGROUND

In pre-hospital Emergency Medical Services (EMS) more research is needed to direct and underpin care delivery and inform policy. To target future research efforts, this study aimed to determine future research priorities with representatives of the EMS field.

METHODS

A four-round online Delphi survey was used to discuss different viewpoints and reach consensus on research priorities. A multidisciplinary panel of experts was recruited in the field of pre-hospital EMS and adjoining (scientific) professional organisations (n = 62). 48 research topics were presented in Delphi I, and the panel was asked to rate their importance on a 5-point scale. In Delphi II and III the panel selected their priority research topics, and arguments why and suggestions for research questions were collected and reported back. In Delphi IV appropriateness of the remaining topics and agreement within the expert panel was taken into account to make up the final list of research priorities.

RESULTS

The response on the Delphi-survey was high: 95% (n = 59; Delphi I); 97% (n = 60, Delphi II); 94% (n = 58, Delphi III); 97% (n = 60, Delphi IV). The panel reduced the number of research topics from 48 topics in Delphi I to 12 topics in Delphi III. A variety of arguments and suggestions for research questions were collected, giving insight in reasons why research on these topics in the near future is needed. Delphi IV showed an adequate level of agreement with respect to the 12 presented research topics. The following 9 topics were rated as appropriate for the national pre-hospital EMS research agenda: Non-conveyance to the hospital (ranked highest); Performance measures for quality of care; Hand over/registration/exchange of patient data; Care and task substitution; Triage; Assessment of acute neurologic signs & symptoms; Protocols and protocol adherence; Immobilisation; and Open/secure airway.

DISCUSSIONS

The research priorities identified in our study resemble those in other studies. However, the topic 'non-conveyance to the hospital' was determined as a priority in this study but not in other studies.

CONCLUSIONS

The national pre-hospital EMS research agenda can focus future research efforts to improve the evidence base and clinical practice of pre-hospital emergency medical services. Dissemination and implementation of the research agenda deserves careful attention.

Discrepancies between transcutaneous and serum bilirubin measurements

OBJECTIVE

To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States.

METHODS

Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB--TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB--TSB difference.

RESULTS

Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB--TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB--TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB--TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥ 3 mg/dL.

CONCLUSIONS

During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.