Infant Infections Following Cesarean Delivery on Maternal Request: A Population-Based Cohort Study

OBJECTIVES

Investigations about cesarean delivery (CD) on maternal request (CDMR) and infant infection risk frequently rely on administrative data with poorly defined indications for CD. We sought to determine the association between CDMR and infant infection using an intent-to-treat approach.

METHODS

This was a population-based cohort study of low-risk singleton pregnancies with a term live birth in Ontario, Canada between April 2012 and March 2018. Subjects with prior CD were excluded. Outcomes included upper and lower respiratory tract infections, gastrointestinal infections, otitis media, and a composite of these 4. Relative risk and 95% CI were calculated for component and composite outcomes up to 1 year following planned CDMR versus planned vaginal deliveries (VDs). Subgroup and sensitivity analyses included age at infection (≤28 vs. >28 days), type of care (ambulatory vs. hospitalisation), restricting the cohort to nulliparous pregnancies, and including individuals with previous CD. Last, we re-examined outcome risk on an as-treated basis (actual CD vs. actual VD).

RESULTS

Of 422 134 pregnancies, 0.4% (1827) resulted in a planned CDMR. After adjusting for covariates, planned CDMR was not associated with a risk of composite infant infections (adjusted relative risk 1.02; 95% CI 0.92-1.11). Findings for component infection outcomes, subgroup, and sensitivity analyses were similar. However, the as-treated analysis of the role of delivery mode on infant risk for infection demonstrated that actual CD (planned and unplanned) was associated with an increased risk for infant infections compared to actual VD.

CONCLUSIONS

Planned CDMR is not associated with increased risk for neonatal or infant infections compared with planned VD. Study design must be carefully considered when investigating the impact of CDMR on infant infection outcomes.

Exploring implementation processes of a parent-targeted educational video for improving newborn pain treatment: A sequential exploratory mixed-methods study

Despite known analgesic effects of breastfeeding (BF), skin-to-skin care (SSC), and sweet solutions (sucrose) for newborns, these interventions remain underutilized. Our team produced a five-minute parent-targeted video (BSweet2Babies) demonstrating BF, SSC, and sucrose during newborn blood sampling. We conducted a sequential exploratory mixed-methods study with eight maternal-newborn units across Ontario, Canada to identify barriers and facilitators to implementing the video and the three pain management strategies.Over a 6-month period, data collection included 15 telephone interviews, two email communications, and three community of practice teleconferences with the participating sites (n = 8). We used the Theoretical Domains Framework as the coding matrix. Participants discussed integrating the video in prenatal education and the importance of involving leadership when planning for practice change. Key barriers included lack of comfort with parental presence, perception of high complexity of the strategies, short postpartum stays, competing priorities, and interprofessional challenges. Key facilitators included alignment with the Baby-Friendly Hospital Initiative, modeling by Lactation Consultants, and frequent reminders.

Bottle-Feeding Intervention Detection in the NICU

Video-based monitoring of patients in the neonatal intensive care unit (NICU) has great potential for improving patient care. Video-based detection of clinical events, such as bottle feeding, would represent a step towards semi-automated charting of clinical events. Recording such events contemporaneously would address the limitations associated with retrospective charting. Such a system could also support oral feeding assessment tools, as the patient's feeding skills and nutrition are pivotal in monitoring their growth. We therefore leverage transfer learning using a pretrained VGG-16 model to classify images obtained during an intervention, to determine if a bottle-feeding event is occurring. Additionally, we explore a data expansion technique by extracting similar-feature images from publicly available sources to supplement our dataset of real NICU patients to address data scarcity. This work also visualizes and quantifies the gap between the source domain (ImageNet data subset) and target domain (NICU dataset), thereby illustrating the impact of expanding our training set for knowledge transfer proficiency. Results show an increase of over 18% in sensitivity after data expansion. Analysis of network activation maps indicates that data expansion is able to reduce the distance between the source and target domains.

RGB-D scene analysis in the NICU

Continuity of care is achieved in the neonatal intensive care unit (NICU) through careful documentation of all events of clinical significance, including clinical interventions and routine care events (e.g., feeding, diaper change, weighing, etc.). As a step towards automating this documentation process, we propose a scene recognition algorithm that can automatically identify key features in a single image of the patient environment, paired with a rule-based sentence generator to caption the scene. Color and depth video were obtained from 29 newborn patients from the Children's Hospital of Eastern Ontario (CHEO) using an Intel RealSense SR300 RGB-D camera and manual bedside event annotation. Image processing techniques are implemented to classify two lighting conditions: brightness level and phototherapy. A deep neural network is developed for three image classification tasks: on-going intervention, bed occupancy, and patient coverage. Transfer learning is leveraged in the feature extraction layers, such that weights learned from a generic data-rich task are applied to the clinical domain where data collection is complex and costly. Different depth fusion techniques are implemented and compared among classification tasks, where the depth and color data are fused as an RGB-D image (image fusion) or separately at various layers in the network (network fusion). Promising results were obtained with >84% sensitivity and >73% F1 measure across all context variables despite the large class imbalance. RGBD-based models are shown to outperform RGB models on most tasks. In general, a 4-channel image fusion and network fusion at the 11th layer of the VGG-16 architecture were preferred. Ultimately, achieving complete scene understanding through multimodal computer vision could form the basis for a semi-automated charting system to assist clinical staff.

The validity of skin conductance for assessing acute pain in mechanically ventilated infants: A cross-sectional observational study

BACKGROUND

Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants.

METHODS

A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures.

RESULTS

From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho = 0.4-0.62) and the four-item NFCS (Spearman's rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain.

CONCLUSIONS

SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation.

SIGNIFICANCE OF THE STUDY

Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

Video-Based Neonatal Motion Detection

Newborns admitted to the neonatal intensive care unit (NICU) require a high level of care due to their precarious condition. Nurses typically monitor their vital signs continuously using wearable sensors such as electrocardiogram (ECG) electrodes placed on their chest and a pulse oximeter on a limb. When the patient moves, this can cause motion artifacts on one or more physiologic signals, potentially resulting in a false alarm on the patient monitor. We therefore propose a motion detection algorithm to mitigate these alarms by providing context. Using a camera positioned above the crib or overhead warming bed, we recorded videos from six patients and annotated all patient movements. These data were used to train and evaluate two different approaches for non-contact motion detection. Results were stronger for the optical flow technique than for the long short-term memory network approach. This represents a challenging problem due to variable lighting, patient clothing and bed coverings, and the complex clinical environment in the NICU.

Economic Analysis of Exclusive Human Milk Diets for High-Risk Neonates, a Canadian Hospital Perspective

Background: There is increasing evidence that premature newborns and infants with low birth weight can benefit substantially from an exclusive human milk-based diet (EHMD), consisting of human milk supplemented with a pasteurized donor human milk-derived fortifier. However, compared with the standard infant diet, EHMD also represents a significant added cost to the hospital and/or health system, thereby raising important questions about the economic feasibility of incorporating EHMD into newborn care. Design: We conducted a cost analysis and estimated the potential cost savings to a Canadian tertiary hospital based on the attributable complications averted from EHMD among low-weight neonates. A meta-analysis was performed to derive input parameters. A probabilistic analysis was conducted to determine the probability that EHMD is cost saving and 95% confidence interval (CI) around our estimates. Results: Our findings show that providing EHMD to preterm infants under 750 g at birth and at the highest risk of developing major complications is likely to be cost saving in the amount of $107,567 (95% CI: -145,229 to 360,362) per year. Extending EHMD to higher weight classes may be economically feasible depending on the pricing of the human milk-derived fortifier and the baseline risk of complications in the hospital setting. Conclusions: This comprehensive study provides critical insight for hospital-based decision makers to evaluate the potential gains and uncertainties associated with improved nutritional care for neonatal patients.

Effect of sildenafil on maternal hemodynamics in pregnancies complicated by severe early-onset fetal growth restriction: planned subgroup analysis from a multicenter randomized placebo-controlled double-blind trial

OBJECTIVES

Fetal growth restriction (FGR) is associated with maternal cardiovascular changes. Sildenafil, a phosphodiesterase type-5 inhibitor, potentiates the actions of nitric oxide, and it has been suggested that it alters maternal hemodynamics, potentially improving placental perfusion. Recently, the Dutch STRIDER trial was stopped prematurely owing to excess neonatal mortality secondary to pulmonary hypertension. The main aim of this study was to investigate the effect of sildenafil on maternal hemodynamics in pregnancies with severe early-onset FGR.

METHODS

This was a cardiovascular substudy within a UK multicenter, placebo-controlled trial, in which 135 women with a singleton pregnancy and severe early-onset FGR (defined as a combination of estimated fetal weight or abdominal circumference below the 10^th centile and absent/reversed end-diastolic flow in the umbilical artery on Doppler velocimetry, diagnosed between 22 + 0 and 29 + 6 weeks' gestation) were assigned randomly to receive either 25 mg sildenafil three times daily or placebo until 32 + 0 weeks' gestation or delivery. Maternal blood pressure (BP), heart rate (HR), augmentation index, pulse wave velocity (PWV), cardiac output, stroke volume (SV) and total peripheral resistance were recorded before randomization, 1-2 h and 48-72 h post-randomization, and 24-48 h postnatally. For continuous data, analysis was performed using repeated measures ANOVA methods including terms for timepoint, treatment allocation and their interaction.

RESULTS

Included were 134 women assigned randomly to sildenafil (n = 69) or placebo (n = 65) who had maternal BP and HR recorded at baseline. At 1-2 h post-randomization, compared with baseline values, sildenafil increased maternal HR by 4 bpm more than did placebo (mean difference, 5.00 bpm (95% CI, 1.00-12.00 bpm) vs 1.25 bpm (95% CI, -5.38 to 7.88 bpm); P = 0.004) and reduced systolic BP by 1 mmHg more (mean difference, -4.13 mmHg (95% CI, -9.94 to 1.44 mmHg) vs -2.75 mmHg (95% CI, -7.50 to 5.25 mmHg); P = 0.048). Even after adjusting for maternal mean arterial pressure, sildenafil reduced aortic PWV by 0.60 m/s more than did placebo (mean difference, -0.90 m/s (95% CI, -1.31 to -0.51 m/s) vs -0.26 m/s (95% CI, -0.75 to 0.59 m/s); P = 0.001). Sildenafil was associated with a non-significantly greater decrease in SV index after 1-2 h post-randomization than was placebo (mean difference, -5.50 mL/m² (95% CI, -11.00 to -0.50 mL/m² ) vs 0.00 mL/m² (95% CI, -5.00 to 4.00 mL/m² ); P = 0.056).

CONCLUSIONS

Sildenafil in a dose of 25 mg three times daily increases HR, reduces BP and reduces arterial stiffness in pregnancies complicated by severe early-onset FGR. These changes are short term, modest and consistent with the anticipated vasodilatory effect. They have no short- or long-term clinical impact on the mother. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Data accuracy in the Ontario birth Registry: a chart re-abstraction study

Background

Ontario’s birth Registry (BORN) was established in 2009 to collect, interpret, and share critical data about pregnancy, birth and the early childhood period to facilitate and improve the provision of healthcare. Since the use of routinely-collected health data has been prioritized internationally by governments and funding agencies to improve patient care, support health system planning, and facilitate epidemiological surveillance and research, high quality data is essential. The purpose of this study was to verify the accuracy of a selection of data elements that are entered in the Registry.

Methods

Data quality was assessed by comparing data re-abstracted from patient records to data entered into the Ontario birth Registry. A purposive sample of 10 hospitals representative of hospitals in Ontario based on level of care, birth volume and geography was selected and a random sample of 100 linked mother and newborn charts were audited for each site. Data for 29 data elements were compared to the corresponding data entered in the Ontario birth Registry using percent agreement, kappa statistics for categorical data elements and intra-class correlation coefficients (ICCs) for continuous data elements.

Results

Agreement ranged from 56.9 to 99.8%, but 76% of the data elements (22 of 29) had greater than 90% agreement. There was almost perfect (kappa 0.81–0.99) or substantial (kappa 0.61–0.80) agreement for 12 of the categorical elements. Six elements showed fair-to-moderate agreement (kappa <0.60). We found moderate-to-excellent agreement for four continuous data elements (ICC >0.50).

Conclusion

Overall, the data elements we evaluated in the birth Registry were found to have good agreement with data from the patients’ charts. Data elements that showed moderate kappa or low ICC require further investigation.

Use of a maternal newborn audit and feedback system in Ontario: a collective case study

Background

As part of a larger study examining the effectiveness of the Maternal Newborn Dashboard, an electronic audit and feedback system to improve maternal-newborn care practices and outcomes, the purpose of this study was to increase our understanding of factors explaining variability in performance after implementation of the Dashboard in Ontario, Canada.

Methods

A collective case study. A maximum variation sampling approach was used to invite hospitals reflecting different criteria to participate in a 1-day to 2-day site visit by the research team. The visits included: (1) semistructured interviews and focus groups with healthcare providers, leaders and personnel involved in clinical change processes; (2) observations and document review. Interviews and focus groups were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code and categorise the data.

Results

Between June and November 2016, we visited 14 maternal-newborn hospitals. Hospitals were grouped into four quadrants based on their key indicator performance and level of engagement with the Dashboard. Findings revealed four overarching themes that contribute to the varying success of sites in achieving practice change on the Dashboard key performance indicators, namely, interdisciplinary collaboration and accountability, application of formal change strategies, team trust and use of evidence and data, as well as alignment with organisational priorities and support.

Conclusion

The diversity of facilitators and barriers across the 14 hospitals highlights the need to go beyond a ‘one size fits all’ approach when implementing audit and feedback systems. Future work to identify tools to assess barriers to practice change and to evaluate the effects of cointerventions to optimise audit and feedback systems for clinical practice change is needed.

Elective Repeat Caesarean Section in Low-Risk Women-Economic Evaluation Comparing Births Before vs. After 39 Weeks Gestation in Ontario, Canada

PURPOSE

To undertake an economic analysis of repeat Caesarean births in low-risk women (LRW) not in labour in Ontario who delivered at 37-38 weeks (<39 weeks) vs. 39-40 weeks (≥39 weeks) gestation.

METHODS

Data from the Better Outcomes Registry & Network (BORN) Information System for fiscal years 2012-2013 and 2013-2014 meeting the definition for elective repeat CS (ERCS) for LRW between 37 and 40 weeks gestation. Costs were obtained from the Ottawa Hospital Data Warehouse and applied through to discharge.

RESULTS

For April 2012 to March 2013, we extracted 3637 ERCS dyads at <39 weeks and 3282 dyads at ≥39 weeks. There were 334 NICU admissions at <39 weeks (0.92%) and 235 at ≥39 weeks (0.72%). Average neonate cost was $1247.99 (<39 weeks) vs. $1200.77 (≥39 weeks)-a difference of $47.22. Average dyad cost was $3608.92 (<39 weeks) vs. $3577.04 (≥39 weeks)-a difference of $31.88 per birth. If these births were delayed to ≥39 weeks, net savings of $173 864 and $115 947 annually would be realized on "baby only" and "dyad" costs, respectively. For April 2013 to March 2014, we extracted 2875 ERCS dyads at ≤39 weeks and 3892 dyads at ≥39 weeks. There were 216 NICU admissions ≤39 weeks (0.75%) and 224 at ≥39 weeks (0.58%). Average neonate cost was $1268.56 (<39 weeks) vs. $1126.56 (≥39 weeks)-a difference of $142.00 per birth. Average dyad cost was $3605.70 (≤39 weeks) vs. $3456.61 (≥39 weeks)-a difference of $149.08. If these births were delayed to ≥39 weeks, net annual savings of $404 842 and $428 605 would be realized on "baby only" and "dyad" costs respectively.

CONCLUSIONS

Restricting repeat CS in LRW to ≥39 weeks is a cost-effective strategy.

Data on items of AKUSSI in Alkaptonuria collected over three years from the United Kingdom National Alkaptonuria Centre and the impact of nitisinone

Alkaptonuria is a rare genetic disorder characterized by a high level of circulating (and urine) homogentisic acid (HGA), which contributes to ochronosis when it is deposited in connective tissue as a pigmented polymer. In an observational study carried out by National AKU Centre (NAC) in Liverpool, a total of thirty-nine AKU patients attended yearly visits in varying numbers. At each visit a mixture of clinical, joint and spinal assessments were carried out and the results calculated to yield an AKUSSI (Alkaptonuria Severity Score Index), see "Nitisinone arrests ochronosis and decreases rate of progression of Alkaptonuria: evaluation of the effect of nitisinone in the United Kingdom National Alkaptonuria Centre" (Ranganath at el., 2018). The aim of this data article is to produce visual representation of the change in the components of AKUSSI over 3 years, through radar charts. The metabolic effect of nitisinone is shown through box plots.

Nitisinone arrests ochronosis and decreases rate of progression of Alkaptonuria: Evaluation of the effect of nitisinone in the United Kingdom National Alkaptonuria Centre

QUESTION

Does Nitisinone prevent the clinical progression of the Alkaptonuria?

FINDINGS

In this observational study on 39 patients, 2 mg of daily nitisinone inhibited ochronosis and significantly slowed the progression of AKU over a three-year period.

MEANING

Nitisinone is a beneficial therapy in Alkaptonuria.

BACKGROUND

Nitisinone decreases homogentisic acid (HGA), but has not been shown to modify progression of Alkaptonuria (AKU).

METHODS

Thirty-nine AKU patients attended the National AKU Centre (NAC) in Liverpool for assessments and treatment. Nitisinone was commenced at V1 or baseline. Thirty nine, 34 and 22 AKU patients completed 1, 2 and 3 years of monitoring respectively (V2, V3 and V4) in the VAR group. Seventeen patients also attended a pre-baseline visit (V0) in the VAR group. Within the 39 patients, a subgroup of the same ten patients attended V0, V1, V2, V3 and V4 visits constituting the SAME Group. Severity of AKU was assessed by calculation of the AKU Severity Score Index (AKUSSI) allowing comparison between the pre-nitisinone and the nitisinone treatment phases.

RESULTS

The ALL (sum of clinical, joint and spine AKUSSI features) AKUSSI rate of change of scores/patient/month, in the SAME group, was significantly lower at two (0.32 ± 0.19) and three (0.15 ± 0.13) years post-nitisinone when compared to pre-nitisinone (0.65 ± 0.15) (p < .01 for both comparisons). Similarly, the ALL AKUSSI rate of change of scores/patient/month, in the VAR group, was significantly lower at one (0.16 ± 0.08) and three (0.19 ± 0.06) years post-nitisinone when compared to pre-nitisinone (0.59 ± 0.13) (p < .01 for both comparisons). Combined ear and ocular ochronosis rate of change of scores/patient/month was significantly lower at one, two and three year's post-nitisinone in both VAR and SAME groups compared with pre-nitisinone (p < .05).

CONCLUSION

This is the first indication that a 2 mg dose of nitisinone slows down the clinical progression of AKU. Combined ocular and ear ochronosis progression was arrested by nitisinone.

Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey

BACKGROUND

Parents take neonates to the emergency department for many reasons, often nonurgent, pressuring an already burdened system. We aimed to characterize these visits and families to identify potential strategies to decrease neonatal emergency department visits.

METHODS

We developed and implemented a survey that explored characteristics of neonates and parents/guardians evaluated in the emergency department, perspectives of parents and use of health care services. Parents presenting with a neonate to the emergency department in 5 large academic hospitals in Ontario were surveyed between December 2013 and June 2015. We used descriptive statistics to report survey data and explored correlations between factors.

RESULTS

A total of 1533 surveys were completed. The most common reasons for presenting were jaundice (441 [28.8%]) and feeding issues (251 [16.4%]). The majority of respondents (73.9% [1104/1494]) had received advice before going to the emergency department. In most cases (86.4% [954/1104]), this was from a health care provider, who frequently advised going to the emergency department. Although most parents (86.8% [1280/1475]) reported high confidence in caring for a sick or injured child, 42.3% (643/1519) were unsure of the severity, and most (90.4% [578/639]) of these parents felt that the infant required assessment immediately or the same day. Of parents who felt the condition was not serious, 83.2% (198/238) thought that same-day evaluation was required. Nearly half of respondents (44.4% [621/1400]) said they would have gone to their health care provider with a same-day appointment, and 28.1% (344/1225) would have gone to their care provider with a next-day appointment.

INTERPRETATION

Parents' reported confidence in caring for sick or injured infants does not match the perceived urgency of neonatal conditions, which likely contributes to emergency department overuse. Any system to decrease nonurgent emergency department use by neonates would need to be immediately responsive, providing same-day help.

Effect of a population-level performance dashboard intervention on maternal-newborn outcomes: an interrupted time series study

OBJECTIVES

To assess the effect of the Maternal Newborn Dashboard on six key clinical performance indicators in the province of Ontario, Canada.

DESIGN

Interrupted time series using population-based data from the provincial birth registry covering a 3-year period before implementation of the Dashboard and 2.5 years after implementation (November 2009 through March 2015).

SETTING

All hospitals in the province of Ontario providing maternal-newborn care (n=94).

INTERVENTION

A hospital-based online audit and feedback programme.

MAIN OUTCOME MEASURES

Rates of the six performance indicators included in the Dashboard.

RESULTS

2.5 years after implementation, the audit and feedback programme was associated with statistically significant absolute decreases in the rates of episiotomy (decrease of 1.5 per 100 women, 95% CI 0.64 to 2.39), induction for postdates in women who were less than 41 weeks at delivery (decrease of 11.7 per 100 women, 95% CI 7.4 to 16.0), repeat caesarean delivery in low-risk women performed before 39 weeks (decrease of 10.4 per 100 women, 95% CI 9.3 to 11.5) and an absolute increase in the rate of appropriately timed group B streptococcus screening (increase of 2.8 per 100, 95% CI 2.2 to 3.5). The audit and feedback programme did not significantly affect the rates of unsatisfactory newborn screening blood samples or formula supplementation at discharge. No statistically significant effects were observed for the two internal control outcomes or the four external control indicators-in fact, two external control indicators (episiotomy and postdates induction) worsened relative to before implementation.

CONCLUSION

An electronic audit and feedback programme implemented in maternal-newborn hospitals was associated with clinically relevant practice improvements at the provincial level in the majority of targeted indicators.

Effects of Targeting Higher or Lower Oxygen Saturations in Centers with More Versus Less Separation between Median Saturations

Subgroup analysis of the Canadian Oxygen Trial to compare outcomes of extremely preterm infants in centers with more versus less separation between median arterial oxygen saturations in the two target ranges_. Centers with more separation observed lower rates of death or disability in the 85%-89% range than in the 91%-95% target range.

A mixed methods evaluation of the maternal-newborn dashboard in Ontario: dashboard attributes, contextual factors, and facilitators and barriers to use: a study protocol

Background

There are wide variations in maternal-newborn care practices and outcomes across Ontario. To help institutions and care providers learn about their own performance, the Better Outcomes Registry & Network (BORN) Ontario has implemented an audit and feedback system, the Maternal-Newborn Dashboard (MND), for all hospitals providing maternal-newborn care. The dashboard provides (1) near real-time feedback, with site-specific and peer comparison data about six key performance indicators; (2) a visual display of evidence-practice gaps related to the indicators; and (3) benchmarks to provide direction for practice change. This study aims to evaluate the effects of the dashboard, dashboard attributes, contextual factors, and facilitation/support needs that influence the use of this audit and feedback system to improve performance. The objectives of this study are to (1) evaluate the effect of implementing the dashboard across Ontario; (2) explore factors that potentially explain differences in the use of the MND among hospitals; (3) measure factors potentially associated with differential effectiveness of the MND; and (4) identify factors that predict differences in hospital performance.

Methods/design

A mixed methods design includes (1) an interrupted time series analysis to evaluate the effect of the intervention on six indicators, (2) key informant interviews with a purposeful sample of directors/managers from up to 20 maternal-newborn care hospitals to explore factors that influence the use of the dashboard, (3) a provincial survey of obstetrical directors/managers from all maternal-newborn hospitals in the province to measure factors that influence the use of the dashboard, and (4) a multivariable generalized linear mixed effects regression analysis of the indicators at each hospital to quantitatively evaluate the change in practice following implementation of the dashboard and to identify factors most predictive of use.

Discussion

Study results will provide essential data to develop knowledge translation strategies for facilitating practice change, which can be further evaluated through a future cluster randomized trial.

Performance Evaluation of New-Generation Pulse Oximeters in the NICU: Observational Study

This crossover observational study compares the data characteristics and performance of new-generation Nellcor OXIMAX and Masimo SET SmartPod pulse oximeter technologies. The study was conducted independent of either original equipment manufacturer (OEM) across eleven preterm infants in a Neonatal Intensive Care Unit (NICU). The SmartPods were integrated with Dräger Infinity Delta monitors. The Delta monitor measured the heart rate (HR) using an independent electrocardiogram sensor, and the two SmartPods collected arterial oxygen saturation (SpO2) and pulse rate (PR). All patient data were non-Gaussian. Nellcor PR showed a higher correlation with the HR as compared to Masimo PR. The statistically significant difference found in their median values (1% for SpO2, 1 bpm for PR) was deemed clinically insignificant. SpO2 alarms generated by both SmartPods were observed and categorized for performance evaluation. Results for sensitivity, positive predictive value, accuracy and false alarm rates were Nellcor (80.3, 50, 44.5, 50%) and Masimo (72.2, 48.2, 40.6, 51.8%) respectively. These metrics were not statistically significantly different between the two pulse oximeters. Despite claims by OEMs, both pulse oximeters exhibited high false alarm rates, with no statistically or clinically significant difference in performance. These findings have a direct impact on alarm fatigue in the NICU. Performance evaluation studies can also impact medical device purchase decisions made by hospital administrators.

Reduction of noise in the neonatal intensive care unit using sound-activated noise meters

OBJECTIVES

To determine if sound-activated noise meters providing direct audit and visual feedback can reduce sound levels in a level 3 neonatal intensive care unit (NICU).

DESIGN/METHODS

Sound levels (in dB) were compared between a 2-month period with noise meters present but without visual signal fluctuation and a subsequent 2 months with the noise meters providing direct audit and visual feedback.

RESULTS

There was a significant increase in the percentage of time the sound level in the NICU was below 50 dB across all patient care areas (9.9%, 8.9% and 7.3%). This improvement was not observed in the desk area where there are no admitted patients. There was no change in the percentage of time the NICU was below 45 or 55 dB.

CONCLUSIONS

Sound-activated noise meters seem effective in reducing sound levels in patient care areas. Conversations may have moved to non-patient care areas preventing a similar change there.

Examining the effects of a targeted noise reduction program in a neonatal intensive care unit

OBJECTIVES

To determine whether implementation of a noise reduction policy followed by the addition of direct audit and feedback reduces noise levels in a tertiary-level neonatal intensive care unit (NICU).

STUDY DESIGN

Noise level data was collected in three phases: (1) baseline (preintervention), (2) immediately postimplementation of our noise reduction policy, (3) postunveiling of direct audit and feedback mechanism.

SETTING

A level 3 NICU in Ontario, Canada.

INTERVENTIONS

Noise reduction policy and a direct audit and feedback mechanism.

MAIN OUTCOME MEASURES

Average noise level.

RESULTS

The baseline level of noise in our unit consistently exceeds guidelines with an average baseline noise of 49 dB (±1.4). Our intervention resulted in a significant reduction in noise levels for one of the four areas in our NICU [-1.06 dB (-1.52, -0.6)], with a trend towards reduction in a second area (-0.21 dB (-0.6, 0.18)). Unexpectedly, two other areas experienced a significant increase in noise (2.05 dB (1.18, 2.94); 0.85 dB (0.11, 1.59)).

CONCLUSIONS

The baseline noise in the NICU consistently exceeds guidelines, but reductions in noise levels are achievable. Nonetheless, more work is needed to find the optimal NICU design and noise reduction strategy.

Ingested soluble CD14 from milk is transferred intact into the blood of newborn rats

BACKGROUND

Milk acts as an edible immune system that is transferred from mother to newborn. Soluble Cluster of Differentiation 14 (sCD14) is a protein found in significant quantities in human milk (~8-29 µg/ml). At a 10-fold lower concentration in the blood (~3 µg/ml), the most notable role of sCD14 is to sequester lipopolysaccharides of Gram-negative bacteria from immune cells.

METHODS

To explore the pharmacodynamics of this milk protein and its biological fate, the biodistribution of radiolabeled sCD14 ((14)C, (125)I) was monitored in 10-d-old rat pups.

RESULTS

Up to 3.4 ± 2.2% of the radiolabeled sCD14 administered was observed, intact, in the pup blood for up to 8 h post-ingestion. Additionally, 30.3 ± 13.0% of the radiolabeled sCD14 administered was observed degraded in the stomach at 8 h post-ingestion. A reservoir of intact, administered sCD14 (3.2 ± 0.3%), however, remained in the stomach at 8 h post-ingestion. Intact sCD14 was observed in the small intestine at 5.5 ± 1.6% of the dose fed at 8 h post-ingestion.

CONCLUSION

The presence of intact sCD14 in the blood and the gastrointestinal tract of newborns post-ingestion has implications in the development of allergies, obesity, and other inflammation-related pathogeneses later in life.

The use of a quality indicator to reduce elective repeat Caesarean section for low-risk women before 39 weeks' gestation: the Eastern Ontario experience

OBJECTIVE

Elective repeat Caesarean section (ERCS) for low-risk women at < 39 weeks' gestation has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission, and lengthier hospital stays than ERCS at 39 to 40 weeks' gestation. The objective of this quality improvement project was to reduce high rates of ERCS < 39 weeks across the Eastern Ontario region.

METHODS

All hospitals within the region providing care during labour and birth (n = 10) were asked to participate. Representatives from each hospital received information about their site-specific rates and knowledge-translation resources to assist them with the project. A benchmark rate for ERCS < 39 weeks was set at 30%. The rates of ERCS < 39 weeks were calculated for two different times (the 2009-2010 and 2010-2011 fiscal years) and the relative difference and 95% confidence intervals were calculated to quantify the magnitude and statistical significance of any change. Qualitative interviews were completed with key informants from each hospital.

RESULTS

The proportion of ERCS at < 39 weeks' gestation across the region in the fiscal year 2010-2011 (n = 197/497; 39.6%) was significantly decreased (relative difference: -21%; 95% CI -31% to -8%, P = 0.002) from the previous fiscal year 2009-2010 (n = 229/459; 49.9%). A number of barriers to, and facilitators of, practice change were identified.

CONCLUSION

A reduction in the rate of ERCS < 39 weeks among low-risk women was achieved across the region. Awareness of the issue, possession of site-specific data, and agreement about the evidence and the need for change are critical first steps to improving practice.

Evidence-based neonatology: making a difference beyond discharge from the neonatal nursery

The number of controlled clinical trials in neonatal medicine has increased steadily over recent years. However, most of these trials examine only short-term outcomes during the initial hospital stay. To determine whether a common neonatal intervention does more good than harm, it is important to study its long-term efficacy and safety. This review summarizes randomized trials of neonatal therapies published between October 2000 and September 2001. Only trials that examine outcomes beyond the initial hospital discharge were considered. Four beneficial interventions were identified: promotion of breast-feeding, comprehensive follow-up care for high-risk, very low birthweight infants, cryotherapy for threshold retinopathy of prematurity, and extracorporeal membrane oxygenation for mature infants with severe respiratory failure. Indomethacin prophylaxis in extremely low birthweight infants is of questionable use. Thyroxine supplementation for premature infants and head cooling for asphyxiated term infants require further study and should not be prescribed outside of rigorous clinical trials.

Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project

OBJECTIVE

To determine the extent to which older or seriously ill inpatients would prefer to have their family and physician make resuscitation decisions for them rather than having their own stated preferences followed if they were unable to decide themselves.

DESIGN

Analysis of existing data from the Hospitalized Elderly Longitudinal Project (HELP) and the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT).

SETTING

Five teaching hospitals in the United States.

PARTICIPANTS

2203 seriously ill adult inpatients (SUPPORT) and 1226 older inpatients (HELP) who expressed preferences about resuscitation and about advance decision-making.

MEASURES

We used a logistic regression model to determine which factors predicted preferences for family and physician decision-making.

RESULTS

Of the 513 HELP patients in this analysis, 363 (70.8%) would prefer to have their family and physician make resuscitation decisions for them whereas 29.2% would prefer to have their own stated preferences followed if they were to lose decision-making capacity. Of the 646 SUPPORT patients, 504 (78.0%) would prefer to have their family and physician decide and 22.0% would prefer to have their advance preferences followed. Independent predictors of preference for family and physician decision-making included not wanting to be resuscitated and having a surrogate decision-maker.

CONCLUSIONS

Most inpatients who are older or have serious illnesses would not want their stated resuscitation preferences followed if they were to lose decision-making capacity. Most patients in both groups would prefer that their family and physician make resuscitation decisions for them. These results underscore the need to understand resuscitation preferences within a broader context of patient values.

Hypothalamic orexin expression: modulation by blood glucose and feeding

Orexins (hypocretins), novel peptides expressed in specific neurons of the lateral hypothalamic area (LHA), stimulate feeding when injected intracerebroventricularly. We investigated their role in feeding in the rat by measuring hypothalamic prepro-orexin mRNA levels under contrasting conditions of increased hunger. Prepro-orexin mRNA levels increased significantly after 48 h of fasting (by 90-170%; P < 0.05) and after acute (6 h) hypoglycemia when food was withheld (by 90%; P < 0.02). By contrast, levels were unchanged during chronic food restriction, streptozotocin-induced diabetes, hypoglycemia when food was available, voluntary overconsumption of palatable food, or glucoprivation induced by systemic 2-deoxy-D-glucose. Orexin expression was not obviously related to changes in body weight, insulin, or leptin, but was stimulated under conditions of low plasma glucose in the absence of food. Orexins may participate in the short-term regulation of energy homeostasis by initiating feeding in response to falls in glucose and terminating it after food ingestion. The LHA is known to contain neurons that are stimulated by falls in circulating glucose but inhibited by feeding-related signals from the viscera; orexin neurons may correspond to this neuronal population.

The development of Ca2+ channel responses and their coupling to exocytosis in cultured cerebellar granule cells

Using single-cell imaging, we investigated developmental changes in the modulation of KCl-evoked Ca2+ entry by various voltage-dependent Ca2+ channels and the coupling of these channels to exocytosis in cultured cerebellar granule neurons. A component of the KCl-evoked Ca2+ elevation sensitive to nifedipine and localized at cell somata, decreases with culture age. A component blocked by 200 nM omega-Agatoxin-IVA increases with age and whilst localized primarily at the cell somata, also becomes evident at the neurites. The change in activity between nifedipine-sensitive Ca2+ channels and omega-Agatoxin-IVA-sensitive Ca2+ channels occurs at 13 days in vitro at cell somata. A component of Ca2+ entry insensitive to nifedipine and 200 nM omega-Agatoxin-IVA is localized primarily at the neurites and is apparent at all ages. Single-cell imaging of exocytosis using FM1-43 destaining indicates that the residual, but not the nifedipine- or omega-Agatoxin-IVA-sensitive components of Ca2+ entry, modulates exocytosis. However cells cultured for 20-26 days develop a component of Ca2+ entry at the neurites which is sensitive to 200 nM omega-Agatoxin-IVA and omega-Conotoxin-MVIIC and which partially controls release. Immunolocalization studies reveal that binding sites for omega-Conotoxin-GVIA are present throughout development, even though this toxin does not inhibit KCl-evoked [Ca2+]c elevations or exocytosis. 300 nM omega-Agatoxin-IVA labels both somata and, at later developmental stages, neurites, consistent with the functional studies.

Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Alleviating the problems faced by dying persons and their families has drawn substantial public attention, but little is known about the experience of dying.

OBJECTIVE

To characterize the experience of dying from the perspective of surrogate decision makers, usually close family members (89%).

DESIGN

Prospective cohort study.

SETTING

Five teaching hospitals.

PATIENTS

Persons who had one of nine serious medical conditions or were 80 years of age or older who died and for whom a surrogate decision maker completed an interview about the death.

MEASUREMENTS

Medical records were reviewed and surrogate decision makers were interviewed.

RESULTS

4124 of 9105 seriously ill patients died (46%); 408 of 1176 elderly patients died (35%). The patients' family members were interviewed after 3357 persons (73%) had died. Of 1541 patients who survived the enrollment hospitalization, 46% died during a later hospitalization. In the last 3 days of life, 55% of patients were conscious. Among these patients, pain, dyspnea, and fatigue were prevalent. Four in 10 patients had severe pain most of the time. Severe fatigue affected almost 8 in 10 patients. More than 1 in 4 patients had moderate dysphoria. Sixty-three percent of patients had difficulty tolerating physical or emotional symptoms. Overall, 11% of patients had a final resuscitation attempt. A ventilator was used in one fourth of patients, and a feeding tube was used in four tenths of patients. Most patients (59%) were reported to prefer a treatment plan that focused on comfort, but care was reported to be contrary to the preferred approach in 10% of cases.

CONCLUSIONS

Most elderly and seriously ill patients died in acute care hospitals. Pain and other symptoms were commonplace and troubling to patients. Family members believed that patients preferred comfort, but life-sustaining treatments were often used. These findings indicate important opportunities to improve the care of dying patients.

Intrarater reliability of manual muscle testing and hand-held dynametric muscle testing

Physical therapists require an accurate, reliable method for measuring muscle strength. They often use manual muscle testing or hand-held dynametric muscle testing (DMT), but few studies document the reliability of MMT or compare the reliability of the two types of testing. We designed this study to determine the intrarater reliability of MMT and DMT. A physical therapist performed manual and dynametric strength tests of the same five muscle groups on 11 patients and then repeated the tests two days later. The correlation coefficients were high and significantly different from zero for four muscle groups tested dynametrically and for two muscle groups tested manually. The test-retest reliability coefficients for two muscle groups tested manually could not be calculated because the values between subjects were identical. We concluded that both MMT and DMT are reliable testing methods, given the conditions described in this study. Both testing methods have specific applications and limitations, which we discuss.