The effect of physician sleep deprivation on patient safety in perinatal-neonatal medicine

Recent data indicate that as many as 180,000 patients die each year due to harm suffered as a result of medical care. Between 40 and 60% of these deaths-and the millions of injuries due to medical care-are preventable. In the neonatal intensive care unit (NICU), neonates' size and fragility makes them especially susceptible to serious medical errors, which occur at a far higher rate in this population than elsewhere in hospitals. A growing body of literature demonstrates that the work schedules and sleep deprivation of physicians are important contributors to this epidemic of error. Nowhere is there a higher risk of adverse outcomes due to provider sleep deprivation than in the NICU, where even minor lapses of attention or miscalculations can lead to dire patient outcomes. This review will discuss what is known about how provider sleep deprivation may impact perinatal and neonatal medicine and will discuss ongoing research questions that must be addressed to guide future improvement efforts.     

Risk factors for hospital-acquired infections in the neonatal intensive care unit

Infants in the neonatal intensive care unit (NICU) have many risk factors for infection. Compared with older children and adults, infants, particularly premature infants, are relatively immunocompromised. Patients in the NICU have intrinsic risk factors for infections due to immunological "deficiencies" or inadequate development of mechanical barriers such as skin and gastrointestinal tract mucosa. Like other ICU populations, NICU patients have extrinsic risk factors for infection such as prolonged hospitalization, invasive procedures, instrumentation, medical treatments and concomitant medical conditions. Compared with healthy full-term infants, patients in the NICU develop abnormal flora, which is generally acquired in the NICU from patient-to-patient transmission via hand carriage of healthcare workers. This flora is frequently multidrug-resistant as it has developed under the selective pressure of antibiotics and can cause invasive disease. An understanding of the risk factors that are associated with hospital-acquired infections is essential to design preventive strategies.     

Lighting for caregivers in the neonatal intensive care unit

The primary aim of this article is to define good lighting for caregivers(both medical staff and families) working in the hospital neonatal intensive care unit (NICU) and other areas associated with the critical care environment. Defining good lighting requires understanding that lighting is not only important for the infants in the NICU but that it also plays significant roles for adults in the NICU. First, lighting supports visual processes (eg, acuity, color vision, visual performance). Second, lighting affects circadian regulation (eg, alertness, sleeping, hormone production). Finally,lighting communicates a message to professional staff as well as parents and visitors about the level of care and sophistication provided by the hospital. By thoughtfully addressing all three roles, the lighted environment in the NICU can support the productivity and well-being of the professional staff, the health and safety of patients, as well as the profitability of the NICU. A secondary aim of this chapter is to provide practical guidance to health care professionals on how to articulate good lighting objectives to application engineers and designers responsible for the lighting in the NICU.     

Iatrogenic environmental hazards in the neonatal intensive care unit

Premature infants in the neonatal intensive care unit (NICU) face many illnesses and complications. Another potential source of iatrogenic disease is the NICU environment. Research in this area, however, is limited.     

Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact

Family-centered care (FCC) has been increasingly emphasized as an important and necessary element of neonatal intensive care. FCC is conceptualized as a philosophy with a set of guiding principles, as well as a cohort of programs, services, and practices that many hospitals have embraced. Several factors drive the pressing need for family-centered care and support of families of infants in NICUs, including the increase in the number of infants in NICUs; growth in diversity of the population and their concurrent needs; identification of parental and familial stress and lack of parenting confidence; and gaps in support for families, as identified by parents and NICU staff. We explore the origins of and advances in FCC in the NICU and identify various delivery methods and aspects of FCC and family support in the NICU. We examine the research and available evidence supporting FCC in the NICU and offer recommendations for increased dissemination and for future study.     

Development of neonatal respiratory and intensive care: Chinese perspectives

Recent economic improvements in China have allowed the development of perinatal-neonatal care in sub-provincial regions. However, variations in neonatal respiratory and intensive care exist, especially in regions with limited resources. We conducted a series of collaborative clinical investigations into neonatal hypoxemic respiratory failure (NRF). In the study period from 2004 to 2005, this nationwide study found an incidence of NRF of 13.4% of total admissions to neonatal intensive care units (NICUs), with a mortality of 32%. Fewer than 30% of infants with respiratory distress syndrome (RDS) received surfactant treatment. Most cases of NRF had birth weights (BWs) of 1,000-1,500 g. Approximately 60% of deaths were due to withdrawal of respiratory support because of economic restraints despite initial response to therapy. Extremely low BW or gestational age accounted for less than 2% of all NRF cases, and their survival rate was less than 50%. A prospective clinical epidemiologic study of NRF in 14 NICUs, mainly sub-provincial centers, in Hebei province was undertaken in the study period from 2007 to 2008. NRF made up 16.9% of total NICU admissions, with increased use of surfactant (>50%) and continuous positive airway pressure (>80%) in this study. However, mortality due to RDS, meconium aspiration syndrome and pulmonary infection/sepsis remained higher than 30%, in part affected by socioeconomic factors. With measures to assist hospitalized neonates from low income families in urban areas, as well as the 'new rural cooperative health care program' to subsidize families from rural areas, the quality and affordability of NICU services may be improved in the forthcoming years.     

Professional liability in a neonatal intensive care unit: a review of 20 years' experience.

OBJECTIVE: To examine neonatal intensive care unit (NICU) malpractice claims and identify common characteristics likely to result in malpractice. STUDY DESIGN: A retrospective study (1972 to 1992) at a tertiary care children's hospital examining malpractice claims involving NICU infants. RESULTS: A total of 31 cases of malpractice out of 9367 NICU admissions (incidence 0.33%) were found. Although not statistically significant, the incidence of legal action increased with NICU growth from 0.19% (1972 to 1974) to 0.39% (1980 to 1992). Infants who were significantly over-represented in malpractice cases compared with the general NICU population included those who were full-term, white, privately insured, and those with neurologic conditions. Families' motives for legal action included (1) treatment error/delay (48%), (2) missed/delayed diagnosis (16%), (3) equipment malfunction/misuse (6%), and (4) general improper care (30%). CONCLUSION: Based on this research, three factors may be associated with increased risk of malpractice in the NICU: (1) increased unit growth, (2) parental perceptions of negligence, and (3) full-term infants with diagnoses associated with neurologic conditions.     

Unequal care: Racial/ethnic disparities in neonatal intensive care delivery

Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.     

Ethnic differences in risk factors for neonatal mortality and morbidity in the neonatal intensive care unit.

OBJECTIVE: Although our knowledge about how to care for high-risk neonates who require intensive care is continually improving, disparities in health outcomes among various ethnic groups living in developed countries are becoming more evident. The purpose of this study was to identify the risk factors for neonatal intensive care unit (NICU) mortality among Canadian-born minority infants and, furthermore, to determine whether ethnicity was in itself an independent predictor of mortality or major morbidity in the NICU. STUDY DESIGN: Data were prospectively gathered on 6528 infants admitted to nine regionally located NICUs across Canada. Multiple logistic regressions were used to develop risk-adjusted models for NICU mortality and major morbidity. RESULT: Despite adjusting for differences in small for gestational age (SGA), outborn status and gestational age less than or equal to 28 weeks, South Asian infants still had significantly greater odds of mortality in the NICU. Neonatal sepsis was the strongest predictor of mortality among African infants, even greater than birth at 28 weeks or less. At significantly greater odds of survival with major morbidity were Aboriginal males and East Asian females. CONCLUSION: There are ethnic disparities in the risks of neonatal mortality and morbidity in the NICU. Understanding these differences is important to be able to determine specific areas to target in improving healthcare delivery and reducing disparities in health outcomes among Canada's diverse population.     

Understanding how biologic and social determinants affect disparities in preterm birth and outcomes of preterm infants in the NICU

To understand the disparities in spontaneous preterm birth (sPTB) and/or its outcomes, biologic and social determinants as well as healthcare practice (such as those in neonatal intensive care units) should be considered. Disparities in sPTB have been largely intractable and remain obscure in most cases, despite a myriad of identified risk factors for and causes of sPTB. We still do not know how they lead to the different outcomes at different gestational ages and if they are independent of NICU practices. Here we describe an integrated approach to study the interplay between the genome and exposome, which may drive biochemistry and physiology and lead to health disparities.     

Infant neurobehavioral development

The trend toward single-room neonatal intensive care units (NICUs) is increasing; however scientific evidence is, at this point, mostly anecdotal. This is a critical time to assess the impact of the single-room NICU on improving medical and neurobehavioral outcomes of the preterm infant. We have developed a theoretical model that may be useful in studying how the change from an open-bay NICU to a single-room NICU could affect infant medical and neurobehavioral outcome. The model identifies mediating factors that are likely to accompany the change to a single-room NICU. These mediating factors include family centered care, developmental care, parenting and family factors, staff behavior and attitudes, and medical practices. Medical outcomes that plan to be measured are sepsis, length of stay, gestational age at discharge, weight gain, illness severity, gestational age at enteral feeding, and necrotizing enterocolitis (NEC). Neurobehavioral outcomes include the NICU Network Neurobehavioral Scale (NNNS) scores, sleep state organization and sleep physiology, infant mother feeding interaction scores, and pain scores. Preliminary findings on the sample of 150 patients in the open-bay NICU showed a "baseline" of effects of family centered care, developmental care, parent satisfaction, maternal depression, and parenting stress on the neurobehavioral outcomes of the newborn. The single-room NICU has the potential to improve the neurobehavioral status of the infant at discharge. Neurobehavioral assessment can assist with early detection and therefore preventative intervention to maximize developmental outcome. We also present an epigenetic model of the potential effects of maternal care on improving infant neurobehavioral status.     

Parents' coping in the neonatal intensive care unit: a theoretical framework

The conceptual framework that has been widely used to study the coping strategies of parents of preterm infants in neonatal intensive care units (NICU) has been the transactional model of stress and coping proposed by Lazarus and colleagues. This model supports the cognitive system as the key factor in stress transactions. The cognitive system produces an interpretation of events that leads to making sense of numerous sensations and perceptions from both external and social sources as well as from the internal physiological environment. The individual cognitive system appraises stimuli in two ways: primary appraisal and secondary appraisal. Another factor that may influence the individual's coping effort is gender difference. Mothers and fathers of preterm infants have been found to use different coping strategies to deal with the preterm birth. Other factors such as personality traits and the perceived and actual availability of social support may also influence the parents' coping effort. Implications for clinical practice by the NICU interdisciplinary team are considered.     

Barriers to provision of developmental care in the neonatal intensive care unit: neonatal nursing perceptions

The role of the neonatal nurse is vital for the successful implementation of developmental care and the provision of an optimal neonatal intensive care unit (NICU) environment. The goal was to identify nurses' perceived barriers to implementation or improving developmental care in their NICUs. Nursing perceptions related to barriers for implementing developmental care were assessed using a 12-point questionnaire during two New York City Neonatal Nursing regional conferences. One hundred forty-six (86%) of 170 nurses representing 24 regional hospitals returned the survey. Developmental care was viewed as essential by 136 nurses (93%), yet 125 nurses (86%) believed that their NICU was not providing optimal developmental care. Light and sound standards were viewed as important to providing care by 71% and 91% of respondents, respectively, yet only four NICUs (3%) had light and sound meters to identify or standardize this environmental source of pain. As a group, the perceived barriers to provision of optimal developmental care in order of decreasing importance were staff nurses and staff physicians (53%) > NICU funds (42%) > physician leadership (37%) > facility limitations (31%) > registered nurse leadership (25%). In contrast, 90% of nurses whose NICU did not use developmental multidisciplinary team meetings or developmental care champions or advocates were significantly more likely to identify nursing or physician colleagues as barriers to implementing or improving developmental care, compared with 38% of nurses whose NICU used such activities ( P < 0.001). Developmental care is perceived by the neonatal nurse as a vital component to the care provided in the NICU. Use of simple light and sound measures may enhance perception of providing an optimal NICU environment. Neonatal nurses perceived barriers to care are often attributed to neonatal staff nursing and physician colleagues. This perception is decreased considerably in those NICUs in which multidisciplinary team meetings or champions are used to address the needs of caregivers by providing developmental care strategies.     

α1-Acid glycoprotein for the early diagnosis of neonatal sepsis

Objective.?We aimed to evaluate the diagnostic value of C-reactive protein (CRP) and α1-acid glycoprotein (α1AG) in the early diagnosis of neonatal sepsis.

Design.?The study was prospectively conducted among newborns hospitalized for ‘rule out sepsis’ to neonatal intensive care unit (NICU).

Setting and subjects.?A total of 97 children [16 with confirmed sepsis (Group I), 34 with clinical sepsis (Group II), and 47 in control group (Group III)] were enrolled in the study. On admission to NICU, blood was sampled for CRP, blood culture, and α1AG before starting antibiotherapy. Twenty-four hours later CRP and α1AG levels were detected for second tests in the study group.

Results.?In Group I and II, while the 1st and 2nd tests CRP levels were not different, the 2nd test α1AG levels were significantly higher than the 1st test results (p?<?0.01). Second test CRP and α1AG levels were also statistically higher in Group I than Group II (p?<?0.05).

Conclusion.?It is shown that CRP has limited value in the early diagnosis of neonatal sepsis. A significant increase in α1AG levels was detected in neonatal sepsis but its high specificity was accompanied with low sensitivity. Since the 2nd test α1AG values resulted with high sensitivity, we suggest that serial α1AG tests may be used but a single test for α1AG has limited usefulness in the neonatal sepsis which requires rapid diagnosis.     

Expanding antimicrobial stewardship strategies for the NICU: Management of surgical site infections,perioperative prophylaxis,and culture negative sepsis

Objective: To review antibiotic stewardship strategies for neonatal intensive care units (NICU) in the areas of management of surgical site infections, perioperative prophylaxis and culture negative late onset sepsis. Finding: Review of local microbiology, stratification of surgical procedures by risk of contamination of the surgical site, and adherence to evidence-based principles of perioperative antibiotic administration (targeted therapy, effective dosing, appropriate timing and limiting duration post-operatively) can help to minimize unnecessary antibiotic use for neonatal surgery. Creating a late onset sepsis case definition, appropriate collection and interpretation of blood cultures, and instituting antibiotic time-outs can minimize the overuse of antibiotics for culture negative sepsis. Conclusion: Effective implementation of these antimicrobial stewardship strategies in the NICU can reduce unnecessary antimicrobial use and limit the emergence of resistant pathogens.     

Hematopoietic growth factors in neonatal medicine: the use of enterally administered hematopoietic growth factors in the neonatal intensive care unit

The practice of complete bowel rest in prematurely delivered neonates and those who have undergone surgery for congenital anomalies of the gastrointestinal (GI) tract is common in neonatal intensive care units (NICU). However, increased recognition of the critical role of growth factors in GI development suggests that this practice might be modified to include the administration of synthetic amniotic fluid-like solutions designed to bridge the neonate between their intra-uterine environment and that of the NICU.This article reviews advances in administering synthetic amniotic fluid-like solutions in the NICU.     

Use of furosemide and hearing loss in neonatal intensive care survivors

Hearing loss is a significant morbidity in survivors of the neonatal intensive care unit (NICU). The overall prevalence of hearing loss in neonates is 0.93 per 1000 live births, whereas in neonates weighing less than 2000 g, it is as high as 15.5 per 1000 live births. The increased incidence of hearing loss in NICU graduates has been attributed to their underlying disease process as well as exposure to ototoxic drugs including furosemide. A retrospective chart review of all neonatal intensive care survivors was done to evaluate the potential effect of furosemide on hearing loss. From July 2000 to January 2002, there were 57 neonates who received and 207 neonates who did not receive furosemide. The incidence of abnormal hearing screen was 15.5% in the furosemide group and 15.9% in the nonfurosemide group ( p = 0.9). Although the incidence of hearing loss is significantly higher in NICU graduates in comparison with the general neonatal population, it does not seem to be directly related to the use of furosemide.     

The importance of pro-inflammatory signaling in neonatal necrotizing enterocolitis

Despite modern medical advances, necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality in neonatal intensive care units, affecting 10% of premature neonates born weighing less than 1500 g. Although many advances have been made in the understanding of NEC, the etiology and pathophysiology remain incompletely understood, and treatment is limited to supportive care. In recent years, many studies have evaluated the inflammatory cascade that is central to the disease process, and research is ongoing into strategies to prevent and/or ameliorate neonatal NEC. In this review, we examine the key points in the signaling pathways involved in NEC, and potential strategies for prevention and treatment of this dreaded disease.