Factors associated with iatrogenesis in neonatal intensive care units: an observational multicenter study

The objective of our study was to assess factors associated with iatrogenic events in Neonatal Intensive Care Units (NICUs). This was a retrospective analysis based on a cohort of patients who participated in our previous prospective study (Pediatrics 122:550?C555, 2008), conducted in four tertiary university-affiliated NICUs in Israel, that included all consecutive infants (n?=?615) hospitalized during the study period. Ongoing monitoring of iatrogenic events was performed by designated ??iatrogenesis advocates.?? The main outcome measures were the association of individual infant characteristics and NICUs?? environmental characteristics with iatrogenic events assessed by univariate and multiple logistic regression analysis. We found that four infant characteristics were significantly (p?<?0.001) associated with iatrogenic events in a univariate analysis: gestational age, birth weight, severity of initial illness as assessed by the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE II), and length of stay (LOS). All four factors demonstrated a significant (p?<?0.001) dose?Cresponse relationship with iatrogenic events. Univariate analysis for environmental characteristics showed that type of shift, but not nursing workload, was significantly associated with iatrogenic events (p?<?0.001). In a multiple logistic regression analysis, only LOS (adjusted OR 1.02 [95?% CI, 1.01?C1.03]) and type of shift, morning vs. evening (adjusted OR 3.44 [95?% CI, 2.33?C5.08]) and morning vs. night (adjusted OR 6.07 [95?% CI, 3.86?C9.56]), remained independently associated with iatrogenic events (p?<?0.001). Prolonged LOS and morning shifts were found to be significantly associated with iatrogenic events. Further prospective research is warranted to identify the specific causes for iatrogenic events in order to target active interventions to prevent them.     

新生儿重症监护室的手消毒顺应性观察

随着各种生命支持技术的进步和广泛应用,危重新生儿,尤其是早产儿的存活率大大提高.与之相应地长的住院时间和侵人性操作的大量使用,造成了新生儿重症监护室(NICU)内感染率的上升.在控制NICU感染的措施中,手卫生管理是一个重要环节.     

Risk factors associated with pneumothorax in Malaysian neonatal intensive care units

Aims: This study aimed to determine the risk factors associated with the development of pneumothorax among infants admitted to the Malaysian neonatal intensive care units (NICUs). Methods: Twenty‐nine of forty NICUs in Malaysian public hospitals participated in the 2006 Malaysian National Neonatal Registry (MNNR). Data of infants from this registry with and without pneumothorax were analysed. A diagnosis of pneumothorax was made in the presence of extra‐pleural air detected by chest radiograph or needle aspiration. Results: There were 10 387 infants admitted to these NICUs who met the MNNR inclusion criteria and were included in this study. Pneumothorax developed in 505 (4.9%) of them. Pneumothorax was most common (7.3%) among the extremely low birthweight infants (birthweight equal or less than 1000 g) and the extremely preterm infants of gestation equal or less than 26 weeks (6.8%). Logistic regression analysis showed that the significant risk factors associated with increased risk of development of pneumothorax were: meconium aspiration syndrome (adjusted odds ratio (OR) = 2.1, 95% confidence intervals (CI): 1.7, 2.7), intermittent mandatory ventilation (adjusted OR = 1.5, 95% CI: 1.2, 2.0), high‐frequency oscillatory ventilation (adjusted OR = 3.9, 95% CI: 3.0, 5.2) and confirmed sepsis (adjusted OR = 1.6, 95% CI: 1.3, 2.1). Infants on nasal continuous positive airway pressure (nCPAP) therapy were associated with significantly lower risk of pneumothorax (adjusted OR = 0.5, 95% CI: 0.4, 0.6). Conclusion: Meconium aspiration syndrome, mechanical ventilation and sepsis were associated with increased risk and the use of nCPAP with decreased risk of pneumothorax in Malaysian NICUs.     

A national survey of the enteral feeding practices in Canadian neonatal intensive care units

AimNutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs).MethodThe research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices.ResultsFive of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively.ConclusionThis study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.     

Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units.

OBJECTIVE: Bloodstream infections caused by Gram-negative bacilli are a substantial cause of morbidity and mortality in infants in neonatal intensive care units. This study describes the species of Gram-negative bacilli causing bloodstream infections in two neonatal intensive care units, compares characteristics of catheter-related and non-catheter-related bloodstream infections, and compares species and antibiotic resistance patterns of these organisms with those isolated from the hands of nurses working in the same neonatal intensive care units. DESIGN: Interventional study. SETTING: Two high-risk neonatal intensive care units. PATIENTS: Neonates hospitalized for >or =24 hrs. INTERVENTIONS: Prospective surveillance for bloodstream infections was performed in two neonatal intensive care units from March 2001 to January 2003. Hand cultures were obtained quarterly from participating nurses immediately after they performed hand hygiene. MEASUREMENTS AND MAIN RESULTS: There were 298 episodes of bloodstream infections among 2,935 admissions (5.75 episodes per 1,000 patient-days); 77 of 298 (26%) episodes were caused by Gram-negative bacilli. Among these, 47 (61.0%) were catheter-related bloodstream infections (2.61 episodes per 1,000 catheter-days). Eleven and 24 Gram-negative bacilli species were isolated from neonates and nurses, respectively. The most common Gram-negative bacilli causing bloodstream infections were Klebsiella pneumoniae (38.7%), Escherichia coli (21.2%), Enterobacter cloacae (11.2%), and Serratia marcescens (11.2%). In contrast, Acinetobacter lwoffi (18.1%), K. pneumoniae (11.7%), E. cloacae (10.6%), K. oxytoca (10.6%), and Pseudomonas spp. (7.4%) were most commonly isolated from hands of nurses. E. coli, P. aeruginosa, E. cloacae, and E. aerogenes were significantly more likely to cause bloodstream infections than to be isolated from nurses' hands (all p < .001). Although 39% of bloodstream infections were non-catheter-related, there were no significant differences in types of organisms or antimicrobial resistance patterns between catheter-related bloodstream infections and non-catheter-related bloodstream infections (all p > or = .35). Resistance patterns were similar between Gram-negative bacilli isolates from neonates and nurses' hands except for a significantly higher proportion of resistance to cefotaxime and gentamicin among neonatal isolates of K. pneumoniae (p < .05). CONCLUSIONS: Gram-negative bacilli species isolated from neonatal bloodstream infections and nurses' hands varied significantly. Clean hands of providers are an unlikely source of endemic Gram-negative bacilli, suggesting that prevention strategies should focus more on control of endogenous neonatal flora or environmental sources.     

Management of outbreaks in neonatal intensive care units

Outbreaks in neonatal intensive care units (NICUs) have disastrous consequences for neonates and raise enormous concerns in staff, altering usual practice patterns of the NICU. Our objective was to perform a systematic analysis for gaining insights into the control and prevention of NICUs outbreaks. Epidemiology, risk factors and outcomes are reviewed.     

Transcutaneous bilirubinometry in neonatal intensive care units.

AIMS: To study the influence of several clinical and paraclinical factors on the association between jaundice meter readings and plasma bilirubin concentration; and to comment on the usefulness of the jaundice meter as a screening device for hyperbilirubinaemia in neonatal intensive care units. METHODS: Three hundred and seventy seven newborn babies admitted to the neonatal intensive care unit for various causes were included in the study. When the plasma bilirubin concentration needed to be determined for clinical reasons, the extent of the yellow skin colour was measured transcutaneously, using a jaundice meter. The haemoglobin concentration was also determined. This had no independent influence on the jaundice meter readings. The yellow skin colour was significantly and positively correlated with the bilirubin concentration and the presence of respiratory distress syndrome (RDS), and negatively with gestational age and postnatal ages. CONCLUSIONS: These findings were interpreted as being due to variations in the ability of albumin to bind bilirubin, and in the basal yellow skin colour. It was impossible to derive simple criteria for detection of hyperbilirubinemia by jaundice meter readings in this study group.     

Surveillance of infection in neonatal intensive care units

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.     

Pain management in French neonatal intensive care units

The aim of this study was to investigate pain management in neonatal intensive care units (NICUs) in France and to identify factors associated with variability across units. A questionnaire sent to 143 heads of level II or III NICUs investigated the use of pain scores, pain management organization and pharmacological treatment in five clinical situations (endotracheal intubation, prolonged mechanical ventilation, acute stage of necrotizing enterocolitis, central venous catheter insertion and cephalhaematoma). The response rate was 81%. Among the 35 (30%) units that used no pain scores, 40% ascribed this to lack of knowledge. Factors associated with failure to use pain scores were level II status, no university affiliation, no surgical patients and neonatal patients only. Among the units that scored pain, 78% used valid scores for acute pain and 73% for prolonged pain. Written guidelines were available for acute pain in 65% of units and for prolonged pain in 36%. The rate of pharmacotherapy use varied widely across the five clinical situations studied (from 16 to 77%) and across units for a given clinical situation. Also extremely variable were the regimens used in each situation and the dosages of analgesics and sedatives. Only 11% of units adjusted dosages to gestational age. CONCLUSION: Pain assessment was performed in the most French NICUs, but a strong heterogeneity for pain treatment was observed. Reference to recently published pain management guidelines and new randomized trials could be useful to optimize pain treatment in NICUs.     

新生儿重症监护病房早产儿袋鼠式照护的评估与实施

<正>袋鼠式护理(KC)最早始于哥伦比亚首都波哥大,当时早产儿的死亡率高达70%[1],缺乏暖箱是其原因之一。同一台暖箱里面放2名甚至更多的婴儿,增加了感染率;同时,母婴分离状态也使得很多早产儿被放弃治疗。研究者发现将婴儿放到母亲裸露的皮肤上进行大面积的皮肤接触,不仅可以提高早产儿的生存率,还可以促进其生长发育[2],20世纪80～90年代该研究结果得以广泛传播,很多NICU纷纷开展了KC。KC在中国NICU也已陆续开展,尽管医护人员知道KC有很多益处,但是很多NICU的医护人员并没有积极地开展,与缺乏医疗机构领导层的支持、护士临床工作负荷     

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

AIM: Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. METHODS: A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. RESULTS: Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. CONCLUSION: Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.     

Ultrathin flexible bronchoscopy in neonatal intensive care units.

Thirty seven flexible bronchoscopies were performed in 33 infants in a neonatal intensive care unit, using a 2.2 mm flexible ultrathin bronchoscope. Twenty eight procedures were performed via an endotracheal tube or tracheostomy and nine in spontaneously breathing infants. Indications for endoscopy included persistent atelectasis and/or emphysema (n = 21), unexplained acute respiratory distress (n = 10), stridor (n = 3), assessment of congenital abnormalities of the tracheobronchial tree (n = 2), and follow up of an endobronchial granuloma during the course of corticosteroid treatment (n = 1). Abnormal airway dynamics and/or abnormal structure were seen in 23 of 37 cases. In 54% of the procedures, the results of bronchoscopy had a direct effect on further management. The procedure was well tolerated and completed in less than two minutes. Our results suggest that the ultrathin flexible bronchoscope improves airway exploration and the understanding of respiratory disorders during the first months of life, particularly in ventilated infants.