HFNC introduction was significantly associated with a longer duration of mid-level respiratory support, decrease in oral feeding at discharge, increased retinopathy of prematurity rates, and higher use of intermediate care facilities, leading us to examine our noninvasive ventilation and weaning strategies.
Neonates and infants in the neonatal intensive care unit suffer significant morbidity when intravenous (IV) catheters infiltrate. The underreporting of adverse events through hospital voluntary reporting systems, such as ours, can complicate the monitoring of low incidence events, like IV infiltrates. Based on severe cases of IV infiltrates observed in our neonatal intensive care unit, we attempted to improve the detection of all infiltrates and reduce the incidence of Stage 4 infiltrates.We developed, and initiated the use of, an evidence-based guideline for the improved surveillance, prevention, and management of IV infiltrates, with corresponding educational interventions for faculty and staff. We instituted the use of a checklist for compliance with guidelines, and as a mechanism of surveillance.The baseline incidence rate of IV infiltrates, determined by the voluntary reporting system, was 5 per 1000 line days. Following initiation of the guidelines and checklist, the IV infiltrate rate increased to 9 per 1000 line days. In most months, the detection of IV infiltrates was improved by use of the checklist. During the post-intervention period the rate of Stage 4 infiltrates, as measured by usage of nitroglycerin ointment, was significantly reduced.In conclusion, the detection of IV infiltrates was improved following our quality improvement interventions. Further, use of an evidence-based guideline for managing infiltrates may reduce the most severe infiltrate injuries.
In-hospital neonatal falls are increasingly recognized as a postpartum safety risk, with maternal fatigue contributing to these events. Recommendations to support rooming-in may increase success with breastfeeding; however, this practice may also be associated with maternal fatigue. We report a cluster of in-hospital neonatal falls associated with a hospital program to improve breastfeeding, which included rooming-in practices. Metrics related to breastfeeding were prospectively collected by chart audit or patient survey while ongoing efforts to improve breastfeeding occurred (September 2015–August 2017). Falls were identified through the hospital adverse event reporting system from January 2011 to February 2018. Medical records were reviewed to determine factors associated with the falls, including time of event, pain medication administration, hours of life at fall, method of delivery, or other notable factors that may have contributed to the fall event. Three fall events occurred within 1 year of commencing improvement efforts as process and outcome metrics associated with breastfeeding improved. All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am. Falls occurred from 38.0 to 75.7 hours after birth. No sedating pain medications were administered within 4 hours of any event. In 2 of 3 cases, mothers experienced notable ongoing social stressors. Rooming-in was the most significant change involved in our health care delivery during the programmatic effort to improve breastfeeding. Monitoring for in-hospital neonatal falls may be needed during projects aimed at improving breastfeeding, particularly if rooming-in practices are involved.
Introduction: Therapeutic hypothermia (TH) is a time-sensitive, efficacious treatment for newborns who experience perinatal hypoxic–ischemic encephalopathy. Optimal management of patient temperatures during TH may improve newborn outcomes and reduce side effects. We noted that patients undergoing TH were often outside of the target temperature range during treatment. This project sought to improve the timely initiation of effective treatment and temperature stability during TH through system-based changes in practice. Methods: Measures include the time to target temperature, the percentage of core temperatures outside of the target range, and the absolute difference between core and peripheral temperatures over 41 months. System-based changes in the TH protocol included changing from passive to active hypothermia on transport and utilizing a delivery mode that uses more gradual temperature fluctuations during TH. We compared measures of health status and side effects as balancing measures. Results: The TH protocol changes resulted in a significant reduction of time to goal temperature from 1.67 to 0.49 hours, in the percentage of temperature readings outside goal range from 12.6% to 6.3%, and the average absolute difference between core and peripheral temperatures from 1.78°C to 1.47°C. No adverse health outcomes were detected. We observed decreases in vasopressor use with each protocol change. Conclusions: This study demonstrates that detailed attention to the method of delivery of TH has an impact on ensuring effective delivery of therapy and minimizing the risks of treatment. The protocol changes were not associated with an increase in adverse events and were associated with a reduction in vasopressor use.
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