BACKGROUND AND OBJECTIVES: Unplanned extubation can be a significant event that places the patient at risk for adverse events. Our goal was to reduce unplanned extubations to <1 unplanned extubation per 100 patient-intubated days. METHODS: All unplanned extubations in the NICU beginning in October 2009 were audited. Data collected included time of day, patient weight, and patient care activity at the time of the event. Bundles of potentially better practices were implemented in sequential Plan-Do-Study-Act cycles. Rates of unplanned extubation (number per patient-intubated day) for each month were analyzed by using control charts, and causes of unplanned extubation were analyzed by using Pareto charts. RESULTS: We found a significant decrease in the unplanned extubation rate after implementation of the first bundle of potentially better practices in May 2010 (2.38 to 0.41 per 100 patient-intubated days). Several more Plan-Do-Study-Act cycles were conducted to sustain this improvement. A persistent reduction in the unplanned extubation rate (0.58 per 100 patient-intubated days) began in February 2013. Causes included dislodgement during care and procedures and variation in the fixation of the endotracheal tube. The majority of events occurred in very low birth weight infants during the daytime shift. CONCLUSIONS: Unplanned extubations in the NICU can be reduced by education of staff and by implementing standard practices of care. Sustainability of any practice change to improve quality is critically dependent on culture change within the NICU. We suggest that the benchmark for unplanned extubation should be a rate <1 per 100 patient-intubated days.

A standard dose of the beta-adrenoceptor-blocking drug oxprenolol which was sufficient to produce a significant fall in pulse rate and systolic blood pressure had no obvious effect on either overall speech performance or anxiety scores. Analysis of the results was complicated by the effect of timing of the administration of the drugs. Those subjects who took oxprenolol on the first day of each assessment tended to do better than those given placebo, while the reverse occurred on the second day. There was a tendency for performance on the second day to be similar to the first. This tendency has been reported,1' and possibly these behavioural effects were greater than the drug effects being investigated. We recommend that in future studies one group should be given placebo on both days in addition to the standard cross-over groups.Beta-blockade is likely to be most effective in very anxious subjects, but despite efforts to make the test stressful the level of anxiety achieved was not very great. The pretest anxiety scores were much lower than those obtained in a similar study,1'3 in which oxprenolol had a significant effect on performance and the placebo pulse rate was lower-88 compared with 99. We have seen several trained subjects who seemed to benefit from the drug when they were under stress, such as when being interviewed for an important post, and who requested the drug for subsequent occasions. We therefore conclude that the drug may still be of value in very anxious subjects or on stressful occasions, though there is no evidence that additional fluency can be expected when the drug is given routinely. Adult respiratory distress syndrome in Leptospira canicola infection M ZALTZMAN, J M KALLENBACH, G D GOSS, M LEWIS, S ZWI, J H S GEAR Abstract A man was admitted to the Johannesburg Hospital with a history of fever, diarrhoea, and dry cough for four days. He began to produce bloodstained sputum and was found to have severe arterial hypoxaemia. Radiography showed widespread opacification over both lung fields, and the clinical and haemodynamic features were consistent with the adult respiratory distress syndrome. Serology for Leptospira canicola was positive. Despite antibiotics, supportive therapy, and ventilation the patient died. Necropsy excluded cardiac disease.This case shows that leptospirosis may cause the adult respiratory distress syndrome.

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Aim Skin conductance (SC) provides an objective measure of autonomic system regulation through sympathetic-mediated filling of sweat glands. This study aimed to test the utility of SC to detect sympathetic activation in neonatal abstinence syndrome (NAS). Methods 14 term (mean, SE: 38.8 ± 0.35 weeks gestational age) neonates with chronic prenatal opiate exposure were enrolled. SC (peaks/sec and mean of peaks) were measured at baseline, during heel lance/squeeze (HLS) and recovery from HLS at 24-48 (mean 38) hours of life prior to treatment for NAS. Blinded coders with established reliability assessed neonates using the Modified Finnegan Neonatal Scoring System (MFNSS). Non-parametric tests were used to determine group differences, phase differences from baseline to HLS and HLS to recovery, and associations between MFNSS and SC measures. Results Neonates that would later require morphine treatment for NAS (n = 6) had higher baseline SC mean of peaks than those that did not require treatment (n = 8) (P<0.05). Moreover, there were unique phase differences between groups and SC positively correlated with MFNSS (P< 0.05). Conclusion SC provides early identification of NAS severity. However, a larger sample is needed to determine sensitivity and specificity of SC for early identification of NAS and treatment effectiveness.

BACKGROUND AND OBJECTIVES Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children’s hospital. METHODS A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children’s hospital.