The Ethics and Practice of Periviability Care.

Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...

Overdiagnosis of Newborn Hyperbilirubinemia: A Natural Experiment in Quality Improvement Fundamentals.

Unlabelled: Two hospitals noted increased newborn hyperbilirubinemia coinciding with an undisclosed total serum bilirubin (TSB) assay change. Clinicians rapidly applied quality improvement methodologies to ascertain increased jaundice evaluations, readmissions, and possible safety issues.

Methods: In January 2020, 2 hospitals (A and B) transitioned to a new method of measuring TSB using a new clinical chemistry analyzer (Siemens Atellica CH), which measured TSB by vanadate oxidase assay instead of the previous diazo assay.

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm.

Objective: To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm.

Study Design: Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS.

Extremely premature birth bioethical decision-making supported by dialogics and pragmatism.

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason.

The Triple Aim Quality Improvement Gold Standard Illustrated as Extremely Premature Infant Care.

Objectives: The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress.

Change in neurodevelopmental outcomes for extremely premature infants over time: a systematic review and meta-analysis.

Objective: Survival rates of extremely premature infants are rising, but changes in neurodevelopmental impairment (NDI) rates are unclear. Our objective was to perform a systematic review of intrainstitutional variability of NDI over time.

Design: Systematic review and meta-analysis.

Do small baby units improve extremely premature infant outcomes?

Increasing numbers of neonatal intensive care units have formed small baby units or small baby teams with the intention to optimize care of extremely premature infants. Considerable time, energy, and resources are required to develop and sustain complex quality improvement constructs, so legitimate questions about effectiveness, unintended consequences, and lost opportunity costs warrant scrutiny. The small baby unit literature is diminutive.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns.

Aim: Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress.

Methods: We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric).

Aletheia-20 unconcealed observations from quality improvement and evidence-based medicine.

Quality improvement (QI) and evidence-based medicine (EBM) activities ideally generate value (benefit/cost). Physicians and hospitals vary in ability to demonstrate efficiency despite common methodology available to all. Based upon our 60-some years of combined QI and EBM experience, we suggest reasoned consideration of meta-cognition-thinking about thinking.

Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units.

Background: Continuous quality improvement (CQI) collaboration has not eliminated the morbidity variability seen among neonatal intensive care units (NICUs). Factors other than inconstant application of potentially better practices (PBPs) might explain divergent proficiency.

Objective: Measure a composite morbidity score and determine whether cultural, environmental and cognitive factors distinguish high proficiency from lower proficiency NICUs.

Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne.

Most extremely premature infants die in the intensive care unit or suffer significant neurologic impairment. Many therapies result in unhealthy consequences, and the emotional and financial turmoil for families warrant reappraisal of our motives. Shared decision-making and informed consent in preference-sensitive conditions imply the family: (a) understands the medical problem, (b) grasps the risks and benefits of each therapy, (c) has the opportunity to ask questions and reflect upon options, (d) knows their values and preferences are understood, and (e) accepts or declines therapies without judgment or penalty.

A risk-adjusted, composite outcomes score and resource utilization metrics for very low-birth-weight infants.

Importance: It is difficult for neonatal intensive care units (NICUs) to determine the overall efficacy of multiple continuous quality improvement (CQI) projects aimed at reducing very low-birth-weight (VLBW) infant morbidities. It is challenging to know whether a NICU is becoming more proficient, and it is not usually apparent whether concurrent resource use is changing.

Objective: To develop a risk-adjusted composite score of the major morbidities in VLBW infants and a companion metric that accounts for resource use to enhance the ability to measure overall progress in CQI and to identify proficient NICUs.

Delayed umbilical cord clamping in premature neonates.

Objective: Delayed umbilical cord clamping is reported to increase neonatal blood volume. We estimated the clinical outcomes in premature neonates who had delayed umbilical cord clamping compared with a similar group who had early umbilical cord clamping.

Methods: This was a before-after investigation comparing early umbilical cord clamping with delayed umbilical cord clamping (45 seconds) in two groups of singleton neonates, very low birth weight (VLBW) (401-1,500 g) and low birth weight (LBW) (greater than 1,500 g but less than 35 weeks gestation).

NICU practices and outcomes associated with 9 years of quality improvement collaboratives.

Objective: Quality improvement collaboratives (QICs) can improve short-term outcomes, but few have examined their long-term results. This study evaluated the changes in treatment practices and outcomes associated with participation in multiple sequential QICs.

Design And Methods: This retrospective, 9-year, pre-post study of very low birth weight infants, we assessed treatment and outcomes from the 8 NICUs of the Reduce Lung Injury (ReLI) group of a QIC sponsored by the Vermont Oxford Network (VON).

Caring for the pregnant woman presenting at periviable gestation: acknowledging the ambiguity and uncertainty.

Counseling the periviable pregnant woman presenting at the edge of viability can often be confusing for the patient and frustrating for the clinician. Although neonatal survival rates have improved dramatically over the last few decades, severe morbidity is still common. This is further complicated by the fact that the information provided to the parents regarding the outcomes may not be up to date or completely accurate.

Counseling pregnant women who may deliver extremely premature infants: medical care guidelines, family choices, and neonatal outcomes.

Objectives: The justification of neonatal intensive care for extremely premature infants is contentious and of considerable importance. The goal of this report is to describe our experience implementing consensus medical staff guidelines used for counseling pregnant women threatening extremely premature birth between 22 and 26 weeks' postmenstrual age and to give an account of family preferences and the immediate outcome of their infants.

Methods: Retrospective chart review was performed for all women threatening premature birth between 22 and 26 weeks postmenstrual age who presented to our high-risk obstetric service between June 2003 and December 2006.

Attitudes of obstetric and pediatric health care providers toward resuscitation of infants who are born at the margins of viability.

Objectives: The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability.

Methods: A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation.

Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants.

Objectives: The goal of this report is to describe the collaborative formation of rational, practical, medical staff guidelines for the counseling and subsequent care of extremely early-gestation pregnancies and premature infants between 22 and 26 weeks. The purposes of the guidelines were to improve knowledge regarding neonatal outcomes, to provide consistency in periviability counseling, and to promote informed, supportive, responsible choices.

Methods: To formulate the guidelines, a 5-step process was conducted; it began with a series of multidisciplinary meetings among maternal-fetal medicine specialists (MFMs), obstetricians, neonatologists, neonatal nurse practitioners, and nurses from both the labor and delivery unit and the NICU at Providence St Vincent Medical Center (Portland, OR).

Implementing potentially better practices to improve neonatal outcomes after reducing postnatal dexamethasone use in infants born between 501 and 1250 grams.

Objective: The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially better practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD).

Methods: This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs.