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The article addresses Standards for Levels of Neonatal Care of the American Academy of Pediatrics (AAP). Topics discussed include when the work of the AAP Neonatal Intensive Care Unit (NICU) Verification Program began, consequence of the lack of standardized or state-specific risk-appropriate neonatal care policies, and overview on the AAP 'Standards for Levels of Neonatal Care II, III, and IV'.

BACKGROUND: Discharge readiness is a key determinant of outcomes for families in the NICU. Since 2003, using a broad set of outcome and process measures, we have conducted an ongoing quality improvement initiative to improve the discharge preparation process in our NICU and readiness of families being discharged from the NICU. METHODS: Iterative improvements to the discharge preparation process were made by a multidisciplinary committee. Discharge readiness was measured by using a parental and nurse survey for all families discharged from our NICU. Primary outcome measures included parental self-assessment of discharge readiness and nurse assessment of the family's emotional and technical discharge readiness. Secondary outcome measures included assessment of specific technical skills and emotional factors. Process measures included nursing familiarity with family at discharge. Improvement over time was analyzed by using statistical process control charts. RESULTS: Significant improvement was seen in all primary outcome measures. Family self-assessment of discharge readiness increased from 85.1% to 89.1%; nurse assessment of the family's emotional discharge readiness increased from 81.2% to 90.5%, and technical discharge readiness increased from 81.4% to 87.7%. Several secondary outcome measures revealed significant improvement, whereas most remained stable. Nurse familiarity with the family at discharge increased over time. CONCLUSIONS: Quality improvement methodology can be used to measure and improve discharge readiness of families with an infant in the NICU. This model can provide the necessary framework for a structured approach to systematically evaluating and improving the discharge preparation process in a NICU. [ABSTRACT FROM AUTHOR]

Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns—infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns—infants of 34 or more weeks' gestation—account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them. [ABSTRACT FROM AUTHOR]

Frontline providers of neonatal care have a moral imperative to enhance value and inform senior administrators of how to most efficiently spend healthcare dollars. This article argues that the frontline is the ideal setting to pursue these efforts, offers recommendations for how to measure value, and describes five simple yet effective concrete tools that can improve value. It concludes with tips on advancing a value-added agenda through the Model for Improvement and advice for teams on ways of approaching senior leaders to help align unit-level aims with system-level goals and mission. Armed with these instruments, multidisciplinary teams can help ensure that neonatal care remains at the forefront of high-value healthcare. [ABSTRACT FROM AUTHOR]

Background: Understanding behavioural psychology and the human side of change are guiding principles for quality improvement (QI). Tools to measure these to guide improvement efforts are lacking., Methods: We created a clinical vignette-based survey to measure provider preferences for respiratory care in the neonatal intensive care unit. Fourteen vignettes were included, each vignette offering two reasonable practice choices. Responses were based on a 5-point Likert scale, ranging from neutral to strong preference for either choice. The survey was completed by physicians, nurses, advanced practice providers and respiratory therapists in 2017 and again in 2019. Net preference was measured as the median value of responses, and agreement was measured as the SD of responses. Net preference and agreement were assessed for all responses, by discipline, and by year., Results: Response rates were 51% of all staff in 2017 and 57% in 2019. Vignettes asking about non-invasive respiratory support showed more defined net preferences and higher agreement between years, coinciding with QI efforts and guideline implementation in this area during the interval time. Results on other areas of practice were consistent between years. Discipline comparisons showed nurses and physicians agreed the least often. Six response patterns were identified, ranging from net preference and high agreement to no net preference and low agreement., Conclusion: We propose this survey, called the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool, is a novel method for measurement of hospital unit psychology and culture. Demonstrated improvement where QI efforts were focused and consistency in results in other areas support the validity of this tool. Measuring the human side of change may impact QI efforts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the association of age-appropriate maternal educational attainment in teenage and young mothers on infant health outcomes across racial/ethnic groups., Study Design: In this retrospective, cross-sectional study using Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Natality data (2016-2017), we included live births comparing 14- to 19- year-old mothers with 20- to 24-year-old mothers. To analyze the association of maternal age-appropriate education (≥8th grade for 15-18 years of age, 9th-12th grade/completed high school for 19-24 years of age), we conducted multivariable regression adjusting for mothers' demographics, reporting adjusted incidence rate ratios with 95% CI for infant mortality rate, and logistic regression for extreme prematurity and low birth weight, reporting aORs with 95% CI., Results: From 2016 to 2017, there were 1 976 334 live births among women 14-24 years of age; 407 576 (20.6%) were in 14- to 19-year-olds. In the multivariable model, increased term infant mortality rate was associated with age 14-19 years (adjusted incidence rate ratio 1.18, 95% 1.10, 1.27), age-inappropriate education (adjusted incidence rate ratio 1.38, 95% CI 1.28, 1.48), and non-Hispanic Black mothers (adjusted incidence rate ratio 1.21, 95% CI 1.12, 1.30). Extreme prematurity was associated with women age 14-19 years (aOR 1.35, 95% CI 1.30, 1.40), non-Hispanic Black (aOR 2.50, 95% CI 2.39, 2.61), and Hispanic mothers (aOR 1.09, 95% CI 1.04, 1.15). Term infant low birth weight was associated with age 14-19 years (aOR 1.14, 95% CI 1.12, 1.16), age-inappropriate education for non-Hispanic White (aOR 1.16, 95% CI 1.11, 1.21), and non-Hispanic Black (aOR 1.08, 1.04, 1.12) mothers., Conclusions: Inadequate maternal educational attainment, which is influenced by modifiable social policies, is associated with increased adverse infant outcomes in mothers 14-24 years of age., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns., Methods: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit., Results: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% ( P for trend < .0013), a 34% relative risk reduction., Conclusions: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Work within the US health care system has sought to improve outcomes, decrease costs, and improve the patient experience. Combining those three elements leads to value-added care. Quality improvement within neonatology has focused primarily on the improvement of clinical outcomes without explicit consideration of cost. Future improvement efforts in neonatology should consider opportunities to decrease or eliminate waste, and improve outcomes. Consideration of how a change affects all stakeholders reveals potential cost-saving opportunities, and developing aims with value in mind facilitates understanding and goal-setting with senior administrative leaders., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Rising health care costs challenge governments, payers, and providers in delivering health care services. Tremendous pressures result to deliver better quality care while simultaneously reducing costs. This has led to a wholesale re-examination of current practice methods, including explicit consideration of efficiency and waste. Traditionally, reductions in the costs of care have been considered as independent, and sometimes even antithetical, to the practice of high-quality, intensive medicine. However, it is evident that provision of evidence-based, locally relevant care can result in improved outcomes, lower resource utilization, and opportunities to reallocate resources. This is particularly relevant to the practice of neonatology. In the United States, 12% of the annual birth cohort is affected by preterm birth, and 3% is affected by congenital anomalies. Both of these conditions are associated with costly health care during, and often long after, the NICU admission. We will discuss how 3 drivers of clinical practice in neonatal care (evidence-based medicine, evidence-based economics, and quality improvement) can together optimize clinical and fiscal outcomes., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine., Methods: A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments., Results: A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants., Conclusions: The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care., (Copyright © 2015 by the American Academy of Pediatrics.)

Background and Objectives: Despite recommendations for universal HIV testing during routine prenatal care, maternal HIV status is not always available at the time of delivery, which may lead to missed opportunities for antiretroviral prophylaxis. We completed a quality improvement project focused on increasing the availability of maternal HIV status documentation at our perinatal facility. Our primary aim was to improve documentation rates from 50% to 100% between 2009 and 2013. Our secondary aim was to identify predictors of documentation., Methods: After an initial needs assessment, we performed a multidisciplinary quality improvement effort to address lack of HIV documentation in perinatal charts. The interventions included a switch to a verbal-only consent process, a rapid HIV testing protocol, and a simplified newborn admission document. To assess the impact of our intervention, we audited 100 charts per month and formally analyzed a second random sample of 200 charts in the postimplementation phase., Results: Rates of HIV status documentation improved between 2009 and 2013, from 55.5% to 96.5%. Multivariable models revealed that before our interventions, mothers receiving care at freestanding offices (versus community-based outreach clinics) and those privately insured (versus publicly) were less likely to have HIV status documented. In 2013, neither ambulatory site nor insurance type predicted documentation., Conclusions: We demonstrated improvement in maternal HIV status documentation on admission to labor and delivery after implementation of a 3-pronged intervention. Next steps include investigating persistent barriers to achieving universal screening and documentation., (Copyright © 2015 by the American Academy of Pediatrics.)

The complex multidisciplinary nature of neonatal intensive care combined with the numerous hand-offs occurring in this shift-based environment, requires efficient and clear communication and collaboration among staff to provide optimal care. However, the skills required to function as a team are not typically assessed, discussed, or even taught on a regular basis among neonatal personnel. We developed a multidisciplinary, small group, interactive workshop based on Team STEPPS to provide staff with formal teamwork skills, and to introduce new team-based practices; 129 (95%) of the eligible 136 staff were trained. We then compared the results of the pretraining survey (completed by 114 (84%) of staff) with the post-training survey (completed by 104 (81%) of participants) 2 years later. We found an improvement in the overall teamwork score from 7.37 to 8.08 (p=<0.0001) based on a range of poor (1) to excellent (9). Respondents provided higher ratings in 9 out of 15 team-based categories after the training. Specifically, staff found improvements in communication (p=0.037), placed greater importance on situation awareness (p=<0.00010), and reported that they supported each other more (p=<0.0001). Staff satisfaction was rated higher post-training, with responses showing that staff had greater job fulfilment (p=<0.0001), believed that their abilities were being utilised properly (p=0.003), and felt more respected (p=0.0037). 90% of staff found the new practice of team meetings to help increase awareness of unit acuity, and 77% of staff noted that they had asked for help or offered assistance because of information shared during these meetings. In addition to summarising the results of our training programme, this paper also provides practical tools that may be of use in developing team training programmes in other neonatal units.