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Objective: The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity., Study Design: We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network., Results: Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios., Conclusions: A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location., (Copyright © 2022. Published by Elsevier Inc.)

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., Competing Interests: Declarations of Competing Interest Drs. Braun, Edwards, Profit, Pursley, Schulman: none. Dr. Goodman reports funding for this project from the Kettering Family Foundation., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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.)

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., 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.)

: media-1vid110.1542/5839992664001PEDS-VA&#95;2017-4322 Video Abstract BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs), while the Choosing Wisely for Newborn Medicine Top 5 list identified antibiotic therapy as an area of overuse. We identify the baseline prevalence and makeup of newborn-specific ASPs and assess the variability of NICU antibiotic use rates (AURs)., Methods: Data were collected using a cross-sectional audit of Vermont Oxford Network members in February 2016. Unit measures were derived from the 7 domains of the CDC's Core Elements of Hospital ASPs, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Patient-level measures included patient demographics, indications, and reasons for therapy. An AUR, defined as the number of infants who are on antibiotic therapy divided by the census that day, was calculated for each unit., Results: Overall, 143 centers completed structured self-assessments. No center addressed all 7 core elements. Of the 7, only accountability (55%) and drug expertise (62%) had compliance >50%. Centers audited 4127 infants for current antibiotic exposure. There were 725 infants who received antibiotics, for a hospital median AUR of 17% (interquartile range 10%-26%). Of the 412 patients on >48 hours of antibiotics, only 26% (107 out of 412) had positive culture results., Conclusions: Significant gaps exist between CDC recommendations to improve antibiotic use and antibiotic practices during the newborn period. There is wide variation in point prevalence AURs. Three-quarters of infants who received antibiotics for >48 hours did not have infections proven by using cultures., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Objectives: Early term infants (37-<39 weeks' gestation) are at higher risk of adverse outcomes than term infants (39-<41 weeks' gestation). We hypothesized that a policy to eliminate elective, early term deliveries would result in fewer NICU admissions and shorter lengths of stay among infants born ≥37 weeks., Methods: This was a retrospective cohort study of singleton infants born ≥37 weeks at a tertiary medical center from 2004 to 2015 (preperiod: 2004-2008; postperiod: 2010-2015; washout period: 2009). We compared the incidence of early term delivery, NICU admissions (short: ≥4-<24 hours, long: ≥24 hours), NICU diagnoses, and stillbirths in both periods. We used modified Poisson regression to calculate adjusted risk ratios., Results: There were 20 708 and 24 897 singleton infants born ≥37 weeks in the pre- and postperiod, respectively. The proportion of early term infants decreased from 32.5% to 25.7% ( P < .0001). NICU admissions decreased nonsignificantly (9.2% to 8.8%; P = .22), with a significant reduction in short NICU stays (5.4% to 4.6%; adjusted risk ratio: 0.85 [95% confidence interval: 0.79-0.93]). Long NICU stays increased slightly (3.8% to 4.2%), a result that was nullified by adjusting for neonatal hypoglycemia. A nonsignificant increase in the incidence of stillbirths ≥37 to <40 weeks was present in the postperiod (7.5 to 10 per 10 000 births; P = .46)., Conclusions: Reducing early term deliveries was associated with fewer short NICU stays, suggesting that efforts to discourage early term deliveries in uncomplicated pregnancies may minimize mother-infant separation in the newborn period., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

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.)

Objective: To investigate specific post-neonatal intensive care unit (NICU) discharge outcomes and issues for families., Study Design: The authors prospectively surveyed family's discharge preparedness at the infant's NICU discharge. In the weeks after the infant was discharged, families were interviewed by telephone for self-reported utilization of health services as well as any infant-associated problems or issues., Results: At discharge, 35 of 287 (12%) families were "unprepared" as defined by a Likert response of less than 7 by either the family member or nursing assessment. Unprepared families were more likely to report that their pediatrician could not access the infant's NICU hospital discharge summary, problems with the infant's milk/formula, and an inability to obtain needed feeding supplies., Conclusions: Although most of the families are "prepared" for discharge at the time of discharge, this study highlights several issues that primary care providers accepting care and NICU staff discharging infants/families should be aware.

The purpose of this study was to describe infection control practices for influenza in mother and newborn units in United States hospitals in the context of the 2009 H1N1 pandemic. We conducted surveys of neonatal intensive care unit directors in February and November 2010 and requested information on infection control practices during the 2009 and 2010 influenza seasons. We received 111 responses to the initial survey and 48 to the follow-up survey. In 2009, 58% of respondents restricted breastfeeding by mothers with influenza-like illness; 42% did not. Ninety percent of the respondents maintained physical separation between an ill mother and her newborn infant, although the approaches to this separation varied. Eighty percent of postpartum units and 89% of neonatal intensive care units restricted access by children. In 2010, fewer hospitals restricted mother-infant contact and children visitation compared with 2009. Infection control practices for influenza in mother and newborn units vary considerably in US hospitals, particularly regarding contact between an ill mother and her newborn infant. The identification of this variation may inform best practices in this area, as well as future investigations and future guideline development., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: The goal was to examine nursing team structure and its relationship with family satisfaction., Methods: We used electronic health records to create patient-based, 1-mode networks of nursing handoffs. In these networks, nurses were represented as nodes and handoffs as edges. For each patient, we calculated network statistics including team size and diameter, network centrality index, proportion of newcomers to care teams according to day of hospitalization, and a novel measure of the average number of shifts between repeat caregivers, which was meant to quantify nursing continuity. We assessed parental satisfaction by using a standardized survey., Results: Team size increased with increasing length of stay. At 2 weeks of age, 50% of shifts were staffed by a newcomer nurse who had not previously cared for the index patient. The patterns of newcomers to teams did not differ according to birth weight. When the population was dichotomized according to median mean repeat caregiver interval value, increased reports of problems with nursing care were seen with less-consistent staffing by familiar nurses. This relationship persisted after controlling for factors including birth weight, length of stay, and team size., Conclusions: Family perceptions of nursing care quality are more strongly associated with team structure and the sequence of nursing participation than with team size. Objective measures of health care team structure and function can be examined by applying network analytic techniques to information contained in electronic health records.