Abstracts
Conclusions: NIPPV is capable of CO2 elimination despite substantial reduction in delivered lung pressure but less effective with RAM cannula as compared with FP. CO2 elimination occurs at such small Tv that
these data suggest that NIPPV may depend on non-conventional mechanisms of ventilation.
Figure 2) Number of significant impairments
Figure 1) A and B
4
BIRTH WEIGHT BELOW 500 GRAMS: DEVELOPMENTAL
CONSEQUENCES
*RA Bashir, J Petrie Thomas, M MacKay, J Agnew,
P Hubber-Richard, A Synnes
Neonatology, BC Children's and Women's Hospitals, Vancouver,
British Columbia
Background: Data on survival and morbidities of babies weighing
<500 g at birth is needed for antenatal counseling and decision making
regarding resuscitation.
Objectives: To describe survival of babies <500 g birth weight (BW)
born 1985-2012 and long term outcomes of babies born 1985-2008.
Design/Methods: Institutional survival rates were calculated for all
births and live births for epochs: 1985-87, 1988-92, 1993-97, 1998-2002,
2003-07 and 2008-12. Pregnancy terminations were excluded. All survivors with BW <500 g were invited to the Neonatal Follow-Up Program
(NFUP). Birth characteristics and neurodevelopmental outcomes at
18 months (m) corrected age (CA) and at 4.5 years (yr) were evaluated
and analyzed descriptively. Definitions: Cerebral palsy (CP) – abnormalities of tone and reflexes according to Bax; bilateral visual impairment;
hearing impairment – hearing aid or cochlear implant prescribed. Motor
impairment was defined at 18 m CA as <70 on the Bayley I, II or III; and
at 4.5 yr as <70 on a motor quotient of the Peabody PDMS 1 or 2 and/or
Developmental Coordination Disorder (DCD) as less than or equal to
5%le on Movement ABC I or II. Cognitive impairment was defined at
18 m CA as <70 on the BSID-I or II and adjusted Bayley-III score (Moore
et al, 2012) and at 4.5 yr as <70 on Wechsler testing (WPPSI-R and
WPPSI III).
Results: Survival rates were 2.7% for all births (according to epochs:
0.9%, 0%, 1.2%, 2.0%, 10.5% and 3.6%) and 6.6% for live births (according to epochs: 1.9%, 0%, 3.4%, 4.1%, 24% and 11.1%). Of 25 neonatal
survivors, one died at 9 m CA (BW 492 g) and one refused follow-up. Data
were extracted for 23 children. The earliest survivor was born in 1987
(male, BW 480 g). Babies had a median BW 465 g (range 380 g to 495 g),
and gestation 26 1/7 weeks (range 22 4/7 to 30 2/7 weeks); 21 (84%) were
inborn and 12 (48%) were male; 20% were of multiple pregnancy;
19 babies (76%) were small for gestational age (BW <3rd percentile).
Median Apgar at 5 min was 7 (range 1 to 10).
Conclusions: Chance of impairment free survival is low in babies
<500 g and these survivors face a variety of developmental challenges.
Antenatal counseling should address this outcome.
5
IMPACT OF OPEN LUNG STRATEGY ON THE NEONATAL
OUTCOMES IN PRETERM INFANTS
*V Nair, A Soraisham, W Yee, N Singhal
University of Calgary, Calgary, Alberta
Background: Our aim was to reduce bronchopulmonary dysplasia
(BPD) at Foothills Medical Center (FMC), which had one of the highest
rates among Canadian NICUs. We developed evidence-based practice
guidelines called Open Lung Strategy (OLS), to help maintain functional
residual capacity with distending pressures.
Objectives: To examine the impact of ‘open lung strategy’ on short term
neonatal outcomes among preterm infants with gestational age <33 weeks.
Design/Methods: This is retrospective cohort study. In October
2011, OLS was implemented through multidisciplinary meeting, use of
checklist and quarterly feedback to the neonatal group. We included all
infants with gestational age <33 weeks. The pre-OLS group included
infants admitted between July 2010 and Sept 2011 and the post-OLS group
were those admitted between Oct 2011 to Dec 2012.
Neonatal outcomes between the two groups were analyzed using univariate
and multivariate analysis. The primary outcome was bronchopulmonary
dysplasia (BPD) at 36 weeks postmenstrual age. Secondary outcomes
included intraventricular hemorrhage (IVH), retinopathy of prematurity
(ROP) and necrotizing enterocolitis (NEC).
Results: Of the 792 eligible infants, 396 were admitted in post OLS
study period. No significant differences were observed in the baseline characteristics between the two groups. On univariate analysis, BPD and ROP
≥ stage3 was significantly reduced in post OLS group. However, IVH was
significantly increased in the Post OLS group.
Conclusions: The implementation of a practice change targeting a
respiratory management strategy resulted in reduced rates of BPD. There
was an associated decrease in ROP and increase in IVH the secondary
outcomes. A longer period of study will determine if the improvement in
BPD and ROP is sustained and if the change in IVH is a true increase.
When quality improvement strategies are implemented comprehensive
disease free survival should be studied.
Table 1)
6
PATIENT VOLUME AND NURSING OVERTIME INCREASED
RISK OF NOSOCOMIAL INFECTION IN THE NICU
Table 1) Follow-up data
Paediatr Child Health Vol 19 No 6 June/July 2014
*M Beltempo, G Lacroix, M Cabot, V Beauchesne, B Piedboeuf
Neonatology, CHU de Québec, Quebec, Quebec
Background: Adult studies have shown that outbreaks in nosocomial infections are associated with understaffing and overcrowding.
BACK TO TABLE OF CONTENTS
e37
Abstracts
However, no study has assessed the impact of nurse overtime and patient
volume in the neonatal intensive care unit (NICU) on neonatal nosocomial bacteremia.
Objectives: The objective of this study was to assess the impact of
patient volume and nurse overtime on neonatal nosocomial bacteremia in
all infants hospitalised in the NICU.
Design/Methods: We conducted a retrospective study on all infants
(n=7473) admitted in the CHU de Québec NICU (capacity of 51 beds)
from April 1, 2008 to March 31, 2013. Administrative data (nursing overtime hours per day, patient census per day) were obtained from the database
Logibec, patient information was obtained from Med-Echo and information
on neonatal nosocomial bacteremia was obtained from the local infectious
disease database TDR. We assessed the association between administrative
data and patient outcomes by using logit and probit models.
Results: The average patient volume as percentage of capacity during
the study period was 98.7±6.5%. The average overtime as percentage of
total daily hours of work was 4.0±3.4%. Overtime is positively related to
occupancy levels. For every increase of occupation by one patient, there
was an increase of 1.65 h of overtime per day (P<0.001).
There were a total of 306 events of nosocomial bacteremia during the study
period. Coagulase-negative staphylococcus caused 82% of infections. The
overall risk of nosocomial bacteremia was 4.2%. The total number of regular worked hours was not associated with a higher risk of infection. Higher
overtime (expressed as percentage of total worked hours) was significantly
associated with an increased risk of nosocomial bacteremia (P=0.02). Also,
days when overtime was >8% of total worked hours, are significantly associated with an increase risk of nosocomial bacteremia (OR 1.51 [95% CI
1.10 to 2.08]; P=0.01). There was a trend between higher patient volume
(100% occupancy compared to 90% capacity) and higher risk of nosocomial bacteremia (OR=1.60; P=0.08).
Conclusions: In our study, high patient volume and nursing overtime was directly associated with a higher risk of nosocomial bacteremia in
the NICU. This suggests that re-organising the medical workforce to better
adapt to periods of high activity in the NICU should become an integral
part of nosocomial infection prevention.
7
HEALTH RESOURCE USE FOLLOWING NEONATAL
DISCHARGE OF EXTREMELY PRETERM INFANTS IN
CANADA
S Cross, *T Pillay, T Luu, M McGuire, A Synnes, C de Cabo, K Dow,
A Majnemer, M Ballantyne
Neonatal Follow-up, Victoria General Hospital, Victoria, British
Columbia
Background: Preterm birth conveys an increased risk of medical and
development problems,which may translate into higher health resource
utilization. Resource use has not been described among preterm born
infants in Canada.
Objectives: To describe health resource use including health technology aides, medication and community referrals in infants born prematurely
and examine factors associated with use.
Design/Methods: A total of 818 preterm infants born <29 weeks
gestation between January 1 to December 31, 2010, and seen at a Canadian
Neonatal Follow-Up site at 18 to 22 months’ corrected age (CA) were
studied. Data was collected through chart review and parental interview
using standardized forms. The associations between health resource use
child/family characteristics were assessed by Pearson χ2 analyses or Fisher's
exact test and by ANOVA F-test for continuous variables.
Results: Between NICU discharge home and the 18-month CA visit,
181 infants (22%) utilized various aides in the home: supplemental oxygen
(n=112), pulse oximeter (n=37), CPAP (n=8), tracheostomy (n=7), tube
feeding (n=60), braces (n=42) and walker (n=10). Aid use decreased from
68.8% for infants born ≤23 weeks’ gestational age (GA) to 37.5% at
24 weeks’ GA and 17.5% at 28 weeks’ GA.
More than one-half (56.2%) received regular medication in the three
months preceding the 18-month visit, including 20% on inhalers, 32% on
vitamins, 17.5% on antibiotics, 5% on anti-reflux treatment and 2% on
anti-convulsants.
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BACK TO TABLE OF CONTENTS
Longer time to neonatal discharge was associated with health resource use.
Children with technology dependence were also more likely to be neurologically abnormal at 18 months’ CA (30% vs. 6%; P<0.01) and to have
foster parents (4.6% vs. 1.3%; P=0.01) and slightly more were on social
welfare (12% vs. 8%).
Most infants (78.6%) were referred to an allied health professional (Table 1)
Conclusions: A substantial number of extremely preterm infants require
various health care resources. The association between health technology
dependence and social disadvantage warrants further investigation as this may
indicate that families of medically fragile children need more support.
Table 1)
8
EARLY ORAL FEEDING FOR VERY LOW BIRTHWEIGHT
NEONATES MAINTAINED ON CONTINUOUS POSITIVE
AIRWAY PRESSURE FOR LUNG OPTIMIZATION IS FEASIBLE
*SR Dalgleish, L Kostecky
Neonatology, Foothills Medical Centre, Calgary, Alberta
Background: Low birth weight neonates in the neonatal intensive care
unit (NICU) are commonly managed with early and prolonged continuous
positive airway pressure (CPAP). CPAP therapy is used to maintain functional residual capacity and allow the lungs to grow at optimized inflation.
Historically, CPAP has been considered a contraindication for initiation of
oral feeding. Delayed introduction of oral feeding is associated with
delayed progression of oral feeding skills. Although prolonged CPAP has
lessened the burden of bronchopulmonary dysplasia (BPD), oral feeding
delay has resulted in longer NICU stays and increased the potential for
long term feeding problems.
Objectives: To study the clinical feasibility of initiating early oral
feeding for neonates who are CPAP dependent. Physiological stability and
infant cues guide the nursing assessment for oral readiness. Breastfeeding is
encouraged and preferred method of feeding. Emerging evidence suggests
such a technique encourages the neonate to associate food and eating with
safety and pleasure.
Design/Methods: We report a quality improvement project designed
as an observational study. An original algorithm called “Eating “in SINC”
(Safe Individualized Nipple-feeding Competence) was introduced for all
neonates <32 weeks’ corrected gestational age who have been on CPAP.
The SINC algorithm encourages frequent oral feeding practice opportunities, specifies maximum oral feeding volumes and limits oral feeding times
with a goal of building skill and stamina in fragile feeders. Breastfeeding is
encouraged at every stage of the algorithm. Progression in the SINC algorithm is allowed only if the neonate displays competency over a number of
days. The intervention group eating with the SINC algorithm (collected
over a six month period) is compared to a historical cohort of neonates
from a similar time period during which time the neonates were maintained on prolonged CPAP for lung optimization but did not receive any
oral feeding while on CPAP therapy.
Results: Early project results support our SINC algorithm. Neonates
can be maintained on CPAP to prevent BPD and oral feeding can be safely
initiated at the same time. Overall length of stay has been reduced between
the two comparative groups. Breast feeding rates and oral feeding difficulties following discharge from the NICU are being tracked.
Conclusions: It is possible to maintain prolonged CPAP for lung optimization in very low birth weight neonates and initiate safe early oral feeding.
Paediatr Child Health Vol 19 No 6 June/July 2014