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PubMed2005

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

Artificial Intelligence↗
PubMed1996

Models for determining cost of care and length of stay in neonatal intensive care units.

New models for determining the cost of care and length of stay in the neonatal intensive care unit (NICU) were developed using financial and clinical data from 588 admissions to our NICU. The model for determining costs explained 71% of the variability in total hospital costs. Models such as the ones developed in this study can be used to compare costs in different institutions, determine temporal trends in costs, and examine the financial impact of using new technologies. Such models can also be useful components of a rational prospective pricing system for the NICU.

Chicago↗
PubMed1979

Intensive care for sick neonates, the earlier the better: improved survival rate of IRDS children, referred by means of a mobile neonatal intensive care unit.

A mobile intensive care unit has been used since september 1976 in the region referring sick neonates to the two University Hospital NICU's of Amsterdam. The present study compares two groups of neonates (suffering from the I.R.D.S.) i.e. a group that had been referred by non specialized transport teams (N S T-group) and a group admitted after institution of the neonatal-transport service (S. T.-group). Significant difference is found in the temperature on admission (S T group greater than N S T group). In the N S T-and the S T-group the need for ventilatory assistance was not significantly different but in the S T-group it was started significantly earlier. Survival after institution of ventilatory assistance and overall-survival are significantly better in the S T-group. These conclusions point to the fact that administering intensive care to sick neonates as early as possible and transportation of this group by means of special "neonatal"-transport services increases their survival rates.

Humans↗
PubMedDate not supplied

Education and training of occupational therapists for neonatal intensive care units.

OBJECTIVE: The neonatal intensive care unit (NICU) is an area in which occupational therapists require specialized advanced training and skills. The purpose of this study was to evaluate the nature of current practice among occupational therapists in NICU settings, their training, and their opinions regarding educational experiences necessary for NICU work. METHOD: One hundred seventy-four NICU occupational therapists completed a survey questionnaire designed to elicit information about these issues. RESULTS: The majority of respondents were engaged in similar practice duties in NICUs, most of which had been using therapy services for less than 10 years. Most of the respondents (83%) reported that their primary source of training was on the job rather than through formal course work or training programs. Many of the respondents (40%) lacked training in the use of any infant assessments, and 50% had 2 years or less of pediatric work experience before entering practice in the NICU. The respondents indicated that mentored experience, on-the-job training, pediatric work experience, extended continuing education courses, and formal internships could prove helpful to future occupational therapists who wish to acquire the knowledge and skills to become competent in the NICU. CONCLUSION: Results of the survey indicate that current training and education to work in an NICU is inadequate and needs to be addressed. Occupational therapists working in NICUs desire and express the need for specialized training to work in this practice area. A more aggressive effort toward standard NICU education and training is necessary to ensure that occupational therapists are competent members of the NICU team.

Adult↗
PubMed1997

Adolescent mothers' perceptions of the neonatal intensive care unit environment.

The neonatal intensive care unit (NICU) environment has been found to be a major source of distress for older parents, but what about adolescent mothers? A prospective, descriptive study was conducted to describe adolescent mothers' perceptions of the stressors found in the NICU environment. Data were collected using the NICU Parental Stress Scale and a demographic data form. These 46 mothers found that the most stressful aspects of the NICU were parental role alterations and the infant's appearance and behavior. Less stressful were the sights and sounds of the NICU and communication with staff. Nurses should continue to identify and alleviate stressors that can compromise the parenting experience of mothers of all age groups.

Adolescent↗
PubMed1987

Care of very low birthweight infants with limited neonatal intensive care resources.

The advanced technology that is available to treat the tiniest infants has raised the legal and moral dilemma of where and how to distribute limited intensive care resources. In one neonatal intensive care unit it was determined that approximately 80% of its resources over a two-year period were utilized by very low birthweight infants, in spite of the fact that these infants comprised less than 50% of the total admissions to the unit. It was not possible to offer all very low birthweight infants full intensive care; to make this possible, it was calculated that resources would have to increase by 26%. In the present economic climate, and with limited numbers of nurses who are skilled in neonatal intensive care, the prospects for extra resources are poor. What action can or should be taken, legally and morally, when no facilities exist to treat a live-born infant who may possibly benefit from intensive care?

Australia↗
PubMed1995

Evaluation of neonatal intensive care technologies.

The development and dissemination of neonatal intensive care technology has been associated with improved survival for critically ill newborn infants, particularly those with birth weights of less than 1,500 grams (3 pounds, 5 ounces). Despite these advances, there are concerns about the long-term health status of surviving infants and the costs of their initial and subsequent care. In this article, the authors review current evidence for the effectiveness of neonatal intensive care and discuss several approaches to evaluating neonatal intensive care technology. They discuss a four-step process originally proposed by Roper for assessing and improving neonatal intensive care practices which includes (1) monitoring of practices, outcomes, and costs; (2) analysis of variation in practices, outcomes, and costs; (3) assessment of the efficacy of individual interventions, and (4) feedback and education to alter clinical behavior. The authors conclude that organized networks of neonatal intensive care units can play a crucial role in this process.

Birth Weight↗
PubMed2002

Handheld, portable ultrasound in the neonatal intensive care nursery: a new, inexpensive tool for the rapid diagnosis of common neonatal problems.

The use of ultrasound imaging in the neonatal intensive care unit (NICU) has become an essential part of the evaluation and delivery of care for most neonates. Until recently, ultrasound machines were large, expensive, and often not immediately available, particularly at night and during weekends. Additionally, serial studies to define the evolution of an acute clinical situation were often not practical because of the dedicated time required and the expense involved. The recent introduction into our NICU of a high-quality, reasonably priced, and completely portable neonatal ultrasound unit (Sonosite, Bothell, WA) has now made it possible for neonatologists to rapidly obtain the hour-by-hour information that can be extremely helpful in the evaluation of a critically ill neonate. This paper illustrates some of the capabilities of this simplified device, and the value of having continuous on-site ultrasound availability in the NICU.

Cost-Benefit Analysis↗
PubMed1998

Annual league tables of mortality in neonatal intensive care units: longitudinal study. International Neonatal Network and the Scottish Neonatal Consultants and Nurses Collaborative Study Group.

OBJECTIVE: To assess whether crude league tables of mortality and league tables of risk adjusted mortality accurately reflect the performance of hospitals. DESIGN: Longitudinal study of mortality occurring in hospital. SETTING: 9 neonatal intensive care units in the United Kingdom. SUBJECTS: 2671 very low birth weight or preterm infants admitted to neonatal intensive care units between 1988 and 1994. MAIN OUTCOME MEASURES: Crude hospital mortality and hospital mortality adjusted using the clinical risk index for babies (CRIB) score. RESULTS: Hospitals had wide and overlapping confidence intervals when ranked by mortality in annual league tables; this made it impossible to discriminate between hospitals reliably. In most years there was no significant difference between hospitals, only random variation. The apparent performance of individual hospitals fluctuated substantially from year to year. CONCLUSIONS: Annual league tables are not reliable indicators of performance or best practice; they do not reflect consistent differences between hospitals. Any action prompted by the annual league tables would have been equally likely to have been beneficial, detrimental, or irrelevant. Mortality should be compared between groups of hospitals using specific criteria-such as differences in the volume of patients, staffing policy, training of staff, or aspects of clinical practice-after adjusting for risk. This will produce more reliable estimates with narrower confidence intervals, and more reliable and rapid conclusions.

Cohort Studies↗
PubMed2006

Changing patterns of drug utilization in a neonatal intensive care population.

Newborns in the neonatal intensive care unit (NICU) typically are exposed to a large number of drugs and are especially vulnerable to adverse drug reactions. It is important to review changes in drug use patterns periodically in the NICU to identify newly introduced drugs as well as drugs with increasing use. The objective of this study was to determine the changes in drug utilization patterns over a 7-year period in an NICU population. Drug utilization of 2332 neonates treated at an intramural NICU between January 1, 1997 and December 31, 1998, and 2691 neonates between January 1, 2001 and June 30, 2004 was analyzed using chi-square tests, T tests, and linear regression. There was an increased utilization of antibiotics, central nervous system drugs, endocrine agents, cardiovascular and gastrointestinal drugs, and a decreased utilization of ophthalmic drugs. No changes in nutritional, biological, renal, and pulmonary drugs were observed. Some individual drug changes include an increased use of vancomycin, cefepime, caffeine, and a decreased use of morphine. Significant changes in drug utilization patterns in an NICU were observed during a 7-year period. These data are useful in monitoring drug resistance patterns, adverse drug reactions, and prioritizing areas of relevant therapeutic research and educational programs.

Drug Utilization↗
PubMedDate not supplied

[Nosocomial infection and its impact on the stay in a neonatal intensive care unit (1988-1991)].

BACKGROUND: Neonatal intensive care units show one of the highest frequencies of nosocomial infections (NI), specially in teaching hospitals. METHODS: The cumulative incidence and distribution of NI in a neonatal intensive care unit of a teaching hospital during three years and three months (536 children) is studied, evaluating the relation between NI and its risk factors with X2 and variance analysis and, finally, estimating the excess stays with a multiple linear regression. RESULTS: The global cumulative incidence of NI was 11% (or an incidence density of 30.7 per 100 children/month); the prevailing etiological agents were negative coagulase Staphylococcus and fungi of Candida Sp. When analyzing, according to the kind of infection, sepsis associated to catheter, stands out. The relation between the different intrinsic or extrinsic risk factors and the NI was studied as well, and it stood out that infected children suffer manipulations as: Central catheter, assisted respiration, parenteral feeding et cetera, with a greater frequency (twice as much) that of non infected children. CONCLUSIONS: The cumulative incidence of NI is moderate-low; but is is necessary to continue insisting and increasing the current control measures and on the other hand, is is necessary to calculate the excess stays, due to NI, with multivariate methods because the direct estimation produces an overestimation of that one.

Analysis of Variance↗
PubMed1997

Point-of-care glucose testing in the neonatal intensive care unit is facilitated by the use of the Ames Glucometer Elite electrochemical glucose meter.

OBJECTIVE: To evaluate the Ames Glucometer Elite glucose meter for use in point-of-care glucose testing in the neonatal intensive care unit. METHODS: An important part of our quality control program involves a weekly comparison of glucose values obtained with each of the seven Elite analyzers and the Beckman CX7 analyzer located in the central laboratory. Each "split" sample involves measurement of the glucose by using the Elite analyzer in a sample of blood obtained from a heel stick at the bedside, followed by bleeding ("milking") 150 to 200 microl (4 to 5 drops) of blood into a heparinized microcontainer. This process should take no longer than 1 to 2 minutes, whereupon the microcontainer is placed on ice and sent to the laboratory. The values obtained were compared by regression analysis. Imprecision of the Elite meter was estimated at four levels of blood glucose concentration and on a normal-level quality control sample used for a period of 4 months. RESULTS: Regression analysis between the glucose values obtained on the Elite meter and the CX7 meter revealed r = 0.93, p less than 0.0001, n = 188, Sy/x = 0.59 mmol/L, intercept = 0.47 +/- 0.14 mmol/L (1 SEM), and slope = 0.91 +/- 0.028 (1 SEM). When we switched to on-ice delivery of split samples to reduce metabolic activity during transport of the specimens to the laboratory, scatter about the regression line was decreased and the Sy/x was reduced to 0.45 mmol/L. Before the on-ice delivery of split samples, 24% of the Elite analyzer's results differed from those of the CX7 analyzer by more than 15%, whereas only 8% differed from those of the CX7 meter by more than 15% after on-ice delivery of split samples. Of 30 samples read as "Lo" by the Elite meter, 29 were less than 2.2 mmol/L on the CX7 meter, whereas only 1 was 2.2 mmol/L. The coefficients of variation taken as a measure of imprecision were less than 5% for the normal-level aqueous control and less than 5% for four heel-stick blood glucose levels. CONCLUSIONS: The Ames Glucometer Elite analyzer can be used with confidence in measuring heel-stick blood glucose concentrations at the bedside in the neonatal intensive care unit. Hypoglycemic blood samples are reliably detected. As with adults, meticulous technique should be followed to prevent filling defects, and all split samples should be analyzed promptly on the CX7 analyzer, with delivery to the laboratory on ice. Unlike previous generations of glucometers, the Elite meter has been well accepted by the neonatal nursing staff.

Autoanalysis↗
PubMed1988

Medical care costs of high-risk infants after neonatal intensive care: a controlled study.

Total medical care costs were studied prospectively from neonatal intensive care unit (NICU) discharge to 3 years of age for 60 children, 35 of whom had neurologic and/or developmental deficits detected immediately following NICU discharge and 25 children did not. At the end of the study period the children were classified as unhandicapped (group A), mildly handicapped (group B), or moderately-severely handicapped (group C). Medical costs are reported per infant per month following NICU discharge (mean +/- SD). The outpatient costs in group A were $31 +/- 23 as compared with $86 +/- 93 in group B and $109 +/- 59 in group C (A less than B, A less than C; P less than .001). The greatest contributor to outpatient costs was occupational and physical therapy (with unproven efficiency to date). The inpatient costs were $31 +/- 56 in group A, $328 +/- 574 in group B, and $542 +/- 737 in group C (A less than C; P less than .01). The US Department of Agriculture estimates of medical costs of raising a child at home ranges from $22 to $26.80 per month. The cost of raising one of our NICU infants in an institution was $1,216 per month. Children with and without neurodevelopmental deficits after NICU discharge have significantly higher medical costs than children without.

Ambulatory Care↗
PubMed2005

Cost of neonatal intensive care in a tertiary care center.

BACKGROUND: The number of neonatal intensive care units (NICUs) in India has increased substantially over the last decade; yet many more are required. There is limited information on the actual costs of setting up and running an NICU in India. OBJECTIVE: Systematic and comprehensive calculation and analysis of the costs of neonatal intensive care in a tertiary care teaching hospital. METHODS: The costs were compiled by studying the detailed records of various hospital departments and prospectively documenting the costs of drugs, consumables and investigations for a representative group of 30 babies. RESULTS: The total cost of establishing a 16 bed level III tertiary care NICU was Rs 3.78 crore (Rs. 37.8 million, USdollar 860,000) (2003). Equipment cost formed two-thirds of the establishment cost. The running cost of NICU care per patient per day was Rs 5450 (USdollar 125). NICU and ancillary personnel salary comprised the largest proportion of the running costs. The average total cost of care for a baby less than 1000 grams was Rs. 168000 (USdollar 3800), Rs. 88300 (USdollar 2000) for babies 1000 g to 1250 g. and Rs. 41700 (USdollar 950) for those between 1250 to 1500 g. The family had to bear only 25 percent; rest was subsidized. CONCLUSIONS: Equipment and personnel salary form the biggest proportion of establishment and running costs. The costs of treatment for a baby in NICU should be seen in context with costs of other types of health care and the number of useful life years gained.

Cost Control↗
PubMed2004

Molecular epidemiology of gram-negative bacilli from infected neonates and health care workers' hands in neonatal intensive care units.

We sought to characterize the molecular epidemiology of gram-negative bacilli (GNB) causing infections in infants and associated with carriage on nurses' hands after hand hygiene was performed. From March 2001 to January 2003, GNB caused 192 (34%) of 562 hospital-acquired infections in the 2 participating neonatal intensive care units (NICUs) and were isolated from the hands of 45 (38%) of 119 nurses. Five species--Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Serratia marcescens and Enterobacter cloacae, all of which were typed by pulsed-field gel electrophoresis--caused 169 (88%) of 192 of GNB infections. Overall, 58% of infections were caused by unique strains not cultured from other infants or nurses, and 31% of infections were part of unrecognized molecular clusters. In contrast, only 9% of strains that caused infections were cultured from nurses' hands. These data suggest that practices in addition to hand hygiene are needed to prevent horizontal transmission of GNB in the NICU.

Adult↗
PubMed1983

Economic evaluation of neonatal intensive care of very-low-birth-weight infants.

We evaluated the economic aspects of neonatal intensive care of very-low-birth-weight infants, using outcomes and costs of care before and after the introduction of a regional neonatal-intensive-care program. Neonatal intensive care increased both survival rates and costs. For newborns weighing 1000 to 1499 g, the cost (in 1978 Canadian dollars) was $59,500 per additional survivor, $2,900 per life-year gained, and $3,200 per quality-adjusted life-year gained; intensive care resulted in a net economic gain when figures were undiscounted but a net economic loss when future costs, effects, and earnings were discounted at 5 per cent per annum. For infants weighing 500 to 999 g, the corresponding costs were $102,500 per additional survivor, $9,300 per life-year gained, and $22,400 per quality-adjusted life-year gained; intensive care resulted in a net economic loss. By every measure of economic evaluation, the impact of neonatal intensive care was more favorable among infants weighing 1000 to 1499 g than among those weighing 500 to 999 g. A judgment concerning the relative economic value of neonatal intensive care of very-low-birth-weight infants requires a comparison with other health programs.

Adolescent↗
PubMed2001

Caring for dying infants: experiences of neonatal intensive care nurses in Hong Kong.

Ten registered nurses working in a neonatal intensive care unit in Hong Kong were interviewed to explore their experiences of caring for infants whose disease is not responsive to curative treatment, their perceptions of palliative care, and factors influencing their care. Eight categories emerged from the content analysis of the interviews: disbelieving; feeling ambivalent and helpless; protecting emotional self; providing optimal physical care to the infant; providing emotional support to the family; expressing empathy; lack of knowledge and counselling skills; and conflicting values in care. The subtle cultural upbringing and socialization in nurse training and workplace environment also contributed to their moral distress. Hospital and nurse administrators should consider different ways of facilitating palliative care in their acute care settings. For example, by culture-specific death education, peer support groups, bereavement teams, modification of departmental policies, and a supportive work environment. Future research could include the identification of family needs and coping as well as ethical decision-making among nurses.

Adaptation, Psychological↗