The New York City Health and Hospitals Corporation: Transforming a Public Safety Net Delivery System to Achieve Higher Performance

Describes the results of the public benefit corporation's improvement initiatives -- a common clinical information system for continuity, coordination on chronic disease management, teamwork and continuous innovation, and access to appropriate care

LVHN Weekly

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Infant populations at risk for possible short-term and long-term consequences after exposure to prolonged sedation

INTRODUCTION: Prolonged sedation treatment in neonatal pediatric populations is associated with opioid and benzodiazepine tolerance, dependence, and withdrawal syndrome. Despite the clinical relevance of this problem, we have limited knowledge of the long-term repercussions. Current literature focuses on premature neonates and suggests that opioid exposure may cause neurodevelopmental sequelae. The main objective of this literature review was to investigate what infant populations are at risk of developing short-term and/or long-term consequences from prolonged infantile sedation exposure. PUBLISHED STUDIES: A literature review was conducted on previous studies that focused primarily on the effects of opioids and benzodiazepines on infants and how it may affect the future development in these children. Studies show that short-term consequences include increased heart rate, increased respiratory rate, increased blood pressure, intracranial pressure fluctuations, and risk of further complications such as intraventriculat hemorrhage (IVH), periventricular leukomalacia (PVL), or even death. Long-term repercussions incluse the possibility of decreased brain volume, decreased head circumference and body weight, intelligence deficits, and social and behavioral issues. DISCUSSION: Standard pain and sedation management involves the use of opioids and benzodiazepines. Treatment duration and medication dosage depend on severity of the patient’s illness. Since prolonged sedation administration is often associated with tolerance and dependence, future research (such as long-term follow up of these infants at later neurological milestones) is necessary to determine possible short-term and long-term neurological and behavioural sequelae for infants exposed to prolonged treatment with opioids and benzodiazepines. Standardized pain and sedation management guidelines may also increase the effectiveness of treatment and drug administration

Parent-infant closeness and family-centered care in neonatal intensive care

Abstract Early interaction and closeness with a caregiver are important for the development of newborn infants. Postpartum separation between parent and newborn is still common in the hospital care of premature babies. Parent-infant closeness in neonatal units can be supported by a family-centered care culture, in which hospital care for the newborn is implemented in cooperation with parents. Measuring both parent-infant closeness and family-centered care culture is challenging, and hardly any prospective metrics reported by parents exists in the literature. The aim of this dissertation was to examine a) first the closeness between the infant and parent, b) second the parents’ participation in their infant’s care and how each are supported, and c) third how family-centered care practices are implemented in neonatal intensive care units (NICUs). New measures were developed and tested in order to obtain reliable information on the physical closeness between parent and infant and the perceived quality of family-centered care in NICUs. The results of the present study indicate that it is possible to modify care practices to better support parent-infant closeness and parents’ participation in their infant’s care without endangering the growth of the premature infant or lengthening hospitalization. In a prospective multi-center study including 11 NICUs in 6 European countries, differences among countries as well as among units within the same country were observed. The most significant factor explaining the observed differences was the possibility for parents to stay overnight in the unit. The new methods developed and validated in the present study can be used in the future, for example in studies exploring the effects of parent-infant closeness on short- and long-term outcomes of the hospitalized newborns. With these new tools, it is also possible to support the implementation of FCC practices.Tiivistelmä Varhainen vuorovaikutus ja läheisyys ovat tärkeä perusta vastasyntyneen kehitykselle. Vanhemman ja vastasyntyneen välistä läheisyyttä sairaaloissa voidaan tukea perhekeskeisellä hoitokulttuurilla (Family-centered care), jossa vastasyntyneen sairaalahoito toteutetaan yhteistyössä vanhempien kanssa. Läheisyyden ja perhekeskeisen hoitokulttuurin mittaaminen on haastavaa ja kirjallisuudesta ei juuri löydy prospektiivisia vanhempien raportoimia mittareita. Tämän väitöstutkimuksen tavoitteena oli selvittää, miten vanhemman ja lapsen välistä läheisyyttä ja vanhempien osallistumista keskosen hoitoon tuetaan ja miten perhekeskeisiä hoitokäytäntöjä toteutetaan vastasyntyneiden teho-osastoilla. Tutkimuksessa kehitettiin ja testattiin uusia mittareita, joilla voidaan saada luotettavaa tietoa vanhemman ja lapsen välisestä fyysisestä läheisyydestä ja perhekeskeisen hoidon laadusta vastasyntyneiden teho-osastoilla. Tutkimuksessa todettiin, että vastasyntyneiden teho-osaston hoitokäytäntöjä voidaan muokata läheisyyttä ja vanhempien osallistumista tukevampaan suuntaan vaarantamatta keskosen kasvua tai pidentämättä sairaalahoitoaikoja. Eurooppalaisessa monikeskustutkimuksessa osoitettiin eroja niin eri maiden välillä kuin myös saman maan sisällä eri yksiköiden välillä. Selkeimmin eroja selittävä tekijä oli vanhempien mahdollisuus yöpyä osastolla. Tutkimuksessa käytetyt prospektiiviset mittarit osoittautuivat helppokäyttöisiksi ja vähän kuormittaviksi, ja pystyivät osoittamaan merkittäviä yksiköiden välisiä eroja. Uusia menetelmiä voidaan tulevaisuudessa hyödyntää esimerkiksi selvitettäessä vanhemman ja lapsen välisen läheisyyden fysiologisia vaikutuksia ja vaikutuksia pitkäaikaiskehitykseen. Kehitettyjen mittareiden avulla voidaan myös tukea perhekeskeisten hoitokäytäntöjen käyttöönottoa

LVHN Weekly

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Quality of Health Care for Children and Adolescents: A Chartbook

Contains 40 charts and analyses that represent the current state of pediatric health care. Provides practical guidance and recommendations for policymakers, health care professionals, and patient advocates

Minimizing Parental Posttraumatic Stress Disorder in the NICU: An Efficacy Analysis of Trauma Counseling

abstract: The birth of a new baby is known to be a joyful time for families. However, such a treasured experience can quickly reroute in a matter of moments which leaves the family feeling helpless, frightened, and guilty. The innate process of bonding and attachment is interrupted by the resuscitative course following a traumatic birth. Separation, grief, anger, and fear promote what’s being deemed more and more frequently as parental posttraumatic stress disorder (PTSD). Rates of parental PTSD associated with separation at birth are equivalating those of post-partum depression and post-partum psychosis. Emotionally unstable parents are unable to adequately care for their newborn for both short and long term needs. Facilitation and support of the parental role in an altered environment, such as a neonatal intensive care unit (NICU), is thought to create opportunities for relationship security. Establishment of an emotionally invested caregiver has been proven to minimize sequelae of the NICU patient, reduce length of stay, cut readmission rates, and lower the incidence of failure to thrive post-discharge. A parental psychosocial program was instituted in a 32-bed NICU within a southwest children’s hospital. The program efficacy was analyzed several months after implementation. Results are concurrent with the thought that individual counseling for NICU families reduces stress scores and improves patient satisfaction at discharge

Learning Health-Care Worker Networks from Electronic Health Record Utilization

The health-care system is a highly collaborative environment where health-care workers collaborate to care for patients. Health-care organizations (HCOs) design and develop various types of staffing plans to promote collaboration among health-care workers. The existing staffing plans describe the cooperation at a coarse-grained level, such as team scheduling. They seldom consider connections among health-care workers and investigate how health-care workers receive and disseminate information, which is essential evidence to inform actionable staffing interventions to improve care quality and patient safety. In this chapter, we introduce how to apply network analysis methods to electronic health record (EHR) utilization data to learn connections among health-care workers and build networks to describe teamwork in a fine-grained level. The chapter includes: (i) a brief description of the EHR utilization data, (ii) approaches to learn connections among health-care workers, (iii) building health-care worker networks, (iv) developing survey instruments to validate health-care worker networks, (v) introducing sociometric measurements to quantify network structures and positions of health-care workers in the networks, (vi) using statistical models to test associations between teamwork structures and patient outcomes, and (vii) listing examples to learn health-care worker networks in an HCO and a specific setting, including neonatal intensive care unit and trauma

Promoting Pre-Feeding Skills: Development and Implementation of an Oral Motor Protocol and Clinical Guidelines in a Level IV NICU

Intro: Oral feeding is often the last discharge criterion for preterm infants in the NICU and a leading cause of extended hospital stay. Preterm infants lack motor practice they would receive in utero when swallowing amniotic fluid and have underdeveloped physiological systems and oral structures, delaying feeding skills. Standardized pre-feeding oral motor protocols that include stimulation of oral structures and sucking on pacifiers have been shown to improve feeding efficiency, decrease transition time to full oral feeding, and decrease length of stay. Purpose: The purpose of this doctoral capstone project was to update the clinical guidelines on oral motor interventions in the University of Minnesota Masonic Children’s Hospital (UMMCH) NICU to improve the neurodevelopmental outcomes of premature infants by targeting oral motor skills through a new protocol to enhance breastfeeding and bottle feeding. Approach: Following an extensive literature review on best oral motor practices, the occupational therapists participated in a survey and focus group, were trained to implement the new protocol, and completed a follow-up survey to assess the utility of the protocol and updated clinical guidelines. Infant oral motor outcomes were also analyzed. Outcomes: All therapists reported feeling satisfied with the guidelines and confident in implementing the protocol and modifying it with intubated infants. Therapists also reported improved patient outcomes, including secretion management and swallowing, arousal levels, tolerance to stimulation and oral interest, and bottling skills. Short-term infant outcomes during the protocol include high percentages of good secretion management, activated swallowing, and latching to a pacifier. Recommendations: UMMCH NICU should continue to implement the protocol with infants of appropriate gestational age, utilize the clinical guidelines to train new therapists, provide additional training on the protocol as needed, continue quality improve cycle and adjust guidelines appropriately based on new evidence, provide parent education on protocol, and distribute modified nursing guidelines to further promote positive oral input for premature infants in the NICU