Malathi Balasundaram, MD

Abstract

In the adult and pediatric critical care population, point-of-care ultrasound (POCUS) can aid in diagnosis, patient management, and procedural accuracy. For neonatal providers, training in ultrasound and the use of ultrasound for diagnosis and management is increasing, but use in the neonatal intensive care unit (NICU) is still uncommon compared with other critical care fields. Our objective was to describe the process of implementing a POCUS program in a large academic NICU and evaluate the role of ultrasound in neonatal care during early adaption of this program.A POCUS program established in December 2018 included regular bedside scanning, educational sessions, and quality assurance, in collaboration with members of the cardiology, radiology, and pediatric critical care divisions. Core applications were determined, and protocols outlined guidelines for image acquisition. An online database included images and descriptive logs for each ultrasound.A total of 508 bedside ultrasounds (76.8% diagnostic and 23.2% procedural) were performed by 23 providers from December 2018 to December 2020 in five core diagnostic applications: umbilical line visualization, cardiac, lung, abdomen (including bladder), and cranial as well as procedural applications. POCUS guided therapy and influenced clinical management in all applications: umbilical line assessment (26%), cardiac (33%), lung (14%), abdomen (53%), and cranial (43%). With regard to procedural ultrasound, 74% of ultrasound-guided arterial access and 89% of ultrasound-guided lumbar punctures were successful.Implementation of a POCUS program is feasible in a large academic NICU and can benefit from a team approach. Establishing a program in any NICU requires didactic opportunities, a defined scope of practice, and imaging review with quality assurance. Bedside clinician performed ultrasound findings can provide valuable information in the NICU and impact clinical management. Use of point-of-care ultrasound is increasing in neonatology and has been shown to improve patient care.. Implementation of a point-of-care ultrasound program requires the definition of scope of practice and can benefit from the support of other critical care and imaging departments and providers.. Opportunities for point-of-care ultrasound didactics, imaging review, and quality assurance can enhance the utilization of bedside ultrasound..

View details for DOI 10.1055/s-0042-1750118

View details for PubMedID 35691294

Abstract

OBJECTIVE: Increase the proportion of 33 weeks newborns exposed to mother's own milk (MOM) oral care by 12h of age by 20% over 2 years to support a healthier microbiome.STUDY DESIGN: We implemented interventions to support early expression of colostrum and reliable delivery of resultant MOM to premature newborns. Statistical process control charts were used to track progress and provide feedback to staff. Proportions of newborns exposed to MOM by 12h were compared relative to baseline.RESULTS: There were 46, 66, and 46 newborns in the baseline, implementation, and sustainability periods, respectively. The primary outcome improved from 48% to 61% in the implementation period (relative change 1.27, 95% CI 0.89, 1.81, p=0.2), to 69% in sustainability period (relative to baseline 1.45, 95% CI 1.02, 2.08, p=0.03).CONCLUSION: An interdisciplinary team-based, multicycle, quality improvement intervention resulted in increased rates of early exposure to MOM.

View details for DOI 10.1038/s41372-022-01376-8

View details for PubMedID 35396577

Abstract

BACKGROUND: A serial clinical examination approach to screen late preterm and term neonates at risk for early onset sepsis has been shown to be effective in large academic centers, resulting in reductions in laboratory testing and antibiotic use. The implementation of this approach in a community hospital setting has not been reported. Our objective was to adapt a clinical examination approach to our community hospital, aiming to reduce antibiotic exposure and laboratory testing.METHODS: At a community hospital with a level III NICU and >4500 deliveries annually, the pathway to evaluate neonates 35 weeks at risk for early onset sepsis was revised to focus on clinical examination. Well-appearing neonates regardless of perinatal risk factor were admitted to the mother baby unit with serial vital signs and clinical examinations performed by a nurse. Neonates symptomatic at birth or who became symptomatic received laboratory evaluation and/or antibiotic treatment. Antibiotic use, laboratory testing, and culture results were evaluated for the 14 months before and 19 months after implementation.RESULTS: After implementation of the revised pathway, antibiotic use decreased from 6.7% (n = 314/4694) to 2.6% (n = 153/5937; P < .001). Measurement of C-reactive protein decreased from 13.3% (n = 626/4694) to 5.3% (n = 312/5937; P < .001). No cases of culture-positive sepsis occurred, and no neonate was readmitted within 30 days from birth with a positive blood culture.CONCLUSIONS: A screening approach for early onset sepsis focused on clinical examination was successfully implemented at a community hospital setting resulting in reduction of antibiotic use and laboratory testing without adverse outcomes.

View details for DOI 10.1542/hpeds.2021-006058

View details for PubMedID 34935049

Abstract

Neonatal intensive care unit (NICU) families are often overwhelmed by the discharge process. Their anxiety can inhibit learning and contribute to poor infant outcomes and increased healthcare utilization after discharge. Quality of the discharge teaching is the strongest predictor of discharge readiness, so NICUs must develop excellent discharge preparation programs.This improvement project enhances NICU discharge preparedness by providing consistent, early discharge teaching using technology as a supplemental resource and raises parental satisfaction with the process.Neonatal intensive care unit staff and former NICU parents developed a task force to create technology-based discharge education content. The content was originally uploaded to an e-book and later transferred to the electronic health record inpatient portal. Families were able to view discharge teaching content at their own convenience and pace and review topics as needed with the NICU staff. Postdischarge follow-up phone calls provided insight into parental reaction to the new education format.Parent satisfaction top-box scores, reflecting the highest rating in the "Prepared for Discharge" category of the patient satisfaction survey, improved from a baseline of 47% in 2017 to 70% in 2019. Overwhelmingly, 92% of families highly rated the tablet-based discharge teaching during postdischarge phone calls.A comprehensive, consistent, and early discharge program using technology can lead to more effective and efficient NICU discharge education and improved parent satisfaction.Further studies are needed to generalize hospital-based inpatient portal teaching as an additional resource for parental education in the NICU.

View details for DOI 10.1097/ANC.0000000000000841

View details for PubMedID 33534225

Abstract

OBJECTIVE: Multicystic dysplastic kidney (MCDK) is one of the most common anomalies detected by prenatal ultrasound. Our objective was to identify factors associated with severe adverse neonatal outcomes of prenatally diagnosed MCDK STUDY DESIGN: A retrospective review of prenatally diagnosed MCDK (1 January 2009 to 30 December 2014) from a single academic center was conducted. The primary outcome was death or need for dialysis among live-born infants. Associations between prenatal characteristics and outcome were analyzed by Fisher's exact test and Mann-Whitney test.RESULTS: A total of 53 cases of prenatally suspected MCDK were included, of which 46 cases were live-born and confirmed postnatally (38 survivors, 8 non-survivors). Prenatally diagnosed extrarenal anomalies, bilateral MCDK, contralateral renal anomalies, and anhydramnios were significantly associated with death or need for dialysis (all p<0.0001).CONCLUSIONS: Prenatally identified findings are associated with adverse neonatal outcome, and can guide counseling and management planning. In the absence of significant associated findings, prenatally diagnosed unilateral MCDK has a benign neonatal course.

View details for PubMedID 29572458