Showing posts with label NICU. Show all posts
Showing posts with label NICU. Show all posts

Tuesday, July 14, 2015

If You Like It You Shoulda Put A Name On It: Generic Baby Names And Errors In The NICU


By: Joann Schulte  DO, MPH; Editorial Board Member 

     William Shakespeare was sure that a rose by another name would still smell as sweet. But the playwright's sentiment from Romeo and Juliet doesn't apply to patients. Matching up the medication and the name can be a matter of life or death. Numerous quality improvement projects have focused on patient safety and an article by Adelman et al. (doi: 10.1542/peds.2015-0007) published this month in Pediatrics explores what can happen in nurseries where neonates are often Baby Boy Jones or Baby Girl Garcia. 
     Oh the parents have plans to make their newborns into individuals with a first name that might be Stephen James or Esperanza Maria.  Most of the 4 million infants born in 2012 needed no major interventions after birth and soon departed for home with their parents. But 12% of those infants were admitted to neonatal intensive care units (NICUs) for prolonged therapy that might be anything from jaundice to cyanotic heart disease.  You can be sure that more than one NICU had multiple babies with the name Baby Girl Jones or Baby Boy Garcia.  When multiple babies share the same or similar names, the chance for medical errors obviously goes up.
      The study published this month in Pediatrics is important for several reasons.  First the authors surveyed NICU physicians about naming conventions for neonates and then tested a hypothesis that assigning a unique name at birth would be associated with a decrease in wrong patient errors.
     The authors did an email survey of the 3,179 members of the AAP section on Perinatal Pediatrics asking about naming convention and identified which of the 886 NICUs they practiced in.  The authors got 453 responses, representing 339 NICUs for a 37.8% response rate. More than 80% of the NICUs (277, 81.7%) reported using non-distinct naming conventions of Baby Boy or Baby Girl.
      The intervention was done at Montefiore Medical Center in the Bronx, N.Y. where patients are cared for in two NICUs, a Level IV with 35 beds and a Level III with 15 beds.  The distinct naming convention implemented at Montefiore incorporated the mother's first name. So Baby Girl Jones became Martha's Girl Jones and Baby Boy Garcia became Lucia's Boy Garcia. The naming convention made the infants into more distinct individuals.
     The authors examined wrong-patient error rates before and after implementation of the distinct naming intervention.  They used the Retract and Reorder (RAR) tool, which identifies orders placed into the computer system and then retracted and entered for a different patient.  Such events are considered near misses where the patient is not harmed because the error is caught in time. Earlier research has suggested that more than three-fourths of RAR events represent wrong patient errors. The use of such near misses to test patient safety improvements is encouraged by patient safety organizations.
     During the pre-intervention period, Montefiore physicians placed 157,857 orders for 1,115 neonates.  After the name change convention placed 142,437 orders for 1,067 neonates.  The RAR error rate decreased from 59.5 per 100,000 orders to 37.9 per 100,000 orders, a decrease of 36.3%.
     This study is important because it demonstrates that Baby Boy and Baby Girl naming conventions are a recipe for trouble.  The simple intervention of attaching the mother's first name to her infant reduced errors and that's an important outcome.   With apologies to Shakespeare, a baby with a unique name in a NICU will be safer and that is a good sniff for patient safety.

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Friday, June 12, 2015

Forging Bonds in the NICU: Parenting and Maternal Sensitivity


By: Lydia Furman, MD,  Assistant Editor
      As a Case Western Reserve Universisty medical student, I and many others spent long and rewarding hours watching and coding videotape of mothers feeding their term and preterm infants as part of  Dr. John Kennell’s research elective which was a perennial favorite among students. Kennell, along with Dr. Marshall Klaus of “Bonding” fame are widely credited with bringing humane, sensitive, and parent-friendly practices to the Neonatal Intensive Care Unit. They also brought all of us, trainees and colleagues, along with them: there was no way to deny the importance of maternal sensitive touch while watching Dr. Kennell help a new mother connect with her premature infant. 
     After a very protracted birthing process, measures of parenting and maternal sensitivity have finally become accepted by many as mainstream and scientifically valuable research outcomes. Doctors Bilgin and Wolke (doi: 10.1542/peds.2014-3570) have done a great service in systematically examining the literature on this topic to compare mothers of preterm and term infants- is there a difference in sensitivity in how they respond to their infants? Fortunately, we are well past the question of whether this matters! 
     In this meta-analysis, the authors found that study heterogeneity was high, despite clear criteria for study selection, e.g.  the study must have used an observational instrument, must have included both term and preterm comparison groups, and was required to use a defined construct for the outcome (“…maternal sensitivity …defined as mother's ability to perceive and infer the meaning behind her infant's behavioral signals, and to respond to them promptly and appropriately; “maternal responsiveness”, such as providing stimulation to the infant or “maternal facilitation” such as positive regard and respect for the child’s autonomy...”). I note that the mean gestational age and birthweight of the studied “preterm” infants were 30.4 weeks and 1374 grams respectively, babies who would be considered relatively mature and stable in today’s NICU.
      In general, the results of the meta-analysis are both reassuring and intriguing. Of interest, half (exactly 50%) of the studies that could be included used a single “snap shot” observation period, rather than multiple measurements. This led me to wonder whether multiple measurements for hospitalized infants, for example weekly measures, might be a way to prospectively identify parents who are either doing very well in connecting with their infant, or more importantly, those in need of additional support and assistance. We have just learned from authors Bilgin and Wolke that gestational age and neonatal morbidity alone cannot guide us in finding parents at risk, and yet maternal sensitivity and responsiveness are linked to positive developmental outcomes (Magill-Evans et al. Child Health Care 2001).   We really need to find a way to identify those parents who need help, Just as growth and chemistry profiles are routinely measured and monitored, maybe it’s time to begin to have the same level of vigilance about parenting behaviors and skills?

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