BACKGROUND: Early-term infants (37-38 weeks) are at increased risk of short- and long-term morbidities compared with full term infants (39-40 weeks). In 2009, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines to discourage early elective deliveries prior to 39 weeks of gestation, and Beth Israel Deaconess Medical Center (BIDMC) in Boston, MA, adopted a policy to implement these guidelines. The impact of this policy on Neonatal Intensive Care Unit (NICU) utilization at BIDMC is unknown. Objectives: The objectives of this study were to (1) examine the gestational age distribution of infants at BIDMC from 2004 to 2015 and confirm a reduction in proportion of early-term births (37-38 weeks) after policy implementation in 2009, (2) compare the incidence of NICU admissions among infants ≥37 weeks of gestation before and after policy implementation, and (3) compare the length of NICU stays among infants ≥37 weeks of gestation before and after policy implementation. METHODS: We conducted a medical record review of infants ≥37 weeks of gestation born from January 1, 2004, through November 10, 2015. We used chi-square tests to compare the incidence of early-term deliveries and NICU admissions in two time periods: 2004-2008 (pre-period) and 2010-2015 (post-period). We excluded infants born in 2009 from the analysis. We used logistic regression to calculate the odds ratio of both short (>4 to <24 hours) and long (≥24 hours) NICU admissions in the two time periods. NICU stays ≤4 hours were excluded as they most often occur among asymptomatic infants for evaluation of sepsis in the setting of maternal fever during labor. We also excluded infants transferred to other hospitals. We considered potential confounding variables such as multiple births, maternal age, race and ethnicity, parity, insurance, and marital status. We compared median lengths of stay using a Wilcoxon test. RESULTS: A total of 50,373 infants were born ≥37 weeks of gestation during the study period, 46,254 of whom were included in the analysis excluding 4,119 infants born in 2009, the washout period. The incidence of early-term delivery was lower in the post-period (27.1%) versus the pre-period (34.2%) (P <0.0001). We detected a slight but statistically insignificant decrease in the incidence of overall NICU admissions from 9.1% in the pre-period to 8.9% in the post-period (P = 0.3). The incidence of short NICU admissions also decreased from 5.3% in the pre-period to 4.6% in the post-period (P < 0.0001). Interestingly, there was an increase in the incidence of long NICU stays from 3.8% in the pre-period to 4.3% in the post-period (P = 0.006). Term infants born after 2009 had lower odds of short NICU stays in adjusted models (adj. OR 0.84; 95% CI 0.77, 0.91). Among NICU admissions >4 hours, the median length of stay (LOS) increased from 21 hours (pre-period) to 39 hours (post-period) (P <0.0001). CONCLUSION: A local policy aligned with ACOG national guidelines to reduce early elective deliveries was associated with a reduction in early-term births. We observed a concurrent reduction of short but not long NICU stays. Our findings suggest that a reduction in early elective deliveries before 39 weeks of gestation may lead to more opportunities for infants to stay with their families in the first 24 hours but may not affect the incidence of significant morbidities requiring longer NICU stays. / 2017-06-16T00:00:00Z

The objectives of this study were to determine the current rates of immunization and identify variables associated with immunizations of NICU graduates who were 60 days of age or older at time of discharge. This is a descriptive pilot study utilizing retrospective paper chart review. The relationships between immunization status and study variables were examined using logistic regression. Of 43 infants discharged at least 60 days of age or older from the NICU, 74.4% were up to date for immunizations in accordance with AAP recommendations. Additional variables were not significant. Immunization needs to be a priority in order to give NICU infants every advantage regarding their future health status.

Premature and ill infants are admitted to neonatal intensive care units (NICU) for specialized medical and nursing care. Infants admitted to NICUs require the use of life sustaining technology and care from a multidisciplinary health care team. While in hospital, an infant’s prognosis and expected outcomes can dramatically change. Depending on the circumstances of their infant’s health, parents may choose to withdraw life sustaining treatment, or alternatively, face a future reality with the potential of long-term impact related to their infant’s diagnosis. Parents with an infant in the NICU experience many different types of losses which can generate a grief response. The purpose of this thesis is to explore parental loss and grief in the NICU. A systematic review of qualitative evidence modelled on the Joanna Briggs Institute method (2014) was completed. This approach included a systematic and rigorous approach to the searching, critical appraisal, and aggregation procedures. Four databases (CINAHL, Medline, PsycINFO, Nursing and Allied Health) were systematically searched using pre-identified search criteria. Two reviewers were involved in the search and screening, and three additional reviewers were used to identify included articles. This search process resulted in five studies being included in the review. Five themes were identified from the original research studies: support, not knowing what to expect, hospital practices, communication, and coming through grief. The results of this systematic review of qualitative evidence demonstrate that loss and grief have been described by parents in the NICU, both in the presence and absence of neonatal death.

The goal of this project was to explore mothers’ experiences of caring for infants in the Neonatal Intensive Care Unit (NICU) using a microsystem perspective. This perspective focuses on the structure, processes and people and in so doing allows for a critical exploration of how these elements work together to influence mothers in the NICU. The research framework involved an institutional ethnography to explore care delivery, relationships, and discourses in the NICU. Data was collected using nonparticipant-observations, interviews, and collection of discourse artifacts. There is clear evidence that caring for an infant in the NICU can result in significant increases in maternal stress and associated outcomes. Results from triangulation of the data indicated that being separated from the infant and learning to mother in the unit were particularly salient experiences retold by the mothers. These experiences were affected – either positively or negatively – by different elements of the microsystem including consistency in communications, increased opportunities for mothers’ inclusion in decision-making and infant care and lastly, access to more support resources. Implementing improvements to the microsystem could better empower mothers adjusting to parenthood within the NICU context.

Introduction: Past studies have indicated that nursing support reduces parental stress and anxiety during a child’s NICU hospitalisation and therefore fosters the parents’ abilities to cope with the difficulties they are facing. The importance of parental support has been emphasised in numerous studies in Western countries, however the nursing support which is responsive to the parents may vary between different cultures. The cultural norms of medical and nursing care environments can affect parental stress-related experiences as well as nursing roles in the NICUs across different countries. The aims of this study are, first, to compare the medical and nursing care environments of the two NICUs. Second, the study establishes any similarities and differences in sources of parental stress in the two NICUs. Third, the study illustrates the underlying philosophy of Doane and Varcoe’s (2005) relational approach to family nursing and highlights the importance of relational inquiry in the process of determining the parental support which best responds to individual families’ needs in the NICU. Methods: This study analyses the nursing roles that support parents of children hospitalised in a Neonatal Intensive Care Unit (NICU). It is a cross-cultural comparison between two NICUs, one in Christchurch, New Zealand and the other in Tokyo, Japan, with both quantitative and qualitative components. Thirty-one families participated voluntarily in the study from each NICU (n=121). The three main sources of data were a NICU staff interview, parental interview, and parental questionnaire using the Parental Stress Scale: Neonatal Intensive Care Unit (PSS: NICU) (Miles, 2002). A thematic analysis was used in order to examine parental comments. Results: The differences between the two NICUs in terms of the NICU care environment, including NICU regulations and routine nursing care, were identified by the staff interviews, highlighting the contrasting dominant ideologies of individualism and collectivism reflected in each culture. The three sources of parental stress, measured by PSS: NICU: Sights and Sounds; Baby’s Appearance and Behaviour; the Parental Role Alteration, were examined. The sources most responsible for parental stress differed between the four groups of parents. Overall, The Tokyo parents seemed to be most concerned about the infant’s condition. The Christchurch parents, however, perceived the change in parental role to be most stressful. Additionally, only the Tokyo fathers experienced stress in association with Sights and Sounds more often than other areas of stress. The infant’s medical/nursing care requirements, oxygen therapy and/or tube feeding, were associated with a high degree of stress for each of the parents’ groups except that of the Christchurch fathers. There was a positive relationship between parental NICU visiting and stress level among the Tokyo parents while this was not the case for the Christchurch parents. The infants’ and parental characteristics were found to be associated with stress level for the Tokyo mothers and Christchurch fathers only. The thematic analysis of interview data revealed three key themes of NICU parental experiences: Uncertainty, NICU contexts and Communication with staff. These themes were identical between the two NICUs. Discussion: This study highlighted the influence of the norms of each NICU, particularly the NICU regulations and nursing care on parental stress-related experiences, and the importance of reflecting upon these norms to critique those professional beliefs which may hamper parental coping abilities. The areas of parental support needing attention were different between the two NICUs. These areas were: the establishment of oral feeding, and infants’ nursing care-related decision-making for the Christchurch NICU whilst parental information/involvement in the early stage of hospitalisation, the influence of visiting regulations, and importing Western-based NICU intervention for the Tokyo NICU. In providing these areas of parental support, the importance of effective, meaningful communication between parents and staff was equally evident in the two NICU settings. In the light of the relational approach to family nursing, this study demonstrated that how nurses communicate with families is not universal: one way to reach across the differences is to listen to parents, and this, it is clear, is crucial to the role of nurses in NICU settings.

No description available.

Background: Approximately 25,000 pediatric deaths occur in hospitals in the United States each year with over 50% of these deaths occurring in Newborn Intensive Care Units (NICU). NICU nurses are frequently involved in end-of-life (EOL) care and face unique obstacles. Objective: The objective of this study was to obtain NICU nurses suggestions for improving obstacles in EOL care in NICUs. Methods: Suggestions were obtained through mailed survey research in qualitative study design. Returned surveys yielded 121 nurse respondents who gave a total of 138 suggestions.Results: A total of 10 cohesive themes were identified: (1) environmental design issues, (2) improved communication between healthcare teams, (3) ending futile care earlier, (4) realistic and honest physician communications to families, (5) providing a œgood death, (6) improved nurse staffing, (7) need for EOL education, (8) earlier entry into hospice/palliative care, (9) availability of ancillary staff, and (10) allowing parents more time to prepare for death.Conclusions: Despite the variety of obstacles encountered in providing EOL care to dying infants and their families, NICU nurses can use self-assessment tools to identify obstacles to EOL care and collaborate with key members of the healthcare team to alleviate these obstacles.

In this work we examine Ag-Au and Ni-Cu nanoclusters: their structural,compositional, and morphological characteristics are investigated in detail. The clusters are produced by the inert gas aggregation (IGA) method from magnetron sputtered alloy targets, in an UHV compatible system. The design of the system is optimized for production and deposition of the clusters with size in the range 5 nm < D < 10 nm. In order to increase the flux of sub-5 nm clusters in the system, we conducted modeling and experimental studies of cluster motion: the simulations showed that skimmers with wider internal angles might significantly improve the flux of smaller nanoclusters; however, the experimental study revealed a major influence of the background gas on scattering of such nanoclusters which consequently led to the loss of their flux. A comprehensive study of Ag0:85Au0:15 nanoclusters was conducted over a period of more than 2 years. Nanoclusters with sizes in the range 3 nm < D < 10 nm were deposited onto a-C films at various surface coverages and systematically investigated by transmission electron microscopy. We found that Ag-Au nanoclusters initially exhibited icosahedral and decahedral structural motifs, with a very small fraction of face centered cubic nanoclusters present. This may suggest that the source conditions used in the experiments (primarily Ar flow) left Ag-Au nanoclusters kinetically trapped in structures which correspond to local thermodynamic minima, rather than global energetically favoured atomic configurations. When left exposed to ambient conditions, over time Ag-Au nanoclusters exhibited structural, morphological, and compositional changes: core-shell and Janus nanoclusters were observed in aged samples, as well as fragmentation of bigger particles. We attribute these changes to oxidation of the Ag component and increased diffusion of Ag₂O over the substrates. The final morphology of aged nanocluster-based thin films is governed by a combination of diffusion, Ostwald ripening, and the Plateau-Rayleigh instability. High resolution transmission electron microscopy confirmed the presence of fivefold symmetric structures in Ni-Cu nanoclusters; however, their higher oxidation rate may have influenced the structures from the outset. In addition, when these nanoclusters were exposed to the electron beam, crystalline artifacts (nanochimneys)started to grown on them, with a structure corresponding to the NiO structure. Ni-Cu nanoclusters are subsequently used as catalysts in a pilot study of carbon nanotube synthesis which confirmed that such alloy nanoclusters are catalytically active for single-wall and multi-wall carbon nanotube growth.

Background Hyperbilirubinemia is a condition that affects most infants, but typically self-resolves and is not harmful. However, if bilirubin levels exceed neuroprotective defenses, the compound can cross the blood-brain barrier and have neurotoxic and potentially fatal effects. Treatment of neonatal hyperbilirubinemia with phototherapy is necessary for the prevention of kernicterus. Guidelines for the use of phototherapy in infants born at ≥ 35 weeks’ gestation were published by Bhutani et al. and endorsed by the American Academy of Pediatrics. Consensus-based recommendations for phototherapy treatment and exchange transfusion of premature infants were published in 2012 by Maisels, et al. However, there are no published recommendations for the timing of screening for hyperbilirubinemia in NICU patients. In 2012, the Kapʻiolani Medical Center for Women & Children Neonatology Division implemented internal guidelines for phototherapy with recommendations for the timing of screening serum bilirubin levels, based on the group’s opinion. Five years later, the current study queried whether these guidelines for screening were appropriate. Objective The present study sought to describe current practices of obtaining serum bilirubin levels and the use of phototherapy in the NICU during the first five days of life. It was hypothesized that many bilirubin levels obtained at ≤ 48 hours of life are below published recommended treatment thresholds and are potentially unnecessary. Methods Retrospective chart review was performed on all infants admitted to the NICU at < 24 hours of life, from July 2016-June 2017. Eligible infants were divided into three gestation age groups: ≤ 28, 29-35, and ≥ 36 weeks at birth. Patient demographics, bilirubin levels, and phototherapy treatment were noted. The primary outcome of interest was the percent of serum bilirubin levels obtained during the first 48 hours of life that did not meet phototherapy treatment criteria. Results 931 charts were reviewed. Infants born at ≤ 28, 29-35 and ≥ 36 weeks’ gestation made up 10%, 51% and 39% of the cohort. Overall mortality was 3%, and no exchange transfusions were performed during the study period. At least one serum bilirubin level was obtained for 96% of the patients, but only 55% were treated with phototherapy within the first five days of life. Phototherapy was rarely prescribed on day of life (DOL) 1 (0.7%). By DOL 2, a total of 563 bilirubin levels were obtained, but only 108 infants (19%) were treated with phototherapy. However, one-third of these patients’ bilirubin levels did not meet published criteria for treatment. The timing of phototherapy treatment varied by gestational age. Ninety percent of infants born ≤ 28 weeks’ gestation who received phototherapy were treated starting between DOL 2-3. In contrast, eighty-five percent of infants born ≥ 29 weeks’ gestation who received phototherapy, started on DOL 3-5. Discussion Far more bilirubin levels were obtained than courses of phototherapy prescribed. Given the distinct patterns of phototherapy for infants of varying gestational age, there is ample opportunity to improve resource utilization with targeted recommendations for obtaining screening bilirubin levels in the neonate without early jaundice.

Prematurity is a worldwide healthcare problem affecting 15 million births every year. Having a child that is born prematurely brings forth numerous challenges, placing significant stress on families, impacting family dynamics and overall well-being. In addition, advancements in perinatal health care have increased the survival rates of premature infants, placing most infants at higher risk for complex medical needs and developmental impairments that extend beyond discharge from the Neonatal Intensive Care Unit. Research shows that while parental psychological support is provided while in the hospital and the infant may receive allied health services for developmental care, these services are often delayed, not accessible or discontinued following discharge. A two-part educational initiative called “The Preemie Toolkit” is introduced in this doctoral project, guided by evidence and the Knowledge to Action theoretical framework. This initiative aims to fill the identified gap in care and provide accessible knowledge and support for families living in northeast Pennsylvania during this critical period. The project highlights the vital role of occupational therapists in enhancing support for preterm infants and their families. By providing a feasible avenue to provide comprehensive care and support, families will be able to navigate the complexities of caring for their premature infants with greater confidence and well-being during the first few weeks at home until other services begin. This doctoral project includes a plan for program evaluation, funding and dissemination.