RESUMO
OBJECTIVE: Ballard scores are commonly used to estimate gestational age (GA). The purpose of this study was to determine the accuracy of the New Ballard Score (NBS) for infants <28 weeks GA by accurate menstrual history and to evaluate NBS as an outcome predictor. METHODS: Infants weighing 401 to 1500 g in 12 National Institute of Child Health and Human Development Neonatal Research Network centers had NBS performed before age 48 hours. Accuracy of NBS estimates of GA was assessed for infants with GA determined by accurate menstrual history. In a larger cohort of infants, NBS was included in regression models of the association of NBS and death, poor outcome, and duration of hospital stay. RESULTS: At each week from 22 to 28 weeks GA by accurate menstrual history, NBS estimates exceeded GA by dates by 1.3 to 3.3 weeks, and estimates varied widely (range of widths of 95% CIs for the observations, 6.8 to 11.9 weeks). NBS did not contribute significantly to regression models of death, poor outcome, or duration of hospital stay. CONCLUSIONS: Inaccuracies in GA determined by the NBS should be considered when treating extremely premature infants, particularly in decisions to forego or administer intensive care. Refinement of GA scoring systems is needed to optimize clinical benefit.
Assuntos
Idade Gestacional , Recém-Nascido Prematuro/crescimento & desenvolvimento , Recém-Nascido de muito Baixo Peso/crescimento & desenvolvimento , Exame Neurológico/métodos , Exame Físico/métodos , Feminino , Humanos , Recém-Nascido , Terapia Intensiva Neonatal , Modelos Lineares , Modelos Logísticos , Menstruação , Razão de Chances , Gravidez , Reprodutibilidade dos TestesAssuntos
Anemia Neonatal/terapia , Transfusão de Eritrócitos , Doenças do Prematuro/terapia , Anemia Neonatal/sangue , Humanos , Recém-Nascido , Doenças do Prematuro/sangue , Recém-Nascido de muito Baixo Peso , Terapia Intensiva Neonatal , Avaliação de Processos e Resultados em Cuidados de Saúde , Guias de Prática Clínica como Assunto , Padrões de Prática MédicaRESUMO
OBJECTIVE: To assess the effect of an early discharge program on the use of hospital-based health care services in the first 3 months of life. DESIGN: Retrospective cohort study. SETTING: Metropolitan university hospital and a children's hospital. PATIENTS: Term infants cared for in a single term nursery, before and after implementation of an early discharge program. INTERVENTION: Early discharge program. METHODS: Linking of the birth hospital and the children's hospital records and chart review. OUTCOME MEASURES: Pattern of emergency department visits and rehospitalizations in the first 3 months of life. RESULTS: The early discharge group had a shorter stay, 32 +/- 21 hours (mean +/- SD) than the control group (48 +/- 22 hours). There was no effect of early discharge on mean age at rehospitalization, rehospitalization rate, or reason for rehospitalization. Twenty-eight percent of infants in both study and control groups had at least one emergency department visit by 3 months of age. There was no difference between study and control groups in mean age or frequency of emergency department visits. Maternal age and race had a significant effect on the odds of visiting the emergency department. For any maternal age, nonwhite mothers were more likely to visit the emergency department. CONCLUSIONS: Early discharge of newborn infants to inner city parents can be accomplished without increasing hospital-based resource use in the first 3 months of life provided coordinated postdischarge care and home visiting services are available.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cuidado do Lactente/estatística & dados numéricos , Tempo de Internação , Alta do Paciente , Adulto , Estudos de Coortes , Feminino , Registros Hospitalares/estatística & dados numéricos , Hospitais Pediátricos , Hospitais Universitários , Humanos , Lactente , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Idade Materna , Berçários Hospitalares , Ohio , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pobreza , Estudos RetrospectivosRESUMO
OBJECTIVE: Late-onset sepsis (occurring after 3 days of age) is an important problem in very low birth weight (VLBW) infants. To determine the current incidence of late-onset sepsis, risk factors for disease, and the impact of late-onset sepsis on subsequent hospital course, we evaluated a cohort of 7861 VLBW (401 to 1500 gm) neonates admitted to the 12 National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers during a 32-month period (1991 to 1993). METHODS: The NICHD Neonatal Research Network maintains a prospectively collected registry of all VLBW neonates cared for at participating centers. Data from this registry were analyzed retrospectively. RESULTS: Of 6911 infants who survived beyond 3 days, 1696 (25%) had one or more episodes of blood culture-proven sepsis. The vast majority of infection (73%) were caused by gram-positive organisms, with coagulase-negative staphylococci accounting for 55% of all infections. Rate of infection was inversely related to birth weight and gestational age. Complications of prematurity associated with an increased rate of infection included intubation, respiratory distress syndrome, prolonged ventilation, bronchopulmonary dysplasia, patent ductus arteriosus, severe intraventricular hemorrhage, and necrotizing enterocolitis. Among infants with bronchopulmonary dysplasia, those with late-onset sepsis had a significantly longer duration of mechanical ventilation (45 vs 33 days; p <0.01). Late-onset sepsis prolonged hospital stay: the mean number of days in the hospital for VLBW neonates with and without late-onset sepsis was 86 and 61 days, respectively (p <0.001). Even after adjustment for other complications of prematurity, including intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia, infants with late-onset sepsis had a significantly longer hospitalization (p <0.001). Moreover, neonates in whom late-onset sepsis developed were significantly more likely to die than those who were uninfected (17% vs 7%; p <0.000 1), especially if they were infected with gram-negative organisms (40%) or fungi (28%). Deaths attributed to infection increased with increasing chronologic age. Whereas only 4% of deaths in the first 3 days of life were attributed to infection, 45% of deaths after 2 weeks were related to infection. CONCLUSIONS: Late-onset sepsis is a frequent and important problem among VLBW preterm infants. Successful strategies to decrease late-onset sepsis should decrease VLBW mortality rates, shorten hospital stay, and reduce costs.
Assuntos
Recém-Nascido de muito Baixo Peso , Sepse/epidemiologia , Idade de Início , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Candidíase/epidemiologia , Candidíase/microbiologia , Candidíase/mortalidade , Causas de Morte , Estudos de Coortes , Feminino , Humanos , Incidência , Recém-Nascido , Tempo de Internação , Masculino , Análise Multivariada , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Sepse/microbiologia , Sepse/mortalidadeRESUMO
OBJECTIVE: Early-onset sepsis (occurring within 72 hours of birth) is included in the differential diagnosis of most very low birth weight (VLBW) neonates. To determine the current incidence of early-onset sepsis, risk factors for disease, and the impact of early-onset sepsis on subsequent hospital course, we studied a cohort of 7861 VLBW neonates (401 to 1500 gm) admitted to the 12 National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers during a 32-month period (1991-1993). METHODS: The NICHD Neonatal Research Network maintains a prospectively collected registry on all VLBW neonates born or cared for at participating centers. Data from this registry were analyzed retrospectively. RESULTS: Blood culture-proven early-onset sepsis was uncommon, occurring in only 1.9% of VLBW neonates. Group B streptococcus was the most frequent pathogen associated with early-onset sepsis (31%), followed by Escherichia coli (16%) and Haemophilus influenzae (12%). Decreasing gestational age was associated with increased rates of infection. Antibiotic therapy for suspected sepsis is frequently initiated at birth in VLBW neonates. Almost half of the infants in this cohort were considered to have clinical sepsis and continued to receive antibiotics for 5 or more days, despite a negative blood culture result in 98% of cases. These findings underscore the difficulty of ruling out sepsis in the symptomatic immature neonate and the special concern for culture-negative clinical sepsis in the face of maternal antibiotic use. Neonates with early-onset sepsis were significantly more likely to have subsequent comorbidities, including severe intraventricular hemorrhage, patent ductus arteriosus, and prolonged assisted ventilation. Although 26% of VLBW neonates with early-onset sepsis died, only 4% of the 950 deaths that occurred in the first 72 hours of life were attributed to infection. For those infants discharged alive, early-onset sepsis was associated with a significantly prolonged hospital stay (86 vs 69 days; p <0.02). CONCLUSIONS: Early-onset sepsis remains an important but uncommon problem among VLBW preterm infants. Improved diagnostic strategies are needed to enable the clinician to distinguish between the infected and the uninfected VLBW neonate with symptoms and to target continued antibiotic therapy to those who are truly infected.
Assuntos
Recém-Nascido de muito Baixo Peso , Sepse/epidemiologia , Idade de Início , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Estudos de Coortes , Feminino , Humanos , Incidência , Recém-Nascido , Masculino , Fatores de Risco , Sepse/microbiologia , Sepse/mortalidadeRESUMO
The effect of a cost-containment program focused on decreasing the lengths of hospital stay of high-risk neonates was assessed by comparison of discharge weights and lengths of stay for 257 study infants, discharged from a neonatal intensive care unit (NICU) after an early-discharge program began, with those of 477 control infants discharged during a prior 1-year period. Demographic data and costs, as well as data on emergency department use and hospital readmissions, were included in the comparisons. There was a significant decrease in mean discharge weight and length of stay for infants in the study group. During a 7-month period, an estimated 2073 days of hospital care and approximately $2,700,000 in hospital charges were saved, or $10,609 per infant discharged. The cost of instituting and maintaining the program was $120,413, or $468 per infant. Seven visits were made to the emergency department by the study infants during the first 14 days after discharge. One infant was readmitted for a 4-day hospital stay for suspected sepsis. Significantly earlier discharge of high-risk neonates produced a decrease in hospital charges without causing excessive morbidity. The success of the program was coincident and presumed related to the institution of multiple elements focused toward family support through early-discharge planning. The reduction in hospital charges was 30 times higher than program expenses.
Assuntos
Custos Hospitalares/estatística & dados numéricos , Recém-Nascido de Baixo Peso , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Tempo de Internação/economia , Alta do Paciente , Assistência ao Convalescente/economia , Estudos de Casos e Controles , Controle de Custos , Feminino , Serviços de Assistência Domiciliar/economia , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/economia , Masculino , Ohio , Avaliação de Resultados em Cuidados de Saúde , Readmissão do Paciente , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Fatores de TempoRESUMO
OBJECTIVE: The Medicus Patient Classification System (PCS) and the lameter Acuity Index Method (AIM) are two proprietary scoring systems in common use for stratifying patient populations before making comparisons of the medical care they receive. In this study the validities of these scores were tested when the scores were used to evaluate cost-related elements of high-risk neonatal intensive care. METHODS: A total of 687 surviving inborn infants cared for in a university hospital newborn intensive care unit provided data for these analyses. The infants were stratified into the five diagnosis-related groups (DRGs) for surviving neonates (386, 387, 388, 389, and 390), as determined from their discharge diagnoses. Each infant's summed total of daily PCS scores, a single AIM score, and birth weight were extracted from the hospital's decision-support data files and used as independent variables in regression analyses to determine correlations with lengths of hospital stay, ancillary resource utilizations, and hospital charges. RESULTS: The Medicus scores, which are computed prospectively on a daily basis, when summed retrospectively, correlated highly with lengths of stay, ancillary resource utilization, and associated hospital charges. The lameter scores, which are assigned retrospectively, were far less predictive of these outcome variables and generally worse than birth weight in explaining outcome variances. CONCLUSIONS: Although in common use, the lameter AIM could not be validated as an appropriate method for assessing cost-related outcomes after newborn intensive care. The Medicus PCS produced daily scores that, when summed after patient discharge, correlated highly with the same outcome variables. There is a need to test further these and other proprietary methods now used to compare the cost-related elements of care provided by different hospitals and physicians.
Assuntos
Terapia Intensiva Neonatal/estatística & dados numéricos , Peso ao Nascer , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Idade Gestacional , Custos Hospitalares , Registros Hospitalares/estatística & dados numéricos , Humanos , Recém-Nascido , Terapia Intensiva Neonatal/economia , Tempo de Internação/economia , Masculino , Ohio , Avaliação de Resultados em Cuidados de Saúde , Discrepância de GDH/economia , Discrepância de GDH/estatística & dados numéricos , Estudos Prospectivos , Estados UnidosRESUMO
One hundred and eight "exchange" blood transfusions were done on 61 newborn infants. Baseline serum PTH concentrations and the PTH rise in response to citrate-induced hypocalcemia were studied. Baseline PTH values increased with postnatal age, particularly after the first three days of life. The acute response of PTH to citrate-induced hypocalcemia appears within ten minutes following the initiation of exchange transfusion and was shortlived in spite of further decline of serum ionized calcium. The dominant effect of postnatal age over gestational age was demonstrated: postnatally older but gestationally less mature infants exhibited greater responsiveness than postnatally younger, but gestationally more mature, infants. The PTH response during exchange transfusion was blunted in hypomagnesemic infants. Since lower serum magnesium concentrations were also present during the first three days of life, a separate effect of serum magnesium concentrations on parathyroid responsiveness cannot be ruled out in this study.
Assuntos
Transfusão Total/métodos , Magnésio/sangue , Hormônio Paratireóideo/sangue , Cuidado Pós-Natal/métodos , Fatores Etários , Cálcio/sangue , Citratos/efeitos adversos , Feminino , Idade Gestacional , Humanos , Hiperbilirrubinemia/terapia , Hipocalcemia/induzido quimicamente , Recém-Nascido , Magnésio/administração & dosagem , Masculino , Fatores SexuaisRESUMO
Twenty pre-eclamptic mothers treated with MgSO4 and their newborn infants were studied prospectively to determine the clinical and biochemical effects of hypermagnesemia. Maternal serum magnesium concentration rose to 4.4 mg/dl at delivery and was accompanied by a fall in maternal serum calcium concentration during labor. Neonatal serum Mg concentration remained elevated for the first 72 hours of life (mean at 72 hours = 3.0 mg/dl). Serum Mg concentration was higher in premature infants and in babies with birth asphyxia and/or hypotonia. Serum Ca concentration was higher and serum PTH was lower in hypermagnesemic study infants when compared to a retrospectively selected, matched froup of control infants. We speculate that elevated serum Mg values in these infants result in a shift of Ca from bone to plasma, and that elevated Mg and Ca concentrations further suppress neonatal parathyroid function.
Assuntos
Cálcio/sangue , Doenças do Recém-Nascido/sangue , Magnésio/sangue , Hormônio Paratireóideo/sangue , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Sulfato de Magnésio/uso terapêutico , Troca Materno-Fetal , Pré-Eclâmpsia/tratamento farmacológico , Gravidez , Estudos ProspectivosRESUMO
Sixteen neonates, ranging in gestational age from 27 to 41 weeks and in postnatal age from birth to 8 days, were evaluated for their renal response to an endogenous PTH stimulus in 22 separate experiments. The PTH stimulus was generated by the decreased serum ionized Ca that accompanies exchange transfusion with citrated blood. The neonates increased their serum PTH from 95.8 +/- 13.1 to 133.9 +/- 15.4 microliterEq/ml (mean +/- SEM) during the transfusion, while increasing their urinary cAMP from 0.77 +/- 0.11 to 1.45 +/- 0.22 nmol/ml, and their urinary P from 12.9 +/- 2.6 to 30.6 +/- 6.1 mg/dl in the four hours following the exchange transfusion. This response was not related to postnatal or gestational age. We speculate that lack of renal responsiveness to PTH does not play a major role in the pathogenesis of early neonatal hypocalcemia.