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Background The impact of mode of delivery in chorioamnionitis on neonatal outcomes is unclear. This retrospective cohort study compares the rate of early onset neonatal sepsis between vaginal delivery and cesarean section. Methods Singleton pregnancies at greater than 24 + 0 weeks gestation with live birth and clinically-diagnosed chorioamnionitis from January 1, 2019 to December 31, 2021 were included. Cases with multiple gestations, terminations or histological chorioamnionitis alone were excluded. Rates of early onset neonatal sepsis, select secondary neonatal outcomes and a composite outcome of maternal infectious morbidity were compared using propensity score weighting. Subgroup analysis was done by indication for cesarean section. Results After chart review, 378 cases were included with 197 delivering vaginally and 181 delivering via cesarean section. The groups differed on age, parity, hypertension, renal disease, gestational age, corticosteroid use, magnesium sulfate use, presence of meconium and percentage meeting Gibbs criteria before propensity score weighting. Rate of early onset neonatal sepsis was greater in the cesarean section group (13.8% versus 3.1%, adjusted risk difference 8.3% [3.5–13.1], p  < 0.001). Secondary neonatal outcomes were similar between groups. When compared by indication, the rate of early onset neonatal sepsis was greater in the cesarean section for abnormal fetal surveillance group compared to vaginal delivery but not in the cesarean section for other reasons group. Adjusted rates of secondary neonatal outcomes did not differ between groups. The rate of maternal infectious morbidity was greater with cesarean section. (13.8% versus 1.5% [adjusted risk difference 13.0% [7.1–18.9], p  < 0.0001). No other difference in maternal secondary outcomes was identified. Conclusions The rate of early onset neonatal sepsis was highest in the cesarean section group, particularly in those with abnormal fetal surveillance. Fetuses affected by or vulnerable to sepsis likely have a greater need for cesarean section.

Background Post-resuscitation debriefing (PRD) is the process of facilitated, reflective discussion, enabling team-based interpersonal feedback and identification of systems-level barriers to patient care. The importance and benefits of PRD are well recognized; however, numerous barriers exist, preventing its practical implementation. Use of a debriefing tool can aid with facilitating debriefing, creating realistic objectives, and providing feedback. Objectives To assess utility of two PRD tools, Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) and Post-Code Pause (PCP), through user preference. Secondary aims included evaluating differences in quality, subject matter, and types of feedback between tools and implications on quality improvement and patient safety. Methods Prospective, crossover study over a 12-month period from February 2019 to January 2020. Two PDR tools were implemented in 8 week-long blocks in acute care settings at a tertiary care children’s hospital. Debriefings were triggered for any intubation, resuscitation, serious/unanticipated patient outcome, or by request for distressing situations. Post-debriefing, team members completed survey evaluations of the PDR tool used. Descriptive statistics were used to analyze survey responses. A thematic analysis was conducted to identify themes that emerged from qualitative responses. Results A total of 114 debriefings took place, representing 655 total survey responses, 327 (49.9%) using PCP and 328 (50.1%) using DISCERN. 65.2% of participants found that PCP provided emotional support while only 50% of respondents reported emotional support from DISCERN. PCP was found to more strongly support clinical education (61.2% vs 56.7%). There were no significant differences in ease of use, support of the debrief process, number of newly identified improvement opportunities, or comfort in making comments or raising questions during debriefs between tools. Thematic analysis revealed six key themes: communication, quality of care, team function & dynamics, resource allocation, preparation and response, and support. Conclusion Both tools provide teams with an opportunity to reflect on critical events. PCP provided a more organized approach to debriefing, guided the conversation to key areas, and discussed team member wellbeing. When implementing a PRD tool, environmental constraints, desired level of emotional support, and the extent to which open ended data is deemed valuable should be considered.

Preterm birth is the leading cause of morbidity and mortality in children younger than 5 years. We report the changes in neonatal outcomes and care practices among very preterm infants in Canada over 14 years within a national, collaborative, continuous quality-improvement program. We retrospectively studied infants born at 23–32 weeks’ gestation who were admitted to tertiary neonatal intensive care units that participated in the Evidence-based Practice for Improving Quality program in the Canadian Neonatal Network from 2004 to 2017. The primary outcome was survival without major morbidity during the initial hospital admission. We quantified changes using process-control charts in 6-month intervals to identify special-cause variations, adjusted regression models for yearly changes, and interrupted time series analyses. The final study population included 50 831 infants. As a result of practice changes, survival without major morbidity increased significantly (56.6% [669/1183] to 70.9% [1424/2009]; adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 1.06–1.10, per year) across all gestational ages. Survival of infants born at 23–25 weeks’ gestation increased (70.8% [97/137] to 74.5% [219/294]; adjusted OR 1.03, 95% CI 1.02–1.05, per year). Changes in care practices included increased use of antenatal steroids (83.6% [904/1081] to 88.1% [1747/1983]), increased rates of normothermia at admission (44.8% [520/1160] to 67.5% [1316/1951]) and reduced use of pulmonary surfactant (52.8% [625/1183] to 42.7% [857/2009]). Network-wide quality-improvement activities that include better implementation of optimal care practices can yield sustained improvement in survival without morbidity in very preterm infants.

Background Extremely preterm infants are prone to hyperbilirubinemia and its sequelae. Currently recommended thresholds for initiating phototherapy in these newborns are consensus-based (CB). Methods A multi-site retrospective cohort study of 642 infants born at 24 0/7 to 28 6/7 weeks’ gestation, between January 2013 and June 2017, was conducted at three NICUs in Canada. Pre-phototherapy TSB percentile levels at 24 h of age were generated and contrasted with published CB thresholds. Results Among infants born 24 0/7 to 25 6/7 weeks’ gestation, the differences between our TSB percentiles vs. the CB threshold of 85.0 µmol/L were 10.0 µmol/L (95% CI, 6.0–16.0) at the 75th percentile and 35.3 µmol/L (95% CI, 26.1–42.8) at the 95th percentile. Respectively, among infants born at 26 0/7 to 27 6/7 weeks, differences were 19.4 µmol/L (95% CI, 16.8–23.4) and 43.3 µmol/L (95% CI, 34.7–46.9). Born at 28 0/7 to 28 6/7 weeks’ gestation, differences between our 75th and 95th TSB percentiles and the CB threshold of 103 µmol/L were 6.9 µmol/L (95% CI, 3.2–12.0) and 36.0 µmol/L (95% CI, 31.0–44.3), respectively. Conclusions We provide statistically derived pre-phototherapy TSB levels that may clarify patterns of pre-phototherapy TSB levels in extremely preterm infants. Impact We present statistically derived pre-phototherapy total serum bilirubin levels in a cohort of extremely preterm infants. Most of these preterm infants received phototherapy—some at below currently published thresholds. There are notable differences between our statistically derived pre-phototherapy TSB levels and currently published lower limit TSB thresholds for phototherapy. Our study results assist in the understanding of pre-phototherapy TSB levels in extremely preterm infants.

BackgroundHealthcare organisations face widespread challenges in optimising their safety culture, especially amid conflicting stakeholder needs, staffing shortages and increasing acuity of patients. McMaster University Children’s Hospital Neonatal Intensive Care Unit developed a safety culture programme that prioritises the needs of patients, hospital staff and learners altogether.MethodsThe safety culture programme and activities revolve around six primary drivers: psychological safety, provider well-being, equity, diversity and inclusion, teamwork and communication, organisational learning and leadership. We describe how these drivers influence safety culture, the ongoing activities being implemented, stakeholder feedback and contextual factors. We evaluated the maturity of our safety culture using the Manchester Patient Safety Framework (MaPSaF) questionnaire.ResultsMaPSaF assessments were conducted three times over 4 years. Most domains of safety culture in MaPSaF maintained their position despite COVID-19 while some indicators declined or have been maintained.ConclusionsWe provide a framework for implementing a safety culture programme that addresses the needs of diverse stakeholders. Transformation of the safety culture takes time and the failure to improve the patient safety measures over the period may be attributed to rapidly increasing workload and worsening patient acuity. These challenges underscore the imperative of balancing transactional and transformational projects to preserve a safety culture.

Background As compared to term neonates, those < 35 weeks gestation (wks GA) are at greater risk for both acute and chronic bilirubin encephalopathy (ABE, CBE). Among these with postnatal total bilirubin rate of rise, (TB ROR) at age 0 to 72 hours has been observed because of either loss placental elimination system or increased postnatal production due to hemolysis. The ranges are known to vary > 8.5 umol/L/h in neonates with Rh disease to >3.4 umol/L/h at the 95th percentile track of the hour-specific nomogram. TB ROR in healthy term neonates is <3.4 umol/L/h. Objectives To determine the GA ranges on TB ROR to explore predictive TB ROR in preterm neonates who are more vulnerable with each <35 wks GA. Design/Methods A multi-site observational study to quantify TB ROR in preterm infants between 28 to 35 weeks. 1804 infants born between January 2013- March 2018 at 28–35 wks GA from three canadian perinatal centres were included and those with Rh disease were excluded. Analysis included infants >27 weeks with at least one TB prior to the initiation of treatment for severe hyperbilirubinemia treatment. Feeding patterns, birth history and maternal health conditions were documented. Results The TB ROR were compared by two prematurity GA groups (28–31 weeks and 32–35 weeks) then per individual gestational age in four time periods in hours, 0–24, 24–48, 48–96, and 96 -120 in 1049 preterm infants using 3065 TB samples. Infants <28 weeks GA were excluded since they represented a more diverse population. TB ROR by prematurity groups over all was higher in 32–35 weeks group at 0–12 hours (3.85 umol/L/h) and 25–36 hours (2.81umol/L/h) and decreased at 49–72 hours (0.24umol/L/h) time period as compared to the less mature group. Conclusion Though TB ROR were of similar patterns between prematurity groups (28–31 weeks and 32–35 weeks) it was at higher rate of rise between 13–36 hours and decreasing from 36–72 hours, with a plateau after 72 hours of age. There was a significant difference in the magnitude of TB ROR between prematurity groups at 0–24 hours. Additional research into the clinical care impact on the TB ROR should be conducted to study impact of production and elimination. Table 1: Total Bilirubin Rate of Rise Between 0–96 hours of age by Gestational Age. Postnatal Age (h) TB ROR (umol/l/h) GA (weeks) 0 to 12h 13-24h 25 to 36h 37-48h 49-72h 73-96h 28–31 0.27 2.26 2.53 1.13 1.33 0.18 32–35 3.85 1.88 2.81 1.77 1.07 0.24

Background Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care. Methods/Design The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model. Discussion In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns. Trial registration ClinicalTrial.gov, NCT02912780 . Retrospectively registered on 22 September 2016.

Abstract Introduction Rh sensitization occurs when Rh(D)-negative women develop anti-Rh(D) antibodies following exposure through pregnancy or transfusion. Rh disease may cause jaundice, anemia, neurological impairment, and death. It is rare in countries where Rh Immune Globulin (RhIg) is used. Canadian Rh sensitization and disease rates are unknown. Methods This survey-based study was conducted using a Canadian Paediatric Surveillance Program questionnaire sent to Canadian paediatricians and paediatric subspecialists to solicit Rh disease cases from May 2016 to June 2018. Paediatricians reported Rh-positive infants ≤ 60 days of age, born to Rh-negative mothers with RhD sensitization. Results Sixty-two confirmed cases of infants affected by Rh(D) sensitization were reported across Canada. The median gestational age of neonates was term, age at presentation was 2 hours, and hemoglobin at presentation was 137.5 g/L (33 to 203 g/L). The median peak bilirubin and phototherapy duration were 280 µmol/L (92 to 771 µmol/L), and 124 hours, respectively. Thirty (48%) infants received Intravenous immune globulin (IVIG) (median two doses). Seventeen (27%) received one to three simple transfusions; 10 (16%) required exchange transfusions. Six (10%) infants presented with acute bilirubin encephalopathy, and less than five presented with seizures. Fourteen mothers with affected infants were born outside of Canada. Discussion Rh disease continues to exist in Canada. Additional efforts are needed to raise awareness of Rh disease, prevent disease, and minimize sequelae when it does occur. The ongoing global burden of Rh Disease, as well as the possibility of emerging Rh immunoglobulin refusal are among factors that could be taken into consideration in future prevention efforts.

This chapter contains sections titled: Introduction Overview of treatment structure (Saxe, Ellis, & Kaplow, 2007) Assessment under Trauma Systems Therapy (Saxe, Ellis, & Kaplow, 2007) How to identify the most important problem(s) to address in treatment (Saxe et al., 2007) Services under Trauma Systems Therapy (Saxe et al., 2007) Treatment duration (Saxe et al., 2007) Adaptations: TST in different settings and with different populations Conclusion References

In the Neolithic megasite at Çatalhöyük families lived side by side in conjoined dwellings, like a pueblo. It can be assumed that people were always in and out of each others' houses – in this case via the roof. Social mechanisms were needed to make all this run smoothly, and in a tour-de-force of botanical, faunal and spatial analysis the authors show how it worked. Families stored their own produce of grain, fruit, nuts and condiments in special bins deep inside the house, but displayed the heads and horns of aurochs near the entrance. While the latter had a religious overtone they also remembered feasts, episodes of sharing that mitigated the provocations of a full larder.