David A. Paul, M.D.

Chair, Department of Pediatrics; Director, Neonatal Research; Service Line Leader, Women and Children; Professor of Pediactrics, Jefferson Medical College

Publications

Variation in NICU Admission Rates Without Identifiable Cause
Variation in NICU Admission Rates Without Identifiable Cause
Ziegler KA, Paul DA, Hoffman M, Locke R

Hosp Pediatr 2016 May;6(5):255-60

PMID: 27117951

Abstract

OBJECTIVES: Admission to the NICU is influenced by physiologic compromise and by hospital care protocols. Providing appropriate care must be balanced with adverse consequences of NICU admission, such as interrupting maternal-infant bonding and unnecessary interventions. This study aims to determine the variation in NICU admissions in term and late preterm infants among 19 hospitals.
METHODS: We used the Consortium on Safe Labor (CSL) database to determine NICU admission rates. This database includes data from 217 442 infants aged 35 to 42 weeks within 19 US maternal delivery hospitals from 2002 to 2008. NICU admission rates were evaluated for absolute factors including, but not limited to, sepsis, asphyxia, respiratory distress, and intracranial hemorrhage, as well as relative factors, such as maternal drug use, chorioamnionitis, and infant birth weight ≤ 2500 g.
RESULTS: Percentage of infants 35 to 42 weeks' gestation admitted to the NICU without an identifiable absolute or relative cause for intensive care services ranged from 0% to 59.4% (mean, 10.8%; P < .001). Among infants 35 to 42 weeks' gestation and ≥ 2500 g, infants without absolute or relative identified cause accounted for 9.1% of total NICU days and had lower length of stays (-2.7 days; 95% confidence interval -3.4; -2.1) compared to those with an identified reason.
CONCLUSIONS: There is significant variation in admission rates among NICUs that cannot be explained by infant health conditions. Further analysis is needed to determine the cause of between-site variation and potential opportunities to refine protocols and optimize use of NICU services.
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Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?
Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?
Goldstein ND, Eppes SC, Ingraham BC, Paul DA

J Perinatol 2016 Sep;36(9):753-7

PMID: 27149054

Abstract

OBJECTIVE: Infants in neonatal intensive care units (NICUs) are vulnerable to a variety of infections, and occupancy in the unit may correlate with risk of infection.
STUDY DESIGN: A retrospective cohort of infants admitted to the NICUs between 1997 and 2014. Survival analysis was used to model the relative hazard of sepsis infection in relation to two measures of occupancy: 1) the average census and 2) proportion of infants <32 weeks gestation in the unit.
RESULT: There were 446 (2.3%) lab-confirmed cases of bacterial or fungal sepsis, which steadily declined over time. For each additional percentage of infants <32 weeks gestation, there was an increased hazard of 2% (hazard ratio 1.02, 95% confidence interval: 1.00, 1.03) over their NICU hospitalization. Census was not associated with risk for infection.
CONCLUSION: During times of a greater proportion of infants <32 weeks gestation in the NICU, enhanced infection-control interventions may be beneficial to further reduce the incidence of infections.
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Time Series Analysis for Forecasting Hospital Census: Application to the Neonatal Intensive Care Unit
Time Series Analysis for Forecasting Hospital Census: Application to the Neonatal Intensive Care Unit
Capan M, Hoover S, Jackson EV, Paul D, Locke R

Appl Clin Inform 2016;7(2):275-89

PMID: 27437040

Abstract

BACKGROUND: Accurate prediction of future patient census in hospital units is essential for patient safety, health outcomes, and resource planning. Forecasting census in the Neonatal Intensive Care Unit (NICU) is particularly challenging due to limited ability to control the census and clinical trajectories. The fixed average census approach, using average census from previous year, is a forecasting alternative used in clinical practice, but has limitations due to census variations.
OBJECTIVE: Our objectives are to: (i) analyze the daily NICU census at a single health care facility and develop census forecasting models, (ii) explore models with and without patient data characteristics obtained at the time of admission, and (iii) evaluate accuracy of the models compared with the fixed average census approach.
METHODS: We used five years of retrospective daily NICU census data for model development (January 2008 - December 2012, N=1827 observations) and one year of data for validation (January - December 2013, N=365 observations). Best-fitting models of ARIMA and linear regression were applied to various 7-day prediction periods and compared using error statistics.
RESULTS: The census showed a slightly increasing linear trend. Best fitting models included a non-seasonal model, ARIMA(1,0,0), seasonal ARIMA models, ARIMA(1,0,0)x(1,1,2)7 and ARIMA(2,1,4)x(1,1,2)14, as well as a seasonal linear regression model. Proposed forecasting models resulted on average in 36.49% improvement in forecasting accuracy compared with the fixed average census approach.
CONCLUSIONS: Time series models provide higher prediction accuracy under different census conditions compared with the fixed average census approach. Presented methodology is easily applicable in clinical practice, can be generalized to other care settings, support short- and long-term census forecasting, and inform staff resource planning.
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Prolonged early antibiotic use and bronchopulmonary dysplasia in very low birth weight infants
Prolonged early antibiotic use and bronchopulmonary dysplasia in very low birth weight infants
Novitsky A, Tuttle D, Locke RG, Saiman L, Mackley A, Paul DA

Am J Perinatol 2015 Jan;32(1):43-8

PMID: 24792766

Abstract

OBJECTIVE: The objective of the article is to determine if > 48 hours of antibiotic treatment during the 1st week of life is associated with subsequent isolation of bacteria from the endotracheal tube (ETT), and an increased risk of bronchopulmonary dysplasia (BPD).
STUDY DESIGN: Retrospective cohort study of very low birth weight infants. Routine weekly surveillance ETT cultures were obtained to monitor bacterial colonization in all intubated infants. Risk factors for BPD were assessed using unadjusted and multivariable analyses.
RESULTS: In the study sample (n = 906), infants with BPD (n = 182) were more likely to have received > 48 hours antibiotic treatment (31 vs. 14%, p 48 hours of antibiotics remained associated with BPD (adjusted odds ratio, 2.2; 95% confidence interval, 1.4-3.5) after controlling for confounding variables.
CONCLUSIONS: Antibiotic duration > 48 hours in the 1st week of life was associated with subsequent BPD and the presence of resistant bacteria in routine ETT cultures.
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Instability of delay classification and determination of early intervention eligibility in the first two years of life
Instability of delay classification and determination of early intervention eligibility in the first two years of life
Lobo MA, Paul DA, Mackley A, Maher J, Galloway JC

Res Dev Disabil 2014 Jan;35(1):117-26

PMID: 24176257

Abstract

The purpose of this study was to determine the effectiveness of the Bayley Scales of Infant Development, Third Edition (Bayley-III) to track development and classify delays in low- and high-risk infants across the first two years of life. We assessed cognitive, language, and motor development in 24 low-risk full-term and 30 high-risk preterm infants via seven assessments performed between 3 and 24 months corrected age. The Bayley-III resulted in highly unstable delay classifications, low sensitivities, and poor positive predictive values across time. The results highlight that early intervention professionals, researchers, and policy makers should: (1) emphasize clinical opinion and prevalence of risk factors rather than standardized assessment findings when classifying delays and determining eligibility for services, and (2) develop more effective developmental assessments for infants and young children.
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Complementary and Alternative Medicine use in women during pregnancy: do their healthcare providers know?
Complementary and Alternative Medicine use in women during pregnancy: do their healthcare providers know?
Strouss L, Mackley A, Guillen U, Paul DA, Locke R

BMC Complement Altern Med 2014;14:85

PMID: 24592860

Abstract

BACKGROUND: The National Institutes of Health reported in 2007 that approximately 38% of United States adults have used at least one type of Complementary and Alternative Medicine (CAM). There are no studies available that assess general CAM use in US pregnant women.The objectives of our study were to determine the prevalence and type of CAM use during pregnancy at one medical center; understand who is using CAM and why they are using it; and assess the state of patients' CAM use disclosure to their obstetrical providers.
METHODS: A cross-sectional survey study of post-partum women was done to assess self-reported CAM use during pregnancy. Results of this survey were compared to results from a previous survey performed by this research team in 2006. Data were analyzed using binary logistic regression.
RESULTS: In 2013, 153 women completed the survey, yielding a response rate of 74.3%. Seventy-two percent and 68.5% of participants reported CAM use during their pregnancies in 2006 and 2013 respectively. The percentage of participants who reported discussing CAM use with their obstetrical providers was less than 1% in 2006 and 50% in 2013. Increased use of different CAM therapies was associated with increased maternal age, primagravida, being US-born, and having a college education (p ≤ 0.05). However, these factors were poor predictors of CAM use.
CONCLUSIONS: Given the frequency of CAM use and the difficulty in predicting who is using it, obstetrical providers should consider being informed about CAM and incorporating discussions about its use into routine patient assessments.
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Thyroid function in late preterm infants in relation to mode of delivery and respiratory support
Thyroid function in late preterm infants in relation to mode of delivery and respiratory support
Behme RM, Mackley AB, Bartoshesky L, Paul DA

J. Pediatr. Endocrinol. Metab. 2013 Nov;:1-6

PMID: 24259241

Abstract

Abstract The relationship between thyroid function, mode of delivery, and illness in infants 34-36 weeks' gestation has not been well studied. We hypothesized that infants born by cesarean delivery and those with increased illness would have a reduction in thyroxine (T4) following birth. Total T4 and thyroid-stimulating hormone were obtained at birth (Time 1) and between days 2 and 5 (Time 2). The study sample included 129 infants 34-36 weeks' gestation. There were no differences in total T4 between infants born by cesarean or vaginal delivery (p=0.18), or between those requiring respiratory support compared to infants not requiring respiratory support (p=0.09). At Time 2, 93% of the study population had a total T4 below one standard error of the reference laboratory mean. In our study sample, despite many infants having a low total T4, there was no association between total T4 levels, respiratory support, or mode of delivery.
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Transfusing neonates based on platelet count vs. platelet mass: A randomized feasibility-pilot study
Transfusing neonates based on platelet count vs. platelet mass: A randomized feasibility-pilot study
Zisk JL, Mackley A, Clearly G, Chang E, Christensen RD, Paul DA

Platelets 2013 Nov;

PMID: 24224920

Abstract

Abstract The objective of this study was to obtain pilot data on which to judge the feasibility and sample size needed for a future comparative-effectiveness trial of platelet transfusions in the NICU. We conducted a limited-scope pilot trial in which neonates were randomized to receive platelet transfusions based on platelet mass vs. platelet count, using preset "transfusion-trigger" values. Analysis included parental consent rate, number of platelet transfusions given, bleeding episodes recorded, and mortality rate. Statistical analysis included ANOVA and Chi-square. A convenience sample of 30 were randomized; 15 per group. No differences were found between groups in gestational age, birth weight, race, gender or clinical diagnoses. The study consent rate was 52% (30/58). No differences were found in number of platelet transfusions received, bleeding episodes, or mortality. Lack of a trend in transfusion-reduction resulted in inability to estimate the number needed in a future comparative-effectiveness trial. Using platelet mass, rather than platelet count, for a NICU platelet transfusion trigger is feasible. However, any future comparative-effectiveness trial, testing the hypothesis that a platelet mass-based trigger reduces the transfusion rate will likely require a very large sample size.
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