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Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center | Baer V.L.,Intermountain Healthcare | Baer V.L.,y Dee Hospital Center | And 7 more authors.
Pediatrics | Year: 2012

BACKGROUND AND OBJECTIVE: Both high and low lymphocyte counts at birth have been associated with adverse outcomes. However, the validity of defining a lymphocyte count as "abnormal" depends on having an accurate reference range. We established a reference range for neonatal lymphocyte counts by using multihospital data and used this to assess previously reported relationships between abnormal counts and early onset sepsis (EOS), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), periventricular leukomalacia, and birth asphyxia. METHODS: We first created a data set that excluded counts fromneonates with diagnoses previously associated with abnormal lymphocyte counts. Then the complete data (counts excluded plus included in the reference range) were used to test associations between abnormal counts and EOS, IVH, ROP, periventricular leukomalacia, and outcomes after birth asphyxia. RESULTS: Lymphocyte counts were retrieved from 40 487 neonates, 10 860 of which were excluded from the reference range. A count >95th percentile was associated with EOS (2.07; 95% confidence interval [CI]: 1.80-2.38) and IVH ≥grade 3 (2.93; 95% CI: 1.83-4.71). A count <5th percentile was associated with EOS (odds ratio:1.24; 95% CI: 1.04-1.48), IVH≥grade 3 (3.23; 95% CI: 1.95-5.36), and ROP ≥stage 3 (4.80: 95% CI: 2.38-9.66). Among 120 meeting criteria for birth asphyxia, those with a low count and a high nucleated red cell count had higher mortality (37% vs 11%, P = .001), more transfusions (P = .000), and more neurology referrals (P < .01). CONCLUSIONS: A reference range for lymphocytes can identify neonates with abnormal counts, which can be useful because these neonates are at higher risk for certain adverse outcomes. Copyright © 2012 by the American Academy of Pediatrics.

Keren R.,Children's Hospital of Philadelphia | Keren R.,University of Pennsylvania | Luan X.,Children's Hospital of Philadelphia | Localio R.,Children's Hospital of Philadelphia | And 6 more authors.
Archives of Pediatrics and Adolescent Medicine | Year: 2012

Objective: To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics. Design: Retrospective analysis of administrative and billing data for hospital encounters. Setting: Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009. Participants: Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges. Main Outcome Measures: Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters. Results: Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter. Conclusions: Detailed administrative and billing data can be used to standardize hospital costs and identify highpriority conditions for comparative effectiveness research - those that are high cost, are high prevalence, and demonstrate high variation in resource utilization. ©2012 American Medical Association. All rights reserved.

Henry E.,Institute for Healthcare Delivery Research | Henry E.,Intermountain Healthcare | Andres R.L.,Intermountain Healthcare | Andres R.L.,University of Utah | And 3 more authors.
Journal of Perinatology | Year: 2013

Objective: The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord. Study Design: This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head. Result: Of 219 337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die. Conclusion: The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200 000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord. Copyright © 2013 Nature America, Inc.

Stone B.L.,Primary Childrens Medical Center | Stone B.L.,University of Utah | Boehme S.,Primary Childrens Medical Center | Mundorff M.B.,Primary Childrens Medical Center | And 4 more authors.
Archives of Disease in Childhood | Year: 2010

Objective: To evaluate admission medication reconciliation in children with medically complex conditions (MCC) by determining the availability and accuracy of five information sources and characterising admitting order errors. Design: Prospective quality improvement cohort study. Setting: Tertiary care free-standing children's hospital in the Intermountain west, USA. Participants: 23 children with MCC identified from 219 admissions between 16 December 2004 and 7 January 2005. Intervention: Medication reconciliation at hospital admission using information from five sources. Main outcomes: The accuracy of information sources was determined by sensitivity and specificity compared with verified outpatient medication lists. Errors were determined by comparing admitting orders with reconciled inpatient medication lists and categorised by frequency, type and clinical risk. Results: Children with MCC averaged 5.3 chronic medications. The reconciliation process took an average of 90 min. Availability/sensitivity/specificity respectively were parents 52%/0.75/0.96, pharmacy 61%/0.64/0.74, primary provider 43%/0.25/0.86, last admission electronic health record 87%/0.74/0.33 and admitting history 65%/0.31/0.94. Thirty-nine errors were identified in 182 admission medications (21%) including 17 omissions, affecting 13 patients (57%). The estimated clinical risk, if an adverse drug event had occurred, was serious or life-threatening in five instances. Conclusions: In children with MCC admitted at our institution during the study period, no medication information source was optimally available, sensitive and specific. Admitting order medication errors affected more than half of patients, the most common being omissions. Efforts to improve medication reconciliation at hospital admission in this population must account for availability and accuracy of information sources and medication omissions at the time of hospital admission.

Christensen R.D.,Institute for Healthcare Delivery Research | Baer V.L.,Institute for Healthcare Delivery Research | Lambert D.K.,Institute for Healthcare Delivery Research | Ilstrup S.J.,Institute for Healthcare Delivery Research | And 2 more authors.
Transfusion | Year: 2014

Background Previous reports describe a statistical association, among very-low-birthweight (VLBW, <1500 g) neonates, between red blood cell (RBC) transfusion in the first days after birth and development of severe intraventricular (brain) hemorrhage (IVH). Study Design and Methods We hypothesized that after we established a neonatal intensive care unit (NICU) transfusion management program in 2009, a decrease in early (first week after birth) RBC transfusion rate and a decrease in the incidence of severe IVH occurred concomitantly. Results During a 9-year period 2716 VLBW neonates were admitted to our NICUs. In 2004, 58% of VLBW neonates received one or more RBC transfusions during the first week. After a transfusion compliance program was established in 2009, this rate declined, reaching 25% by 2012. In parallel, the severe IVH rate also declined, from 17% in 2004 to 8% in 2012 (R2 = 0.73). IVH occurred in 27% of those who received a RBC transfusion during the first week versus less than 2% of those with no early transfusion (p < 0.001). The decrease in IVH rate occurred exclusively among neonates born in an Intermountain Healthcare perinatal center and not among those initially cared for in an "outside" hospital and subsequently transported to an Intermountain NICU. Conclusions It remains unclear whether transfusing VLBW neonates during the first days after birth is a proximate cause of IVH. However, the present report is consistent with previous studies showing that successful efforts to reduce early RBC transfusions is associated with a decrease in the incidence of severe IVH. © 2013 American Association of Blood Banks.

Christensen R.D.,Intermountain Healthcare | Lambert D.K.,Intermountain Healthcare | Henry E.,Intermountain Healthcare | Henry E.,Institute for Healthcare Delivery Research | And 2 more authors.
Blood Cells, Molecules, and Diseases | Year: 2015

In the first days of life, low grade jaundice is essentially universal. The source of the elevated bilirubin level giving rise to "physiological jaundice of the newborn" is only partly known. We hypothesized that it is, at least in part, the result of active and specific hemolysis involving a physiological mechanism to lower the high fetal hematocrit, appropriate for the relatively low oxygen environment in utero, to a lower level appropriate for the state of oxygen abundance after birth. We tested this by quantifying end tidal carbon monoxide (ETCO) as a marker of the rate of heme metabolism to bilirubin. We found that ETCO values of 20 neonates and children with known hemolytic disorders were higher than 20 age-matched healthy controls (p. <. 0.0001), indicating that this instrumentation recognizes hemolysis in neonates and children. We also found that ETCO reference intervals were indeed higher in healthy neonates during the first three days after birth (5th to 95th percentile reference range, 1.4 to 1.7. ppm) than after 1. month of age (all ≤. 1.0. ppm, p. <. 0.0001). These results suggest to us that hemolysis is physiological during the first days after birth. The cellular and molecular mechanisms responsible for transient hemolysis after birth are topics of current investigation. © 2014 Elsevier Inc.

Sheffield M.J.,y Dee Hospital Center | Lambert D.K.,y Dee Hospital Center | Henry E.,Institute for Healthcare Delivery Research | Christensen R.D.,y Dee Hospital Center
Journal of Perinatology | Year: 2010

Objective:Studies in adults indicate that ampicillin, in a dose-dependent manner, impairs platelet function and moderately prolongs the bleeding time (generally by 60 to 90 s). Unlike aspirin, the inhibition induced by ampicillin involves both reversible and irreversible mechanisms and is not observed immediately after initial dosing (generally requiring approximately 24 h). Ampicillin is administered commonly to neonatal intensive care unit (NICU) patients, but its effect on bleeding time in this population has not been reported earlier.Study Design:We performed neonatal template bleeding times and platelet function analyzer (PFA)-100 tests on 15 NICU patients before and at various intervals after intravenous ampicillin dosing.Result:Neonates were only studied if no beta-lactam antibiotics were administered to their mother during labor, and if they had ampicillin ordered by the clinician at a dose of 50 to 100 mg kg -1 every 12 h. Subjects ranged from 33 to 41 weeks gestation and weighed 1760 to 3835 g. Bleeding times before the first ampicillin dose (n15) averaged 134 s (95% confidence interval (CI), 120 to 148 s) and PFA-100 times averaged 123 s (95% CI, 96 to 149 s). After the first dose of ampicillin (n5), bleeding times and PFA-100 times did not increase, but after the third (n5) and fourth doses (n4) bleeding times lengthened by an average of 60 s (95% CI, 37 to 83 s, P<0.001) and PFA-100 times lengthened by an average of 20 s (95% CI, 20 to 60 s, P0.15).Conclusion:Ampicillin administered intravenously to NICU patients prolongs the bleeding time, with a magnitude-of-effect and time-to-effect similar to that shown earlier in adults. © 2010 Nature America.

Metz T.D.,Intermountain Healthcare | Stoddard G.J.,University of Utah | Henry E.,Institute for Healthcare Delivery Research | Jackson M.,Intermountain Healthcare | And 2 more authors.
American Journal of Obstetrics and Gynecology | Year: 2013

Objective: Our aim was to compare good candidates for trial of labor after cesarean (TOLAC) who underwent repeat cesarean to those who chose TOLAC. Study Design: Data for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with a primary cesarean and 1 subsequent delivery in the dataset were included. The choice of elective repeat cesarean vs TOLAC was assessed in the first delivery following the primary cesarean. Women with ≥70% chance of successful vaginal birth after cesarean as calculated by a published nomogram were considered good candidates for TOLAC. Good candidates who chose an elective repeat cesarean were compared to those who chose TOLAC. Women who were delivered at 2 preselected tertiary centers by a general obstetrician-gynecologist practice were subanalyzed to determine whether there was an effect of physician group. Results: In all, 5445 women had a primary cesarean and a subsequent delivery. A total of 3120 women were calculated to be good TOLAC candidates. Of this group, 925 (29.7%) chose TOLAC. Women managed by a family practitioner or who were obese were less likely to choose TOLAC while women who were managed by a midwife or had a prior vaginal delivery were more likely to choose TOLAC. At the 2 tertiary centers, 1 general obstetrician-gynecologist group had significantly more patients who chose TOLAC compared to the other obstetrician-gynecologist physician groups (P <.001), with 63% of their patients choosing TOLAC. Conclusion: Less than one-third of the good candidates for TOLAC chose TOLAC. Managing provider influences this decision. © 2013 Mosby, Inc.

Christensen R.D.,University of Utah | Christensen R.D.,Intermountain Healthcare | Henry E.,Intermountain Healthcare | Henry E.,Institute for Healthcare Delivery Research | And 2 more authors.
Journal of Perinatology | Year: 2016

Objective:The automated reticulocyte parameters (absolute reticulocyte count, immature reticulocyte fraction (IRF) and reticulocyte hemoglobin content (RET-He)) are of value in managing adults and older children with a variety of hematological disorders. However, the lack of reference intervals for these parameters in neonates and young infants has limited their application to that population.Study Design:During a span of 12 months (29 May 2014 to 5 May 2015), a convenience sample of reticulocyte parameters were run from clinically ordered complete blood counts (CBCs) of infants within the first 90 days after birth. Measuring the reticulocyte parameters as a research-only adjunct to the CBC did not require any additional blood or generate a patient charge, and the reticulocyte results were not reported to the provided and did not appear in the clinical records. Values from neonates who had a transfusion or a diagnosis of anemia were subsequently excluded from the reference data set.Results:Nine Intermountain Healthcare clinical laboratories contributed 8438 CBCs to the initial reticulocyte parameter database. From these, 1806 were excluded because of a transfusion or a diagnosis of anemia, leaving 6632 in the reference interval database. The parameters charted over the first 90 days after birth were: (1) blood hemoglobin concentration (g dl -1), (2) mean corpuscular volume (fL), (3) reticulocyte count (x10 3 per μl), (4) IRF (%) and (5) RET-He (pg).Conclusions:The new reference interval charts can help clinicians identify abnormalities in the reticulocyte parameters. This information could be of value in identifying and following neonates with various hematological problems including hemolytic disorders, occult hemorrhage, or iron deficiency or other limitations of erythrocyte production. © 2016 Nature America, Inc.

Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center | Henry E.,Intermountain Healthcare | Henry E.,Institute for Healthcare Delivery Research
Pediatrics | Year: 2010

OBJECTIVES: Hereditary spherocytosis (HS) is the most common inherited hemolytic disease among people of Northern European decent. Neonates with HS can develop significant hyperbilirubinemia, but we suspect that HS is underrecognized as a cause of neonatal jaundice. METHODS: We used electronic record repositories of Intermountain Healthcare to identify all neonates with a diagnosis of HS in a recent 5-year period. We compared these with the number of new HS cases anticipated on the basis of national prevalence and also with the number who had elevations in mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), and bilirubin. We compared MCHC and RDW values of neonates who had direct antiglobulin test-positive (DAT[+]) and DAT(-) results and jaundice with values of neonates who had HS. RESULTS: Eight neonates received a diagnosis of HS; however, we may have failed to diagnose 90% of cases. To assess whether some with a missed diagnosis of HS developed significant hyperbilirubinemia, we examined records of all 670 with a bilirubin level of ≥20 mg/dL. Records of the 20 with the highest MCHC and RDW values suggested that HS was present but unrecognized in at least 7. Follow-up revealed a subsequent diagnosis of HS in 5; the other 2 are no longer in our health system. MCHC and RDW values were highest in those with HS, intermediate in the DAT(+) group, and lowest in the DAT(-) group. An MCHC of ≥36.0 g/dL had 82% sensitivity and 98% specificity for identifying HS. CONCLUSION: We speculate that HS is underrecognized as a cause of neonatal hyperbilirubinemia. We speculate further that an MCHC of ≥36.0 g/dL can alert caregivers to the possibility of HS. Copyright © 2009 by the American Academy of Pediatrics.

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