To:          PMB Team Colleagues

From:    David Wirtschafter, MD

                Brian Reichman, MBChB

Date:     December 30, 2018

Subj:      Recent California (CPQCC) Reports on SIVH prevention practices and outcome: Highlights relevant to the PMB Project with approximately comparable data from the Israel  Neonatal Network (INN).

Report #1: Sara C. Handley CPQCC.  Survey of preterm neuro-centric care practices in California neonatal

intensive care units. J PERINATOLOGY 2018

Report #2:  Sara C. Handley CPQCC. Incidence Trends and Risk Factor Variation in Severe Intraventricular

Hemorrhage across a Population Based Cohort. J PEDIATRICS 2018          

#1 SIVH PREVENTION PRACTICES adopted 2015-2016.

Practices aggregated from the annual surveys of implemented practices in California NICUs (65% compliance rate), much like we are starting to do with our PMB surveys:

Their list of surveyed practices includes many that are part of our PMB program, either already distributed or likely to be considered and released in one form or another soon, with the major exceptions of intubation premedication, PDA algorithm and Indomethacin prophylaxis.

Their overall summary is:

Practices changing recently were:

There are other useful observations in the article besides these highlights (see attachment).  Their report can be usefully looked at in the context of an accompanying CPQCC report on SIVH outcomes over a nearly identical time period: 2005-2015 (see below).

#1 SIVH PREVENTION PRACTICES adopted 20015-2015

Study design The retrospective cohort included infants 22 ^0/7-31 ^6/7 weeks of gestation without severe congenital anomalies, born at hospitals in the California Perinatal Quality Care Collaborative (CPQCC) between 2005 and 2015. The primary study outcome was severe (grade III or IV) IVH.

Results….[SIVH in California fell] from 9.7% in 2005 to 5.9% in 2015. After stratification by gestational age, antenatal steroid exposure was the only factor associated with a decreased odds of severe IVH for all gestational age subgroups. Other factors, including delivery room intubation, were associated with an increased odds of severe IVH, though significance varied by gestational age. Factors analyzed in the mediation analysis accounted for 45.6% (95% CI 38.7%-71.8%) of the reduction in severe IVH, with increased antenatal steroid administration and decreased delivery room intubation mediating a significant proportion of this decrease, 19.4% (95% CI 13.9%-27.5%) and 27.3% (95% CI 20.3%-39.2%), respectively.

Methods:

Linear regression models were used to determine if the change in the incidence of severe IVH was significant over time, as well as the rates of antenatal steroid exposure and delivery room intubation. A mediation analysis was performed to determine the proportion of the effect attributable to a variable or subset of variables in the change in the incidence of severe IVH over time.

The overall results over the period 2005-2015 are shown in Figure 1

Direct comparison of these rates with Israeli ones are problematic, because the CPQCC authors used different criteria for defining the population from which the calculations were made.  An approximate

comparison has been calculated from the latest report (Israeli Neonatal Database 2016, Editor: Brian Reichman, MD,MPH) and can be used minimally for noting qualitative trends. Please note: a) we do not include a 22-23- wk cohort and b) we only included a 28 wk cohort, whereas CPQCC reports both 28 and 29 wk together. 

Significant drivers associated in the regression analysis are best visualized by the following two associated changes in care process: Antenatal Steroids and Delivery Room Intubation.

Approximately comparable data from the Israel Neonatal Database are:

Steady improvement in Israeli ANS use is apparent, but the seemingly “small” percentage differences from Californian rates have the potential to make a “large” impact on SIVH occurrence rates.

Delivery room intubation dramatically changed in California following a consensus to abandon the practice of early prophylactic Surfactant administration and to maximize the infant stability prior to a demonstrated need for intubation. 

Discussion:

“Antenatal steroids accounted for 16.1% of the decrease in the 24-25 ^6/7 gestational age infants, 12.9% in the 26-27 ^6/7 gestational age infants, 24.1% in the 28-29 ^6/7 gestational age infants, and 19.4% across the whole cohort.  These data highlight the importance of ongoing vigilance in antenatal steroid administration efforts.” (DW note: achieved ANS administration rates in California are now over 90%!) 

“The change in delivery room intubation practices and the attributable impact on the decrease in IVH in a key finding of this study and demonstrate how a widespread change in practice can impact outcomes. In all but the 24-25 ^6/7 gestational age subgroup, the impact of decreased intubation was more significant than antenatal steroids [italics added by DW], accounting for as much as 43.7% of the decrease in severe IVH seen in the 28-29  ^6/7 gestational age subgroup.”  [DW note: Their analysis does not include some items discussed at great length already by the PMB Project Team, such as Magnesium sulfate, pre-medication for non-delivery room intubations and PDA algorithm.}

DW Comment:

I hope that everyone will find these helpful reports in identifying PMB care processes that require emphasis in achieving optimal execution and complete documentation.