Stetson, Raymond C.

BACKGROUND AND OBJECTIVES Neonatal tracheal intubation is a high-risk procedure, and multiple attempts are associated with adverse events. At our tertiary neonatal intensive care unit, the baseline first-attempt success rate was 45%, which we aimed to increase to over 55% through a quality improvement (QI) initiative. METHODS A multidisciplinary team conducted a QI project using the define-measure-analyze-improve-control framework. Root cause analysis identified poor glottic visualization and patient instability as primary drivers of failure. Plan-do-study-act cycles were carried out (April 2023–July 2024), followed by a sustainability phase (August 2024–May 2025). Key interventions included the phased implementation of video laryngoscopy (VL) as the primary intubation device and the standardization of oxygenation during laryngoscopy using nasal high flow. First-attempt success was tracked using statistical process control, and bimonthly VL use was monitored as a process measure. RESULTS A total of 642 intubations were analyzed. By control chart analysis, the first-attempt success rate increased from a baseline of 45% to a sustained process mean of 61% during the intervention and sustainability phases. VL use increased from 0% at baseline to 70% to 90% during the sustainability phase. Success rates improved across all clinician types and locations. Notably, first-attempt success in infants weighing less than 1000 g increased from 38% at baseline to 62% during the intervention phase. CONCLUSION A systematic QI initiative focused on VL and standardized oxygenation improved and sustained neonatal intubation success rates, exceeding the project aim. The maintenance of high-success rates confirms the durability of these safety improvements.

Background: Pregnancies complicated by fetal growth restriction are at increased risk of fetal demise and adverse neonatal outcomes. Distinguishing growth-restricted fetuses from constitutionally small ones remains challenging. Given the variability in current diagnostic criteria and the importance of identifying at-risk fetuses, fetal growth velocity has emerged as a predictor of adverse neonatal outcomes. Objective: To evaluate whether percentile-based fetal growth velocity, defined as change in estimated fetal weight percentile per week, predicts adverse neonatal outcomes in pregnancies affected by fetal growth restriction or small-for-gestational-age neonates. The primary aim was to determine the relationship between growth velocity and a composite of adverse neonatal outcomes. Study Design: This was a retrospective cohort study of pregnant patients 18 - 45 years old who delivered between August 2017 to December 2022 in a single healthcare system. Patients were excluded who had fewer than 2 ultrasounds after 16 weeks gestation, genetic or anatomic abnormalities, or a multiple gestation. Results: 300 patients met all inclusion criteria, and most patients (n=199) delivered at the tertiary care center. Three had an intrauterine fetal demise at a mean gestational age of 35w3d. 74 neonates were admitted to the NICU with a mean length of stay of 8.5 days; 29 required respiratory support. No neonatal deaths occurred. In fetuses with initial estimated fetal weight <3rd percentile (n=33), the probability of composite outcome was increased (50%, 95% CI 44.8-55.2) compared to those >50th percentile (5%, 95% CI 3.7-6.6). In the 3-10th and 10 - 50th percentile subgroups with decelerated growth, composite outcome rates were also increased (56.2% and 44.1%) compared to those with neutral or increased growth velocity. Conclusion: Percentile-based fetal growth velocity is a simple calculation that correlates with adverse neonatal outcomes regardless of initial estimated fetal weight. As fetal growth velocity decreased, our cohort saw increased rates of adverse outcomes. Change in EFW percentile normalizes for gestational age and allows ease of clinical interpretation. Decelerated growth identified fetuses at highest risk, suggesting growth velocity as a useful metric in routine surveillance.

Background Youth-onset diabetes mellitus (DM) is an increasing public health concern, especially among adolescents facing socioeconomic challenges. Food insecurity (FI), a key social determinant of health, has been linked to adverse metabolic outcomes, but its association with youth-onset DM and the role of preventive care remain unclear. Methods Using repeated cross-sectional data from the National Survey of Children’s Health (2016–2021), we examined the association between FI status (food secure, mild FI and moderate-to-severe FI) and youth-onset DM among adolescents aged 10–17 years. We also evaluated whether usual preventive care modified this association. Propensity score weighting (PSW) was used to reduce the imbalance of measured confounders across FI groups. These weights were applied in the least absolute shrinkage and selection operator logistic regression for variable selection and in the final multivariable logistic regression models. Results In the PSW analysis of 66 560 adolescents, 432 had youth-onset DM. Moderate-to-severe FI was associated with higher odds of DM than food-secure adolescents (OR 1.55, 95% CI 1.35 to 1.77; p<0.0001), whereas mild FI was not associated with youth-onset DM. Among adolescents with preventive care visits, both mild FI (OR 1.19, 95% CI 1.04 to 1.37; p=0.0126) and moderate-to-severe FI (OR 1.67, 95% CI 1.46 to 1.92; p<0.0001) were associated with higher odds of DM. Among those without preventive care visits, FI was associated with lower odds of having a reported DM diagnosis, especially in the moderate-to-severe FI group (OR 0.11, 95% CI 0.03 to 0.35; p=0.0002). Conclusions Moderate-to-severe FI was associated with youth-onset DM, and this relationship varied by access to preventive care. Adolescents with FI who lack regular preventive care may have fewer opportunities for DM diagnosis. Public health strategies should integrate FI screening, equitable access to preventive services and culturally responsive approaches to chronic disease prevention.

Background Excellence in healthcare delivery is dependent on individuals working together on a team. Objective We sought to enhance team performance by partnering with human resources (HR) to identify opportunities unrecognised by unit leadership. Methods 100 individuals representing a cross-section of the multidisciplinary team participated in an interview focused on teamwork conducted by an HR representative. Action plans were then developed and implemented. Press Ganey Survey results for the question, “Staff worked together to care for you/your baby?” were tracked to assess patient perception of teamwork. Results Between 2022 and 2024, we observed improvement in the per cent of patients who assigned the highest rating of teamwork, culminating in 100% of patients reporting the highest score in the final quarter. Conclusion The model of HR facilitated discussions with work unit team members identified barriers to optimal teamwork, led to the implementation of action plans and resulted in an improvement in our teamwork rating by patients.

Abstract Background Pharmacokinetics of beta-lactams vary widely in neonatal and pediatric patients due to developmental biology and critical illness. Cefepime (FEP), meropenem (MEM), and piperacillin/tazobactam (TZP) are highly susceptible to pharmacokinetic changes as hydrophilic, small molecules with renal clearance. Subtherapeutic levels are associated with clinical and microbiologic failure, and supratherapeutic levels associated with toxicity. Beta-lactam therapeutic drug monitoring (TDM) may optimize the effectiveness and safety of these agents. The purpose of this investigation is to describe the % of pediatric and neonatal patients with beta-lactam serum levels within target range. Methods In August 2023, TDM launched at the Mayo Clinic Children’s Center for select patients treated with FEP, MEM, or TZP with expected durations ≥ 48 hours, or who were on kidney replacement therapy (KRT), extracorporeal membrane oxygenation (ECMO), weighed &gt; 120 kg, had a BMI &gt; 95th percentile, or at the discretion of pediatric ID team. Validated drug assays were performed daily, Monday through Friday. A two-level sampling strategy was preferred with a peak 1 hour after the end of the infusion and a trough 30 minutes before the next dose. Empiric trough target ranges were set at FEP 8-50 mg/L, MEM 2-30 mg/L, and piperacillin 16-150 mg/L. These target ranges were adjusted with confirmed microbiology to a time above the minimum inhibitory concentration of the organism for 100% of the dosing interval (100%T &gt; MIC). Results From August 2023 to April 2024, 74 episodes of TDM were performed on 45 patients. Thirty-seven (82%) patients were in an intensive care unit (ICU) at the time of TDM, 8/45 (22%) of whom were in the neonatal ICU. Target range was achieved in 67% of patients on FEP, 50% on MEM, and 52% on TZP. Median (IQR) trough values were 22.1 (8.6, 44.2) mg/L for FEP, 0.6 (0, 4.1) mg/L for MEM, and 15.5 (3.8, 27.1) mg/L for TZP. Seven levels were above target for FEP and 0 for MEM and TZP. Seven levels were below target for FEP, 4 for MEM, and 11 for TZP. Conclusion Implementation of a TDM program for FEP, MEM and TZP in pediatric and neonatal patients revealed drug levels frequently outside target range. TDM may facilitate dose individualization to optimize medication efficacy and minimize toxicity. Disclosures Raymond Stetson, MD, MS, Moderna: Grant/Research Support Christina G. Rivera (O'Connor), Pharm.D, Gilead Sciences: Board Member Erin F. Barreto, PharmD, MSc, Baxter Health: Advisor/Consultant|Wolters Kluwer: Advisor/Consultant

Abstract Background Staphylococcus aureus (SA) infections, both methicillin-susceptible and methicillin-resistant (MSSA, MRSA), cause significant morbidity among infants in neonatal intensive care units (NICU). Colonization usually precedes infection. We studied the molecular epidemiology of SA colonization in NICU infants using whole genome sequencing (WGS) and in relation to the opening of a new NICU with single-family rooms. Methods From 2019-22, a prospective cohort of infants admitted to the Level IV NICU at Mayo Clinic, Rochester, MN was screened twice weekly for SA colonization using cultures of nares/axilla/groin swabs. Infection control procedures were consistent throughout, including use of Contact Precautions for infants colonized with MRSA but not for MSSA. The study was divided into period 1 (1/1/2019-11/30/2020) and period 2 (12/1/2020-12/31/2022) due to a move from a 34-bed unit (26 beds in four open-bay rooms and 8 beds in single-family rooms) to a new 34-bed unit (all single-family rooms). WGS was performed using Illumina MiSeq instrumentation and chemistry with Illumina Nextera XT library chemistry. Assembly and core genome multilocus sequence typing analysis were performed with Ridom SeqSphere+ software. Groups of related isolates were identified based on the number of allelic differences (related 0-8 differences, possibly related 9-29 differences, unrelated ≥ 30 differences). Groups of MRSA-related isolates were compared with reference USA genotypes. Chi square tests did not adjust for clustering. Results There were 663 admissions in period 1 and 730 in period 2. The prevalence of MSSA and MRSA colonization was unchanged in the two periods (MSSA, 18.6% vs. 16.7%, p=0.37; MRSA 1.8% vs. 3.3%, p=0.08). By WGS, most MSSA and MRSA isolates were unrelated to another isolate in both periods (Table). Groups of related MSSA and MRSA isolates differed between the two periods and the number of isolates/group was small (&lt; 6 isolates). Groups of related MRSA isolates were associated with reference genotypes USA100 (period 1), USA1000 (periods 1 & 2), and USA300 (period 2). WGS Results for MSSA and MRSA in Periods 1 and 2 Conclusion NICU infants were usually colonized with unrelated strains of MSSA and MRSA, with only small clusters of related strains. The new NICU was not associated with a change in MSSA or MRSA colonization. Disclosures Priya Sampathkumar, MD, Merck Vaccines: Advisor/Consultant Robin Patel, MD, Abbott Laboratories: Advisor/Consultant|Adaptive Phage Therapeutics: Grant/Research Support|Adaptive Phage Therapeutics: Mayo Clinic has a royalty-bearing know-how agreement and equity in Adaptive Phage Therapeutics.|BIOFIRE: Grant/Research Support|CARB-X: Advisor/Consultant|ContraFect: Grant/Research Support|Day Zero Diagnostics: Advisor/Consultant|HealthTrackRx: Advisor/Consultant|Mammoth Biosciences: Advisor/Consultant|Netflix: Advisor/Consultant|Oxford Nanopore Technologies: Advisor/Consultant|PhAST: Advisor/Consultant|See details: Patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic|See details: continued, patent on an anti-biofilm substance issued|TenNor Therapeutics Limited: Grant/Research Support|Torus Biosystems: Advisor/Consultant|Trellis Bioscience, Inc.: Advisor/Consultant W. Charles Huskins, MD, MSc, ADMA Biologics: Advisor/Consultant|Bristol Myers Squibb: Stocks/Bonds|Pfizer: Advisor/Consultant|Pfizer: Stocks/Bonds|Zimmer Biomet: Stocks/Bonds

AbstractCongenital myopathies, such as nemaline myopathy, may present with hypotonia and respiratory failure in the neonatal period. Respiratory function can be further compromised in affected infants by the development of chylous effusions. We present the case of a preterm male infant born at 326/7 weeks' gestation, who was profoundly hypotonic and required intubation at birth. His clinical course progressed from acute to chronic respiratory failure with mechanical ventilation dependence. He developed bilateral chylous pleural effusions during the newborn period. Whole exome sequencing identified an ACTA1 gene mutation leading to the presumed diagnosis of nemaline myopathy. This case highlights the need to include congenital myopathies in the differential for a preterm newborn with hypotonia and respiratory failure.

Introduction: Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project’s primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months. Methods: A multidisciplinary care team used Define, Measure, Analyze, Improve, Control methodology to identify root causes of the quality gap including: (1) inconsistent reporting of objective pain scales; (2) variable provider prescribing patterns; and (3) variable provider bedside assessment of pain. These root causes were addressed by two interventions: (1) standardized reporting of the premature infant pain profile scores and (2) implementation of an analgesia management pathway. Results: Mean opioid exposure, measured in morphine equivalents, in infants less than 1,250 g at birth during their first 14 days of life decreased from 0.64 mg/kg/d (95% confidence interval 0.41–0.87) at baseline to 0.08 mg/kg/d (95% confidence interval 0.03–0.13) during the postintervention period (P < 0.001). There was no statistical difference in rates of days to full feedings, unintentional extubations, or central line removals between epochs. Conclusions: Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.