Objectives The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress.Study Design Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network calculated the Triple Aim in 23 (0/7) to 27 (6/7) -week infants using three surrogate measures: (1) population health/x-axis-eight major morbidity rates as a composite, risk-adjusted metric; (2) cost/y-axis-total hospital length of stay; and (3) individual care/z-axis-mortality, then illustrated this relationship as a sphere within a three-dimensional cube.Results Three thousand seven hundred six infants born between January 1, 2014 and December 31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth weight of 803 (208) grams were analyzed. Triple Aim three-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric), but moved backward in the y-axis length of stay and z-axis mortality measurements.Conclusion Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions.

Introduction:Two hospitals noted increased newborn hyperbilirubinemia coinciding with an undisclosed total serum bilirubin (TSB) assay change. Clinicians rapidly applied quality improvement methodologies to ascertain increased jaundice evaluations, readmissions, and possible safety issues. Methods:In January 2020, 2 hospitals (A and B) transitioned to a new method of measuring TSB using a new clinical chemistry analyzer (Siemens Atellica CH), which measured TSB by vanadate oxidase assay instead of the previous diazo assay. Five affiliated hospitals (C-G) continued to utilize the diazo assay. This natural experiment led to a comparison of data across the 7 hospitals. We analyzed: (1) TSB levels, (2) hospital hyperbilirubinemia readmissions, and (3) paired TSB measurements comparing the diazo assay and vanadate oxidase method. Results:Compared to the 2019 baseline, Hospitals A and B had a significant increase in TSBs & GE;17.0 mg/dl and TSBs & GE;20 mg/dl in 2020; Hospitals C-G did not. Readmissions for phototherapy significantly increased in hospitals A and B in 2020 compared to 2019. Paired blood samples showed bias-elevated TSBs by vanadate assay compared to the diazo method. By 2021, the laboratory resumed processing TSB samples by diazo assay, and the frequency of elevated TSBs and hyperbilirubinemia readmissions returned to 2019 levels. Conclusions:Factitious TSB elevation related to an assay change significantly increased newborn hyperbilirubinemia evaluations and phototherapy readmissions. Imbedded quality improvement methodologies of careful structure, process, and outcomes review hastened resolution.

Cardiogenic shock in the setting of severe aortic stenosis is associated with poor outcomes. We describe 5 patients with cardiogenic shock and severe aortic stenosis who received an axillary microaxial pump (Impella) as an extended bridge to transcatheter aortic valve replacement. The median (range) age was 65 (61-87) years old, 80% were male, and 80% presented with stage D or E cardiogenic shock. In most cases, balloon aortic valvuloplasty was performed prior to pump insertion. Stabilization by Impella allowed for heart team evaluation and additional interventions, including percutaneous coronary intervention, MitraClip, and cardioversion. After a median (range) of 7 (5-14) days of Impella support, semi-elective transcatheter aortic valve replacement was successfully performed. All patients survived to discharge. Four patients (80%) were alive beyond 1 year. In these high-risk patients, prolonged support with a microaxial pump allowed for stabilization, ancillary interventions, and multi-disciplinary heart team evaluation prior to transcatheter aortic valve replacement.

Background: Despite enthusiasm for inpatient ward redesign, coordinated models require high effort with uncertain return on investment. Objective: We aimed to reduce mortality and achieve a benchmark of zero preventable deaths by committing to an interprofessional model, including partnered nurse-physician unit leadership, geographic localization, and structured interdisciplinary bedside rounds (SIBR). Methods: An observational pre-post design with 5-year follow-up studied the transition of a medical unit to an Accountable Care Unit (ACU). This geographic model enables partnered nurse-physician leadership and patient-centered workflows, including daily interdisciplinary bedside rounds. Potentially additive or confounding hospital-wide safety initiatives were tracked. Yearly mortality was compared using multivariable logistic regression and reported as odds ratio (OR). For the pre-specified goal of no preventable deaths, we report unexpected deaths, defined as those occurring without documentation of comfort as the goal of care. Results: 12,158 inpatients (55.1% female, mean [sd] age 62.2 [19.7]) were observed over 6 years. Reduction in the risk-adjusted mortality was observed following ACU implementation, with Year 2 significantly lower than the pre-implementation year (adjusted odds ratio [aOR] = 0.58 [0.35–0.94]). Risk-adjusted mortality was similar in Year 3 (aOR = 0.64 [0.39–1.0]) but returned to baseline for Years 4 and 5. Unexpected deaths reached zero in Year 3 and plateaued in Years 4 and 5 at a rate below pre-implementation year (~0.1% vs. 0.38%). Conclusions: A geographic ACU with nurse-physician partnered leadership and daily structured interdisciplinary bedside rounds can reduce total and unexpected mortality. However, maintenance requires constant effort and, in the real world, multiple confounders complicate study.

Background: Procedural anticoagulation with bivalirudin (BIV), trans-radial intervention (TRI), and use of a vascular closure device (VCD) are thought to mitigate percutaneous coronary intervention (PCI)-related bleeding. We compared the impact of these bleeding avoidance strategies (BAS) for PCIs stratified by bleeding risk. Methods: We performed a retrospective cohort analysis of PCIs from 18 facilities within one health care system from 2009Q3 to 2017Q4. Bleeding risk was assessed per the National Cardiovascular Data Registry CathPCI bleeding model, with procedures stratified into 6 categories (first, second, third quartiles, 75th–90th, 90th–97.5th, and top 2.5th percentiles). Regression models were used to assess the impact of BAS on bleeding outcome. Results: Of 74 953 PCIs, 9.4% used no BAS, 12.0% used BIV alone, 20.8% used TRI alone, 26.8% used VCD alone, 5.4% used TRI+BIV, and 25.6% used VCD+BIV. The crude bleeding rate was 4.4% overall. Only 2 comparisons showed significant trends across all risk strata: VCD+BIV versus no BAS, odds ratio (95% CI) range: first quartile, 0.36 (0.18–0.72) to top 2.5th percentile, 0.50 (0.32–0.78); TRI versus no BAS, odds ratio (95% CI) range: first quartile, 0.15 (0.06–0.38) to top 2.5th percentile, 0.49 (0.28–0.86). TRI had lower odds of bleeding compared with BIV for all risk strata except the top 2.5th percentile. Addition of BIV to TRI did not change the odds of bleeding for any risk strata. Factors potentially limiting use of TRI (renal failure, shock, cardiac arrest, and mechanical circulatory support) were present in ≤10% of procedures below the 90th percentile. Conclusions: Among individual BAS, only TRI had consistently lower odds of bleeding across all risk strata. Factors potentially limiting TRI were found infrequently in procedures below the 90th percentile of bleeding risk. For transfemoral PCI, VCD+BIV had lower odds of bleeding compared with no BAS across all risk strata.

Human milk is the recommended feeding for preterm infants. It is a dynamic, non-homogenized fluid. The most variable component is the fat content, which rapidly separates out when milk is allowed to sit. Fat from human milk is thought to adhere to the plastic syringe and tubing products used to administer tube feedings. The objective of this study was to identify best practices for tube feeding preterm infants to minimize nutrient loss from human milk during administration in the Neonatal Intensive Care Unit (NICU). A study was conducted to investigate the effect of different tube feeding methods on the macronutrient content of donated unpasteurized (raw) frozen human milk samples. Tube feeding scenarios tested were: (1) 30 min pump syringe tip horizontal; (2) 30 min pump syringe tip up; (3) 4 hr pump syringe tip horizontal; (4) 4 hr pump syringe tip up; (5) 15 min gravity syringe tip down; (6) 30 min gravity syringe tip down; and (7) controls. Fat loss was calculated using paired "pre" and "post" samples (n = 51 pairs). Percent fat loss was compared for each scenario versus control. More fat was lost with syringe tip horizontal or down than with tip pointed up. Another contributing factor was the pump infusion time. Greatest fat loss occurred with the 4 hr pump syringe tip horizontal (average fat loss 13.1%), followed by: 4 hr tip up (8.3%); 30 min tip horizontal (6.7%); and 30 min tip up (3.4%). Fat loss via gravity drip was similar for 15 min (6.6%) and 30 min (5.7%), so the two gravity scenarios were combined into one. Fat loss for controls was small (1.5%). Except for the 30 min pump tip up scenario (P = 0.16), all the other scenarios had higher fat loss when compared to control (P-values <0.001). These findings suggest that, for best delivery of fat, tube feedings of raw human milk given by pump should be run with the syringe tip pointed directly up and with the shortest infusion time that the infant will tolerate. In contrast to previous published studies, both 15 and 30 min gravity drip delivery resulted in more fat loss than 30 min pump infusion with syringe tip up. This difference may be due to the short gravity delivery times (<5 min) reported in prior studies. In our study, 15 and 30 min times were tested for gravity delivery to more realistically mimic those observed in routine NICU care. N/A.

ObjectiveProvide a progress report updating our long-term quality improvement collaboration focused on major morbidity reduction in extremely premature infants 23–27 weeks.Methods10 Vermont Oxford Network (VON) neonatal intensive care units (NICUs) (the POD) sustained a structured alliance: (A) face-to-face meetings, site visits and teleconferences, (B) transparent process and outcomes sharing, (C) utilisation of evidence-based potentially better practice toolkits, (D) family integration and (E) benchmarking via a composite mortality–morbidity score (Benefit Metric). Morbidity-specific toolkits were employed variably by each NICU according to local priorities. The eight major VON morbidities and the risk-adjusted Benefit Metric were compared in two epochs 2010–2013 versus 2014–2018.Results5888 infants, mean (SD) gestational age 25.8 (1.4) weeks, were tracked. The POD Benefit Metric significantly improved (p=0.03) and remained superior to the aggregate VON both epochs (p<0.001). Four POD morbidities significantly improved through 2018 – chronic lung disease (48%–40%), discharge weight <10th percentile (32%–22%), any late infection (19%–17%) and periventricular leukomalacia (4%–2%). In epoch 2, 34% of survivors had none of the eight major morbidities, while 36% had just one. Mortality did not change.ConclusionsInter-NICU collaboration, process and outcomes sharing and potentially better practice toolkits sustain improvement in 23–27 week morbidity rates, notably chronic lung disease, extrauterine growth restriction and the lowest zero-or-one major morbidity rate reported by a quality improvement collaboration. Unrevealed biological and cultural variables affect morbidity rates, countless remain unmeasured, thus duplication to other quality improvement groups is challenging. Understanding intensive care as innumerable interactions and constant flux that defy convenient linear constructs is fundamental.

Background: A wireless pulmonary artery pressure sensor (CardioMEMS) is approved for implantation via the femoral vein. The internal jugular vein (IJ) is an attractive alternative access route commonly used in pulmonary artery catheterization. Methods and Results: Retrospective chart review was performed for all sensor implants from 10 providers at 4 centers from September 2016 to June 2018. To compare procedural outcomes and discharge efficiency between groups, multivariate analyses incorporating potential confounders were performed. Seventy-three (28%) patients had femoral access, and 189 (72%) had IJ access; demographics were similar between the groups. Complications, including one case of hematoma and 4 cases of mild hemoptysis, and 30-day mortality (2%-3%) did not differ between groups. Provider preference for IJ access substantially increased over time, with IJ accounting for 90% of cases in 2018. After risk-adjustment, IJ cases had 20% (5%-33%) shorter fluoroscopy time (P=0.01) and 24% (7%-38%) lower contrast volume (P=0.008). Compared with outpatient femoral cases, outpatient IJ cases had 62% (52%-69%) faster needle-to-door time and were 34 times (6-235) more likely to have same-day discharge (P<0.001 for both). Conclusions: IJ access for CardioMEMS implant is a safe alternative associated with superior procedural and discharge outcomes. Implanters at 4 high-volume centers adopted IJ access as the preferred implant approach.

Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23–27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress. We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality–morbidity score (Benefit Metric). A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19–40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one. Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Bleeding after percutaneous coronary intervention (PCI) is associated with increased morbidity, mortality, and cost. Transradial access (TRA), bivalirudin (BIV), and vascular closure devices (VCD) are strategies to reduce bleeding. We compared the impact of these bleeding avoidance strategies (BAS)

Background Heart failure (HF) management guided by CardioMEMS™ pulmonary artery pressure (PAP) monitoring reduces PAP and HF hospitalizations. The objective of this project was to characterize the relationship between medication adjustments, PAP change, and outcomes for all patients at an advanced HF center. Methods We retrospectively analyzed medication changes and hospitalizations for 32 consecutive patients implanted with the CardioMEMS™ sensor at a single HF center and related these outcomes to PAP data from the Merlin.net (Abbott) database. Absolute change in PAP from baseline was estimated using area under the curve normalized to days monitored. Results Patients had an average change in mean PAP of -3.9±1.3 mmHg at 6 months and -5.7±2.1 mmHg at 12 months. Compared to the pre-implant time period, hospital days for HF-related hospitalizations decreased by 6.9 (95% CI = 3.3-10.5) days per patient at 6 months (p<0.001) and 7.9 (95% CI = 4.3-11.5) days per patient at 12 months (p<0.001). Over 12 months, patients with baseline PAP 25-35mmHg and >35mmHg experienced a drop in PAP while their number of medication adjustments decreased, and patients with baseline PAP <25mmHg experienced a rise in PAP and an increase in medication adjustments Conclusions PAP-guided HF management involved time-varying intensity of medication changes, which correlated with sustained reductions in hospital stay.

Background: The Vancouver classification of periprosthetic femur fractures divides B1 and B2 subtypes based on the stability of the femoral stem. However, this classification was described and validated with cemented femoral stems. We sought to assess reliability and validity of the Vancouver classification in patients with cementless femoral stems. Methods: This is a blinded radiographic study which included patients treated for Vancouver B cementless periprosthetic femur fractures between February 2007 and December 2017. Adult reconstruction-trained and trauma fellowship-trained orthopedic surgeons graded all preoperative radiographs using the Vancouver classification on 3 separate occasions. Interobserver and intraobserver reliability was assessed via the Fleiss' kappa statistic. Validity was assessed via accuracy between radiographic and intraoperative assessments. The Landis and Koch criteria were used to interpret the kappa values. Results: Fifty-three patients with Vancouver B fractures (B1, 8; B2, 45) around a cementless femoral stem were included in the study. Five reconstruction-trained and 5 trauma-trained orthopedic surgeons graded all radiographs. The interobserver reliability kappa value was 0.45 (moderate agreement), with all raters agreeing on only 43% of radiographs. Validity analysis showed demonstrated 79% agreement. Overall, 20% (range, 14%-24%) of unstable B2 fractures were misread as B1 fractures. Intraobserver reliability was 0.71 between readings. Conclusion: The reliability of the Vancouver classification for cementless total hip arthroplasty is lower than previously described in cemented femoral stems. Radiographic assessment alone may be inadequate for determination of stability of cementless stems in periprosthetic femur fractures. (C) 2019 Elsevier Inc. All rights reserved.

Aim Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress. Methods We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric). Results A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one. Conclusion Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Background: Iliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks. Methods: A consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort. Results: At last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P=.005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P=.002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series. Conclusion: Endoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA. (c) 2019 Elsevier Inc. All rights reserved.

Introduction: The CardioMEMS™ pulmonary artery pressure sensor is FDA approved for insertion via the femoral vein. The right internal jugular vein (IJ) is an alternative access route used frequentl...

BACKGROUND AND AIMS:In a pilot study, we demonstrated that current guidelines for duodenoscope and linear echoendoscope (DLE) reprocessing using a single cycle of high-level disinfection (HLD) in an automated reprocessor may be inadequate. In August 2015, the U.S. Food and Drug Administration offered double HLD as a possible response to address this concern. As a result, Providence Health and Services adopted double HLD as standard procedure for DLEs, but no rigorous clinical studies supported this practice. We undertook a quality improvement study to compare single HLD versus double HLD at 4 of our 34 hospitals. METHODS:HLD of DLE was randomized, separately in each facility, to either single HLD or double HLD on weekdays, with standard double HLD on weekends or holidays. There was 99.7% compliance with the randomization scheme. Daily qualitative surveillance cultures of dried, post-HLD DLEs were collected for 6 months (1 swab sample from the elevator mechanism and 1 combined brush sample from the suction and working channels for each encounter), and each sample was incubated for 48 hours. Positivity rates of any microbial growth and growth of high-concern pathogens (potentially pathogenic enteric flora) were compared between the 2 study arms. RESULTS:Altogether, 5850 surveillance culture specimens were obtained during 2925 encounters from the 45 DLEs in clinical use in the participating hospitals. Of these, 3052 (52.2%) were from endoscopes cleaned by double HLD. Double HLD demonstrated no benefit over single HLD because similar positivity rates were observed (all P > .05). The elevator mechanism was more frequently colonized than the biopsy channel (5.2% vs 2.9%, P < .001). Among the 224 encounters with positive growth, 140 (62.5%) recovered microbes from only the elevator mechanism specimens, 73 (32.6%) recovered microbes from only the channel specimens, and 11 (4.9%) recovered microbes from both types of specimens. Double HLD failed to improve contamination rates for either sample site at any of the 4 endoscopy facilities, although there were significant overall differences in contamination rates among the facilities (P < .001), as observed in our previous study. Only 8 high-concern pathogens were recovered from 5 DLEs, all from the elevator mechanism. Persistent growth was observed on 2 duodenoscopes. One grew Enterococcus spp (not vancomycin-resistant enterococci) on 3 occasions, and Escherichia coli was present on 2 of these occasions, 1 of which was a multidrug-resistant organism. The other grew different enteric flora on 2 specimens. CONCLUSIONS:Our prospectively randomized study, involving 4 separate endoscopy facilities and standard automated endoscope reprocessing, showed that double HLD did not reduce culture positivity rates compared with single HLD in facilities with an already low positive culture rate. Alternative risk mitigation strategies will be assessed in an ongoing effort to reduce endoscope contamination.

Introduction: Heart failure (HF) management guided by pulmonary artery pressure (PAP) monitoring using the CardioMEMS™ system has been shown to reduce PAP and HF hospitalization (HFH). Our aim was ...

Background Continuous quality improvement (CQI) collaboration has not eliminated the morbidity variability seen among neonatal intensive care units (NICUs). Factors other than inconstant application of potentially better practices (PBPs) might explain divergent proficiency. Objective Measure a composite morbidity score and determine whether cultural, environmental and cognitive factors distinguish high proficiency from lower proficiency NICUs. Design/methods Retrospective analysis using a risk-adjusted composite morbidity score (Benefit Metric) and cultural survey focusing on very low birth weight (VLBW) infants from 39 NICUs, years 2000-2014. The Benefit Metric and yearly variance from the group mean was rank-ordered by NICU. A comprehensive survey was completed by each NICU exploring whether morbidity variance correlated with CQI methodology, cultural, environmental and/or cognitive characteristics. Results 58 272 VLBW infants were included, mean (SD) age 28.2 (3.0) weeks, birth weight 1031 (301) g. The 39 NICU groups' Benefit Metric improved 40%, from 80 in 2000 to 112 in 2014 (P< 0.001). 14 NICUs had composite morbidity scores significantly better than the group, 16 did not differ and 9 scored below the group mean. The 14 highest performing NICUs were characterised by more effective team work, superior morale, greater problem-solving expectations of providers, enhanced learning opportunities, knowledge of CQI fundamentals and more generous staffing. Conclusion Cultural, environmental and cognitive characteristics vary among NICUs perhaps more than traditional CQI methodology and PBPs, possibly explaining the inconstancy of VLBW infant morbidity reduction efforts. High proficiency NICUs foster spirited team work and camaraderie, sustained learning opportunities and support of favourable staffing that allows problem solving and widespread involvement in CQI activities.

OBJECTIVEThe objective of this study was to determine if outcomes at our neonatal intensive care units (NICUs) since we began using calcium chloride (CaCl2) as our preferred calcium additive in order to reduce aluminum (Al) exposure are within expected outcome ranges for NICUs in the U.S. where calcium gluconate in glass vials (CaGlu-Gl) has been the preferred additive.STUDY DESIGNA retrospective study of very low birth weight infants born between January 1, 2000 and December 31, 2014. Outcomes in two intensive care units (NICUs) using CaCl2 were compared to all U.S. NICUs in the Vermont Oxford Network. Primary outcomes were chronic lung disease (CLD), percent requiring supplemental oxygen at 28 days, and mortality excluding early deaths (MEED). The incidence of IV infiltrates of all admissions to the study NICUs in 2013-2014 was compared to the literature.RESULTSThe incidence of CLD and those requiring oxygen at 28 days were 24.0% vs 28.6% and 46.2% vs 51.8% for the study NICUs compared to all U.S. NICUs, respectively (both p < 0.0001). The MEED was 8.7% vs 10.3% (p < 0.002). All major morbidities were lower at the study NICUs. The incidence of infiltrates was lower than that in the literature.CONCLUSIONThe use of CaCl2 was not associated with any detectable adverse effects. Calcium chloride appears to be a safe alternative to the use of CaGlu-Gl based upon studies of clinical outcomes.