- Neonatal-Perinatal Medicine
Clinical Associate Professor, Pediatrics - Neonatal and Developmental Medicine
Fellowship: University of California San Francisco (2013) CA
Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (2016)
Residency: Massachusetts General Hospital (2009) MA
Internship: Massachusetts General Hospital (2007) MA
Medical Education: UCSF (2006) CA
Board Certification: American Board of Pediatrics, Pediatrics (2009)
A Clinical Monitoring Approach for Early Onset Sepsis: A Community Hospital Experience.
BACKGROUND: A serial clinical examination approach to screen late preterm and term neonates at risk for early onset sepsis has been shown to be effective in large academic centers, resulting in reductions in laboratory testing and antibiotic use. The implementation of this approach in a community hospital setting has not been reported. Our objective was to adapt a clinical examination approach to our community hospital, aiming to reduce antibiotic exposure and laboratory testing.METHODS: At a community hospital with a level III NICU and >4500 deliveries annually, the pathway to evaluate neonates ≥35 weeks at risk for early onset sepsis was revised to focus on clinical examination. Well-appearing neonates regardless of perinatal risk factor were admitted to the mother baby unit with serial vital signs and clinical examinations performed by a nurse. Neonates symptomatic at birth or who became symptomatic received laboratory evaluation and/or antibiotic treatment. Antibiotic use, laboratory testing, and culture results were evaluated for the 14 months before and 19 months after implementation.RESULTS: After implementation of the revised pathway, antibiotic use decreased from 6.7% (n = 314/4694) to 2.6% (n = 153/5937; P < .001). Measurement of C-reactive protein decreased from 13.3% (n = 626/4694) to 5.3% (n = 312/5937; P < .001). No cases of culture-positive sepsis occurred, and no neonate was readmitted within 30 days from birth with a positive blood culture.CONCLUSIONS: A screening approach for early onset sepsis focused on clinical examination was successfully implemented at a community hospital setting resulting in reduction of antibiotic use and laboratory testing without adverse outcomes.
View details for DOI 10.1542/hpeds.2021-006058
View details for PubMedID 34935049
Blood pressure goals: Is cerebral saturation the new mean arterial pressure?
American journal of perinatology
To correlate hypotension and cerebral saturation from near-infrared spectroscopy (cNIRS) in neonates on dopamine.Retrospective review of neonates receiving dopamine between August 2018-2019 was performed. Hypotension thresholds included mean arterial pressure (MAP) of postmenstrual age (PMA) ± 5mmHg, 30mmHg, and gestational age (GA) ± 5mmHg. Time below threshold MAP was compared to time with cerebral hypoxia (cNIRS <55%).Hypotension occurred 6-33% of time on dopamine in 59 cases. Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups, or by outcomes. Hypotensive periods with MAP
View details for DOI 10.1055/a-1704-1851
View details for PubMedID 34814195
Reduction of Central Line-associated Bloodstream Infection Through Focus on the Mesosystem: Standardization, Data, and Accountability.
Pediatric quality & safety
2020; 5 (2): e272
Introduction: Efforts to reduce central line-associated bloodstream infection (CLABSI) rates require strong microsystems for success. However, variation in practices across units leads to challenges in ensuring accountability. We redesigned the organization's mesosystem to provide oversight and alignment of microsystem efforts and ensure accountability in the context of the macrosystem. We implemented an A3 framework to achieve reductions in CLABSI through adherence to known evidence-based bundles.Methods: We conducted this CLABSI reduction improvement initiative at a 395-bed freestanding, academic, university-affiliated children's hospital. A mesosystem-focused A3 emphasized bundle adherence through 3 key drivers (1) practice standardization, (2) data transparency, and (3) accountability. We evaluated the impact of this intervention on CLABSI rates during the pre-intervention (01/15-09/17) and post-intervention (07/18-06/19) periods using a Poisson model controlling for baseline trends.Results: Our quarterly CLABSI rates during the pre-intervention period ranged from 1.0 to 2.3 CLABSIs per 1,000 central line-days. With the mesosystem in place, CLABSI rates ranged from 0.4 to 0.7 per 1,000 central line days during the post-intervention period. Adjusting for secular trends, we observed a statistically significant decrease in the post versus pre-intervention CLABSI rate of 71%.Conclusion: Our hospital-wide CLABSI rate declined for the first time in many years after the redesign of the mesosystem and a focus on practice standardization, data transparency, and accountability. Our approach highlights the importance of alignment across unit-level microsystems to ensure high-fidelity implementation of practice standards throughout the healthcare-delivery system.
View details for DOI 10.1097/pq9.0000000000000272
View details for PubMedID 32426638
A Qualitative Analysis of Challenges and Successes in Retinopathy of Prematurity Screening.
2018; 8 (2): e128–e133
Objective The objective of this study is to identify characteristics of neonatal intensive care unit (NICU) practice that influence successful retinopathy of prematurity (ROP) screening. Study Design In this qualitative study, top, improved, and bottom performing NICUs in the California Perinatal Quality Care Collaborative were identified based on ROP screening rates and invited to participate. NICU personnel were interviewed using a semistructured questionnaire. Using thematic analysis, key factors that influence ROP screening were identified. Results Themes found in top performing hospitals include a commitment to quality improvement, a committed ophthalmologist, and a system of double checks. Improved NICUs had a common theme of utilizing telemedicine for exams and identification of eligible neonates on admission. The bottom performing hospital struggled with education and identification of eligible neonates and a lack of a dedicated ophthalmologist. Conclusion Structure, culture, education, and commitment all contribute to the success of ROP screening in the NICU.
View details for PubMedID 29896443
View details for PubMedCentralID PMC5995725
Case 1: Lactic Acidosis and Respiratory Distress in a 10-Day-Old Infant.
2015; 16 (7): e431-e433
View details for PubMedID 26236172
Factors Associated with Failure to Screen Newborns for Retinopathy of Prematurity
JOURNAL OF PEDIATRICS
2012; 161 (5): 819-823
To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed.We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening.Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings.Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population.
View details for DOI 10.1016/j.jpeds.2012.04.020
View details for Web of Science ID 000310370600013
View details for PubMedID 22632876
View details for PubMedCentralID PMC3470784