Dr. Balasundaram finished her fellowship at the University of California San Diego and joined the Stanford neonatology group in 2015. She is the El Camino Health NICU Family-Centered Care committee chair and actively leads different subcommittees to improve NICU quality goals. Her passion is to provide safe and quality neonatal care in a family-integrated NICU in her local NICU and other NICUs. She formed the FCC taskforce partnering with the American Academy of Pediatrics - Trainees and Early Career Neonatologists (TECaN) by recruiting passionate trainees, neonatologists, staff, and family partners. The FCC Taskforce, stands as a pioneering force, being the FIRST international, multicenter, collaborative initiative solely dedicated to quality improvement in family-centered care. She received the 2022 David Wirtschafter Award for building a comprehensive family-centered program. The award is given to individual leaders or NICU quality improvement teams whose contributions impact their unit and the larger neonatal community by the California Perinatal Quality Care Collaborative (CPQCC) and the California Association of Neonatologists (CAN). She is the statewide CPQCC Quality Infrastructure Committee chair and a Perinatal Quality Improvement Executive Panel (PQIP) member.
- NICU Family-Centered Care
- Neonatal quality improvement work
- Neonatal-Perinatal Medicine
- Neonatal resuscitation
- Pediatrics, General
Clinical Associate Professor, Pediatrics - Neonatal and Developmental Medicine
Honors & Awards
David Wirtschafter, CPQCC and the California Association of Neonatologists (2022)
Boards, Advisory Committees, Professional Organizations
Founder & Co-Chair, Family-Centered Care Taskforce (2022 - Present)
Chair, CPQCC Quality Infrastructure Committee (QII) (2022 - Present)
Member, Planning Committee Member at Large, National Gravens Conference (2022 - Present)
Chair, Family-Centered Care Committee, El Camino Health (2016 - Present)
Member, NICU Partnership Council , El Camino Health (2016 - Present)
Member, PQIP Panel CPQCC (2016 - Present)
Physician Liaison, Transport Follow Up, El Camino Health NICU (2016 - Present)
Member, American Academy of Pediatrics (2004 - Present)
Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (2016)
Board Certification, Neonatal-Perinatal Medicine, American Board of Pediatrics (2016)
Fellowship: University of California San Diego (2015) CA
Board Certification: American Board of Pediatrics, Pediatrics (2007)
Residency: St Joseph's Regional Medical Center (2007) NJ
Medical Education: Government Chengalpattu College (2002) India
Additional Clinical Info
Current Research and Scholarly Interests
A Family-Centered Care (FCC) model in the Neonatal Intensive Care Unit (NICU) has been shown to reduce the length of NICU hospital stays for infants, improving neurobehavioral outcomes in preterm infants and increasing the likelihood of breastfeeding at discharge. Research shows that families of infants admitted to an FCC unit experience less stress than those admitted to a standard care unit. Unfortunately, FCC care model is lacking in many NICUs, and family integration is not routinely part of the standard of care. A lack of family involvement or inclusion in the NICU may exacerbate disparities in neonatal health outcomes across racial and ethnic lines.
Although FCC is beneficial for infants and families, implementation can be challenging because it involves a shift in the role of the healthcare provider from caregiver to mentor – but we know that when NICU staff and families collaborate, families are more involved in decision-making and are empowered to influence their infant's recovery. The FCC TaskForce aims to elevate the importance of family integration and empowerment in improving infant outcomes in NICUs across the United States and internationally. Health care professionals partnering with families with lived experience in the NICU, we are confident that we can increase family engagement and improve infant outcomes, particularly for marginalized families.
Understanding family-centered care in the NICU: a scoping review protocol.
JBI evidence synthesis
OBJECTIVE: This scoping review aims to identify and categorize the definitions of neonatal intensive care unit (NICU) family-centered care (FCC) and its associated concepts. It also aims to identify and categorize the practices and interventions that comprise NICU FCC, and catalog the metrics used to evaluate NICU FCC.INTRODUCTION: FCC has been identified as an important element of care for neonates and infants admitted to the NICU, and there is clear evidence that the incorporation of families in care improves clinical outcomes. However, FCC has been linked to numerous associated terms and concepts and lacks a unifying definition or framework, thus limiting the ability to categorize, prioritize, and identify practices and interventions to optimize both institutional approaches for individual centers and for the field at large.INCLUSION CRITERIA: Studies that include or apply at least one FCC concept or its associated terms will be considered eligible for inclusion. Studies not related exclusively to the NICU will be excluded.METHODS: The review will follow the JBI methodology for scoping reviews and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Several electronic databases and sources of gray literature will be searched from 1992 to the present day. The review will include only full-text studies in English and will be independently screened by a minimum of 2 authors. Data will be extracted using a modified JBI data extraction tool and presented using narrative summaries; concept mapping; and categorization of practices, interventions, and metrics.
View details for DOI 10.11124/JBIES-23-00252
View details for PubMedID 38385497
Family Perception of OpenNotes in the Neonatal Intensive Care Unit.
Applied clinical informatics
OpenNotes, or sharing of medical notes via a patient portal, has been studied extensively in the adult population, but less in pediatric populations, and even more rarely in inpatient pediatric or intensive care settings.To understand families' interaction with and perception of inpatient hospital notes shared via patient portal in a community Neonatal Intensive Care Unit (NICU).At the end of the NICU discharge education, completed in the patient portal before discharge, families were offered an anonymous survey on OpenNotes.Out of 446 NICU patients from 3/16/22-3/16/23, there were 59 respondents (13%). Race was primarily Asian (48%), and English was the predominant language (93%). Most families indicated the notes were "very or somewhat easy to understand" (93%). Seventy-three percent of respondents felt much better about the doctor(s) after reading the notes, and 53% contacted the physicians about something in the notes. Six (16%) felt that OpenNotes were more confusing than helpful.To the authors' knowledge, this is the first study on NICU families' perceptions of OpenNotes, which indicated positive interactions with the doctors' daily progress notes and gave important suggestions for improvement.
View details for DOI 10.1055/a-2244-4478
View details for PubMedID 38216145
Implementation of a Bedside Point-of-Care Ultrasound Program in a Large Academic Neonatal Intensive Care Unit.
American journal of perinatology
In the adult and pediatric critical care population, point-of-care ultrasound (POCUS) can aid in diagnosis, patient management, and procedural accuracy. For neonatal providers, training in ultrasound and the use of ultrasound for diagnosis and management is increasing, but use in the neonatal intensive care unit (NICU) is still uncommon compared with other critical care fields. Our objective was to describe the process of implementing a POCUS program in a large academic NICU and evaluate the role of ultrasound in neonatal care during early adaption of this program. A POCUS program established in December 2018 included regular bedside scanning, educational sessions, and quality assurance, in collaboration with members of the cardiology, radiology, and pediatric critical care divisions. Core applications were determined, and protocols outlined guidelines for image acquisition. An online database included images and descriptive logs for each ultrasound. A total of 508 bedside ultrasounds (76.8% diagnostic and 23.2% procedural) were performed by 23 providers from December 2018 to December 2020 in five core diagnostic applications: umbilical line visualization, cardiac, lung, abdomen (including bladder), and cranial as well as procedural applications. POCUS guided therapy and influenced clinical management in all applications: umbilical line assessment (26%), cardiac (33%), lung (14%), abdomen (53%), and cranial (43%). With regard to procedural ultrasound, 74% of ultrasound-guided arterial access and 89% of ultrasound-guided lumbar punctures were successful. Implementation of a POCUS program is feasible in a large academic NICU and can benefit from a team approach. Establishing a program in any NICU requires didactic opportunities, a defined scope of practice, and imaging review with quality assurance. Bedside clinician performed ultrasound findings can provide valuable information in the NICU and impact clinical management.· Use of point-of-care ultrasound is increasing in neonatology and has been shown to improve patient care.. · Implementation of a point-of-care ultrasound program requires the definition of scope of practice and can benefit from the support of other critical care and imaging departments and providers.. · Opportunities for point-of-care ultrasound didactics, imaging review, and quality assurance can enhance the utilization of bedside ultrasound..
View details for DOI 10.1055/s-0042-1750118
View details for PubMedID 35691294
Increasing early exposure to mother's own milk in premature newborns.
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE: Increase the proportion of ≤33 weeks newborns exposed to mother's own milk (MOM) oral care by 12h of age by 20% over 2 years to support a healthier microbiome.STUDY DESIGN: We implemented interventions to support early expression of colostrum and reliable delivery of resultant MOM to premature newborns. Statistical process control charts were used to track progress and provide feedback to staff. Proportions of newborns exposed to MOM by 12h were compared relative to baseline.RESULTS: There were 46, 66, and 46 newborns in the baseline, implementation, and sustainability periods, respectively. The primary outcome improved from 48% to 61% in the implementation period (relative change 1.27, 95% CI 0.89, 1.81, p=0.2), to 69% in sustainability period (relative to baseline 1.45, 95% CI 1.02, 2.08, p=0.03).CONCLUSION: An interdisciplinary team-based, multicycle, quality improvement intervention resulted in increased rates of early exposure to MOM.
View details for DOI 10.1038/s41372-022-01376-8
View details for PubMedID 35396577
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
Increasing Parent Satisfaction With Discharge Planning: An Improvement Project Using Technology in a Level 3 NICU.
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
Neonatal intensive care unit (NICU) families are often overwhelmed by the discharge process. Their anxiety can inhibit learning and contribute to poor infant outcomes and increased healthcare utilization after discharge. Quality of the discharge teaching is the strongest predictor of discharge readiness, so NICUs must develop excellent discharge preparation programs.This improvement project enhances NICU discharge preparedness by providing consistent, early discharge teaching using technology as a supplemental resource and raises parental satisfaction with the process.Neonatal intensive care unit staff and former NICU parents developed a task force to create technology-based discharge education content. The content was originally uploaded to an e-book and later transferred to the electronic health record inpatient portal. Families were able to view discharge teaching content at their own convenience and pace and review topics as needed with the NICU staff. Postdischarge follow-up phone calls provided insight into parental reaction to the new education format.Parent satisfaction top-box scores, reflecting the highest rating in the "Prepared for Discharge" category of the patient satisfaction survey, improved from a baseline of 47% in 2017 to 70% in 2019. Overwhelmingly, 92% of families highly rated the tablet-based discharge teaching during postdischarge phone calls.A comprehensive, consistent, and early discharge program using technology can lead to more effective and efficient NICU discharge education and improved parent satisfaction.Further studies are needed to generalize hospital-based inpatient portal teaching as an additional resource for parental education in the NICU.
View details for DOI 10.1097/ANC.0000000000000841
View details for PubMedID 33534225
Predictors of poor neonatal outcomes in prenatally diagnosed multicystic dysplastic kidney disease.
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE: Multicystic dysplastic kidney (MCDK) is one of the most common anomalies detected by prenatal ultrasound. Our objective was to identify factors associated with severe adverse neonatal outcomes of prenatally diagnosed MCDK STUDY DESIGN: A retrospective review of prenatally diagnosed MCDK (1 January 2009 to 30 December 2014) from a single academic center was conducted. The primary outcome was death or need for dialysis among live-born infants. Associations between prenatal characteristics and outcome were analyzed by Fisher's exact test and Mann-Whitney test.RESULTS: A total of 53 cases of prenatally suspected MCDK were included, of which 46 cases were live-born and confirmed postnatally (38 survivors, 8 non-survivors). Prenatally diagnosed extrarenal anomalies, bilateral MCDK, contralateral renal anomalies, and anhydramnios were significantly associated with death or need for dialysis (all p<0.0001).CONCLUSIONS: Prenatally identified findings are associated with adverse neonatal outcome, and can guide counseling and management planning. In the absence of significant associated findings, prenatally diagnosed unilateral MCDK has a benign neonatal course.
View details for PubMedID 29572458