Evaluating the quality of the processes of care and clinical outcomes of premature newborns admitted to neonatal intensive care units in Mexico

Evaluating the quality of the processes of care and clinical outcomes of premature newborns... Abstract Objectives To develop quality of care (QoC) indicators, evaluate the quality of the processes of care (QPC) and clinical outcomes, and analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to neonatal intensive care units (NICUs). Design Mixed methods approach: (1) development of QoC indicators via modified RAND/UCLA method; (2) cross-sectional study of QoC evaluation and (3) multiple logistic regression analysis to ascertain the association between the QPC and severe clinical outcomes. Setting Two NICUs belonged to the Mexican Institute of Social Security in Mexico City. Participants About 489 preterm neonates (<37 weeks of gestation) without severe congenital anomalies. Main Outcome Measure(s) The QoC indicators; ≥60% of recommended QPC and severe clinical outcomes. Results The QoC included 10 QPC indicators across four domains: respiratory, nutrition and metabolism, infectious diseases, and screening, and five outcome indicators. The lower QPC indicators were for the nutrition and metabolism domain (17.8% started enteral feeding with human milk, and 20.7% received sodium bicarbonate appropriately). The higher QPC indicator was for the screening domain (97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound). The mean recommended QPC that neonates received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. About 60.7% of neonates developed severe clinical outcomes including mortality and healthcare-related major morbidity. Receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes. Conclusion The evaluation of the QoC in NICUs is essential to address modifiable gaps in quality. quality of care, preterm newborns, neonatal intensive care units, Mexico Background Almost half of under-five child deaths worldwide occur within the first 28 days after birth. The toll represents 2.9 million neonatal deaths annually, of which 1.47 million are attributed to preterm birth [1]. The forecast for 2035 is that ‘there will be an additional 49 million neonatal deaths and 99 million children who will not reach their development potential due to disability after preterm birth’ [1]. In Latin America in 2013, there were 5.8 deaths per 1000 live births (LB) in the early neonatal period (0–6 days) and 2.3 deaths per 1000 LB in the late neonatal period (7–28 days) [2]. Honduras had the highest neonatal mortality (9.2 and 2.6 deaths for the corresponding neonatal periods), and Costa Rica the lowest (3.9 and 1.3 deaths, respectively). Mexico was in the middle, with 5.8 deaths and 2.4 deaths, respectively [2]. More than three-quarters of premature babies can survive with evidence-based, cost-effective care during delivery, neonatal and post-neonatal periods [3]. In developed countries, the improvement of newborns survival has been partially attributed to the care that neonatal intensive care units (NICUs) provide [4]. In developing countries, NICUs have wide variability of infrastructure and quality of care (QoC), therefore their evaluation and improvement is relevant [5]. In Mexico, health professionals attend 99% of deliveries, most of them in public hospitals, in two subsystems: the Ministry of Health (MoH) and Social Security institutions (SSIs). The MoH provides healthcare to people without social security, while SSIs provide healthcare to formal sector workers and their families. The Mexican Institute of Social Security (IMSS) is the largest provider of ambulatory and hospital healthcare, covering 60.9% of the Mexican population [6]. In both Mexican subsystems, research on the QoC for preterm neonates is incipient, and NICUs lack validated indicators to measure the QoC. Available studies have reported deficiencies in the QoC for neonates admitted to MoH NICUs with transient tachypnea [7] and necrotizing enterocolitis [8]. At IMSS hospitals, there is a high incidence of nosocomial infections and diseases secondary to prolonged endotracheal intubation [9, 10]. Also, heavy workload reflected in the number of discharges per number of nurses, along with the occurrence of unsafe events such as birth trauma or acute renal failure, increased the probability of a neonate dying at NICUs [11]. To the best of our knowledge, information on the QoC at NICUs is even more limited in other Latin American countries. In clinical practice, evidence-based process of care and clinical outcomes indicators serve to perform comprehensive QoC evaluations [12]. Process indicators represent direct quality measures that provide feedback for quality improvement and providers accountability [12]. Clinical outcome indicators cannot identify accurately the areas that need improvement, but are highly significant for patients and caregivers and can be used for public scrutiny. Also, outcome indicators might indicate the impact of quality improvement efforts [12]. In NICUs, characteristics of preterm neonates and healthcare processes can influence the clinical outcomes. Thus, understanding the links between the QoC processes and clinical outcomes, after controlling for other clinically significant variables is crucial. The objectives of this study were: to develop QoC indicators, to evaluate the quality of the processes of care (QPC) and clinical outcomes, and to analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to NICUs. Methods We conducted a three-stage research study with a mixed methods approach: At the first stage, we developed the processes and outcomes indicators to evaluate QoC at individual (neonate) and facility (NICU) levels through clinical records review. The modified RAND/UCLA Appropriateness Method [13] served to develop the QoC indicators. This method is based on the selection of indicators through the review of scientific evidence and expert panel validation. A list of 23 preliminary QoC indicators for expert vetting was identified through literature review. The review focused on the NICUs’ evidence-based care processes shown to increase the likelihood of achieving the best possible clinical outcomes. It included revision of the clinical guidelines and recommendations of the American Academy of Pediatrics and NICUs’ QoC indicators, such as Baby-Monitor indicators [14]. Also, we considered IMSS and MoH clinical guidelines for neonatal asphyxia [15], apnea of prematurity [16], respiratory distress syndrome [17, 18], necrotizing enterocolitis [18, 19], management of fluids and electrolytes in preterm infants [20], sepsis and septic shock [18, 21], pneumonia in neonates [18] and pneumonias associated with mechanical ventilation [22], congenital and acquired hydrocephalus [23], retinopathy of prematurity [24], hemorrhagic disease [25] and hemolytic disease [18, 26]. A list of QoC indicators was divided into two subgroups (processes and clinical outcomes). An expert panel of six neonatologists, three pediatric nurses and two health system researchers validated the indicators. The experts rated the validity and feasibility of proposed indicators using the Shekelle et al. [27] criteria. These criteria allowed each expert to individually assess the indicators on a 1–9-scale. Only the indicators with a median score ≥7 were considered as valid and feasible to measure QoC [28]. A final list of 15 indicators was produced after three consensus group rounds (voting, feedback and re-voting). In the second stage, a cross-sectional study of the QoC evaluation was conducted in two NICUs of tertiary care IMSS hospitals. One hospital was in the north and the other in the south part of Mexico City. Both hospitals provided care for newborns delivered in the facility and for those referred from secondary care hospitals. The northern NICU had 20 beds and was staffed by 25 neonatologists and 50 pediatric nurses; the southern NICU had 13 beds and was staffed by 15 neonatologists and 45 pediatric nurses. These two NICUs were chosen intentionally. We evaluated the clinical records of all preterm neonates (<37 weeks of gestation) admitted to NICUs from January to December 2015. We excluded the newborns with severe congenital anomalies not compatible with life, those with <24 completed weeks of gestation, those transferred in after 3 days of age, and those transferred out for reasons other than convalescent and chronic care. These exclusion criteria considered previous studies to ensure that the neonate outcomes primarily reflected the QoC of the NICU [29]. Two research-trained nurses collected the information. To describe the study population, we collected information on the following covariates: Characteristics of preterm neonates, including sex, gestational age, type of delivery (labor, cesarean section) and pregnancy product (single, twins or more), Apgar score after 5 min, birth weight and Clinical Risk Index for Babies (CRIB) score [30]. The CRIB assesses initial neonatal risk. Scores are given for birth weight, gestational age, maximum acid–base excess of arterial blood gas, maximum and minimum appropriate fraction of inspired oxygen during the first 12-h of life and the presence of congenital malformations. The International Neonatal Network establishes several scores for each CRIB component. The summary score ranges from 0 to 24. The highest scores correspond to the most severe cases. The CRIB showed the validity of the initial neonatal risk, even in extremely low-birth-weight infants, predicting neonatal mortality [31]. Particularly, the CRIB cutoff point of ≥4 showed a sensitivity of 80.6% and specificity of 75.3% for neonatal mortality [32]. Maternal clinical history during pregnancy and childbirth, such as diabetes, hypertensive disorders or other chronic diseases, amniotic fluid and membranes disorders, placental disorders, genitourinary tract infections during pregnancy, premature rupture of membranes, newborns with intrauterine hypoxia and birth asphyxia. Newborn diagnoses at NICU discharge. Characteristics of the NICUs’ healthcare: length of stay, duration of mechanical ventilation with an endotracheal tube, re-intubation(s), types and duration of central venous catheter, administration of antibiotics, ophthalmological revision and transfontanelar ultrasound. The QoC was evaluated through 10 processes and 5 outcomes indicators. The third stage aimed at ascertaining the association between the QPC (independent variable) and clinical outcomes (dependent variable). To achieve this goal, we created processes and outcomes summary binary indicators. First, we calculated the percentage of recommended QPC using the McGlynn et al. [28] approach. The numerator was the sum of all the recommended care indicators that a preterm neonate received and the denominator was the total number of indicators for which he/she was eligible. We identified that QPC did not have a normal distribution; therefore, we dichotomized QPC as follows: neonates receiving 60% or higher of recommended QPC and those receiving <60%. The cutoff value was based on the 80% of QPC. Next, as the outcome indicators represented different levels of severity, we created the ‘severe clinical outcomes’ variable, defined as the occurrence of mortality or healthcare-related major morbidity during the NICUs stay (pneumothorax, nosocomial infection and bronchopulmonary dysplasia, as indicated by the need for oxygen supply after the age of 28 days). Statistical Analysis The level of quality measurement and the unit of analysis was the neonate. We used descriptive statistics to analyze the characteristics of preterm neonates admitted to the NICUs, the history of maternal disorders related to pregnancy and childbirth, healthcare characteristics and quality. Multiple logistic regressions were performed to determine the association between the recommended QPC and severe clinical outcomes after controlling for the effect of the CRIB ≥4 points and the presence of maternal disorders. The study included two NICUs; therefore, the cluster effect was considered in the analysis, and the standard errors were adjusted for two clusters. Stata 14.0 (StataCorp, College Station, TX, USA) served for the analysis; P < 0.05 was considered statistically significant. The study protocol was approved by the IMSS National Research and Ethics Committees (CNIC: 2013-785-041). Results Stage 1: Indicator development. After the literature review, 23 QoC indicators were proposed and sent to the experts for validation. The panel accepted 15 indicators and 8 were discarded. The primary reason for discarding indicators was unavailability of a specific medicine (e.g. probiotics) or medical devices (e.g. probes) at IMSS. A final list of approved indicators included 10 QPC indicators for respiratory, nutrition and metabolism, infectious diseases and screening domains, and five clinical outcome indicators (Table 1). Table 1 List of indicators selected by an expert panel to evaluate the quality of care process and clinical outcomes of NICUs I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  Note. All numbers in the table should consider preterm infants admitted to the NICU during the calendar year under review. Table 1 List of indicators selected by an expert panel to evaluate the quality of care process and clinical outcomes of NICUs I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  Note. All numbers in the table should consider preterm infants admitted to the NICU during the calendar year under review. Stage 2: Among the 741 neonates admitted to the studied NICUs during 2015, 687 were premature and 489 met the inclusion criteria. Table 2 shows the characteristics of the study population and history of maternal disorders. More than a half neonates were boys (54.6%); 92.2% were delivered by cesarean section; 85.7% were single pregnancy products.15.3% were extremely preterm (<28 weeks); 46.8% were very preterm (from 28 to <32 weeks) and 37.9% were moderate to late preterm (from 32 to <37 weeks). Only 2.7% had birth weight >2500 g and most (38%) weighed between 1000 g and 1499 g; 93.7% had an Apgar score ≥6 at 5 min after birth. The mean score of the clinical risk index for babies was 7.5. Table 2 Characteristics of preterm neonates admitted to the NICU and history of maternal disorders related to pregnancy and childbirth (n = 489) Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  aDenominator for the maternal disorders is neonates even though there were ten women with two neonates admitted to the NICUs at the same time. Table 2 Characteristics of preterm neonates admitted to the NICU and history of maternal disorders related to pregnancy and childbirth (n = 489) Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  aDenominator for the maternal disorders is neonates even though there were ten women with two neonates admitted to the NICUs at the same time. Regarding the maternal clinical history during pregnancy and childbirth, most mothers (89.2%) had one or more complications such as genitourinary tract infections (46.4%), hypertensive disorders (36.4%), diabetes (8.4%), placental disorders (3.9%), amniotic fluid and membrane disorders (2.9%) or premature rupture of membranes (30.9%). Table 3 presents the neonates’ diagnoses and healthcare characteristics. The top five diagnoses were respiratory distress syndrome (93.7%), transitory neonatal endocrine, electrolyte and metabolic disturbances (73%), intracranial nontraumatic hemorrhage (58.5%), early onset bacterial sepsis (58.1%) and perinatal hematological disorders (46%). The mean duration of the NICU stay was 17.5 days; 96.1% received mechanical ventilation with an endotracheal tube; 36% had this ventilation for >7 days and 48.3% had re-intubation(s); 89% had a central venous catheter through the umbilical vein with a mean duration of 5.3 days; 73.4% had a central venous catheter through peripheral puncture with a mean duration of 18 days; 94.7% received antibiotics, 85.7% transfontanelar ultrasound and 8.4% ophthalmological revision. Table 3 Preterm neonates' diagnoses and characteristics of the NICUs healthcare (n = 489)   n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)    n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)  Table 3 Preterm neonates' diagnoses and characteristics of the NICUs healthcare (n = 489)   n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)    n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)  Table 4 shows the results of the QoC evaluation. Regarding the respiratory domain, 86.5% did not receive dexamethasone or hydrocortisone in the first 10 days of life, and 57.7% of neonates younger than 30 weeks of gestation received surfactant in the first 30 min of life. Only 27.2% of newborns with respiratory distress syndrome received initial noninvasive respiratory assistance. In the nutrition and metabolism domains, 20.7% received sodium bicarbonate appropriately, and 17.8% started human milk enteral feeding. In the infectious domain, 57% of neonates with diagnosis of probable sepsis had blood culture sample(s) before administration of antibiotics, and 65.7% of catheterized preterm neonates had peripheral puncture central venous catheter during <21 days. Only 8.5% of neonates with negative bacteriologic cultures and without necrotizing enterocolitis did not receive prolonged (≥5 days) antibiotic treatment. In the screening domain 85.7% of neonates with a diagnosis of probable necrotizing enterocolitis had an abdominal X-ray or abdominal ultrasound and 97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound. Table 4 NICUs' quality of care (n = 489) A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  aRecommended practice or outcomes of care. bNot recommended outcomes. Table 4 NICUs' quality of care (n = 489) A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  aRecommended practice or outcomes of care. bNot recommended outcomes. Regarding clinical outcomes, 14.9% of neonates without congenital malformations incompatible with life died at the NICU. Other negative outcomes included pneumothorax during respiratory assistance (11.5%); nosocomial infection among those with the NICUs stay ≥48 days (49.3%), need for oxygen supply after 27 days of age among those with the NICUs stay ≥28 days (92%) and growth rate <12.4 g/day (97.1%). The mean number of QPC indicators for which each neonate was eligible was 6.6 and the mean recommended QPC that a neonate received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. Furthermore, 60.7% of neonates presented severe clinical outcomes. Stage 3: Table 5 describes the results of the multiple logistic regressions analysis. We found that receiving ≥60% of recommended QPC was associated with decrease of nearly half of odds of severe clinical outcomes (odds ratio: 0.56, 95% confidence interval (CI): 0.50; 0.64), compared with receiving <60% of recommended QPC. This association was statistically significant after controlling for the CRIB ≥ 4 points and maternal disorders. Table 5 Association between the recommended quality of process of care and severe clinical outcomes controlled for the effect of the clinical risk index for babies score and the presence of maternal disorders during pregnancy and childbirth (n = 489)   Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010    Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010  Table 5 Association between the recommended quality of process of care and severe clinical outcomes controlled for the effect of the clinical risk index for babies score and the presence of maternal disorders during pregnancy and childbirth (n = 489)   Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010    Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010  Discussion Multiples studies have shown that the quality of hospital care cannot be guaranteed without being monitored [33]. Comprehensive evaluation of the quality of NICU care is a significant step towards identifying existing gaps, which in turn can lead to the proper design of improvement strategies. To our knowledge, only the NICUs at the USA have developed quality indicators. It is worthwhile to identify relevant, valid and feasible NICUs QoC indicators in the resource limited settings in low and middle-income countries [34]. The evaluation allowed identifying limitations in the QPC and clinical outcomes of NICUs that require attention. The six most pronounced gaps in the QPC involved failures to (1) avoid prolonged antibiotic treatment for neonates with negative bacteriologic cultures and without necrotizing enterocolitis; (2) introduce human milk feeding; (3) justify a prescription of sodium bicarbonate in the clinical record; (4) provide early noninvasive respiratory assistance; (5) take blood culture sample(s) before administering antibiotics and (6) administer surfactant to neonates younger than 30 weeks of gestation in the first 30 min of life. Eventual strategies to improve the QoC should focus on closing these gaps, since there is substantial evidence supporting the beneficial effects of improvements in these areas on clinical outcomes. An association exists between prolonged empirical treatment of preterm infants with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, invasive fungal infection and mortality [35, 36]. Consequently, the American Academy of Pediatrics recommends discontinuing antimicrobial therapy at 48 h in clinical situations where the probability of sepsis is low. Human milk reduces rates of sepsis, necrotizing enterocolitis, and retinopathy of prematurity, leads to fewer hospital readmissions in the first year of life, and improves neurodevelopment, among other benefits [37]. The American Academy of Pediatrics and other institutions recommend that all premature babies receive human milk. Using sodium bicarbonate for metabolic acidosis is common, but there is little evidence of its efficacy and extensive evidence of its adverse effects. The American Heart Association recommends sodium bicarbonate only for hyperkalemia, loss of urinary bicarbonate and prolonged cardiac arrest [38, 39]. Prophylactic nasal CPAP in very preterm infants reduces the need for mechanical ventilation and surfactant and decreases the incidence of bronchopulmonary dysplasia and death [40]. Also, CPAP is associated with reduced respiratory failure and mortality among preterm infants with respiratory distress [41]. Use of a single dose of surfactant to prevent respiratory distress syndrome is associated with a reduction in neonatal mortality and chronic lung disease, and bronchopulmonary dysplasia [42, 43]. The clinical outcomes of NICU care can be explained by the gaps in the care process. 97% of preterm neonates had a slow growth rate (<12.4 g/kg/day). This figure highlights the importance of early human milk feeding, as we found that only 17.8% started enteral feeding with human milk. Almost half of preterm newborns (49.3%) with the NICUs stay ≥48 days developed a nosocomial infection. Nosocomial infection in this population has been shown to double rates of mortality, increase the length of NICU stay and healthcare costs [44]. Studies from the USA and Canada show that ~15% of preterm neonates admitted to NICUs develop late onset sepsis [45, 46] that ranges from 10.6% to 31.7% [47]. In our study, 42.5% of neonates developed late onset sepsis. Several NICUs care processes have protective effects against nosocomial infection, including hand hygiene, early human milk feeding, administration of probiotics, minimization of intubation days, minimization of the use of central lines and minimization of antibiotic treatment in neonates with negative bacteriologic cultures [48, 49]. Three of previously named care processes were identified by the expert panel as valid indicators that can feasibly be obtained through clinical records to comprehensively evaluate the quality of NICU care. However, as mentioned above, these indicators showed gaps. The fact that 92% of newborns who stayed more than 28 days required oxygen supply should set off alarms, since these newborns were in danger of prolonged mechanical ventilation that can lead to bronchopulmonary dysplasia. In our study, 96.1% of neonates received mechanical ventilation, 36% of them for more than 7 days. In our study, 14.9% of preterm newborns died even though they did not have congenital malformations incompatible with life. A recent review found that NICUs mortality rates remain high in both developing (range 0.2–64.4%) and developed countries (range 4–46%) [50]. We found that receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes when controlling for CRIB and maternal disorders. These findings support the importance of implementing quality improvement strategies focused on the gaps in the QPC at NICUs. Several study limitations can be identified. First, this is cross-sectional study. It is impractical to make inferences about causal relationships or the direction of the association between the QPC and clinical outcomes. Second, the study was conducted in two NICUs in Mexico City, the results are not representative of all NICUs in Mexico. However, the QoC indicators can be used in other NICUs. Third, our measure of the QoC relies on clinical records, thus the QoC may be over- or underestimated. We conclude that the QPC and the clinical outcomes in the studied NICUs are poor. The findings presented here could guide interventions to improve the QPC, which in turn could have a positive impact on the clinical outcomes of neonates. Efforts should be made to institutionalize validated evidence-based NICUs' QoC indicators for regular evaluation of NICUs' process and outcomes of care for accountability and improvement purposes. 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Mexico: Ministry of Health, 2009. 18 Hospital Infantil De Mexico ‘Federico Gomez’. Clinical Guides of the Department of Neonatology. México: DF, 2011. 19 Ministry of Health. Clinical Practice Guideline. Prevention, diagnosis and treatment of necrotizing enterocolitis of the newborn in the second and third levels of care . Mexico: Ministry of Health, 2010. 20 Ministry of Health. Clinical Practice Guideline. Management of fluid and electrolytes in the premature newborn in the neonatal intensive care units . Mexico: Ministry of Health, 2010. 21 Ministry of Health. Clinical Practice Guideline. Prevention, diagnosis and treatment of sepsis and septic shock of the newborn in the second and third levels of care . Mexico: Ministry of Health, 2012. 22 Ministry of Health. Clinical Practice Guideline. Diagnosis and treatment of ventilator-associated pneumonia . Mexico: Ministry of Health, 2013. 23 Ministry of Health. Clinical Practice Guideline. 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Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Evaluating the quality of the processes of care and clinical outcomes of premature newborns admitted to neonatal intensive care units in Mexico

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© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Abstract Objectives To develop quality of care (QoC) indicators, evaluate the quality of the processes of care (QPC) and clinical outcomes, and analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to neonatal intensive care units (NICUs). Design Mixed methods approach: (1) development of QoC indicators via modified RAND/UCLA method; (2) cross-sectional study of QoC evaluation and (3) multiple logistic regression analysis to ascertain the association between the QPC and severe clinical outcomes. Setting Two NICUs belonged to the Mexican Institute of Social Security in Mexico City. Participants About 489 preterm neonates (<37 weeks of gestation) without severe congenital anomalies. Main Outcome Measure(s) The QoC indicators; ≥60% of recommended QPC and severe clinical outcomes. Results The QoC included 10 QPC indicators across four domains: respiratory, nutrition and metabolism, infectious diseases, and screening, and five outcome indicators. The lower QPC indicators were for the nutrition and metabolism domain (17.8% started enteral feeding with human milk, and 20.7% received sodium bicarbonate appropriately). The higher QPC indicator was for the screening domain (97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound). The mean recommended QPC that neonates received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. About 60.7% of neonates developed severe clinical outcomes including mortality and healthcare-related major morbidity. Receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes. Conclusion The evaluation of the QoC in NICUs is essential to address modifiable gaps in quality. quality of care, preterm newborns, neonatal intensive care units, Mexico Background Almost half of under-five child deaths worldwide occur within the first 28 days after birth. The toll represents 2.9 million neonatal deaths annually, of which 1.47 million are attributed to preterm birth [1]. The forecast for 2035 is that ‘there will be an additional 49 million neonatal deaths and 99 million children who will not reach their development potential due to disability after preterm birth’ [1]. In Latin America in 2013, there were 5.8 deaths per 1000 live births (LB) in the early neonatal period (0–6 days) and 2.3 deaths per 1000 LB in the late neonatal period (7–28 days) [2]. Honduras had the highest neonatal mortality (9.2 and 2.6 deaths for the corresponding neonatal periods), and Costa Rica the lowest (3.9 and 1.3 deaths, respectively). Mexico was in the middle, with 5.8 deaths and 2.4 deaths, respectively [2]. More than three-quarters of premature babies can survive with evidence-based, cost-effective care during delivery, neonatal and post-neonatal periods [3]. In developed countries, the improvement of newborns survival has been partially attributed to the care that neonatal intensive care units (NICUs) provide [4]. In developing countries, NICUs have wide variability of infrastructure and quality of care (QoC), therefore their evaluation and improvement is relevant [5]. In Mexico, health professionals attend 99% of deliveries, most of them in public hospitals, in two subsystems: the Ministry of Health (MoH) and Social Security institutions (SSIs). The MoH provides healthcare to people without social security, while SSIs provide healthcare to formal sector workers and their families. The Mexican Institute of Social Security (IMSS) is the largest provider of ambulatory and hospital healthcare, covering 60.9% of the Mexican population [6]. In both Mexican subsystems, research on the QoC for preterm neonates is incipient, and NICUs lack validated indicators to measure the QoC. Available studies have reported deficiencies in the QoC for neonates admitted to MoH NICUs with transient tachypnea [7] and necrotizing enterocolitis [8]. At IMSS hospitals, there is a high incidence of nosocomial infections and diseases secondary to prolonged endotracheal intubation [9, 10]. Also, heavy workload reflected in the number of discharges per number of nurses, along with the occurrence of unsafe events such as birth trauma or acute renal failure, increased the probability of a neonate dying at NICUs [11]. To the best of our knowledge, information on the QoC at NICUs is even more limited in other Latin American countries. In clinical practice, evidence-based process of care and clinical outcomes indicators serve to perform comprehensive QoC evaluations [12]. Process indicators represent direct quality measures that provide feedback for quality improvement and providers accountability [12]. Clinical outcome indicators cannot identify accurately the areas that need improvement, but are highly significant for patients and caregivers and can be used for public scrutiny. Also, outcome indicators might indicate the impact of quality improvement efforts [12]. In NICUs, characteristics of preterm neonates and healthcare processes can influence the clinical outcomes. Thus, understanding the links between the QoC processes and clinical outcomes, after controlling for other clinically significant variables is crucial. The objectives of this study were: to develop QoC indicators, to evaluate the quality of the processes of care (QPC) and clinical outcomes, and to analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to NICUs. Methods We conducted a three-stage research study with a mixed methods approach: At the first stage, we developed the processes and outcomes indicators to evaluate QoC at individual (neonate) and facility (NICU) levels through clinical records review. The modified RAND/UCLA Appropriateness Method [13] served to develop the QoC indicators. This method is based on the selection of indicators through the review of scientific evidence and expert panel validation. A list of 23 preliminary QoC indicators for expert vetting was identified through literature review. The review focused on the NICUs’ evidence-based care processes shown to increase the likelihood of achieving the best possible clinical outcomes. It included revision of the clinical guidelines and recommendations of the American Academy of Pediatrics and NICUs’ QoC indicators, such as Baby-Monitor indicators [14]. Also, we considered IMSS and MoH clinical guidelines for neonatal asphyxia [15], apnea of prematurity [16], respiratory distress syndrome [17, 18], necrotizing enterocolitis [18, 19], management of fluids and electrolytes in preterm infants [20], sepsis and septic shock [18, 21], pneumonia in neonates [18] and pneumonias associated with mechanical ventilation [22], congenital and acquired hydrocephalus [23], retinopathy of prematurity [24], hemorrhagic disease [25] and hemolytic disease [18, 26]. A list of QoC indicators was divided into two subgroups (processes and clinical outcomes). An expert panel of six neonatologists, three pediatric nurses and two health system researchers validated the indicators. The experts rated the validity and feasibility of proposed indicators using the Shekelle et al. [27] criteria. These criteria allowed each expert to individually assess the indicators on a 1–9-scale. Only the indicators with a median score ≥7 were considered as valid and feasible to measure QoC [28]. A final list of 15 indicators was produced after three consensus group rounds (voting, feedback and re-voting). In the second stage, a cross-sectional study of the QoC evaluation was conducted in two NICUs of tertiary care IMSS hospitals. One hospital was in the north and the other in the south part of Mexico City. Both hospitals provided care for newborns delivered in the facility and for those referred from secondary care hospitals. The northern NICU had 20 beds and was staffed by 25 neonatologists and 50 pediatric nurses; the southern NICU had 13 beds and was staffed by 15 neonatologists and 45 pediatric nurses. These two NICUs were chosen intentionally. We evaluated the clinical records of all preterm neonates (<37 weeks of gestation) admitted to NICUs from January to December 2015. We excluded the newborns with severe congenital anomalies not compatible with life, those with <24 completed weeks of gestation, those transferred in after 3 days of age, and those transferred out for reasons other than convalescent and chronic care. These exclusion criteria considered previous studies to ensure that the neonate outcomes primarily reflected the QoC of the NICU [29]. Two research-trained nurses collected the information. To describe the study population, we collected information on the following covariates: Characteristics of preterm neonates, including sex, gestational age, type of delivery (labor, cesarean section) and pregnancy product (single, twins or more), Apgar score after 5 min, birth weight and Clinical Risk Index for Babies (CRIB) score [30]. The CRIB assesses initial neonatal risk. Scores are given for birth weight, gestational age, maximum acid–base excess of arterial blood gas, maximum and minimum appropriate fraction of inspired oxygen during the first 12-h of life and the presence of congenital malformations. The International Neonatal Network establishes several scores for each CRIB component. The summary score ranges from 0 to 24. The highest scores correspond to the most severe cases. The CRIB showed the validity of the initial neonatal risk, even in extremely low-birth-weight infants, predicting neonatal mortality [31]. Particularly, the CRIB cutoff point of ≥4 showed a sensitivity of 80.6% and specificity of 75.3% for neonatal mortality [32]. Maternal clinical history during pregnancy and childbirth, such as diabetes, hypertensive disorders or other chronic diseases, amniotic fluid and membranes disorders, placental disorders, genitourinary tract infections during pregnancy, premature rupture of membranes, newborns with intrauterine hypoxia and birth asphyxia. Newborn diagnoses at NICU discharge. Characteristics of the NICUs’ healthcare: length of stay, duration of mechanical ventilation with an endotracheal tube, re-intubation(s), types and duration of central venous catheter, administration of antibiotics, ophthalmological revision and transfontanelar ultrasound. The QoC was evaluated through 10 processes and 5 outcomes indicators. The third stage aimed at ascertaining the association between the QPC (independent variable) and clinical outcomes (dependent variable). To achieve this goal, we created processes and outcomes summary binary indicators. First, we calculated the percentage of recommended QPC using the McGlynn et al. [28] approach. The numerator was the sum of all the recommended care indicators that a preterm neonate received and the denominator was the total number of indicators for which he/she was eligible. We identified that QPC did not have a normal distribution; therefore, we dichotomized QPC as follows: neonates receiving 60% or higher of recommended QPC and those receiving <60%. The cutoff value was based on the 80% of QPC. Next, as the outcome indicators represented different levels of severity, we created the ‘severe clinical outcomes’ variable, defined as the occurrence of mortality or healthcare-related major morbidity during the NICUs stay (pneumothorax, nosocomial infection and bronchopulmonary dysplasia, as indicated by the need for oxygen supply after the age of 28 days). Statistical Analysis The level of quality measurement and the unit of analysis was the neonate. We used descriptive statistics to analyze the characteristics of preterm neonates admitted to the NICUs, the history of maternal disorders related to pregnancy and childbirth, healthcare characteristics and quality. Multiple logistic regressions were performed to determine the association between the recommended QPC and severe clinical outcomes after controlling for the effect of the CRIB ≥4 points and the presence of maternal disorders. The study included two NICUs; therefore, the cluster effect was considered in the analysis, and the standard errors were adjusted for two clusters. Stata 14.0 (StataCorp, College Station, TX, USA) served for the analysis; P < 0.05 was considered statistically significant. The study protocol was approved by the IMSS National Research and Ethics Committees (CNIC: 2013-785-041). Results Stage 1: Indicator development. After the literature review, 23 QoC indicators were proposed and sent to the experts for validation. The panel accepted 15 indicators and 8 were discarded. The primary reason for discarding indicators was unavailability of a specific medicine (e.g. probiotics) or medical devices (e.g. probes) at IMSS. A final list of approved indicators included 10 QPC indicators for respiratory, nutrition and metabolism, infectious diseases and screening domains, and five clinical outcome indicators (Table 1). Table 1 List of indicators selected by an expert panel to evaluate the quality of care process and clinical outcomes of NICUs I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  Note. All numbers in the table should consider preterm infants admitted to the NICU during the calendar year under review. Table 1 List of indicators selected by an expert panel to evaluate the quality of care process and clinical outcomes of NICUs I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  I. Accepted indicators  A. Process of care indicators  (i) Respiratory domain  Formula  1  Percentage of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life (Recommended practice).  Numerator. Number of preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life. Denominator. Number of all preterm neonates admitted to the NICU.  2  Percentage of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life (Recommended practice).  Numerator. Number of preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life. Denominator. Number of all preterm neonates younger than 30 weeks of gestation admitted to the NICU.  3  Percentage of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance (Recommended practice).  Numerator. Number of preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance. Denominator. Number of all preterm neonates with respiratory distress syndrome admitted to the NICU.  (ii) Nutrition and metabolism domain  Formula  4  Percentage of preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest (Recommended practice).  Numerator. Number of preterm neonates who received sodium bicarbonate that was justified by the register of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest. Denominator. Number of all preterm neonates who received sodium bicarbonate during their NICU hospitalization.  5  Percentage of preterm neonates who started enteral feeding with human milk during their NICU hospitalization (e.g. maternal or donor) (Recommended practice).  Numerator. Number of preterm neonates who started enteral feeding with human milk during their NICUs’ hospitalization (e.g. maternal or donor). Denominator. Number of all preterm neonates admitted to the NICU.  (iii) Infectious disease domain  Formula  6  Percentage of preterm neonates with a diagnosis of probable sepsis that had blood culture sample(s) before administration of antibiotics (Recommended practice).  Numerator. Number of preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics. Denominator. Number of all preterm neonates with a diagnosis of probable sepsis admitted to the NICU.  7  Percentage of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days (Recommended practice).  Numerator. Number of catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days. Denominator. Number of all preterm neonates catheterized by the central venous catheter during their NICU hospitalization.  8  Percentage of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment (Recommended practice).  Numerator. Number of preterm neonates with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment. Denominator. Number of all preterm infants with negative bacteriologic cultures (blood, bronchial, urine or catheter cultures) and without necrotizing enterocolitis who were hospitalized in NICU for ≥5 days.  (iv) Screening domain  Formula  9  Percentage of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound (Recommended practice).  Numerator. Number of preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound. Denominator. Number of all preterm neonates with diagnosis of probable necrotizing enterocolitis during their NICU hospitalization.  10  Percentage of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage (Recommended practice).  Numerator. Number of preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage. Denominator. Number of all preterm neonates <30 weeks gestation admitted to the NICU.  B. Indicators of Healthcare Outcomes  Formula  1  Percentage of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization (Not the recommended result).  Numerator. Number of preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization. Denominator. Number of all preterm neonates without congenital malformations incompatible with life who were admitted to the NICU.  2  Percentage of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation (Not the recommended result).  Numerator. Number of preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation. Denominator. Number of all preterm neonates with respiratory assistance with continuous positive airway pressure or mechanical ventilation during their NICU hospitalization.  3  Percentage of preterm neonates who had nosocomial infection after 48 h of admission to the NICU (Not the recommended result).  Numerator. Number of preterm neonates who had nosocomial infection after 48 h of admission to the NICU. Denominator. Number of all preterm neonates admitted to the NICU for more than 48 h.  4  Percentage of preterm neonates with the need for oxygen supply after the age of 28 days (Not the recommended result).  Numerator. Number of preterm neonates with the need for oxygen supply after the age of 28 days. Denominator. Number of all preterm neonates admitted to the NICU for more than 28 days.  5  Percentage of preterm neonates with growth rate <12.4 g/kg/day (Not the recommended result).  Numerator. Number of preterm neonates with growth rate <12.4 g/day. Denominator. Number of all preterm neonates admitted to the NICU. (Growth rate determined by using an exponential model described by Patel AL, Engstrom JL, Meier PP, Jegier BJ, Kimura RE. Calculating Postnatal Growth Velocity in Very Low Birth Weight (VLBW) Premature Infants. J Perinatol. 2009; 29(9): 618–622.)  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  II. Discarded indicators  A. Discarded by the expert group  Reasons for low scoring and elimination  1  Percentage of premature neonates younger than 27 weeks and intubated that received 3–4 doses of surfactant within the first 2 h of life.  The surfactant used at IMSS is beractant, which allows for applying only 1 dose of 100 mg or 200 mg. In addition, if the surfactant is administered in a timely manner, multiple doses are not required. Therefore, it is recommended that this indicator be discarded and that a new indicator be proposed that only considers if the surfactant was administered in the correct time interval.  2  Percentage of preterm neonates between 501 and 1250 g that required mechanical ventilation and/or continuous positive airway pressure via the nasal route and/or fraction of inspired oxygen >30% at 24 h of age, and that were administered vitamin A 5000 IU intramuscularly three times a week for 4 weeks during their NICU hospitalization.  Vitamin A is not used in Mexico because there is no intramuscular presentation.  3  Percentage of preterm neonates who received enteral supplementation with probiotics.  Probiotics are not available at IMSS hospitals.  4  Percentage of preterm neonates with a diagnosis of sepsis for whom the diagnosis was based on two positive blood cultures of peripheral skin punctures or a peripheral skin puncture and a central catheter blood culture.  According to current regulations in Mexico, only one blood culture is used to corroborate the diagnosis of sepsis.  5  Percentage of premature neonates weighted ≥1000 g who were catheterized with umbilical venous catheters  The first catheter option for any preterm neonate that requires venous access at birth is always the umbilical catheter, and the decision does not depend on the weight of the newborn.  6  Percentage of preterm neonates with continuous (daily) recording of temperature.  This indicator does not describe accurately the currently recommended evidence-based practice that preterm neonates in intensive care units should receive. Such practice should include continuous central monitoring by placing a probe over the abdomen when the neonate is in a supine position or in the back when the neonate is in a prone position. The information on temperatures should be recorded hourly. Reference: Heather Parsons, Practice Educator, NICU. Clinical guideline on thermoregulation for neonates. From Great Ormond Street Hospital. Available at http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/thermoregulation-neonates. Also, there are no skin sensor probes at IMSS NICUs, and health personnel measures the axillary temperature with digital thermometers hourly for 24 h a day.  7  Percentage of preterm neonates <30 weeks of gestation or greater with a history of oxygen exposure who underwent ophthalmologic revision to evaluate retinopathy of prematurity at the age recommended by the American Academy of Pediatrics, 2012.  None of the preterm neonates usually stay in the NICU until the age at which ophthalmologic revision is recommended by the American Academy of Pediatrics.  8.  Percentage of catheterized preterm neonates for whom the single lumen catheter was used.  Information about the type of lumen is not registered in the clinical records.  Note. All numbers in the table should consider preterm infants admitted to the NICU during the calendar year under review. Stage 2: Among the 741 neonates admitted to the studied NICUs during 2015, 687 were premature and 489 met the inclusion criteria. Table 2 shows the characteristics of the study population and history of maternal disorders. More than a half neonates were boys (54.6%); 92.2% were delivered by cesarean section; 85.7% were single pregnancy products.15.3% were extremely preterm (<28 weeks); 46.8% were very preterm (from 28 to <32 weeks) and 37.9% were moderate to late preterm (from 32 to <37 weeks). Only 2.7% had birth weight >2500 g and most (38%) weighed between 1000 g and 1499 g; 93.7% had an Apgar score ≥6 at 5 min after birth. The mean score of the clinical risk index for babies was 7.5. Table 2 Characteristics of preterm neonates admitted to the NICU and history of maternal disorders related to pregnancy and childbirth (n = 489) Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  aDenominator for the maternal disorders is neonates even though there were ten women with two neonates admitted to the NICUs at the same time. Table 2 Characteristics of preterm neonates admitted to the NICU and history of maternal disorders related to pregnancy and childbirth (n = 489) Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  Characteristics of preterm neonates  n (%)  Male sex  267 (54.6)  Type of delivery   Labor  38 (7.8)   Cesarean section  451 (92.2)  Type of pregnancy product   Single  419 (85.7)   Twins or more  70 (14.3)  Gestational age, weeks   Mean (standard deviation)  30.5 (2.7)   Median (minimum–maximum)  30 (24–37)  WHO: Gestational age groups   Extremely preterm (<28 weeks)  75 (15.3)   Very preterm (from 28 to <32 weeks)  229 (46.8)   Moderate to late preterm (from 32 to <37 weeks)  185 (37.9)  Birth weight, g   Mean (standard deviation)  1393.1 (523.8)   Median (minimum–maximum)  1300 (490–3630)  Birth weight groups   >2500  13 (2.7)   2000–2500  55 (11.3)   1500–1999  115 (23.5)   1000–1499  186 (38.0)   <999  120 (24.5)  Apgar score 5 min after birth  Mean (standard deviation)  7.8 (0.9)  Median (minimum–maximum)  8 (2–9)  Groups according to the Apgar score   3 or less  7 (1.4)   Between 4 and 6  24 (4.9)  >6  458 (93.7)  Clinical risk index for babies (CRIB) Score   Mean (standard deviation)  7.5 (4.0)   Median (minimum–maximum)  7 (1–20)  CRIB ≥4 points  370 (75.7)  Maternal disorders during pregnancy and childbirtha  436 (89.2)   Infections of genitourinary tract in pregnancy  227 (46.4)   Hypertensive disorders in pregnancy, childbirth and the puerperium  178 (36.4)   Diabetes mellitus in pregnancy  41 (8.4)   Placental disorders and placenta previa  19 (3.9)   Disorders of amniotic fluid and membranes (e.g. polyhydramnios and oligohydramnios)  14 (2.9)   Premature rupture of membranes (PRM)      Without PRM  338 (69.1)    PRM >18 h  94 (19.2)    PRM ≤18 h  57 (11.7)  Chronic non-communicable diseases (e.g. cancer, arthritis, etc.)  36 (7.4)  aDenominator for the maternal disorders is neonates even though there were ten women with two neonates admitted to the NICUs at the same time. Regarding the maternal clinical history during pregnancy and childbirth, most mothers (89.2%) had one or more complications such as genitourinary tract infections (46.4%), hypertensive disorders (36.4%), diabetes (8.4%), placental disorders (3.9%), amniotic fluid and membrane disorders (2.9%) or premature rupture of membranes (30.9%). Table 3 presents the neonates’ diagnoses and healthcare characteristics. The top five diagnoses were respiratory distress syndrome (93.7%), transitory neonatal endocrine, electrolyte and metabolic disturbances (73%), intracranial nontraumatic hemorrhage (58.5%), early onset bacterial sepsis (58.1%) and perinatal hematological disorders (46%). The mean duration of the NICU stay was 17.5 days; 96.1% received mechanical ventilation with an endotracheal tube; 36% had this ventilation for >7 days and 48.3% had re-intubation(s); 89% had a central venous catheter through the umbilical vein with a mean duration of 5.3 days; 73.4% had a central venous catheter through peripheral puncture with a mean duration of 18 days; 94.7% received antibiotics, 85.7% transfontanelar ultrasound and 8.4% ophthalmological revision. Table 3 Preterm neonates' diagnoses and characteristics of the NICUs healthcare (n = 489)   n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)    n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)  Table 3 Preterm neonates' diagnoses and characteristics of the NICUs healthcare (n = 489)   n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)    n (%)  Preterm neonates' diagnoses    Disorders related to length of gestation and fetal growth (Small for gestational age)  184 (37.6)  Birth injuries  177 (36.2)  Respiratory disorders     Respiratory distress syndrome of newborn  458 (93.7)   Congenital pneumonia  137 (28.0)   Pulmonary hemorrhage originating in the perinatal period  68 (13.9)   Pneumothorax  56 (11.5)   Bronchopulmonary dysplasia  55 (11.2)   Other respiratory conditions originating in the perinatal period (atelectasis, apnea, etc.)  165 (33.7)  Cardiovascular disorders (primarily persistent fetal circulation)  155 (31.7)  Infections specific to the perinatal period     Early onset bacterial sepsis  284 (58.1)   Late onset sepsis or pneumonia (>48 h)  208 (42.5)   Laboratory confirmed infections  n = 442 53 (12.0)  Hemorrhagic and hematological disorders     Intracranial no traumatic hemorrhage  286 (58.5)   Neonatal gastrointestinal hemorrhage  106 (21.7)   Perinatal hematological disorders  225 (46.0)  Transitory neonatal endocrine, electrolyte and metabolic disturbances  357 (73.0)  Digestive system disorders (e.g. necrotizing enterocolitis, Intestinal perforation and other digestive system disorders)  63 (12.9)  Congenital malformations compatible with life (e.g. malformations of eye, ear, face and neck, cleft lip and cleft palate, microcephaly, colpocephaly, etc.)  116 (23.7)  Other disorders originating in the perinatal period     Retinopathy of prematurity  16 (3.3)   Renal failure  82 (16.8)   Neonatal cerebral leukomalacia  24 (4.9)  Characteristics of the healthcare    Duration of NICU stay, days     Mean (standard deviation)  17.5 (16.6)   Median (minimum–maximum)  12 (1–126)  Mechanical ventilation with an endotracheal tube  470 (96.1)  Duration of mechanical ventilation     Without mechanical ventilation  19 (3.9)   1 day or less  92 (18.8)   >1 day and ≤3 days  88 (18.0)   >3 days and ≤7 days  114 (23.3)   >7 days  176 (36.0)  Re-intubation(s)  n = 470 227 (48.3)  Central venous catheter through umbilical vein  435 (89.0)  Central venous catheter through peripheral puncture  359 (73.4)  Days of duration of venous catheter through umbilical vein     Mean (standard deviation)  5.3 (3.3)   Median (minimum–maximum)  5 (0.04–18)  Days of duration of venous catheter through peripheral puncture     Mean (standard deviation)  18.0 (16.3)   Median (minimum–maximum)  13 (0.3–114)  Administration of antibiotics  463 (94.7)  Transfontanelar ultrasound  419 (85.7)  Ophthalmological revision  41 (8.4)  Table 4 shows the results of the QoC evaluation. Regarding the respiratory domain, 86.5% did not receive dexamethasone or hydrocortisone in the first 10 days of life, and 57.7% of neonates younger than 30 weeks of gestation received surfactant in the first 30 min of life. Only 27.2% of newborns with respiratory distress syndrome received initial noninvasive respiratory assistance. In the nutrition and metabolism domains, 20.7% received sodium bicarbonate appropriately, and 17.8% started human milk enteral feeding. In the infectious domain, 57% of neonates with diagnosis of probable sepsis had blood culture sample(s) before administration of antibiotics, and 65.7% of catheterized preterm neonates had peripheral puncture central venous catheter during <21 days. Only 8.5% of neonates with negative bacteriologic cultures and without necrotizing enterocolitis did not receive prolonged (≥5 days) antibiotic treatment. In the screening domain 85.7% of neonates with a diagnosis of probable necrotizing enterocolitis had an abdominal X-ray or abdominal ultrasound and 97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound. Table 4 NICUs' quality of care (n = 489) A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  aRecommended practice or outcomes of care. bNot recommended outcomes. Table 4 NICUs' quality of care (n = 489) A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  A. Process of care  Numerator  Denominator  %  (i) Respiratory domaina  1. Preterm neonates who did not receive dexamethasone or hydrocortisone in the first 10 days of life  423  489  86.5  2. Preterm neonates younger than 30 weeks of gestation who received surfactant in the first 30 min of life  101  175  57.7  3. Preterm neonates with respiratory distress syndrome who received noninvasive respiratory assistance as an INITIAL mode of respiratory assistance  133  489  27.2  (ii) Nutrition and metabolism domaina        4. Preterm neonates who received sodium bicarbonate that was justified by the recording of the following parameters/diagnoses: hyperkalemia (≥6.5 mEq/L), loss of urinary bicarbonate and prolonged cardiac arrest  51  246  20.7  5. Preterm neonates who started enteral feeding with human milk during their NICUs hospitalization  87  489  17.8  (iii) Infectious domaina        6. Preterm neonates with a diagnosis of probable sepsis who had blood culture sample(s) before administration of antibiotics  237  416  57.0  7. Catheterized preterm neonates with peripheral puncture central venous catheter duration <21 days  236  359  65.7  8. Preterm neonates with negative bacteriologic cultures and without stage II and III necrotizing enterocolitis who did not receive prolonged (≥5 days) antibiotic treatment  27  316  8.5  (iv) Screening domaina        9. Preterm neonates with diagnosis of probable necrotizing enterocolitis who had an abdominal X-ray or abdominal ultrasound  54  63  85.7  10. Preterm neonates <30 weeks gestation who underwent early (≤14 days) transfontanelar ultrasound to detect intraventricular hemorrhage  164  168  97.6  B. Outcomes of careb        1. Preterm neonates without congenital malformations incompatible with life who died during their NICU hospitalization  73  489  14.9  2. Preterm neonates who had pneumothorax during respiratory assistance with continuous positive airway pressure or mechanical ventilation  56  489  11.5  3. Preterm neonates who had nosocomial infection after 48 h of admission to the NICU  212  430  49.3  4. Preterm neonates with the need for oxygen supply after the age of 28 days  92  100  92.0  5. Preterm neonates with growth rate <12.4 g/kg/day  476  489  97.1  C. Number of the quality of the processes of care (QPC) indicators for which each neonate was eligible and summary indicators    Number of QPC indicators for which each neonate was eligible  n = 489   Mean (standard deviation)  6.6 (1.6)   Median (minimum–maximum)  6.5 (3–10)  Percentage of recommended QPC  n = 489   Mean (standard deviation)  47.5 (16.0)   Median (minimum–maximum)  50.0 (0–100)  ≥60% of recommended QPC  130 (26.6)  Severe clinical outcomes  297 (60.7)  aRecommended practice or outcomes of care. bNot recommended outcomes. Regarding clinical outcomes, 14.9% of neonates without congenital malformations incompatible with life died at the NICU. Other negative outcomes included pneumothorax during respiratory assistance (11.5%); nosocomial infection among those with the NICUs stay ≥48 days (49.3%), need for oxygen supply after 27 days of age among those with the NICUs stay ≥28 days (92%) and growth rate <12.4 g/day (97.1%). The mean number of QPC indicators for which each neonate was eligible was 6.6 and the mean recommended QPC that a neonate received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. Furthermore, 60.7% of neonates presented severe clinical outcomes. Stage 3: Table 5 describes the results of the multiple logistic regressions analysis. We found that receiving ≥60% of recommended QPC was associated with decrease of nearly half of odds of severe clinical outcomes (odds ratio: 0.56, 95% confidence interval (CI): 0.50; 0.64), compared with receiving <60% of recommended QPC. This association was statistically significant after controlling for the CRIB ≥ 4 points and maternal disorders. Table 5 Association between the recommended quality of process of care and severe clinical outcomes controlled for the effect of the clinical risk index for babies score and the presence of maternal disorders during pregnancy and childbirth (n = 489)   Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010    Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010  Table 5 Association between the recommended quality of process of care and severe clinical outcomes controlled for the effect of the clinical risk index for babies score and the presence of maternal disorders during pregnancy and childbirth (n = 489)   Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010    Odds ratio [at 95% CI]  Robust standard errors  P  About ≥60% of recommended quality of the processes of care  0.56 [0.50; 0.64]  0.04  0.000  Clinical risk index for babies score ≥4 points  3.81 [1.64; 8.84]  1.63  0.002  Maternal disorders during pregnancy and childbirth and chronic diseases  1.37 [1.08; 1.75]  0.17  0.010  Discussion Multiples studies have shown that the quality of hospital care cannot be guaranteed without being monitored [33]. Comprehensive evaluation of the quality of NICU care is a significant step towards identifying existing gaps, which in turn can lead to the proper design of improvement strategies. To our knowledge, only the NICUs at the USA have developed quality indicators. It is worthwhile to identify relevant, valid and feasible NICUs QoC indicators in the resource limited settings in low and middle-income countries [34]. The evaluation allowed identifying limitations in the QPC and clinical outcomes of NICUs that require attention. The six most pronounced gaps in the QPC involved failures to (1) avoid prolonged antibiotic treatment for neonates with negative bacteriologic cultures and without necrotizing enterocolitis; (2) introduce human milk feeding; (3) justify a prescription of sodium bicarbonate in the clinical record; (4) provide early noninvasive respiratory assistance; (5) take blood culture sample(s) before administering antibiotics and (6) administer surfactant to neonates younger than 30 weeks of gestation in the first 30 min of life. Eventual strategies to improve the QoC should focus on closing these gaps, since there is substantial evidence supporting the beneficial effects of improvements in these areas on clinical outcomes. An association exists between prolonged empirical treatment of preterm infants with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, invasive fungal infection and mortality [35, 36]. Consequently, the American Academy of Pediatrics recommends discontinuing antimicrobial therapy at 48 h in clinical situations where the probability of sepsis is low. Human milk reduces rates of sepsis, necrotizing enterocolitis, and retinopathy of prematurity, leads to fewer hospital readmissions in the first year of life, and improves neurodevelopment, among other benefits [37]. The American Academy of Pediatrics and other institutions recommend that all premature babies receive human milk. Using sodium bicarbonate for metabolic acidosis is common, but there is little evidence of its efficacy and extensive evidence of its adverse effects. The American Heart Association recommends sodium bicarbonate only for hyperkalemia, loss of urinary bicarbonate and prolonged cardiac arrest [38, 39]. Prophylactic nasal CPAP in very preterm infants reduces the need for mechanical ventilation and surfactant and decreases the incidence of bronchopulmonary dysplasia and death [40]. Also, CPAP is associated with reduced respiratory failure and mortality among preterm infants with respiratory distress [41]. Use of a single dose of surfactant to prevent respiratory distress syndrome is associated with a reduction in neonatal mortality and chronic lung disease, and bronchopulmonary dysplasia [42, 43]. The clinical outcomes of NICU care can be explained by the gaps in the care process. 97% of preterm neonates had a slow growth rate (<12.4 g/kg/day). This figure highlights the importance of early human milk feeding, as we found that only 17.8% started enteral feeding with human milk. Almost half of preterm newborns (49.3%) with the NICUs stay ≥48 days developed a nosocomial infection. Nosocomial infection in this population has been shown to double rates of mortality, increase the length of NICU stay and healthcare costs [44]. Studies from the USA and Canada show that ~15% of preterm neonates admitted to NICUs develop late onset sepsis [45, 46] that ranges from 10.6% to 31.7% [47]. In our study, 42.5% of neonates developed late onset sepsis. Several NICUs care processes have protective effects against nosocomial infection, including hand hygiene, early human milk feeding, administration of probiotics, minimization of intubation days, minimization of the use of central lines and minimization of antibiotic treatment in neonates with negative bacteriologic cultures [48, 49]. Three of previously named care processes were identified by the expert panel as valid indicators that can feasibly be obtained through clinical records to comprehensively evaluate the quality of NICU care. However, as mentioned above, these indicators showed gaps. The fact that 92% of newborns who stayed more than 28 days required oxygen supply should set off alarms, since these newborns were in danger of prolonged mechanical ventilation that can lead to bronchopulmonary dysplasia. In our study, 96.1% of neonates received mechanical ventilation, 36% of them for more than 7 days. In our study, 14.9% of preterm newborns died even though they did not have congenital malformations incompatible with life. A recent review found that NICUs mortality rates remain high in both developing (range 0.2–64.4%) and developed countries (range 4–46%) [50]. We found that receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes when controlling for CRIB and maternal disorders. These findings support the importance of implementing quality improvement strategies focused on the gaps in the QPC at NICUs. Several study limitations can be identified. First, this is cross-sectional study. It is impractical to make inferences about causal relationships or the direction of the association between the QPC and clinical outcomes. Second, the study was conducted in two NICUs in Mexico City, the results are not representative of all NICUs in Mexico. However, the QoC indicators can be used in other NICUs. Third, our measure of the QoC relies on clinical records, thus the QoC may be over- or underestimated. We conclude that the QPC and the clinical outcomes in the studied NICUs are poor. The findings presented here could guide interventions to improve the QPC, which in turn could have a positive impact on the clinical outcomes of neonates. Efforts should be made to institutionalize validated evidence-based NICUs' QoC indicators for regular evaluation of NICUs' process and outcomes of care for accountability and improvement purposes. 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Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Apr 4, 2018

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