Department of Research & Evaluation News

Back in 1991, the American Academy of Pediatrics began recommending testing preterm infants before they left the hospital to check that their breathing ability was mature enough when in a car seat to be discharged safely. At the time, there were no studies that showed whether this screening — which takes 2 hours of NICU nurse time and could cause anxiety for parents — prevented potentially dangerous breathing problems.

In 2016 after reviewing published studies, Kaiser Permanente Southern California neonatal care clinicians stopped doing the screenings on a routine basis. In their study recently published in The Journal of Pediatrics on the effect of stopping screening, they found what some researchers and physicians had suspected: The tests didn’t really help the babies.

“It’s important not only to start doing things that make people better, but also to stop doing things that don’t help make people better,” said David Braun, MD, who led the study. “This is an example of an effort where we saw something that appeared not to be helpful, and so as an organization we assessed the literature, made a decision to change practice, and then carefully checked that there weren’t any adverse or unexpected outcomes with the change.”

More than 40,000 preterm infants evaluated

This study included 41,264 infants born from 22 through 36 weeks’ gestational age at Kaiser Permanente Southern California hospitals from 2010 through 2021.

The researchers looked back at electronic health records to determine the infants’ health after they left the hospital including

• death,
• 911 calls and
• readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening events, or brief resolved unexplained events within 30 days of discharge.

Researchers compared the health of the infants during the time the screening was in place to after it was discontinued. They found no statistically significant differences between the screening period and the discontinuation periods for the outcomes measured.

• During the screening period, 1% of preterm infants had one of the health problems listed above after discharge.
• After screening was no longer performed at the hospitals, there was no change in the rate of those health problems.

The research evolved from a ‘book club”

Dr. Braun is a clinician investigator with the Department of Research & Evaluation, He has practiced over 35 years as a neonatologist at Kaiser Permanente’s Panorama City and Woodland Hills locations and was head of neonatology for the Southern California Permanente Medical Group for 20 years. He pointed to a memorable monthly “journal club” for Kaiser Permanente neonatologists in which a review of the literature around the car seat screening tests for preterm infants was presented. Dr. Braun noted that, while the tests were well intended, there didn’t seem to be evidence-based research that showed the screenings were helping infants.

“This triggered discussions about whether we should be doing this,” Dr. Braun said. “It is a shame to do a test just when the baby seems ready to go home if it doesn’t protect the baby and may undermine parents’ confidence if the baby fails the test and the planned discharge is cancelled.”

The screening also typically requires about 2 hours of a nurse’s time. Across the United States, this testing would take a million nursing hours annually; time that could be spent helping babies and parents in other ways, Dr. Braun pointed out.

Taking away unneeded testing can help patients

This car seat screening project is one of several quality improvement projects that Dr. Braun and his regional neonatology colleagues pursued in collaboration with scientists from Research & Evaluation.

“As physicians, there are things we do with the best of intentions that might not add much value for patients,” Dr. Braun said. “We need to look at those things and make sure that our resources are directed toward procedures and tests that will benefit our patients.”

Other projects he and his neonatal team conducted included

• Changing the gestational age that triggers an automatic admission to the neonatal intensive care unit, which has resulted in avoiding unnecessary NICU admissions.
• Providing decision support for sepsis assessments, which set up algorithms to help determine which babies needed antibiotics.

How this research may evolve

Researchers don’t expect that this study is the final word on car seat tolerance screenings. Though no longer recommended by the Canadian Pediatric Society, the test is still recommended by the American Academy of Pediatrics and widely used in this country. Additional questions deserve answers, said he senior author of the study, Darios Getahun, MD, PhD, a researcher at Research & Evaluation.

“Although the findings of the study suggest that discontinuing predischarge car seat tolerance screenings for premature infants did not cause those children harm … it will be important to follow this study with research that includes more preterm infants to confirm the findings, and also account for some of the issues we might not have taken into account such as the variation we had in the screening protocols,” Dr. Getahun said.

He added that he and his colleagues are continuing to research this screening test to confirm there aren’t groups of infants who might truly benefit from this test or modifications of this test that could make babies safer.

“When you put the infant in the car seat for the first time, the test result may be influenced by many factors that need to be considered,” Dr. Getahun said. “We want to look at, among other factors,  whether the severity of the illness that led the infants to be admitted needs to be accounted for to predict their outcome.”

Dr. Braun noted, “The American Academy of Pediatrics guidelines come up for revision every few years. We hope our work provides information that will help them with the next round of recommendations.”

Additionally, Dr. Braun said that the “tool kit,” or set of procedures they created for this research, can be used to assess other care practices as well.

“We will apply this to other ready-to-discharge practices to see what is working best, and what isn’t working at all,” Dr. Braun said “That will help both the patients and our ability to provide the best possible care.”

In addition to Dr. Braun and Dr. Getahun, co-authors on this study included Joseph W. Kaempf, MD; Ngoc J Ho, PhD; Marielle H. Nguyen, MD; Rohit Passi, MD; Anthony E. Burgos, MD; Marianna Volodarskiy, MSN, RN; Maria Fe B. Villosis, MD; Mandhir Gupta, MD; Talar S. Habeshian, MPH; Henry K. Tam, PhD; Kevin B. Litam, BS; Quinn L. Hong, MS; and Calvin C. Dong, BS.