Special Article
Care levels in neonatal units in Spain: an updated vision for a new reality
Niveles asistenciales en las unidades neonatales en España: una visión actualizada para una nueva realidad
Alejandro Pérez-Muñuzuria,b, Héctor Boixc, María Dolores Sánchez-Redondod, María Cernadae,f, María Gracia Espinosa-Fernándezg, Noelia González-Pachecoh, Ana Martín-Anceli, María L. Coucea,b,
, Manuel Sánchez Lunah, en representación del Comité de Estándares y Junta Directiva y Comité Asesor de la Sociedad Española de Neonatología
Corresponding author
a Servicio de Neonatología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
b Instituto de Investigaciones Sanitarias de Santiago (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain
c Servicio Territorial de Pediatría, Hospital Quirónsalud, Barcelona, Spain
d Unidad de Neonatología, Hospital Virgen de la Salud, Toledo, Spain
e Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
f Grupo de Investigación en Perinatología, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
g Unidad de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain
h Servicio de Neonatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
i Servicio de Neonatología, Hospital Sant Joan de Dèu, Barcelona, Spain
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"apellidos" => "Couce" "email" => array:1 [ 0 => "maria.luz.couce.pico@sergas.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 8 => array:3 [ "nombre" => "Manuel Sánchez" "apellidos" => "Luna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 9 => array:1 [ "colaborador" => "en representación del Comité de Estándares y Junta Directiva y Comité Asesor de la Sociedad Española de Neonatología" ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigaciones Sanitarias de Santiago (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio Territorial de Pediatría, Hospital Quirónsalud, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Neonatología, Hospital Virgen de la Salud, Toledo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Grupo de Investigación en Perinatología, Instituto de Investigación Sanitaria La Fe, Valencia, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Unidad de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Sant Joan de Dèu, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Niveles asistenciales en las unidades neonatales en España: una visión actualizada para una nueva realidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0410" class="elsevierStylePara elsevierViewall">In 2004 and 2013, the Sociedad Española de Neonatología (SENeo, Spanish Society of Neonatology) established criteria to define the different levels of care of neonatal units in Spain.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> These criteria are chiefly based on the definition of groups of neonates that may receive care in a given type of unit based on gestational age, weight, number of deliveries managed in the catchment area as an indirect indicator of the experience of health care staff, amount and type of available equipment or availability of techniques or procedures that could be applied based on disease severity and medical complexity, resulting in the establishment of 3 levels of care with different sublevels.</p><p id="par0415" class="elsevierStylePara elsevierViewall">In brief, the current levels of care of neonatal units in Spain are defined according to the following criteria:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">•</span><p id="par0420" class="elsevierStylePara elsevierViewall">Level I: management of low-risk pregnancies, healthy newborns and clinically stable newborns delivered between 35 and 37 weeks (wk) of gestation. Resuscitation in delivery room and operating room. Triage system established to identify patients that may require transfer to a higher level of care. Stabilization of patients in the event of unexpected neonatal problems, including the stabilization of newborns small for gestational age and severely ill preterm newborns before transport. Management, assessment and identification of neonatal disease in previously healthy newborns. Coordination with primary care to set up the followup of discharged newborns.</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">•</span><p id="par0425" class="elsevierStylePara elsevierViewall">Level II<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">-</span><p id="par0430" class="elsevierStylePara elsevierViewall">IIA: management of select complicated pregnancies and newborns delivered after 32 weeks gestation and with birth weights greater than 1500<span class="elsevierStyleHsp" style=""></span>g. Care of newborns with minor disease and problems that can be resolved quickly without need of respiratory support or arterial vascular access (possibly with availability of nasal intermittent positive pressure ventilation [IPPV] for short-term conditions). Management of newborns transferred from the referral hospital that have overcome the severe phase of disease (back transfer). Programmes for the developmental followup of high-risk newborns.</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">-</span><p id="par0435" class="elsevierStylePara elsevierViewall">IIB: management of at least 1500 deliveries a year in the catchment area. Care of newborns with moderately severe disease, including those who require conventional mechanical ventilation for brief periods (<24<span class="elsevierStyleHsp" style=""></span>h) or noninvasive ventilation.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">•</span><p id="par0440" class="elsevierStylePara elsevierViewall">Level III: management of at least 2000 deliveries a year in the catchment area.<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall">IIIA: management of selected complicated pregnancies and newborns delivered after 28 weeks gestation and with birth weight greater than 1000<span class="elsevierStyleHsp" style=""></span>g. Care of severely ill newborns, including those requiring conventional mechanical ventilation. Minor surgical procedures.</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall">IIIB: management of any form of complicated pregnancy and newborns of any gestational age. Access to advanced respiratory support (high-frequency oscillatory ventilation [HFOV] and administration of inhaled nitric oxide [iNO]). Paediatric surgery resources immediately accessible for performance of major surgical interventions.</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">-</span><p id="par0455" class="elsevierStylePara elsevierViewall">IIIC: newborns requiring the full spectrum of medical and surgical subspeciality services, including cardiac surgery with extracorporeal circulation, extracorporeal membrane oxygenation (ECMO) and paediatric transplantation.</p></li></ul></p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Classification of levels of care in other countries</span><p id="par0460" class="elsevierStylePara elsevierViewall">In the United States, the American Academy of Pediatrics published indicators that were mainly based on morbidity criteria rather than patient volume.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">•</span><p id="par0465" class="elsevierStylePara elsevierViewall">Level I: capabilities to provide neonatal resuscitation, evaluation and postnatal care for stable term newborn infants, stabilization and care for infants born at 35–37 weeks of gestation who remain physiologically stable, stabilization of newborn infants born at before 35 weeks gestation until transfer to a higher level of care.</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">•</span><p id="par0470" class="elsevierStylePara elsevierViewall">Level II: capabilities to provide care for infants born at or after 32 weeks gestation and weighing 1500<span class="elsevierStyleHsp" style=""></span>g or more with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis; to provide care for infants convalescing after intensive care; invasive IPPV (for <24<span class="elsevierStyleHsp" style=""></span>h) or noninvasive ventilation or both; stabilization of infants born before 32 weeks gestation and weighing less than 1500<span class="elsevierStyleHsp" style=""></span>g until transfer.</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">•</span><p id="par0475" class="elsevierStylePara elsevierViewall">Level III (neonatal intensive care unit [NICU]): capabilities to provide life support, care for infants born before 32 weeks gestation and weighing less than 1500<span class="elsevierStyleHsp" style=""></span>g and infants born at all gestational ages and birth weights with critical illness, access to paediatric medical subspecialists, paediatric surgical specialists, paediatric anaesthesiologists, and paediatric ophthalmologists. Full range of respiratory support, including HFOV and iNO, and access to imaging (magnetic resonance [MR], computed tomography [CT], ultrasound).</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">•</span><p id="par0480" class="elsevierStylePara elsevierViewall">Level IV (regional NICU): capability to provide surgical repair of complex congenital or acquired conditions, full range of paediatric subspecialists. Paediatric surgical subspecialists. Capabilities for transport and outreach education. Includes cardiac repair surgery with or without ECMO.</p></li></ul></p><p id="par0485" class="elsevierStylePara elsevierViewall">Neighbouring countries have also established specific levels of care; for instance, in the United Kingdom, there are 3 levels of care corresponding to 3 types of neonatal units based on the care provided.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">•</span><p id="par0490" class="elsevierStylePara elsevierViewall">Level I: provision of care for babies who cannot be looked after at home. Includes breathing and heart rate monitoring, tube feeding, oxygen therapy and phototherapy for jaundice.</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">•</span><p id="par0495" class="elsevierStylePara elsevierViewall">Level II: provision of high-dependency care. Takes place in a specialised neonatal unit and provides continuous monitoring. Patients may include babies who weigh less than 1000<span class="elsevierStyleHsp" style=""></span>g (2 lbs 3 oz), or are receiving help with their breathing via continuous positive airway pressure (CPAP) or intravenous feeding, but who do not fulfil any of the requirements for intensive care.</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">•</span><p id="par0500" class="elsevierStylePara elsevierViewall">Level III: intensive care. Management of babies with the most complex problems who require constant supervision and monitoring and, usually, mechanical ventilation. A doctor must always be available in the premises.</p></li></ul></p><p id="par0505" class="elsevierStylePara elsevierViewall">Types of neonatal units in the United Kingdom:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">•</span><p id="par0510" class="elsevierStylePara elsevierViewall">Special care unit: provide special care for their own local population. Depending on arrangements within their neonatal network, they may also provide some high dependency services. In addition, SCUs provide a stabilisation facility for babies who need to be transferred to a NICU for intensive or high dependency care.</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">•</span><p id="par0515" class="elsevierStylePara elsevierViewall">Local neonatal unit: provide neonatal care for their own catchment population, except for babies who require complex or longer-term intensive care. The majority of babies over 27 weeks of gestation will usually receive their full care, including short periods of intensive care, within their local neonatal unit. Some provide high dependency care and short periods of intensive care for their network population.</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">•</span><p id="par0520" class="elsevierStylePara elsevierViewall">Neonatal intensive care unit: provide the whole range of medical neonatal care for their local population. Many NICUs are co-located with neonatal surgery services and other specialised services.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The case for the redefinition of the levels of care of neonatal care units in Spain</span><p id="par0525" class="elsevierStylePara elsevierViewall">At present, the definition of the levels of care of neonatal care units in Spain must be revised because recent advances in knowledge and their easy online dissemination have resulted in improved knowledge and skills in medical and nursing staff, techniques and equipment have become widely available (improvement in material resources in all units that allow multiple treatments) and there has been an important decline in birth rates throughout Spain. This calls for new criteria for the definition of care levels, not only based on volume, but also on the capabilities for providing different types of care and, perhaps more importantly, indicators of care quality.</p><p id="par0530" class="elsevierStylePara elsevierViewall">Quality in health care is achieved when the needs of individuals and populations (in health education, prevention, promotion and maintenance) are accurately and fully identified, and the necessary resources (human or of a different kind) are allocated as promptly and effectively as current knowledge allows, as noted by the World Health Organization (WHO).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0535" class="elsevierStylePara elsevierViewall">Based on this definition of quality assurance, criteria need to be established to measure the quality of care<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">•</span><p id="par0540" class="elsevierStylePara elsevierViewall">Structure criteria: attributes that need to be in place for the proper operation of the unit. This includes elements such as staff training and qualification, nurse to patient ratios, the physical structure of the unit, the available technology or the presence of organizational structures (ethics committee, mortality review committee, perinatal mortality and morbidity review committee, safety committee, etc).</p></li><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">•</span><p id="par0545" class="elsevierStylePara elsevierViewall">Process criteria: these refer to what is done to the patient and how. This includes the existence of unit protocols and clinical practice guidelines, scientific output of the unit based on its publications, organization of courses and conferences or participation in public or privately funded clinical trials.</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">•</span><p id="par0550" class="elsevierStylePara elsevierViewall">Outcome criteria: patient outcomes at the end of the care episode. This includes indicators such as mortality, incidence of sepsis, retinopathy of prematurity, bronchopulmonary dysplasia or necrotising enterocolitis, satisfaction survey ratings, etc.</p></li></ul></p><p id="par0555" class="elsevierStylePara elsevierViewall">Making these criteria the expression of health care quality requires substantial effort by neonatal units in reformulating their work, so that they can be subject to external or internal auditing and achieve national or international quality and safety certifications. It is an objective of our society of neonatology that any neonatal unit or department, independently of size or patient volume, be able to achieve the highest quality standards in the day-to-day interaction between patients and providers.</p><p id="par0560" class="elsevierStylePara elsevierViewall">The integration and definition of neonatal units based on level of care requires a series of core elements that they must all share. All must have staff trained and qualified to attend a complicated delivery and perform adequate cardiopulmonary resuscitation (CPR) according to the standards of the Group on CPR of the SENeo, the capabilities to stabilize severely ill neonates and transport them to the referral centre offering the necessary level of care, the capabilities to perform the newborn hearing and metabolic screens and promote breastfeeding and parent-child bonding.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Proposed levels of care</span><p id="par0565" class="elsevierStylePara elsevierViewall">Neonatal care units or departments in Spain will come to be defined based on 2 criteria.</p><p id="par0570" class="elsevierStylePara elsevierViewall">Based on the characteristics of the patients that they can manage, the following levels are established:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">•</span><p id="par0575" class="elsevierStylePara elsevierViewall">Level I: neonatal units caring for neonates delivered after 35 weeks and/or weighing 2000<span class="elsevierStyleHsp" style=""></span>g when a complicated delivery or neonatal illness requiring evaluation or treatment are not expected. These are basic units that are part of every maternity ward with staff trained on CPR and qualified to stabilize critical newborns for subsequent transport.</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">•</span><p id="par0580" class="elsevierStylePara elsevierViewall">Level II: neonatal units caring for neonates weighing more than 1500<span class="elsevierStyleHsp" style=""></span>g and/or delivered after 32 weeks in whom significant complications are not expected. They also have the capabilities required to stabilize neonates with a lower weight or gestational age for transport to a higher level facility.</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">•</span><p id="par0585" class="elsevierStylePara elsevierViewall">Level III: neonatal unit with the necessary human, material and technical resources on site to manage any newborn independently of weight, gestational age or medical complexity.</p></li></ul></p><p id="par0590" class="elsevierStylePara elsevierViewall">Neonatal units are also classified into three levels based on quality (Q1, Q2 and Q3) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0595" class="elsevierStylePara elsevierViewall">For a unit to be classified into a given quality level, it must meet at least 80% of the criteria in each dimension (structure, process, outcome). The minimum threshold must be achieved in all three to achieve the given level of quality. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> specifies the minimum number of criteria that must be met in each dimension to achieve each level of quality.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0600" class="elsevierStylePara elsevierViewall">Obtaining and maintaining certifications in a quality management systems standard recognised domestically or internationally (ISO [ISO 9001]/UNE [UNE 179003]/Joint Commission International [JCI], etc) is additional evidence of quality for the unit or department and is denoted by a plus (+) sign next to the Q level (Q1+, Q2+, Q3+). Achieving this type of certification requires the implantation and external evaluation of compliance with the standards of the certification system, which entails the ongoing analysis of health care outcomes and the implementation of corrective actions as needed.</p><p id="par0605" class="elsevierStylePara elsevierViewall">Thus, any neonatal care unit in Spain could be classified as Level I to III based on the complexity of the patients it manages and as Q1 to Q3 based on the quality of the care it delivers. Level I units should have a Q1 or Q2 quality level; Level II units can have a level from Q1 to Q3, ideally Q2 or Q3, and Level III units should have a quality level of Q2 or Q3, ideally Q3, to guarantee access to care of the highest possible quality to very preterm infants. If the setting has an official certification, the<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>symbol is added to the classification of the unit or department.</p><p id="par0610" class="elsevierStylePara elsevierViewall">Achieving a higher level of quality of neonatal units corresponds to improvement in patient care, especially the care of very preterm newborns,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> so it is important for each unit to be aware of where it stands and what it needs to do to improve.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0615" class="elsevierStylePara elsevierViewall">This research did not receive any external funding.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0620" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1874785" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1626727" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1874786" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1626726" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Classification of levels of care in other countries" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "The case for the redefinition of the levels of care of neonatal care units in Spain" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Proposed levels of care" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-16" "fechaAceptado" => "2023-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1626727" "palabras" => array:4 [ 0 => "Quality" 1 => "Care levels" 2 => "Newborn" 3 => "Neonatal units" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1626726" "palabras" => array:4 [ 0 => "Calidad" 1 => "Niveles asistenciales" 2 => "Recién nacido" 3 => "Unidades neonatales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Spanish Society of Neonatology established the care levels of the Neonatal Units in Spain in 2013. Since then, the birth rate in our country, as well as the universalization of knowledge, techniques and patient treatment devices, has evolved significantly. This situation forces a redefinition of the current levels of care based on quality criteria that allow better comparability between the Units and represents a challenge to improve the care of our newborns.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La Sociedad Española de Neonatología estableció en el año 2013 los niveles asistenciales de las Unidades Neonatales en España. Desde entonces, la natalidad en nuestro país, así como la universalización del conocimiento, de las técnicas y de los dispositivos de tratamiento de los pacientes ha evolucionado significativamente. Esta situación obliga a una redefinición de los actuales niveles asistenciales basándose en criterios de calidad que permitan una mejorar comparabilidad entre las Unidades y supongan un impulso para la mejora en la atención de nuestros recién nacidos.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">aEEG: amplitude-integrated electroencephalogram; BP, blood pressure; ECG, electrocardiogram; ECMO: extracorporeal membrane oxygenation; HFOV, high-frequency oscillatory ventilation; ICU, intensive care unit; IPPV, intermittent positive pressure ventilation; iNO, inhaled nitric oxide; JCR, Journal Citation Report; SatO<span class="elsevierStyleInf">2</span>, oxygen saturation.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Note: “health care staff” refers to the doctors and nurses of the unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quality level 1 (Q1) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quality level 2 (Q2) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quality level 3 (Q3) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Structure criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0005" class="elsevierStylePara elsevierViewall">Capabilities for neonatal resuscitation in the delivery room or a separate room.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physician trained in neonatology and qualified to performed resuscitation. Physician does not need to be physically present in the unit.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0015" class="elsevierStylePara elsevierViewall">Nurse to assist in deliveries with training in neonatology. Ratio of 1:8−10.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0020" class="elsevierStylePara elsevierViewall">Access to pharmacy, imaging and laboratory 24<span class="elsevierStyleHsp" style=""></span>h a day.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0025" class="elsevierStylePara elsevierViewall">Oxygen therapy equipment with flow regulation and capability to administer gas mixtures.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1</span><p id="par0030" class="elsevierStylePara elsevierViewall">Capabilities for neonatal resuscitation in the delivery room or a separate room.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2</span><p id="par0035" class="elsevierStylePara elsevierViewall">Physician trained in neonatology and qualified to performed resuscitation. Physician must be physically present in the unit.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3</span><p id="par0040" class="elsevierStylePara elsevierViewall">Neonatal nurse. Ratio of 1:3−5.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4</span><p id="par0045" class="elsevierStylePara elsevierViewall">Access to pharmacy, imaging and laboratory 24<span class="elsevierStyleHsp" style=""></span>h a day.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">5</span><p id="par0050" class="elsevierStylePara elsevierViewall">Oxygen therapy equipment with flow regulation and capability to administer gas mixtures.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">6</span><p id="par0055" class="elsevierStylePara elsevierViewall">Nasal IPPV.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">7</span><p id="par0060" class="elsevierStylePara elsevierViewall">Dedicated space for neonatal hospitalization with basic monitoring (ECG, SatO<span class="elsevierStyleInf">2</span>, BP). It can be continuous with the paediatric ICU.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">8</span><p id="par0065" class="elsevierStylePara elsevierViewall">Continuing education of health care staff (at least one course a year by 60% of the staff in the unit).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">9</span><p id="par0070" class="elsevierStylePara elsevierViewall">Assessment of patient comfort. Use of pain scales.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">1</span><p id="par0075" class="elsevierStylePara elsevierViewall">Capabilities for neonatal resuscitation in the delivery room or a separate room.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2</span><p id="par0080" class="elsevierStylePara elsevierViewall">Adequate staffing of doctors with resuscitation skills in the unit. On-call shifts in the unit with doctor physically present.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">3</span><p id="par0085" class="elsevierStylePara elsevierViewall">Paediatric nurses on staff with specific training in neonatology and critical care. Ratio of 1:1−2, possibly as high as 2:1.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">4</span><p id="par0090" class="elsevierStylePara elsevierViewall">Access to pharmacy, imaging and laboratory 24<span class="elsevierStyleHsp" style=""></span>h a day.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">5</span><p id="par0095" class="elsevierStylePara elsevierViewall">Oxygen therapy equipment with flow regulation and capability to administer gas mixtures</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">6</span><p id="par0100" class="elsevierStylePara elsevierViewall">Nasal IPPV.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">7</span><p id="par0105" class="elsevierStylePara elsevierViewall">Invasive IPPV and HFOV.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">8</span><p id="par0110" class="elsevierStylePara elsevierViewall">iNO.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">9</span><p id="par0115" class="elsevierStylePara elsevierViewall">Availability of therapeutic hypothermia.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">10</span><p id="par0120" class="elsevierStylePara elsevierViewall">Capabilities to provide haemofiltration/haemodialysis within the neonatal unit.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">11</span><p id="par0125" class="elsevierStylePara elsevierViewall">Availability of ECMO in the unit itself.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">12</span><p id="par0130" class="elsevierStylePara elsevierViewall">Architectural design of neonatal inpatient ward-neonatal ICU as separate space from other care settings with full monitoring.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">13</span><p id="par0135" class="elsevierStylePara elsevierViewall">Continuing education of health care staff (at least one course a year by 80% of the staff in the unit).</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">14</span><p id="par0140" class="elsevierStylePara elsevierViewall">Family lounge area.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">15</span><p id="par0145" class="elsevierStylePara elsevierViewall">aEEG monitoring.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">16</span><p id="par0150" class="elsevierStylePara elsevierViewall">Cerebral and somatic oximetry monitoring.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">17</span><p id="par0155" class="elsevierStylePara elsevierViewall">Pain monitoring: fifth vital sign.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">18</span><p id="par0160" class="elsevierStylePara elsevierViewall">Unit-specific mortality review committee.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">19</span><p id="par0165" class="elsevierStylePara elsevierViewall">Specific perinatal review committee.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">20</span><p id="par0170" class="elsevierStylePara elsevierViewall">Specific safety committee. Culture of safety.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Process measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">1</span><p id="par0175" class="elsevierStylePara elsevierViewall">Basic action protocols.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">2</span><p id="par0180" class="elsevierStylePara elsevierViewall">Unequivocal newborn identification.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">1</span><p id="par0185" class="elsevierStylePara elsevierViewall">Basic action protocols.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">2</span><p id="par0190" class="elsevierStylePara elsevierViewall">Informed consent for admission and procedures (at least verbal).</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">3</span><p id="par0195" class="elsevierStylePara elsevierViewall">Unequivocal newborn identification.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">4</span><p id="par0200" class="elsevierStylePara elsevierViewall">Scientific publications in journals included in the JCR (1–4 a year).</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">5</span><p id="par0205" class="elsevierStylePara elsevierViewall">Participation in research projects funded by the private sector.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">6</span><p id="par0210" class="elsevierStylePara elsevierViewall">Daily information on the evolution of the newborn (at least in the inpatient setting).</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">7</span><p id="par0215" class="elsevierStylePara elsevierViewall">Development and family centred care.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">8</span><p id="par0220" class="elsevierStylePara elsevierViewall">Noise control in the unit.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">9</span><p id="par0225" class="elsevierStylePara elsevierViewall">Specific neonatal followup clinic.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">10</span><p id="par0230" class="elsevierStylePara elsevierViewall">Paediatric surgery available in hospital.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">1</span><p id="par0235" class="elsevierStylePara elsevierViewall">Protocols for specific diseases and procedures. Clinical practice guideline.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">2</span><p id="par0240" class="elsevierStylePara elsevierViewall">Written informed consent for admission and procedures.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">3</span><p id="par0245" class="elsevierStylePara elsevierViewall">Unequivocal newborn identification.</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">4</span><p id="par0250" class="elsevierStylePara elsevierViewall">Availability of informational leaflets about procedures/diseases for families.</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">5</span><p id="par0255" class="elsevierStylePara elsevierViewall">Scientific publications in journals included in the JCR (at least 5 per year).</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">6</span><p id="par0260" class="elsevierStylePara elsevierViewall">Organization of continuous education courses (at least 1 per year).</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">7</span><p id="par0265" class="elsevierStylePara elsevierViewall">Participation in research projects funded by the private sector.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">8</span><p id="par0270" class="elsevierStylePara elsevierViewall">Participation in research projects funded by competitive public grants (at least 1 a year).</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">9</span><p id="par0275" class="elsevierStylePara elsevierViewall">Separate room to discuss the evolution of the newborn.</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">10</span><p id="par0280" class="elsevierStylePara elsevierViewall">Individual isolation rooms.</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">11</span><p id="par0285" class="elsevierStylePara elsevierViewall">Point-of-care ultrasound.</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">12</span><p id="par0290" class="elsevierStylePara elsevierViewall">Availability of donor human milk (own milk bank or receiving hospital).</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">13</span><p id="par0295" class="elsevierStylePara elsevierViewall">Individual inpatient rooms.</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">14</span><p id="par0300" class="elsevierStylePara elsevierViewall">Family and developmental centred care.</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">15</span><p id="par0305" class="elsevierStylePara elsevierViewall">Dimmed lights in unit.</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">16</span><p id="par0310" class="elsevierStylePara elsevierViewall">Noise reduction in unit.</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">17</span><p id="par0315" class="elsevierStylePara elsevierViewall">Participation in at least one humane care project.</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">18</span><p id="par0320" class="elsevierStylePara elsevierViewall">Specific neonatal followup clinic.</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">19</span><p id="par0325" class="elsevierStylePara elsevierViewall">Surgical interventions by paediatric surgeons in the hospital that houses the neonatal unit.</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">20</span><p id="par0330" class="elsevierStylePara elsevierViewall">Postoperative care within the neonatal unit.</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">21</span><p id="par0335" class="elsevierStylePara elsevierViewall">Interventional cardiology procedures in the hospital that houses the neonatal unit.</p></li></ul>Postoperative care in neonatal unit. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Outcome measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">1</span><p id="par0340" class="elsevierStylePara elsevierViewall">Correct identification of patients at risk or with severe disease and transfer to a higher level of care</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">1</span><p id="par0345" class="elsevierStylePara elsevierViewall">Correct identification of patients at risk or with severe disease and transfer to a higher level of care.</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">2</span><p id="par0350" class="elsevierStylePara elsevierViewall">Internal audits.</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">3</span><p id="par0355" class="elsevierStylePara elsevierViewall">Mortality outcome indicators.</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">4</span><p id="par0360" class="elsevierStylePara elsevierViewall">Vertical and nosocomial sepsis outcome indicators.</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">5</span><p id="par0365" class="elsevierStylePara elsevierViewall">Register of most prevalent morbidity indicators in very preterm infants.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">1</span><p id="par0370" class="elsevierStylePara elsevierViewall">Internal audits.</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">2</span><p id="par0375" class="elsevierStylePara elsevierViewall">External audits.</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">3</span><p id="par0380" class="elsevierStylePara elsevierViewall">Annual report including mortality indicators.</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">4</span><p id="par0385" class="elsevierStylePara elsevierViewall">Annual report including vertical and nosocomial sepsis indicators.</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">5</span><p id="par0390" class="elsevierStylePara elsevierViewall">Annual report including indicators of frequency of retinopathy of prematurity.</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">6</span><p id="par0395" class="elsevierStylePara elsevierViewall">Annual report including indicators of frequency of bronchopulmonary dysplasia.</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">7</span><p id="par0400" class="elsevierStylePara elsevierViewall">Annual report including indicators of frequency of necrotising enterocolitis.</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">8</span><p id="par0405" class="elsevierStylePara elsevierViewall">Satisfaction survey ratings.</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Quality levels (Q) in neonatal units in Spain.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Q1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Q2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Q3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Structure criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Process criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Outcome criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Minimum number of criteria that must be met in each dimension to achieve a given quality level.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comité de Estándares de la Sociedad Española de Neonatología; Junta Directiva de la Sociedad Española de Neonatología" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Niveles asistenciales y recomendaciones de mínimos para la atención" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "An Pediatr" "fecha" => "2004" "volumen" => "60" "numero" => "1" "paginaInicial" => "56" "paginaFinal" => "64" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Niveles asistenciales y recomendaciones de mínimos para la atención neonatal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 144 | 64 | 208 |
| 2024 September | 131 | 62 | 193 |
| 2024 August | 145 | 70 | 215 |
| 2024 July | 109 | 39 | 148 |
| 2024 June | 100 | 43 | 143 |
| 2024 May | 101 | 56 | 157 |
| 2024 April | 102 | 31 | 133 |
| 2024 March | 79 | 24 | 103 |
| 2024 February | 63 | 28 | 91 |
| 2024 January | 96 | 37 | 133 |
| 2023 December | 83 | 24 | 107 |
| 2023 November | 85 | 39 | 124 |
| 2023 October | 78 | 29 | 107 |
| 2023 September | 93 | 30 | 123 |
| 2023 August | 75 | 20 | 95 |
| 2023 July | 52 | 28 | 80 |
| 2023 June | 46 | 24 | 70 |
| 2023 May | 65 | 35 | 100 |
| 2023 April | 106 | 36 | 142 |
| 2023 March | 85 | 22 | 107 |
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