Management of a heart murmur in an asymptomatic neonate using a standardized approach Levine RA, DO. Miladinovic B, PhD. Nardell K, MD. Galas J, MD. Balakrishnan M, MD. INTRODUCTION RESULTS Provider impression of murmur CCHD (N=13) n (%) Correct: 0 (0%) PPS (N=61) Correct: 10 (16%) PDA (N=53) Correct: 95 (62%) VSD (N=31) Correct: 10 (32%) PFO (N=293) Correct: 44 (15%) Congenital heart disease (CHD) is the most common birth defect in the USA. Newborns murmur evaluations are costly & extensive with low likelihood of diagnosing critical congenital heart disease (CCHD). AAP defines CCHD as cardiac lesions requiring surgical/catheter intervention within the 1st year of life. There is no consensus on appropriate evaluation of a murmur in asymptomatic newborns. Provider impression was documented in 264 of 303 infants w/murmur evaluation Many infants had more than 1 cardiac lesion reported by echo Reason for exclusion n Murmur absent ≥24 hours 399 Evaluation <24 hours 43 Genetic syndrome 11 Abnormal fetal echo 9 Echo ± EKG not done Murmur evaluation >5 days 1 Demographics Follow-up n=290 CCHD n=13 Female n (%)  136 (46.9)  10 (76.9) GA wks (range) 39 2/7 (35-41) 39 2/7 (36-40) BW kg (range) 3.48 (2.14-5.06) 3.56 (2.75-4.22) Maternal age years (range) 28 (15-43) 30 (20-38) Medicaid n (%)  209 (73.1) 10 (76.9) Prenatal care 281 (98.2) 12 (92.3) TGH deliveries: 5,666 (8/2012-8/2013) Asymptomatic newborns with murmur: 775 CCHD: 13 Required NICU admission*: 4 Required immediate intervention: 2 Required intervention in 1st year of life: 2 Newborn Nursery: 9 No CCHD, requires outpatient cardiology follow-up: 289 Normal echo: 1 Excluded: 472 OBJECTIVES Only 35% of murmurs were accurately diagnosed by newborn nursery providers. In asymptomatic newborns with murmurs: Describe the problem with working up all asymptomatic newborns with a heart murmur Develop a screening algorithm for these newborns prior to hospital discharge Preform a cost analysis using our current guidelines prior to implementation of an algorithm. ESTIMATED COST ANALYSIS Total infants w/murmur evaluation: 303 Total infants w/evaluation made outside of guideline recommendations: 43 Family history of risk factors Follow-up N= 290 (%) CCHD N=13 (%) OR (95%CI) p-value Cardiotoxic meds (n=251*) 7 (2.9) 2 (16.7) 6.62 (1.2- 36) 0.03 Drowning (n=253*)  0 (0) 1 (8.3) NA 0.04 The following risks were not significant with p-value >0.05: IDM, Twin to twin transfusion syndrome, genetic syndrome, CHD, arrhythmia, cardiomyopathy, SIDS, sudden cardiac death, seizures, drowning *n represents number of times risk factor documented in total N * 3 of 4 NICU admissions had a positive pulse oximetry screen METHODS Test Cost per test Total cost (n=303) Potential cost savings (n=43) Pulse ox screen probe1 $7 $2,121 $301 EKG2 $450 $136,350 $19,350 Echo & doppler2 $3,909 $1,184,427 $172,000 Approximate total cost $1,322,898 $191,651 3 Prospective observational study Tampa General Hospital (TGH) ~5,500 births per year Study period: 8/2012 to 8/2013 Develop electronic medical record (EMR) template for cardiac history, clinical symptoms, & physical exam Current TGH/USF Newborn Nursery guidelines for any newborn murmur: cardiac history, physical exam, blood pressure (4 extremity), pulse oximetry screening, EKG, Echo, ± Pediatric cardiology consult PROPOSED ALGORITHM Inclusion criteria Exclusion criteria GA ≥ 35 0/7 wks BW ≥ 2 kg 1 to 5 days of life Asymptomatic Admitted to TGH’s newborn nursery Murmur diagnosis by Pediatrician or Nurse practitioner Fetal echo w/CHD Genetic/metabolic syndrome No EKG AND echo General exam findings Follow-up N= 290 (%) CCHD N=13 (%) OR (95%CI) p-value HR (>140 bpm)  102 (35.2)  9 (69.2) 4.15 (1.3- 13.8) 0.02 RR (>60) 8 (2.8) 2 (15.4) 6.4 (1.2- 33.8) 0.03 The following cardiac exam findings were not significant with a p-value >0.05: feeding difficulty, color, blood pressure (upper extremity vs. lower extremity) 1 Pulse ox costs from CDC statistics 2 Echo/EKG costs from TGH statistics CONCLUSIONS There is difficulty in distinguishing benign newborn murmurs from those of CCHD and determining appropriate follow-up in the newborn nursery An algorithm for asymptomatic newborns with a murmur can be developed Preliminary cost analysis using this algorithm shows significant cost savings. EMR template implementation resulted in >85% compliance and completion of documentation for cardiac history, clinical symptoms, & physical exam. Future direction: Implement the developed algorithm at TGH and evaluate utility & cost-effectiveness. Cardiac exam findings Follow-up N= 290 (%) CCHD N=13 (%) OR (95%CI) p-value Grade (≥3/6 ) (n=293*)  15 (5.4) 3 (23.1) 5.3 (1.32- 13.8) 0.03 The following newborn general findings were not significant with a p-value >0.05: S1/S2, timing, radiation, quality *n represents number of times finding documented in total N Newborn nursery providers determined appropriate follow-up in 94% of infants, however they were incorrect for all diagnosed w/CCHD. CONTACT: Dr. Rebecca Levine. Email: rlevine1@health.usf.edu. University of South Florida, Department of Pediatrics, Division of Neonatology, 1 Tampa General Circle, Room F170, Tampa, FL 33611.