Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project.

BACKGROUND: Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year. METHODS/INTERVENTION: A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods. RESULTS: Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001]. CONCLUSIONS: Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness. TYPE OF STUDY: Prospective Quality Improvement. LEVEL OF EVIDENCE: Level III.

Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis.

Same-day discharge of children after appendectomy for simple appendicitis is safe and associated with enhanced parent satisfaction. Our general pediatric surgeons aimed to improve the rate of same-day discharge after appendectomy for simple appendicitis. Methods: We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264). Results: The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385). Conclusions: Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit.

BACKGROUND: Unplanned extubations (UEs) occur frequently in the neonatal intensive care unit (NICU). These events can be associated with serious short-term and long-term morbidities and increased healthcare costs. Most quality improvement (QI) initiatives focused on UE prevention have concentrated efforts within individual NICUs. METHODS: We formed a regional QI collaborative involving the four regional perinatal center (RPC) NICUs in upstate New York to reduce UEs. The collaborative promoted shared learning and targeted interventions specific to UE classification at each center. RESULTS: There were 1167 UEs overall during the four-year project. Following implementation of one or more PDSA cycles, the combined UE rate decreased by 32% from 3.7 to 2.5 per 100 ventilator days across the collaborative. A special cause variation was observed for the subtype of UEs involving removed endotracheal tubes (rETTs), but not for dislodged endotracheal tubes (dETTs). The center-specific UE rates varied; only two centers observed significant improvement. CONCLUSIONS: A collaborative approach promoted knowledge sharing and fostered an overall improvement, although the individual centers' successes varied. Frequent communication and shared learning experiences benefited all the participants, but local care practices and varying degrees of QI experience affected each center's ability to successfully implement potentially better practices to prevent UEs.

A Quality Improvement Initiative to Reduce Bronchopulmonary Dysplasia in a Level 4 NICU-Golden Hour Management of Respiratory Distress Syndrome in Preterm Newborns.

BACKGROUND: Prevention of chronic lung disease (CLD) requires a multidisciplinary approach spanning from the delivery room to Neonatal Intensive Care Unit (NICU) discharge. In 2018, a quality improvement (QI) initiative commenced in a level 4 NICU with the goal of decreasing chronic lung disease rates below the Vermont Oxford Network (VON) average of 24%. METHODS: Improvement strategies focused on addressing the primary drivers of ventilation strategies, surfactant administration, non-invasive ventilation, medication use, and nutrition/fluid management. The primary outcome was VON CLD, defined as need for mechanical ventilation and/or supplemental oxygen use at 36 weeks postmenstrual age. Statistical process control charts were used to display and analyze data over time. RESULTS: The overall CLD rate decreased from 33.5 to 16.5% following several interventions, a 51% reduction that has been sustained for >18 months. Changes most attributable to this include implementation of the "golden hour" gestational age (GA) based delivery room protocol that encourages early surfactant administration and timely extubation. Fewer infants were intubated across all GA groups with the largest improvement among infants 26-27 weeks GA. CONCLUSIONS: Our efforts significantly decreased CLD through GA-based respiratory guidelines and a comprehensive, rigorous QI approach that can be applicable to other teams focused on improvement.

A Quality Improvement Initiative To Optimize Antibiotic Use in a Level 4 NICU.

BACKGROUND: Given the risks associated with antibiotics, efforts to reduce unnecessary antibiotic use in the NICU have become increasingly urgent. In 2016, a comprehensive 3-year quality improvement (QI) initiative was conducted in a level 4 NICU that sought to decrease the antibiotic use rate (AUR) by 20%. METHODS: This local QI initiative was conducted in the context of a multicenter learning collaborative focused on decreasing unnecessary antibiotic use. Improvement strategies focused on addressing gaps in the core elements of antibiotic stewardship programs. Outcome measures included the AUR and the percent of infants discharged without antibiotic exposure. Process measures included the percent of infants evaluated for early-onset sepsis (EOS) and duration of antibiotics used for various infections. Statistical process control charts were used to display and analyze data over time. RESULTS: The AUR decreased from 27.6% at baseline to 15.5%, a 43% reduction, and has been sustained for >18 months. Changes most attributable to this decrease include implementation of the sepsis risk calculator, adopting a 36-hour rule-out period for sepsis evaluations, a 36-hour antibiotic hard stop, and novel guideline for EOS evaluation among infants <35 weeks. The percent of infants discharged without antibiotic exposure increased from 15.8% to 35.1%. The percent of infants ≥36 weeks undergoing evaluation for EOS decreased by 42.3% and for those <35 weeks by 26%. CONCLUSIONS: Our efforts significantly reduced antibiotic use and exposure in our NICU. Our comprehensive, rigorous approach to QI is applicable to teams focused on improvement.

Potential influence of total parenteral nutrition on body composition at discharge in preterm infants.

OBJECTIVE: This study was undertaken to assess the potential influence of total parenteral nutrition (TPN) on body composition (BC) in preterm infants. STUDY DESIGN: This prospective, observational study of infants born <35 weeks measured BC at discharge using air displacement plethysmography. The % body fat (BF) at discharge was correlated with variables gestational age (GA), severity of illness, days on oxygen, time to regain birth weight and duration of TPN. RESULT: The 61 patients enrolled had a %BF at discharge of 13.9%. GA and TPN days correlated with %BF for the entire group. Multiple regression analysis identified that the time to regain birth weight added to the effect of GA, but not TPN. Isolating the influence of TPN in a subgroup of similarly aged infants (30-35 weeks) did not reveal a difference in body composition at the time of discharge between infants who did or did not receive TPN. CONCLUSION: These findings fail to demonstrate a clear influence of TPN on the increased accrual of BF in premature infants and implicate gestational modification in nutrient/caloric utilization as a principle regulator of body composition in premature newborns.