Outcomes of a Quality Improvement Initiative to Prevent Unnecessary Packed Red Blood Cell Transfusions Among Extremely Low Birth-Weight Neonates.

BACKGROUND: Extremely low birth-weight (ELBW) infants frequently receive packed red blood cell (PRBC) transfusions. Recent studies have shown that more restrictive PRBC transfusion guidelines limit donor exposure and reduce transfusion-related costs without any increase in adverse clinical outcomes. PURPOSE: We developed and implemented an evidence-based PRBC transfusion guideline for ELBW infants treated in our unit and then measured provider adherence to this guideline. METHODS/SEARCH STRATEGY: We performed a retrospective review of all PRBC transfusions given to ELBW infants in 2012 (preguideline) and the first half of 2014 (postguideline). We identified the indication for each transfusion by reviewing physiological/laboratory data and the daily clinical note. We then determine whether each transfusion met criteria according to our new evidence-based guideline. FINDINGS/RESULTS: When extrapolating the newly developed protocol to 2012 data, less than 15% of transfusions among ELBW infants would have met the current evidence-based standard. Conversely, during the first 6 months of 2014, 61% of transfusions were administered in adherence to the guideline (P < 001). Using current cost estimates, this represents a projected cost savings of $31,000 in that 6-month period. IMPLICATIONS FOR PRACTICE: A multidisciplinary approach to improving PRBC transfusion practices results in potentially safer, more cost-effective care for ELBW infants. IMPLICATIONS FOR RESEARCH: Given the frequency, potential harms, and costs associated with PRBC transfusions in ELBW infants, it seems both feasible and important to pursue prospective clinical trials comparing permissive and restrictive approaches to transfusion in this vulnerable population.

A quality improvement initiative to reduce necrotizing enterocolitis in high-risk neonates.

OBJECTIVE: Prompted by an acute increase in necrotizing enterocolitis (NEC) rates, we aimed to decrease the rate of stage 2 or greater NEC in infants born at <1500 grams or <30 weeks gestational age from 19.5% to less than 9.7% (a 50% reduction) within 18 months, without adversely affecting central line-associated bloodstream infection (CLABSI) rates. STUDY DESIGN: We utilized Define, Measure, Analyze, Improve, and Control (DMAIC) as our improvement model. Informed by our key driver diagram and root cause analyses, six Plan-Do-Study-Act cycles were completed. RESULTS: 147 infants in the QI initiative had a median gestational age of 28.1 weeks and a median birthweight of 1070 grams. NEC rates decreased from the QI baseline of 19.5% to 6% (p = 0.03). Oral care administration increased, and maximal gavage tube dwell time decreased. CONCLUSION: NEC rates decreased during this QI initiative through a combination of multidisciplinary interventions aimed at reducing dysbiosis.

Improving the Timeliness and Efficiency of Discharge From the NICU.

BACKGROUND: Discharge from the NICU is a highly complex process. Multidisciplinary survey results and chart audits identified gaps in the timeliness and efficiency of discharge in our NICU. Using the define-measure-analyze-improve-control quality improvement framework, we aimed to increase the percentage of patients discharged before 11:00 am from a baseline mean of 9.4% to 50% without adversely impacting caregiver readiness to discharge. METHODS: We used a fishbone diagram to identify causes of late and inefficient NICU discharge. A Pareto chart and Impact-Effort matrix were used to select targets for improvement efforts. Plan-do-study-act (PDSA) cycles established a goal unit discharge time, created a discharge checklist, prioritized rounding on discharging patients, set expectations for caregiver education completion, and increased nurse knowledge and comfort with providing caregiver education. RESULTS: The mean percent of patients discharged before 11:00 am increased from 9.4% to 52.4%, exceeding our aim. Median discharge time improved from 13:30 pm to 11:15 am (P < .001). Discharge was more efficient as demonstrated by significantly earlier completion of many discharge tasks. These improvements did not adversely impact reported caregiver readiness to discharge (75% vs 77%, P = .76). CONCLUSIONS: Quality improvement methods can significantly improve the timeliness and efficiency of NICU discharge. Improvement in this complex process may be facilitated by a multidisciplinary team that offers diverse perspectives, unique process and methodologic knowledge, and the ability to appeal to all unit stakeholders. Lessons learned from this project may benefit other teams working to improve their ICU discharge process.

Reducing Opioid Exposure in a Level IV Neonatal Intensive Care Unit.

INTRODUCTION: Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project's primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months. METHODS: A multidisciplinary care team used Define, Measure, Analyze, Improve, Control methodology to identify root causes of the quality gap including: (1) inconsistent reporting of objective pain scales; (2) variable provider prescribing patterns; and (3) variable provider bedside assessment of pain. These root causes were addressed by two interventions: (1) standardized reporting of the premature infant pain profile scores and (2) implementation of an analgesia management pathway. RESULTS: Mean opioid exposure, measured in morphine equivalents, in infants less than 1,250 g at birth during their first 14 days of life decreased from 0.64 mg/kg/d (95% confidence interval 0.41-0.87) at baseline to 0.08 mg/kg/d (95% confidence interval 0.03-0.13) during the postintervention period (P < 0.001). There was no statistical difference in rates of days to full feedings, unintentional extubations, or central line removals between epochs. CONCLUSIONS: Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.

The impact of telemedicine on the quality of newborn resuscitation: A retrospective study.

OBJECTIVE: We hypothesized that telemedicine consults provided by neonatologists to local care teams (termed teleneonatology) would improve the quality of high-risk newborn resuscitations that occur in community hospitals. METHODS: This retrospective cohort study compared 47 newborns who received a teleneonatology consult during their resuscitation at a community hospital to 45 controls who did not. Controls were matched on gestational age, sex, admission diagnosis, and level of newborn care. A two-person expert panel blinded to the intervention reviewed demographic and resuscitation data for each patient and assigned a resuscitation quality rating using a 1-10 descriptive rating scale. Paired comparisons between groups were evaluated using the Wilcoxon signed rank test for continuous measures and the McNemar's test for dichotomous measures. RESULTS: The median resuscitation quality rating was 7 for the teleneonatology group and 4 for the control group, with a median difference of 1 between matched pairs (P = .002). Neonates who received a teleneonatology consult were more likely to undergo measurement of temperature, glucose, and blood gases. When analyzing the 35 matched pairs that had a consult within one hour of birth, the positive impact of teleneonatology was greater (median rating 8 vs 4, median difference 2, P = .003). Subgroup analysis demonstrated teleneonatology significantly improved the resuscitation of preterm neonates (median rating 8 vs 4, median difference 1.5, P = .004) CONCLUSION: Teleneonatology improves the quality of high-risk newborn resuscitations that occur in community hospitals and increases adherence to process metrics. Earlier teleneonatology consults appear to have greater positive impact.