Small Patients but a Heavy Lift: Workload and Burnout of Advanced Practice Providers and Physicians in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study explored the association between workload and the level of burnout reported by clinicians in our neonatal intensive care unit (NICU). A qualitative analysis was used to identify specific factors that contributed to workload and modulated clinician workload in the NICU. STUDY DESIGN: We conducted a study utilizing postshift surveys to explore workload of 42 NICU advanced practice providers and physicians over a 6-month period. We used multinomial logistic regression models to determine associations between workload and burnout. We used a descriptive qualitative design with an inductive thematic analysis to analyze qualitative data. RESULTS: Clinicians reported feelings of burnout on nearly half of their shifts (44%), and higher levels of workload during a shift were associated with report of a burnout symptom. Our study identified 7 themes related to workload in the NICU. Two themes focused on contributors to workload, 3 themes focused on modulators of workload, and the final 2 themes represented mixed experiences of clinicians' workload. CONCLUSION: We found an association between burnout and increased workload. Clinicians in our study described common contributors to workload and actions to reduce workload. Decreasing workload and burnout along with improving clinician well-being requires a multifaceted approach on unit and systems levels.

Safe to Sleep in Tennessee: A Statewide Quality Improvement Initiative.

OBJECTIVE: Sleep-related deaths were the fourth leading cause of infant death in Tennessee between 2014 and 2018. In response, the Tennessee Initiative for Perinatal Quality Care developed a statewide quality improvement project, which focused on the demonstration and enforcement of a safe sleep environment in participating birthing hospitals to help families learn and practice the same at home. The project's aim was to improve the percent of infants audited for safe sleep practices (0-12 mo of age, cared for in participating newborn nurseries or neonatal intensive care units) that were compliant with the practices recommended by the 2016 American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome. STUDY DESIGN: Participating teams were required to develop and implement safe sleep policies in compliance with the AAP recommendations, provide safe sleep education to staff and families, and complete monthly safe sleep audits. A tool was provided to assess whether each audited infant was compliant with safe sleep recommendations and any reason(s) the infant was not compliant. Teams met virtually for monthly huddles and semiannual learning sessions to discuss the development and testing of change ideas. RESULTS: The project teams were able to improve the percent of infants audited that were compliant with safe sleep recommendations by 22% over the course of the project. Audits revealed the main reasons for noncompliance were additional objects in the crib (49%, 329/671), unsafe bedding (27%, 181/671), and head of bed elevation (24%, 164/671). CONCLUSION: This project demonstrates the positive impact that a statewide quality improvement initiative can have on identifying and addressing barriers, sharing resources and education, and monitoring local and statewide data, which led to increased compliance with safe sleep recommendations in the hospital. Safe sleep education and monitoring should be ongoing as new parents and staff always need to be educated on safe sleep principles. KEY POINTS: · In 2020, 25% of all infant deaths in Tennessee were due to an unsafe sleep environment.. · Sleep-related deaths in infants are frequently preventable.. · State quality improvement projects are effective in increasing safe sleep compliance.. · State perinatal quality collaboratives can partner with their State Department of Health, local hospitals, and providers, to increase awareness, educate parents, and model a safe sleep environment..

Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception.

BACKGROUND: Women face barriers to obtaining contraception and postpartum care. In a review of Tennessee birth data from 2014, 56% of pregnancies were unintended, 22.7% were short-interval pregnancies, and 57.9% of women who were not intending to get pregnant were not using contraception. Offering long-acting reversible contraceptive methods in the immediate postpartum period allows women who desire these effective methods of contraception to obtain unobstructed access and lower unintended and short-interval pregnancy rates. OBJECTIVE: We report the experience of Tennessee's perinatal quality collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting reversible contraception through woman-centered counseling and ensuring reimbursement for devices. This followed a policy change in November 2017 that allowed women who were insured under Tennessee Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception. STUDY DESIGN: From March 2018 to March 2019, 6 hospital sites participated in this statewide quality improvement project that was based on the Institute of Health Improvement Breakout Collaborative model. An evidence-based toolkit was created to provide guidance to the sites. During the year of implementation, monthly huddles occurred, and each facility took a differing amount of time to implement immediate postpartum long-acting reversible contraception. Various statewide and hospital-specific barriers occurred and were overcome throughout the year. RESULTS: In total, 2012 long-acting reversible contraception devices were provided to eligible and desiring women. All but 1 institution was able to offer immediate postpartum long-acting reversible contraception by March 2019. Reimbursement was the biggest statewide barrier because rates were low initially but improved through intensive intervention by dedicated team members at each site and the state level. Even with dedicated team members, false assurances were given repeatedly by billing and claims staff. CONCLUSION: A statewide quality improvement project can increase access to immediate postpartum long-acting reversible contraception. Implementation and reimbursement require a dedicated team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on unintended and short-interval pregnancies requires long-term future investigation.

Building the Driver Diagram: A Mixed-Methods Approach to Identify Causes of Unplanned Extubations in a Large Neonatal ICU.

BACKGROUND: The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants. METHODS: Twenty-seven factors hypothesized to be associated with UE in our NICU were identified. An expert panel of 33 staff members completed three rounds of a modified Delphi process administered through an online interface. After the third round, panel members provided suggestions for interventions to target all factors meeting criteria for consensus. These qualitative data were analyzed by inductive thematic analysis. A follow-up survey to all panel members was used to assess the feasibility of this process for future use. RESULTS: After three Delphi rounds, 14 factors met consensus and eight main interventions were identified through thematic analysis. These data were used to build a KDD for testing. All participants who completed the follow-up survey (20/20) stated willingness to participate in this process in the future and 18/20 (90%) stated they would be "more willing" or "much more willing" to support interventions developed using this process. CONCLUSION: A novel mixed-methods approach was used to generate a KDD combining a Delphi process with thematic analysis. This approach provides improvement teams a rigorous and reproducible method to understand local context, generate consensus KDDs, and improve local buy-in for improvement interventions.

Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states.

Background and aims: Opioid agonist therapies (OATs) are highly effective treatments for opioid use disorders (OUDs), especially for pregnant women; thus, improving access to OAT is an urgent public policy goal. Our objective was to determine if insurance and pregnancy status were barriers to obtaining access to OAT in 4 Appalachian states disproportionately impacted by the opioid epidemic. Methods: Between April and May 2017, we conducted phone surveys of OAT providers, opioid treatment programs (OTPs), and outpatient buprenorphine providers, in Kentucky, North Carolina, Tennessee, and West Virginia. Survey response rates were 59%. Logistic models for dichotomous outcomes (e.g., patient acceptance) and negative binomial models were created for count variables (e.g., wait time), overall and for pregnant women. Results: The majority of OAT providers were accepting new patients; however, providers were less likely to treat pregnant women (91% vs. 75%; p < .01). OTPs were more likely to accept new patients than waivered buprenorphine providers (97% vs. 83%; p = .01); rates of accepting pregnant patients were lower in both (91% and 53%; p < .01). OTPs and buprenorphine providers accepted cash payments for services at high rates (OTP: 100%; buprenorphine: 89.4%; p < .01); Medicaid and private insurance were accepted at lower rates. In adjusted models, providers were less likely to accept pregnant women if they took any insurance (adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI]: 0.03-0.68) or were a buprenorphine provider (aOR = 0.09, 95% CI: 0.02-0.37). Conclusions: We found that OAT providers frequently did not accept any insurance and frequently did not treat pregnant women in an area of the country disproportionately affected by the opioid epidemic. Policymakers could prioritize improvements in provider training (e.g., training of obstetricians to become buprenorphine prescribers) as a means to enhance access to pregnant women or enhancing reimbursement rates as a means of improving insurance acceptance for OAT.

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome.

Importance: Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply. Objective: To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality. Design, Setting, and Participants: Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties. Exposures: County-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files. Main Outcomes and Measure: Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases. Results: The sample included observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties). During the study period, there were 6 302 497 births and 47 224 diagnoses of NAS. The median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas. In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40]; P = .02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70]; P = .04 for test of equivalence between metropolitan counties and rural remote counties). Conclusions and Relevance: In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.

Workload In Neonatology (WORKLINE): Validation and feasibility of a system for measuring clinician workload integrated into the electronic health record.

OBJECTIVE: The purpose of the study was to validate WORKLINE, a NICU specific clinician workload model and to evaluate the feasibility of integrating WORKLINE into our EHR. STUDY DESIGN: This was a prospective, observational study of the workload of 42 APPs and physicians in a large academic medical center NICU over a 6-month period. We used regression models with robust clustered standard errors to test associations of WORKLINE values with NASA Task Load Index (NASA-TLX) scores. RESULTS: We found significant correlations between WORKLINE and NASA-TLX scores. APP caseload was not significantly associated with WORKLINE scores. We successfully integrated the WORKLINE model into our EHR to automatically generate workload scores. CONCLUSION: WORKLINE provides an objective method to quantify the workload of clinicians in the NICU, and for APPs, performed better than caseload numbers to reflect workload. Integrating the WORKLINE model into the EHR was feasible and enabled automated workload scores.

Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants.

BACKGROUND: We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS: The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110-130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS: Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS: A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists.

BACKGROUND: It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia. METHODS: An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization. RESULTS: Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results. CONCLUSIONS: Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.

Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU.

BACKGROUND: Quality improvement (QI) methods have been widely adopted in health care. Although theoretical frameworks and models for organizing successful QI programs have been described, few reports have provided practical examples to link existing QI theory to building a unit-based QI program. The purpose of this report is to describe the authors' experience in building QI infrastructure in a large neonatal ICU (NICU). METHODS: A unit-based QI program was developed with the goal of fostering the growth of high-functioning QI teams. This program was based on six pillars: shared vision for QI, QI team capacity, QI team capability, actionable data for improvement, culture of improvement, and QI team integration with external collaboratives. Multiple interventions were developed, including a QI dashboard to align NICU metrics with unit and hospital quality goals, formal training for QI leaders, QI coaches imbedded in project teams, a day-long QI educational workshop to introduce QI methodology to unit staff, and a secure, Web-based QI data infrastructure. RESULTS: Over a five-year period, this QI infrastructure brought organization and support for individual QI project teams and improved patient outcomes in the unit. Two case studies are presented, describing teams that used support from the QI infrastructure. The Infection Prevention team reduced central line-associated bloodstream infections from 0.89 to 0.36 infections per 1,000 central line-days. The Nutrition team decreased the percentage of very low birth weight infants discharged with weights less than the 10th percentile from 51% to 40%. CONCLUSION: The clinicians provide a pragmatic example of incorporating QI organizational and contextual theory into practice to support the development of high-functioning QI teams and build a unit-based QI program.

Evaluating Definitions for Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: National estimates indicate that the incidence of neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased more than fivefold between 2004 and 2016. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. Our objective was to evaluate how different definitions of NAS modify the calculated incidence when applied to a known population of opioid-exposed infants. METHODS: Data for this retrospective cohort study were obtained from opioid-exposed infants born at Vanderbilt University Medical Center in 2018. Six commonly used clinical and surveillance definitions of opioid exposure and NAS were applied to the study population and evaluated for accuracy in assessing clinical withdrawal. RESULTS: A total of 121 opioid-exposed infants met the criteria for inclusion in our study. The proportion of infants who met criteria for NAS varied by predefined definition, ranging from 17.4% for infants who received morphine to 52.8% for infants with the diagnostic code for opioid exposure. Twenty-eight infants (23.1%) received a clinical diagnosis of NAS by a medical provider, and 38 (34.1%) received the diagnostic code for NAS at discharge. CONCLUSIONS: We found significant variability in the incidence of opioid exposure and NAS among a single-center population using 6 common definitions. Our findings suggest a need to develop a gold standard definition to be used across clinical, research, and public health surveillance settings.

A brief intervention may affect parents' attitudes toward using less physical punishment.

Ninety-six parents in a preschool and pediatric clinic participated in a randomized study of a brief parenting intervention. The Attitudes Toward Spanking (ATS) scale was measured at baseline, and, on average, 4 months postintervention. Higher ATS scores are correlated with increased use of physical punishment. In the intervention group, there was a 2.7-point decrease in the ATS score at follow-up compared with baseline (P = 0.01). There was no decrease in the ATS in the control group. Brief interventions may shift parental attitudes toward using less physical punishment and have implications for improving anticipatory guidance within primary care and early education.

Neonatal Abstinence Syndrome In The United States, 2004-16.

After increasing for nearly two decades, rates of neonatal abstinence syndrome have recently leveled off, reaching a plateau as early as 2014. These findings may represent successful efforts to prevent and treat opioid use before and during pregnancy.

Outcomes, Resource Use, and Financial Costs of Unplanned Extubations in Preterm Infants.

OBJECTIVES: Unplanned extubations (UEs) in adult and pediatric populations are associated with poor clinical outcomes and increased costs. In-hospital outcomes and costs of UE in the NICU are not reported. Our objective was to determine the association of UE with clinical outcomes and costs in very-low-birth-weight infants. METHODS: We performed a retrospective matched cohort study in our level 4 NICU from 2014 to 2016. Very-low-birth-weight infants without congenital anomalies admitted by 72 hours of age, who received mechanical ventilation (MV), were included. Cases (+UE) were matched 1:1 with controls (-UE) on the basis of having an equivalent MV duration at the time of UE in the case, gestational age, and Clinical Risk Index for Babies score. We compared MV days after UE in cases or the equivalent date in controls (postmatching MV), in-hospital morbidities, and hospital costs between the matched pairs using raw and adjusted analyses. RESULTS: Of 345 infants who met inclusion criteria, 58 had ≥1 UE, and 56 out of 58 (97%) were matched with appropriate controls. Postmatching MV was longer in cases than controls (median: 12.5 days; interquartile range [IQR]: 7 to 25.8 vs median 6 days; IQR: 2 to 12.3; adjusted odds ratio: 4.3; 95% confidence interval: 1.9-9.5). Inflation-adjusted total hospital costs were higher in cases (median difference: $49 587; IQR: -15 063 to 119 826; adjusted odds ratio: 3.8; 95% confidence interval: 1.6-8.9). CONCLUSIONS: UEs in preterm infants are associated with worse outcomes and increased hospital costs. Improvements in UE rates in NICUs may improve clinical outcomes and lower hospital costs.

Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals.

OBJECTIVE: A 2001 survey found that most healthcare professionals considered intensive care unit (ICU) delirium as a serious problem, but only 16% used a validated delirium screening tool. Our objective was to assess beliefs and practices regarding ICU delirium and sedation management. DESIGN AND SETTING: Between October 2006 and May 2007, a survey was distributed to ICU practitioners in 41 North American hospitals, seven international critical care meetings and courses, and the American Thoracic Society e-mail database. STUDY PARTICIPANTS: A convenience sample of 1384 healthcare professionals including 970 physicians, 322 nurses, 23 respiratory care practitioners, 26 pharmacists, 18 nurse practitioners and physicians' assistants, and 25 others. RESULTS: A majority [59% (766 of 1300)] estimated that more than one in four adult mechanically ventilated patients experience delirium. More than half [59% (774 of 1302)] screen for delirium, with 33% of those respondents (258 of 774) using a specific screening tool. A majority of respondents use a sedation protocol, but 29% (396 of 1355) still do not. A majority (76%, 990 of 1309) has a written policy on spontaneous awakening trials (SATs), but the minority of respondents (44%, 446 of 1019) practice spontaneous awakening trials on more than half of ICU days. CONCLUSIONS: Delirium is considered a serious problem by a majority of healthcare professionals, and the percent of practitioners using a specific screening tool has increased since the last published survey data. Although most respondents have adopted specific sedation protocols and have an approved approach to stopping sedation daily, few report even modest compliance with daily cessation of sedation.

National rates of diarrhea-associated ambulatory visits in children.

OBJECTIVE: To estimate national rates of ambulatory healthcare visits due to diarrhea- and rotavirus-associated illness before the introduction of rotavirus vaccine. STUDY DESIGN: Annual rates for diarrhea-associated visits in children age < 5 years were calculated for 1995-2004 using National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and US Census Bureau data. Rates by age, race, and time period were compared using Poisson regression. RESULTS: Annual rates of outpatient and emergency department (ED) visits for 1995-2004 were 955 (95% confidence interval [CI] = 803 to 1107) and 314 (95% CI = 278 to 350)/10,000 person-years, respectively. Annual outpatient (P = .470) and ED (P = .734) visit rates remained stable from 1995 to 2004. Outpatient visits were less frequent in African Americans than Caucasians (716/10,000 person-years vs 1012/10,000 person-years; P < .05; incidence rate ratio [IRR] = 0.71; 95% CI = 0.51 to 0.99), whereas ED visits were more frequent in African Americans than Caucasians (520/10,000 person-years vs 286/10,000 person-years; P < .05; IRR = 1.83; 95% CI = 1.58 to 2.11). Approximately 29% of outpatient diarrhea-associated outpatient visits (273/10,000 person-years; 95% CI = 145 to 401) and 25% of diarrhea-associated ED visits (78/10,000 person-years; 95% CI = 64 to 83) were due to rotavirus. CONCLUSIONS: Diarrhea- and rotavirus-associated illness is associated with significant healthcare utilization. Future studies are needed to investigate factors causing differences in healthcare use by race and to explore the impact of the rotavirus vaccine.

Improving neonatal resuscitation in Tennessee: a large-scale, quality improvement project.

OBJECTIVE: We report a statewide collaborative quality initiative to improve resuscitation and stabilization practices following introduction of the 6th edition of the Neonatal Resuscitation Program. METHODS: Participants drafted a consensus toolkit of interventions and corresponding measures. Hospital teams collected baseline data, and implemented changes using PDSA-cycles and statistical process control charts. RESULTS: Nine Tennessee NICUs submitted data on 3771 resuscitations. "Special cause" improvements were achieved and sustained for pre-resuscitation checklists (77-90%) and team briefings (80-92%). Time to intravenous access (50-42 min), glucose infusion initiation (73-60 min), and antibiotic dosing (113-98 min) were also significantly reduced. Teams were unable to meet new NRP oxygen saturation targets. Improvements in post-resuscitation debriefing were not sustained, while communication with parents declined significantly (68-60%). CONCLUSION: Large-scale collaboration facilitated statewide implementation of new guidelines, while highlighting under-appreciated systems challenges among competing resource demands.

Improving the Discharge Process for Opioid-Exposed Neonates.

OBJECTIVES: Opioid-exposed neonates (OENs) are a population at risk for postdischarge complications. Our objective was to improve completion of a discharge bundle to connect patients with outpatient resources to mitigate postdischarge risks. METHODS: Team Hope, a hospital-wide initiative to improve the care of OENs, examined the completion of a discharge bundle from September 2017 through February 2019. A complete discharge bundle was defined as referral to a primary care physician, referral to early intervention services, referral to in-home nursing assessment and educational services, referral to the development clinic if diagnosed with neonatal abstinence syndrome, and referral to the gastroenterology or infectious disease clinic if exposed to hepatitis C virus. After obtaining baseline data, simple interventions were employed as education of providers, social workers, and case management; reminder notes in the electronic health record; and biweekly reminders to resident physicians. A statistical process control chart was used to analyze our primary measure, with special cause variation resulting in a shift indicated by 8 consecutive points above or below the mean line. RESULTS: One hundred nineteen OENs were examined with an initial discharge bundle completion of 2.6% preimplementation. Referral to early intervention services and the development clinic were the least successfully completed elements before intervention implementation. After the development of the discharge bundle in July 2018, special cause variation was achieved, resulting in a mean-line shift with 60.3% now having a complete bundle for 83 OENs. CONCLUSIONS: We implemented a standardized discharge bundle that improved our discharge processes for OENs.