Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

BACKGROUND: Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. METHOD: Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. RESULTS: Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. CONCLUSION: Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: A Quality Improvement Initiative.

Implementation of neuroprotective and neuropromotive (NP2) strategies is essential to optimize outcomes for premature infants. Developmental care, once an addition to medical care, is now recognized by the NICU team as foundational to support long-term neurodevelopment of micropremature infants. A group approach to education and sharing implementation processes can result in collaborative and individual center improvements. This article includes examples of quality improvement (QI) education and tools inspired by implementation of NP2 strategies in a consortium of 11 NICUs in the United States and Canada. Process change guided by potentially better practices are key; however, consistency of application must be included to ensure success. Assessment of NP2 practices via use of surveys and practice audits are described. Increases occurred in family NP2 education and provision of support during painful experiences. There were also increases in skin-to-skin holding, 2-person caregiving, and focus on reducing unnecessary painful procedures.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement.

The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families.

Continued improvement in morbidity reduction in extremely premature infants.

OBJECTIVE: Provide a progress report updating our long-term quality improvement collaboration focused on major morbidity reduction in extremely premature infants 23-27 weeks. METHODS: 10 Vermont Oxford Network (VON) neonatal intensive care units (NICUs) (the POD) sustained a structured alliance: (A) face-to-face meetings, site visits and teleconferences, (B) transparent process and outcomes sharing, (C) utilisation of evidence-based potentially better practice toolkits, (D) family integration and (E) benchmarking via a composite mortality-morbidity score (Benefit Metric). Morbidity-specific toolkits were employed variably by each NICU according to local priorities. The eight major VON morbidities and the risk-adjusted Benefit Metric were compared in two epochs 2010-2013 versus 2014-2018. RESULTS: 5888 infants, mean (SD) gestational age 25.8 (1.4) weeks, were tracked. The POD Benefit Metric significantly improved (p=0.03) and remained superior to the aggregate VON both epochs (p<0.001). Four POD morbidities significantly improved through 2018 - chronic lung disease (48%-40%), discharge weight <10th percentile (32%-22%), any late infection (19%-17%) and periventricular leukomalacia (4%-2%). In epoch 2, 34% of survivors had none of the eight major morbidities, while 36% had just one. Mortality did not change. CONCLUSIONS: Inter-NICU collaboration, process and outcomes sharing and potentially better practice toolkits sustain improvement in 23-27 week morbidity rates, notably chronic lung disease, extrauterine growth restriction and the lowest zero-or-one major morbidity rate reported by a quality improvement collaboration. Unrevealed biological and cultural variables affect morbidity rates, countless remain unmeasured, thus duplication to other quality improvement groups is challenging. Understanding intensive care as innumerable interactions and constant flux that defy convenient linear constructs is fundamental.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns.

AIM: Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress. METHODS: We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric). RESULTS: A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one. CONCLUSION: Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants.

OBJECTIVE: The survival rates for extremely low birth weight (ELBW) infants have improved, but many are discharged from the hospital with significant challenges. Our goal was to improve outcomes for this population by using a multidisciplinary team-based quality improvement approach. METHODS: A unique program called the Small Baby Unit (SBU) was established in a children's hospital to care for the ELBW infant born at 28 weeks or less and weighing less than 1000 g at birth. These patients were cared for in a separate location from the main neonatal unit. A core multidisciplinary team that participates in ongoing educational and process-improvement collaboration provides care. Evidence-based guidelines and checklists standardized the approach. RESULTS: Data from the 2 years before and 4 years after opening the SBU are included. There was a reduction in chronic lung disease from 47.5% to 35.4% (P = .097). The rate of hospital-acquired infection decreased from 39.3% to 19.4% (P < .001). Infants being discharged with growth restriction (combined weight and head circumference <10th percentile) decreased from 62.3% to 37.3% (P = .001). Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 (P < .001) and radiographs decreased from 45 to 22 (P < .001). CONCLUSIONS: Care in a distinct unit by a consistent multidisciplinary SBU team using quality improvement methods improved outcomes in ELBW infants. Ongoing team engagement and development are required to sustain improved outcomes.

Reduction in newborn screening metabolic false-positive results following a new collection protocol.

PURPOSE: Newborn screening includes testing for many metabolic diseases. False-positive results are higher among neonatal intensive care unit infants, resulting in increased confirmatory testing and family stress. Amino acid administration as a component of total parenteral nutrition is commonly used in the neonatal intensive care unit and suggested as a factor increasing false-positive results. The purpose of this study was to investigate the impact of a new sample collection protocol on false-positive results. METHODS: This was a 2-year retrospective cohort study. Infants were grouped by birth year into pre- and postprotocol implementation and stratified by birth weight category. In 2010, newborn screening samples were collected from all infants regardless of total parenteral nutrition administration. In 2011, the protocol was changed, and total parenteral nutrition was replaced with 10% dextrose in water (D10W) for 3 h before sample collection. RESULTS: Data from 539 neonatal intensive care unit admissions were reviewed. The new protocol reduced false-positive results for each birth weight group by at least 50% and overall by 74% (P = 0.008). The odds of having a false-positive result preintervention were 3.87 times higher than postintervention. The protocol reduced estimated costs by >80%. CONCLUSION: A protocol interrupting total parenteral nutrition for 3 h before newborn screening collection resulted in a 74% reduction in false-positive results in a neonatal intensive care unit.

Once-weekly liposomal amphotericin B as Candida prophylaxis in very low birth weight premature infants: a prospective, randomized, open-label, placebo-controlled pilot study.

OBJECTIVE: This study was conducted to evaluate once-weekly liposomal amphotericin B (L-AmB) for Candida prophylaxis in very low birth weight (VLBW) neonates. METHODS: This prospective, randomized, open-label, placebo-controlled study included neonates who were <32 weeks' gestational age, <7 days old, and weighing <1500 g at birth. Subjects were randomized to receive L-AmB 5 mg/kg per week or placebo (dextrose water) and were followed until 6 weeks of age. Surveillance cultures were obtained at baseline, at 72 hours, and weekly thereafter. Study drug was continued until 6 weeks after birth or the discontinuation of high-risk treatments and invasive devices, whichever occurred first. Blood cultures were obtained as clinically indicated. The primary end point was development of Candida colonization by 6 weeks' postnatal age; secondary end points included development of invasive candidiasis and occurrence of treatment-related adverse events. Safety variables included renal and hepatic function tests, incidence of grade III-IV intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC), and mortality. RESULTS: Forty subjects were enrolled and randomized to receive L-AmB (12 males, 8 females; 50% white) or placebo (12 males, 8 females; 35% white). Subjects were evenly distributed by gestational age, age at enrollment, birth weight, race, and sex. Consent was withdrawn after completion of study treatment in 1 subject (L-AmB); 1 subject in each study arm died during the study; and 3 subjects were transferred back to their referring institutions (1 L-AmB, 2 placebo). Thus, 17 subjects in each arm completed all study procedures, although all 40 subjects were evaluable. Colonization before administration of study drug was noted in 4 L-AmB subjects (20%) and 1 placebo subject (5%); 1 (5%) and 3 (15%) subjects in the respective groups developed colonization while receiving study drug. No L-AmB subjects and 1 placebo subject developed candidiasis. One subject in each group died; these deaths were not considered related to study drug or fungal infection. There were no clinical differences between groups in the incidence of grade III-IV IVH, NEC, hypokalemia, nephrotoxicity, need for platelet or packed red blood cell transfusion, or mortality. CONCLUSIONS: L-AmB 5 mg/kg once weekly was generally well tolerated in these VLBW infants. The data did not allow evaluation of efficacy. A larger, multicenter, randomized clinical trial of L-AmB for Candida prophylaxis that is appropriately powered is warranted.