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Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods
A L Patel1, S Trivedi2, N P Bhandari1
1Section of Neonatology, Rush University Medical Center, Chicago, IL, USA.
Insights
Quality improvement initiatives effectively reduced necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. A change in nasogastric tube management significantly decreased NEC incidence, highlighting its importance in VLBW infant care.
Area of Science:
- Neonatalogy
- Pediatric Surgery
- Quality Improvement Science
Background:
- Necrotizing enterocolitis (NEC) incidence increased in very low birth weight (VLBW) infants.
- A rise from 4% to 10% in NEC (stage ⩾ 2) among VLBW infants necessitated targeted interventions.
Purpose of the Study:
- To evaluate the impact of quality improvement (QI) initiatives on NEC incidence in VLBW infants.
- To assess the effectiveness of a new feeding protocol and modified nasogastric tube practices.
Main Methods:
- A multidisciplinary team developed and implemented two QI initiatives: a feeding protocol and a reduction in nasogastric tube indwelling time.
- Infants were analyzed in three groups: baseline, QI phase 1 (feeding protocol), and QI phase 2 (nasogastric tube intervention).
- NEC incidence and intervention compliance were tracked.
Main Results:
- The feeding protocol in QI phase 1 did not decrease NEC incidence (19.4%).
- The modified nasogastric tube management in QI phase 2 significantly reduced NEC incidence to 2.9%.
- Multivariable logistic regression confirmed a significant association between QI phase and NEC incidence.
Conclusions:
- QI initiatives, particularly changes in nasogastric tube management, were effective in reducing NEC incidence in VLBW infants.
- Bacterial contamination from nasogastric tubes may have contributed to the initial rise in NEC.
- These findings support the implementation of targeted QI strategies in neonatal intensive care units (NICUs).
Objective:
Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.
Study Design:
In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).
Result:
The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.
Conclusion:
QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.
