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Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants
Maria M Talavera1, Gary Bixler2, Corin Cozzi3
1Division of Neonatology, Department of Pediatrics, The Ohio State University, Columbus, Ohio; maria.talavera@nationwidechildrens.org.
Insights
Quality improvement initiatives significantly reduced necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. Early human milk feedings and conservative feeding protocols were key to this success, lowering NEC incidence substantially.
Area of Science:
- Neonatalogy
- Pediatric Surgery
- Quality Improvement Science
Background:
- Necrotizing enterocolitis (NEC) poses a significant threat to very low birth weight (VLBW) infants.
- A 2010 baseline indicated an 8.0% incidence of NEC in VLBW infants across eight intensive care nurseries.
- Reducing NEC incidence and related mortality is a critical goal in neonatal intensive care.
Purpose of the Study:
- To decrease the incidence of NEC in VLBW infants from 8.0% to below 4.0% by 2012.
- To sustain this reduction for at least six months using quality improvement (QI) methodologies.
- To lower NEC-related mortality rates in VLBW infants.
Main Methods:
- A multidisciplinary NEC QI team utilized the Vermont Oxford Network definition of NEC and the Institute for Healthcare Improvement model.
- Key interventions included standardized early human milk feedings, conservative feeding guidelines during blood transfusions and indomethacin treatment, and restriction of ranitidine use.
- Incidence of NEC and NEC-related surgery were tracked using statistical process control methodology for VLBW infants admitted within the study period.
Main Results:
- The NEC rate decreased from a baseline of 8.0% (27/335 VLBW infants in 2010) to 3.1% (19/606 VLBW infants) by December 2013 (P = .001).
- NEC-related mortality decreased from a mean of 2.7% in 2010 to 0.9% from January 2011 to December 2013.
- Statistical process control analysis indicated a significant shift in NEC incidence in June 2012.
Conclusions:
- Implementation of QI initiatives effectively reduced NEC rates in VLBW infants from 8.0% to below 4.0%.
- Early human milk feedings and conservative feeding policies during blood transfusions demonstrated a significant impact on NEC reduction.
- These QI strategies offer a viable approach to decreasing NEC incidence and improving outcomes for VLBW infants.
Objective:
To reduce the incidence of necrotizing enterocolitis (NEC) among very low birth weight (VLBW) infants admitted to 8 intensive care nurseries from a 2010 baseline of 8.0% to <4.0% by 2012 and sustain for 6 months using quality improvement (QI) methodology.
Methods:
A multidisciplinary NEC QI team used the Vermont Oxford Network definition of NEC and the Institute for Healthcare Improvement model. The specific aims were evidenced based and included (1) standardized early human milk feedings, (2) conservative feeding guidelines during blood transfusions and indomethacin treatment, and (3) restriction of ranitidine use in VLBW infants. Inclusion criteria included VLBW infants admitted within the study period without NEC. Exclusion criteria included established NEC or spontaneous intestinal perforation unrelated to NEC. The incidence of NEC and NEC-related surgery were tracked using statistical process control methodology.
Results:
The baseline NEC rate in 2010 was 8% (27 NEC cases in 335 VLBW infants). After initiation of early human-milk feeding and conservative feeds during blood transfusions guidelines in November 2011, only 3.1% (19 of 606 VLBW infants) had developed NEC through December 2013 (P = .001). Special cause variation was noted in June 2012 establishing a new centerline at 3.1%. NEC-related mortality decreased from a 2010 baseline mean of 2.7% to a new baseline mean of 0.9% from January 2011 to December 2013.
Conclusions:
Implementation of QI initiatives decreased the NEC rate from 8.0% to <4.0%. Early human milk feedings and conservative feeding during blood transfusion policies appear to have significant impact on NEC reduction.
