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A Quality Improvement Bundle to Improve Outcomes in Extremely Preterm Infants in the First Week
Colm P Travers1, Samuel Gentle1, Amelia E Freeman1
1Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Insights
A quality improvement initiative successfully reduced severe intracranial hemorrhage (ICH) or death in extremely preterm infants. This involved implementing evidence-based practices, leading to significant reductions in adverse outcomes for vulnerable newborns.
Area of Science:
- Neonatalogy
- Pediatric Critical Care
- Quality Improvement Science
Background:
- Extremely preterm infants face high risks of severe outcomes like intracranial hemorrhage (ICH) and death within the first week of life.
- Reducing these adverse events is a critical goal in neonatal intensive care.
Purpose of the Study:
- To decrease the incidence of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants.
- To evaluate the effectiveness of a quality improvement initiative aimed at improving neonatal outcomes.
Main Methods:
- A quality improvement initiative was conducted in a Neonatal Intensive Care Unit (NICU) from April 2014 to September 2020.
- Inclusion criteria: actively treated, inborn, extremely preterm infants (22 0/7 to 27 6/7 weeks' gestation, birth weight ≥400 g) without congenital anomalies.
- Primary outcome: severe ICH or death within 7 days. Balancing measures: acute kidney injury, spontaneous intestinal perforation. Data analyzed using p-charts.
Main Results:
- The study included 820 infants with a mean gestational age of 25 3/7 weeks.
- The rate of severe ICH or death within the first week decreased from 27.4% to 15.0%.
- Severe ICH rates dropped from 16.4% to 10.0%, linked to improved CO2/pH management, delayed cord clamping, and indomethacin prophylaxis.
Conclusions:
- Implementing a bundle of evidence-based practices, facilitated by electronic order sets, significantly lowered the rate of severe ICH or death in extremely preterm infants.
- This quality improvement initiative demonstrates a successful strategy for reducing critical adverse events in this vulnerable population.
Objectives:
Our objective with this quality improvement initiative was to reduce rates of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants.
Methods:
The quality improvement initiative was conducted from April 2014 to September 2020 at the University of Alabama at Birmingham's NICU. All actively treated inborn extremely preterm infants without congenital anomalies from 22 + 0/7 to 27 + 6/7 weeks' gestation with a birth weight ≥400 g were included. The primary outcome was severe ICH or death in the first 7 days after birth. Balancing measures included rates of acute kidney injury and spontaneous intestinal perforation. Outcome and process measure data were analyzed by using p-charts.
Results:
We studied 820 infants with a mean gestational age of 25 + 3/7 weeks and median birth weight of 744 g. The rate of severe ICH or death in the first week after birth decreased from the baseline rate of 27.4% to 15.0%. The rate of severe ICH decreased from a baseline rate of 16.4% to 10.0%. Special cause variation in the rate of severe ICH or death in the first week after birth was observed corresponding with improvement in carbon dioxide and pH targeting, compliance with delayed cord clamping, and expanded use of indomethacin prophylaxis.
Conclusions:
Implementation of a bundle of evidence-based potentially better practices by using specific electronic order sets was associated with a lower rate of severe ICH or death in the first week among extremely preterm infants.
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