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Improving Red Reflex Screening in a Level III NICU Through a Quality Improvement-based Approach
Rishika P Sakaria1, Jennifer M Davidson1, Nakia Coleman1
1University of Tennessee Health Science Center, Memphis, Tennessee.
Insights
Routine newborn eye exams, known as red reflex testing, are crucial for detecting serious ocular conditions. A quality improvement project in a US NICU significantly increased documentation rates from 19% to 89.5%.
Area of Science:
- Neonatal ophthalmology
- Quality improvement in healthcare
- Pediatric eye screening
Background:
- Red reflex examination is a standard, noninvasive newborn screening tool for detecting serious ocular abnormalities.
- The American Academy of Pediatrics recommends this exam before hospital discharge.
- The current documentation rate in US Neonatal Intensive Care Units (NICUs) was unknown, with a baseline of 19% noted in one level III NICU.
Purpose of the Study:
- To implement a quality improvement project aimed at increasing the documentation rate of red reflex examinations in a NICU.
- To achieve a documentation rate exceeding 80% for red reflex assessments.
Main Methods:
- A key-driver diagram was developed to identify potential interventions.
- Multiple interventions were implemented over four plan-do-study-act cycles, including staff education, visual reminders, discharge checklists, and improved ophthalmoscope accessibility.
- The project spanned 19 months of intervention.
Main Results:
- The study included 1168 infants discharged from the NICU without a formal ophthalmologist examination.
- Red reflex documentation rates significantly improved from a baseline of 19% to 89.5% during the intervention period.
- One case of abnormal red reflex was identified.
Conclusions:
- The quality improvement project successfully established a culture of improved documentation for red reflex examinations.
- This initiative is expected to reduce the incidence of missed diagnoses for serious visual abnormalities in newborns.
- Sustained focus on this screening can enhance early detection and management of pediatric eye conditions.
Background:
Red reflex is a routine part of newborn examination in most high-income countries. It is an inexpensive, noninvasive method of detecting serious ocular abnormalities like cataracts, retinoblastoma, vitreous masses, etc. The American Academy of Pediatrics recommends red reflex examination before discharge from newborn nursery. However, the current rate of red reflex examination in the NICUs in the United States is unknown. We noted a low rate of documentation (19%) in our level III NICU, prompting us to initiate this quality improvement project to improve this rate.
Methods:
We created a key-driver diagram and summarized possible interventions to achieve our aim to increase the documentation rate to >80%. We implemented various interventions over 4 plan-do-study-act cycles. Over 19 months, we educated the nurses and the providers regarding the importance of red reflex assessment, placed visual reminders to check red reflex, implemented discharge checklist for the residents, and improved the accessibility to ophthalmoscope.
Results:
Infants discharged from our NICU during a 25-month period included 1168 infants who an ophthalmologist did not formally examine. The rate of red reflex documentation improved significantly from a baseline of 19% (6 months before the first plan-do-study-act cycle) to 89.5% (during the 19-month intervention period). One abnormal red reflex was detected during this study.
Conclusions:
Implementation of this project has led to a culture change at our institution, which will help prevent us from missing the diagnosis of serious visual abnormalities in the future.
