Reducing Osteopenia of Prematurity-related Fractures in a Level IV NICU: A Quality Improvement Initiative
Linsey Cromwell1, Katherine Breznak2, Megan Young3
1From the Department of Pediatrics St Christopher's Hospital for Children, Philadelphia Pa.
Insights
Implementing a standardized approach significantly reduced fractures in premature infants. This quality improvement initiative improved care for osteopenia of prematurity (OOP) in the neonatal intensive care unit (NICU).
Area of Science:
- Neonatal Medicine
- Pediatric Bone Health
- Quality Improvement Science
Background:
- Osteopenia of prematurity (OOP) is a silent condition in neonatal intensive care units (NICUs) linked to increased infant morbidity, including fractures.
- Practices for screening, diagnosing, and managing OOP vary widely, contributing to suboptimal patient outcomes.
- Fractures associated with OOP represent a significant challenge in neonatal care, necessitating standardized interventions.
Purpose of the Study:
- To decrease osteopenia of prematurity (OOP)-related fractures by 20% within one year in a level IV neonatal intensive care unit (NICU).
- To address the inconsistent screening, diagnosis, and management of OOP contributing to fractures.
- To implement a quality improvement initiative to standardize care for at-risk infants.
Main Methods:
- A multidisciplinary quality improvement team identified key drivers of OOP-related fractures.
- Sequential interventions were implemented using the model for improvement, including a standardized screening, diagnosis, and management algorithm.
- A "handle-with-care" bundle was developed and applied to infants identified as at risk for fractures.
Main Results:
- The study included 194 at-risk infants, with 59 diagnosed with OOP.
- Interventions led to a significant reduction in OOP-related fractures, from 0.43 to 0.06 per 1000 patient days.
- The average time between fractures increased from 62 to 337 days, demonstrating sustained improvement.
Conclusions:
- A multidisciplinary team approach is crucial for reducing fractures in premature infants.
- Standardized guidelines for OOP screening, diagnosis, and management effectively decrease fracture rates.
- Implementing a "handle-with-care" bundle as part of a quality improvement initiative improves outcomes for infants at risk of OOP.
Background:
Osteopenia of prematurity (OOP) is often a silent disease in the neonatal intensive care unit (NICU). Despite its association with increased neonatal morbidity, such as fractures, wide variation exists in screening, diagnostic, and management practices. We sought to decrease the rate of OOP-related fractures in our level IV NICU by 20% within 1 year.
Methods:
A multidisciplinary quality improvement team identified inconsistent screening, diagnosis, and management of OOP, as well as handling of at-risk patients, as primary drivers for OOP-related fractures. Using the model for improvement, we implemented sequential interventions, including screening, diagnosis, and a management algorithm as a "handle-with-care" bundle in infants at risk for fractures.
Results:
194 at-risk infants were included, 59 of whom had OOP. There was special cause variation in OOP-related fractures, with a reduction from 0.43 per 1000 patient days to 0.06 per 1000 patient days with our interventions. There was also an improvement in days between fractures from 62 to 337 days. We achieved these improvements despite a similar prevalence of OOP throughout the initiative. We showed special cause variation with increased patients between missed OOP documentation and improved collection of OOP screening laboratories at 4 weeks of life without increased blood testing.
Conclusion:
A multidisciplinary team approach with standardized OOP screening, diagnosis, and management guidelines, including a handle-with-care bundle, reduces OOP-related fractures in a level IV NICU.
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