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Reducing Time to Initiation of Therapeutic Hypothermia in Inborn Infants with Hypoxic-ischemic Encephalopathy
Alyssa Carlson1, Allison Vale1, Tracey Bell2
1From the Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Ga.
Insights
Implementing quality improvement methods successfully increased therapeutic hypothermia (TH) initiation before 3 hours in infants with hypoxic-ischemic encephalopathy (HIE). This advancement is crucial for improving neurodevelopmental outcomes in newborns.
Area of Science:
- Neonatal Medicine
- Quality Improvement Science
- Neurology
Background:
- Earlier therapeutic hypothermia (TH) is linked to better neurodevelopmental outcomes for infants suffering from hypoxic-ischemic encephalopathy (HIE).
- Timely TH initiation is critical for mitigating HIE's effects.
Purpose of the Study:
- To enhance the percentage of inborn infants receiving TH before 3 hours of life from a baseline of 25% to a target of 75% within 12 months.
- To implement and assess quality improvement strategies in neonatal intensive care units (NICUs).
Main Methods:
- The project involved two academically affiliated Level III NICUs.
- Infants born with moderate to severe HIE meeting TH criteria were included.
- Data were analyzed using descriptive statistics and Statistical Process Control charts.
Main Results:
- The study achieved a significant increase in TH initiation before 3 hours, reaching 72% overall and 79% when excluding cases with encephalopathy progression.
- The mean percentage of infants receiving TH before 3 hours improved from 31% (baseline) to 76% (implementation) and 80% (sustainment).
Conclusions:
- Quality improvement initiatives can effectively reduce the time to TH initiation in newborns with HIE.
- Progression from mild to moderate encephalopathy is a primary reason for delayed TH initiation.
Introduction:
Earlier therapeutic hypothermia (TH) is associated with improved neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy (HIE). We aimed to increase the percentage of inborn infants with TH initiation before 3 hours from 25% to 75% within 12 months.
Methods:
This project took place at 2 academically affiliated Level III NICUs. We included infants inborn with moderate or severe HIE who met standard criteria for TH. The team developed a driver diagram and process map, which informed interventions. We compared data using descriptive statistics and Statistical Process Control charts.
Results:
Of the 70 included infants, 13 were in the baseline period, and 57 were in the implementation and sustainment period. There was a special cause variation that increased the centerline from 25% to 72%. The most common cause of initiation of TH after 3 hours of life was progression from mild to moderate HIE (39%). When infants with progression of encephalopathy were excluded, the central line further increased to 79%. In this refined cohort, the mean percentage of infants with TH initiated before 3 hours was 31%, 76%, and 80% in the baseline, implementation, and sustainment periods, respectively.
Conclusions:
Quality improvement methodology can reduce the time to TH initiation in inborn infants, which is associated with improved neurodevelopmental outcomes. A common reason for delayed TH initiation is progression from mild to moderate encephalopathy.
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