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Improving completion of the red reflex examination at neonatal intensive care unit discharge: a practice improvement
Grant Shafer1,2, Kushal Bhakta3,2, Bheru Gandhi4,5
1Neonatology, Children's Hospital of Orange County, Orange, California, USA grant.shafer@choc.org.
Insights
Improving the red reflex examination (RRE) in newborns is crucial. Quality improvement initiatives, including optimized ophthalmoscope placement and EHR reminders, achieved 100% RRE completion in NICUs.
Area of Science:
- Neonatal care
- Ophthalmology
- Quality Improvement
Background:
- The red reflex examination (RRE) is vital for detecting ophthalmologic abnormalities in newborns.
- Low documentation rates of RRE completion were observed across multiple neonatal intensive care units (NICUs).
Purpose of the Study:
- To implement and evaluate a quality improvement initiative to increase RRE completion rates before infant discharge.
- To identify effective interventions for improving RRE documentation in NICUs.
Main Methods:
- A driver diagram guided interventions at NICU 1, including clinician education and EHR reminders.
- A 2^2 factorial planned experiment was conducted at three other NICUs, testing ophthalmoscope placement and EHR triggers.
Main Results:
- Sustained RRE completion improved from 66.8% to 100% at NICU 1.
- The combination of optimized ophthalmoscope placement and EHR RRE triggers achieved 100% compliance at all tested NICUs.
Conclusions:
- Quality improvement efforts successfully enhanced RRE completion rates in a NICU setting.
- A synergistic approach involving ophthalmoscope availability and EHR reminders shows promise for widespread RRE compliance.
Background:
Completing the red reflex examination (RRE) of the eyes to screen for ophthalmologic abnormalities is an essential component of the newborn physical examination. An abnormal RRE should prompt consultation with an ophthalmologist to perform a formal ocular examination.
Local Problem:
Chart review at a level IV neonatal intensive care unit (NICU 1) noted a low rate of documentation that the RRE was completed prior to discharge for eligible patients and suboptimal rates at three other NICUs of varying acuities and operational structures (NICUs 2, 3, 4). This prompted the initiation of a quality improvement initiative to improve RRE completion before discharge.
Methods And Interventions:
A driver diagram was generated to guide testing and implementation of interventions including ophthalmoscope placement, clinician education and electronic health record (EHR) reminders over eight plan-do-study-act cycles at NICU 1. Using the knowledge gained from NICU 1, two impactful tests of change were utilised to perform a 2 ∧ 2 factorial planned experiment (PE) at NICUs 2, 3 and 4.
Results:
This initiative led to sustained improvement in completion of the RRE from baseline 66.8% (13-month period) to 100% (22-month intervention period with special cause noted) at NICU 1 with two abnormal RREs detected. The PE using established factors from NICU 1 at NICUs 2, 3 and 4 demonstrated that the combination of ophthalmoscope placement optimisation plus EHR RRE trigger led to 100% RRE compliance at all sites.
Conclusion:
This initiative led to a sustained improvement in RRE completion at NICU 1. PE at three other NICUs of varying types and staffing structures identified a synergistic set of change factors, which may yield the greatest improvement across the spectrum of NICUs.
