A Multifaceted Approach to Improving Outcomes in the NICU: The Pediatrix 100 000 Babies Campaign.
Dan L. Ellsbury, Reese H. Clark, Robert Ursprung, Darren L. Handler, Elizabeth D. Dodd, Alan R. Spitzer. Pediatrics. Vol 137, No. 4, April 2016: e20150389
BAPM NSQI 1 – Evidenced-base Care
In this article the authors present how large-scale improvements in multiple domains of neonatal care can be achieved through a multi-faceted approach within a neonatal network. The study was undertaken by a group of clinicians who provide neonatal intensive care for approximately 20% of the new-borns in the USA who require intensive care. The clinical settings ranged from small community hospital to large teaching hospitals with variable practices and outcome. The authors hypothesized that a structured approach to system evaluation and re-engineering of neonatal intensive care in multiple key processes would yield sustained improvement in neonatal morbidity and mortality. The term “100,000 Babies campaign” was used because of its similarity to the Institute for Healthcare Improvement’s “100 000 Lives Campaign” which successfully targeted key problem areas with a goal of saving 100 000 lives.
Reviewed by Ambalika Das on behalf of the Publications Team
“Golden Hour” quality improvement intervention and short-term outcome among preterm infants.
Ben Peleg, Omer Globus, Maya Granot, Leah Leibovitch, Ram Mazkereth, Irit Eisen, Iris Morag, Orly Stern, Chava Rozen, Ayala Maayan-Metzger & Tzipora Strauss
BAPM NSQI 2 – Team Communication
BAPM NSQI 3 – Staff Safety Culture
BAPM NSQI 4 – Pathways of Care
BAPM NSQI 17 – Training for Quality & Patient Safety
Peleg et al. describe a neatly devised programme to evaluate impact of QI interventions during the “Golden Hour” for preterm babies. The project maps directly to NSQI 4 - Pathways of Care, aiming to identify improvements in short-term clinical outcomes for our most premature patients. The case-control approach included 194 infants in each group – a sizable undertaking. They included infants <32+6 weeks and performed subset analysis to consider the least mature infants <28 weeks. The team focussed on key issues many of us struggle with – thermoregulation, consistent respiratory stabilisation, team briefings and structured communication. Their attendance to team communication and strategies for improvement are refreshing and links well to NSQI 2/3 - Team Communication/Staff Safety Culture.
They demonstrated significant improvement in admission temperatures by roughly 1 degree, late onset sepsis was reduced and BPD decreased significantly (6% vs 12%). Interestingly, there was a suggestion of most powerful effect for the least mature infants. A good addition to their QI was inclusion of in-situ simulation to improve embedding of changes within the team (NSQI 17 - Training for Quality & Patient Safety). As acknowledged by the authors, the study is neither perfect nor free of bias but embodies a willingness to make systematic changes to ways of working and critically evaluate their efficacy improving outcomes. Maybe take this paper to your journal club and see what measures do and don’t apply to you locally. What are your units already doing in the spirit of embedding the NSQI principles in improvement work?
Reviewed by Chantelle Tomlinson on behalf of the Publication Team
Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units.
Kaempf JW, Wang L, Dunn M. Arch Dis Child Fetal Neonatal Ed 2019; 104:F13-F17
BAPM NSQI 3 – Staff Safety Culture
BAPM NSQI 15 – Structure and resources for quality improvement
This article explores the important question as to why some neonatal units outperform others despite access to the same collaborative networks, quality improvement methodology and evidence based medicine guidelines. The authors calculated a composite morbidity score (JAMA Pediatr. 2015;169(5):459-465) for each of the 39 neonatal units over 14 years (2000-2014) and compared that to the group mean. All units were in North America and data was obtained from the Nightingale Internet Reporting System for the Vermont Oxford Network. Each unit then completed 103 survey questions related to environment and infrastructure and the authors then analysed which of these factors were positively and negatively associated with high performance.
They suggest that what these proficient units have in common is based on social and cultural aspects including positive and well trained leadership, higher morale, frequent learning opportunities with time to learn, staff involvement and knowledge in quality improvement across all levels, effective team work and communication and good staffing levels. Similar aspects are addressed in the BAPM NSQI 3 (staff safety culture) and 15 (structure and resources for quality improvement).
It also reviews the factors that are seen to negatively correlate with composite morbidity reduction in high proficiency units including paediatric trainees regularly rounding on premature infants. It does not offer specific solutions but discusses how social and cultural aspects of a neonatal unit may have a significant impact on achieving good outcomes.
The composite morbidity score is available online for neonatal units to review their own score over time once inputting some key data.
Reviewed by Dr Kirsten Wade, Paediatric ST5, Simpson Centre for Reproductive Heath, Edinburgh
QI publications group: Ambalika Das (Lead), Chantelle Tomlinson, Sarah Bates, Lisa Barker.