Quality I nitiatives Related to Moderately Preterm, Late P re t e r m , a n d E a r l y Ter m B i r t h s Andrea N. Trembath, MD, MPHa,*, Jay D. Iams, Michele Walsh, MD, MSEa
MD
b
,
KEYWORDS Quality improvement Preterm births Infection reduction Delaying preterm birth Human milk KEY POINTS The goal of quality-improvement methodology is to improve the quality and costeffectiveness of health care. The care provided to moderately preterm, late preterm, and early term births is an area with significant practice variation. Prior quality-improvement initiatives designed to reduce nonindicated early term births and bloodstream infections may serve as models for future initiatives in more mature infants. Respiratory care, feeding management, and discharge planning may serve as future directions for quality improvement in moderate preterm, late preterm, and early term births.
INTRODUCTION
Prematurity is the leading cause of death for newborns in the United States and represents more than $26 billion dollars in health care expenditure costs per year.1 Overall, most premature infants born in the United States each year are classified as either moderately preterm (MPT) or late preterm (LPT) infants, defined as birth at 31 0/7 to 33 6/7 and 34 0/7 to 36 6/7 weeks’ gestation respectively.2 Together this group accounts for more than 70% of the preterm population. Ample opportunity exists to improve care using quality improvement (QI) methodology.
Disclosures: The authors have no financial disclosures. a Division of Neonatology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, RBC Suite 3100, Cleveland, OH 44106-6010, USA; b Division of Maternal Fetal Medicine, The Ohio State University Medical Center, 395 West 12 Avenue, Fifth Floor, Columbus, OH 43210-1267, USA * Corresponding author. E-mail address: [email protected] Clin Perinatol 40 (2013) 777–789 http://dx.doi.org/10.1016/j.clp.2013.07.011 perinatology.theclinics.com 0095-5108/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
778
Trembath et al
The principal tenets of QI to improve and ensure the safety, quality, and costeffectiveness of health care are particularly appropriate for application among preterm infants.3 QI in the neonatal intensive care unit (NICU) has primarily focused on extremely low-gestational-age newborns (ELGANs) because they are at highest risk for death or morbidity. However, they represent a minority of premature infants: w5% of premature infants born in the United States each year.2 Therefore, MPT and LPT infants represent an important focus for QI within the United States because they are subject to a great deal of variation in care practices among individual centers as well as among practitioners. Unnecessary variation in care and lack of evidencebased practices may contribute to the morbidities of prematurity. Over the last decade the number of QI projects involving neonatal and perinatal topics has increased substantially. As a result, the number of national collaboratives focused on the care of neonates has also increased. One of the most recognized collaboratives is the Vermont Oxford Network (VON). An international collaborative of more than 900 NICUs established in 1988, the mission of the VON is to improve the quality, safety, and efficiency of health care delivery to newborns.4 The VON iNICU Quality Improvement Collaboratives for Neonatology works to identity and implement evidence-based practices through the creation of shared goals and measurable achievements. iNICU define 4 key habits necessary for effective QI: change, collaborative learning, evidence-based practice, and systems thinking.5 National and international collaboratives are an important component to improving the care delivered to newborns and provides an established platform for sharing strategies for QI. However, the scope and direction of QI initiatives must be taken in the context of the health care systems in which they will function.6 As a result, the VON platform for QI in NICUs has now been applied to multiple regional perinatal quality collaboratives. State collaboratives such as the Perinatal Quality Collaborative of North Carolina, Tennessee Initiative for Perinatal Quality Care, New York State Perinatal Quality Collaborative, California Perinatal Quality Care Collaborative, and the Ohio Perinatal Quality Collaborative (OPQC) have built particularly active quality initiatives based on the VON platform. This article uses the experience of the OPQC to show how quality collaboratives could be applied to decreasing unnecessary variation in the care provided to MPT, LPT, and early term (ET) infants. OPQC
OPQC is a network of Ohio institutions, hospitals, and individuals dedicated to improving perinatal health in the state. The collaborative includes 24 neonatal teams and 19 obstetric teams that represent the 6 perinatal regions of Ohio. The OPQC mission is “Through collaborative use of improvement science methods, to reduce preterm births and improve outcomes of preterm newborns in Ohio as soon as possible.” OPQC uses an adapted methodology from the Institute for Healthcare Improvement’s (IHI) Breakthrough Series Model (Fig. 1). OPQC’s primary goal is to target improvements in outcome through defined shared goals based on established scientific evidence, which includes using rapid-cycle QI techniques such as Plan-Do-Study-Act. OPQC brings together a multidisciplinary team of individuals through face-to-face sessions and webinar-based action period calls to review individual site and collaborative data, share successful QI initiatives and strategies, and plan future OPQC projects. Thus far 6 project titles have been designed: reducing late onset infections, human milk, antenatal corticosteroid (ANC), 39 weeks charter and 39 weeks/birth registry accuracy project. Three of the projects have targeted reducing preterm birth, and the other two are designed to reduce the morbidity and mortalities of preterm birth.
Quality Initiatives
Fig. 1. IHI model for improvement (Plan-Do-Study-Act cycle). (Adapted from Langley GL, Nolan KM, Nolan TW, et al. The improvement guide: a practical approach to enhancing organizational performance. 2nd edition. San Francisco (CA): Jossey-Bass Publishers; 2009; with permission.)
OPQC Neonatal Initiatives Reducing late-onset infections
Prematurity is a well-established risk factor for infection, particularly in the hospital setting. Nosocomial infections occur in 15% to 30% of extremely preterm infants and cause increased morbidity, mortality, and hospital costs. As a result, OPQC identified infection as a key target for a neonatal quality initiative. Bloodstream infection in NICUs is a multifactorial problem with several important factors playing a role in reducing infection, including appropriate use of centrally inserted catheters, hand hygiene, a culture of providing quality care, and maintaining skin integrity (Fig. 2). By focusing on improving the process of inserting and maintaining central lines, several of these modifying factors could be enhanced. For the insertion bundle, key measures include a focus on hand hygiene, sterile technique, and identifying problems with maintaining sterile fields during insertion. For the maintenance bundle, the primary elements identified are related to sterility during tubing changes and catheter hub care and assessing the need for the line daily. As a result of the OPQC infection project, a 20% sustained decrease in bloodstream infections in premature infants was seen among the 24 NICUs.7 Throughout the project it has become apparent that there are significant differences in the relative importance of each of the bundles. Among NICUs the key component to sustaining a decrease in bloodstream infections is the continued use of the maintenance bundle. As a new focus, OPQC members are working to achieve greater than 90% compliance with the catheter maintenance bundle (Fig. 3). OPQC anticipates this will be the most critical component to decreasing and maintaining the new baseline rate of bloodstream infections.8,9 Human milk
The first collaborative to reduce infection noted that 30% of late-onset infections occurred without any line in place. Thus, other measures to further reduce infection were sought. The use of human milk in preterm infants is associated with a decrease in the risk of infection.10,11 Thus, a bundle to increase the number of infants receiving any human milk and with an emphasis on increasing the intake of each infant’s mother’s own milk (MOM) was created. Although targeted at the smallest and most
779
780
INTERVENTIONS
Insertion Bundle Excellent Hand Hygiene Use of maximal sterile barriers Appropriate use of CHG or PI for site preparation Dedicated team for placement and maintenance All supplies required should be available at the bedside prior to catheter insertion Insertion checklist utilized Staff empowered to stop non-emergent procedure if sterile technique not followed
KEY DRIVERS SMART AIM
Appropriate and safe use of central lines
Excellent hand hygiene
Culture of quality and safety
Protect infant’s skin integrity
Maintain optimal nutritional level
Appropriate and safe use of endotracheal tubes
Catheter Maintenance Bundle Excellent Handy Hygiene No Iodine ointment used Daily Assessment if line is necessary Review dressing integrity and site cleanliness daily Use “closed” systems for infusion, blood draws & medication administration Assemble and connect infusion tubing using aseptic or sterile technique Configure tubing consistently for each type of vascular access device Scrub needleless connect for using friction with either alcohol or CHG for at least 15 sec. prior to entry. Allow surface to dry prior to entry Use pre-filled flush containing syringes wherever feasible Staff empowered to stop procedures if sterile technique not followed Perform investigation and analysis of each CABSI Competent trained personnel to perform specialized maintenance activities Education for all staff caring for catheters Spread maintenance practices to off unit service areas Knowledge & Awareness Coaches Educate all staff Skills labs Proximity & Availability of Supplies Personal Hygiene Daily Scrubbing Hand Washing Indications & Technique “See and speak” re: hand washing Routine Surveillance
“secret” observers Data feedback
Quality Collect and report outcome data-display on unit Benchmark unit results with other units Exchange best practices with other unites Evaluation of root causes and common causes of all BSI ASAP See and speak culture Handling protocols Safe use of tape and other adhesives Appropriate and safe peripheral line use Reduce the number of skin punctures
Fig. 2. Late-onset infection key driver diagram for the OPQC. CABSI, central line associated bloodstream infection; CHG, chlorhexidine gluconate; CSF, cerebrospinal fluid. (Courtesy of Ohio Perinatal Quality Collaborative, Cincinnati, Ohio; with permission.)
Trembath et al
Prior to insertion, assess: is catheter really necessary?
Quality Initiatives
Fig. 3. Maintenance bundle data form for reducing late-onset infections among OPQC NICUs. PICC, peripherally inserted central catheter. (Courtesy of Ohio Perinatal Quality Collaborative, Cincinnati, Ohio; with permission.)
premature infants, this project is now being extended to include more mature infants including the MPT and LPT populations. For the human milk project, OPQC intends to reduce late-onset blood stream infections to less than 10% in Ohio NICUs. Intermediate goals include the commencement of human milk feeds within 72 hours of life and the use of greater than 100 mL/kg/d of human milk feeds by 21 days of life. In this setting the use of maternal breast milk should be maximized, donor milk minimized, and ideally the use of formula eliminated.
781
782
Trembath et al
This project has proved particularly challenging because it requires collaboration between multiple caregivers including obstetric, labor and delivery, postpartum, and NICU staff. The key drivers on this project include education of mother and staff on the benefits of breast-feeding, provision of early pumping (
MD
b
,
KEYWORDS Quality improvement Preterm births Infection reduction Delaying preterm birth Human milk KEY POINTS The goal of quality-improvement methodology is to improve the quality and costeffectiveness of health care. The care provided to moderately preterm, late preterm, and early term births is an area with significant practice variation. Prior quality-improvement initiatives designed to reduce nonindicated early term births and bloodstream infections may serve as models for future initiatives in more mature infants. Respiratory care, feeding management, and discharge planning may serve as future directions for quality improvement in moderate preterm, late preterm, and early term births.
INTRODUCTION
Prematurity is the leading cause of death for newborns in the United States and represents more than $26 billion dollars in health care expenditure costs per year.1 Overall, most premature infants born in the United States each year are classified as either moderately preterm (MPT) or late preterm (LPT) infants, defined as birth at 31 0/7 to 33 6/7 and 34 0/7 to 36 6/7 weeks’ gestation respectively.2 Together this group accounts for more than 70% of the preterm population. Ample opportunity exists to improve care using quality improvement (QI) methodology.
Disclosures: The authors have no financial disclosures. a Division of Neonatology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, RBC Suite 3100, Cleveland, OH 44106-6010, USA; b Division of Maternal Fetal Medicine, The Ohio State University Medical Center, 395 West 12 Avenue, Fifth Floor, Columbus, OH 43210-1267, USA * Corresponding author. E-mail address: [email protected] Clin Perinatol 40 (2013) 777–789 http://dx.doi.org/10.1016/j.clp.2013.07.011 perinatology.theclinics.com 0095-5108/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
778
Trembath et al
The principal tenets of QI to improve and ensure the safety, quality, and costeffectiveness of health care are particularly appropriate for application among preterm infants.3 QI in the neonatal intensive care unit (NICU) has primarily focused on extremely low-gestational-age newborns (ELGANs) because they are at highest risk for death or morbidity. However, they represent a minority of premature infants: w5% of premature infants born in the United States each year.2 Therefore, MPT and LPT infants represent an important focus for QI within the United States because they are subject to a great deal of variation in care practices among individual centers as well as among practitioners. Unnecessary variation in care and lack of evidencebased practices may contribute to the morbidities of prematurity. Over the last decade the number of QI projects involving neonatal and perinatal topics has increased substantially. As a result, the number of national collaboratives focused on the care of neonates has also increased. One of the most recognized collaboratives is the Vermont Oxford Network (VON). An international collaborative of more than 900 NICUs established in 1988, the mission of the VON is to improve the quality, safety, and efficiency of health care delivery to newborns.4 The VON iNICU Quality Improvement Collaboratives for Neonatology works to identity and implement evidence-based practices through the creation of shared goals and measurable achievements. iNICU define 4 key habits necessary for effective QI: change, collaborative learning, evidence-based practice, and systems thinking.5 National and international collaboratives are an important component to improving the care delivered to newborns and provides an established platform for sharing strategies for QI. However, the scope and direction of QI initiatives must be taken in the context of the health care systems in which they will function.6 As a result, the VON platform for QI in NICUs has now been applied to multiple regional perinatal quality collaboratives. State collaboratives such as the Perinatal Quality Collaborative of North Carolina, Tennessee Initiative for Perinatal Quality Care, New York State Perinatal Quality Collaborative, California Perinatal Quality Care Collaborative, and the Ohio Perinatal Quality Collaborative (OPQC) have built particularly active quality initiatives based on the VON platform. This article uses the experience of the OPQC to show how quality collaboratives could be applied to decreasing unnecessary variation in the care provided to MPT, LPT, and early term (ET) infants. OPQC
OPQC is a network of Ohio institutions, hospitals, and individuals dedicated to improving perinatal health in the state. The collaborative includes 24 neonatal teams and 19 obstetric teams that represent the 6 perinatal regions of Ohio. The OPQC mission is “Through collaborative use of improvement science methods, to reduce preterm births and improve outcomes of preterm newborns in Ohio as soon as possible.” OPQC uses an adapted methodology from the Institute for Healthcare Improvement’s (IHI) Breakthrough Series Model (Fig. 1). OPQC’s primary goal is to target improvements in outcome through defined shared goals based on established scientific evidence, which includes using rapid-cycle QI techniques such as Plan-Do-Study-Act. OPQC brings together a multidisciplinary team of individuals through face-to-face sessions and webinar-based action period calls to review individual site and collaborative data, share successful QI initiatives and strategies, and plan future OPQC projects. Thus far 6 project titles have been designed: reducing late onset infections, human milk, antenatal corticosteroid (ANC), 39 weeks charter and 39 weeks/birth registry accuracy project. Three of the projects have targeted reducing preterm birth, and the other two are designed to reduce the morbidity and mortalities of preterm birth.
Quality Initiatives
Fig. 1. IHI model for improvement (Plan-Do-Study-Act cycle). (Adapted from Langley GL, Nolan KM, Nolan TW, et al. The improvement guide: a practical approach to enhancing organizational performance. 2nd edition. San Francisco (CA): Jossey-Bass Publishers; 2009; with permission.)
OPQC Neonatal Initiatives Reducing late-onset infections
Prematurity is a well-established risk factor for infection, particularly in the hospital setting. Nosocomial infections occur in 15% to 30% of extremely preterm infants and cause increased morbidity, mortality, and hospital costs. As a result, OPQC identified infection as a key target for a neonatal quality initiative. Bloodstream infection in NICUs is a multifactorial problem with several important factors playing a role in reducing infection, including appropriate use of centrally inserted catheters, hand hygiene, a culture of providing quality care, and maintaining skin integrity (Fig. 2). By focusing on improving the process of inserting and maintaining central lines, several of these modifying factors could be enhanced. For the insertion bundle, key measures include a focus on hand hygiene, sterile technique, and identifying problems with maintaining sterile fields during insertion. For the maintenance bundle, the primary elements identified are related to sterility during tubing changes and catheter hub care and assessing the need for the line daily. As a result of the OPQC infection project, a 20% sustained decrease in bloodstream infections in premature infants was seen among the 24 NICUs.7 Throughout the project it has become apparent that there are significant differences in the relative importance of each of the bundles. Among NICUs the key component to sustaining a decrease in bloodstream infections is the continued use of the maintenance bundle. As a new focus, OPQC members are working to achieve greater than 90% compliance with the catheter maintenance bundle (Fig. 3). OPQC anticipates this will be the most critical component to decreasing and maintaining the new baseline rate of bloodstream infections.8,9 Human milk
The first collaborative to reduce infection noted that 30% of late-onset infections occurred without any line in place. Thus, other measures to further reduce infection were sought. The use of human milk in preterm infants is associated with a decrease in the risk of infection.10,11 Thus, a bundle to increase the number of infants receiving any human milk and with an emphasis on increasing the intake of each infant’s mother’s own milk (MOM) was created. Although targeted at the smallest and most
779
780
INTERVENTIONS
Insertion Bundle Excellent Hand Hygiene Use of maximal sterile barriers Appropriate use of CHG or PI for site preparation Dedicated team for placement and maintenance All supplies required should be available at the bedside prior to catheter insertion Insertion checklist utilized Staff empowered to stop non-emergent procedure if sterile technique not followed
KEY DRIVERS SMART AIM
Appropriate and safe use of central lines
Excellent hand hygiene
Culture of quality and safety
Protect infant’s skin integrity
Maintain optimal nutritional level
Appropriate and safe use of endotracheal tubes
Catheter Maintenance Bundle Excellent Handy Hygiene No Iodine ointment used Daily Assessment if line is necessary Review dressing integrity and site cleanliness daily Use “closed” systems for infusion, blood draws & medication administration Assemble and connect infusion tubing using aseptic or sterile technique Configure tubing consistently for each type of vascular access device Scrub needleless connect for using friction with either alcohol or CHG for at least 15 sec. prior to entry. Allow surface to dry prior to entry Use pre-filled flush containing syringes wherever feasible Staff empowered to stop procedures if sterile technique not followed Perform investigation and analysis of each CABSI Competent trained personnel to perform specialized maintenance activities Education for all staff caring for catheters Spread maintenance practices to off unit service areas Knowledge & Awareness Coaches Educate all staff Skills labs Proximity & Availability of Supplies Personal Hygiene Daily Scrubbing Hand Washing Indications & Technique “See and speak” re: hand washing Routine Surveillance
“secret” observers Data feedback
Quality Collect and report outcome data-display on unit Benchmark unit results with other units Exchange best practices with other unites Evaluation of root causes and common causes of all BSI ASAP See and speak culture Handling protocols Safe use of tape and other adhesives Appropriate and safe peripheral line use Reduce the number of skin punctures
Fig. 2. Late-onset infection key driver diagram for the OPQC. CABSI, central line associated bloodstream infection; CHG, chlorhexidine gluconate; CSF, cerebrospinal fluid. (Courtesy of Ohio Perinatal Quality Collaborative, Cincinnati, Ohio; with permission.)
Trembath et al
Prior to insertion, assess: is catheter really necessary?
Quality Initiatives
Fig. 3. Maintenance bundle data form for reducing late-onset infections among OPQC NICUs. PICC, peripherally inserted central catheter. (Courtesy of Ohio Perinatal Quality Collaborative, Cincinnati, Ohio; with permission.)
premature infants, this project is now being extended to include more mature infants including the MPT and LPT populations. For the human milk project, OPQC intends to reduce late-onset blood stream infections to less than 10% in Ohio NICUs. Intermediate goals include the commencement of human milk feeds within 72 hours of life and the use of greater than 100 mL/kg/d of human milk feeds by 21 days of life. In this setting the use of maternal breast milk should be maximized, donor milk minimized, and ideally the use of formula eliminated.
781
782
Trembath et al
This project has proved particularly challenging because it requires collaboration between multiple caregivers including obstetric, labor and delivery, postpartum, and NICU staff. The key drivers on this project include education of mother and staff on the benefits of breast-feeding, provision of early pumping (
