Quality Improvement Initiatives in Neonatology

The Newborn Medicine Program at UPMC Children’s Hospital of Pittsburgh is renowned for its state-of-the-art care of critically ill newborns, and its decades of ground-breaking clinical advancements and research.

Striving to continually improve the quality of care and outcomes for these most complex and medically fragile cases is on display in the ongoing quality improvement (QI) initiatives of the Newborn Medicine Program and their collaborators within UPMC Children’s.

Leading and collaborating in many of these QI programs is Beverly Brozanski, MD, IHI Improvement Advisor, professor of Pediatrics, and medical director of the Neonatal Intensive Care Unit at UPMC Children’s. In addition to her roles at UPMC Children’s, Dr. Brozanski sits on the executive committee of the Children’s Hospital Neonatal Consortium (CHNC), a 34-member group of level IV NICU Children’s Hospitals devoted to improving care for high risk infants (www.thechnc.org). 

Dr. Brozanski is a co-leader of the CHNC’s Continuous Improvement Quality Initiatives (CIQI) committee that spearheads national quality improvement collaborative efforts within the consortium’s network. The first multi-center project implemented by this group resulted in a 19 percent decrease in central line-associated blood stream infections (CLABSI) across the collaborative, an improvement which was sustained over the subsequent 18 months. 

Improving Postoperative Hypothermia and Perioperative Care Failures

Recent initiatives implemented at UPMC Children’s in concert with the CHNC aimed to improve perioperative hand-off communication and rates of postoperative hypothermia. These efforts have led to sustained low rates of postoperative hypothermia and a decrease in communication care failures at UPMC Children’s, as well as across the collaborative.

Increasing Breast Milk Feeding Rates and Reducing the Incidence of Wrong Breast Milk

At UPMC Children’s, concerted efforts and initiatives beginning in November 2013 to increase the percentages of new mothers breastfeeding their infants met with great success, increasing the rate of babies discharged on the mother’s breast milk by 45 percent to nearly 82 percent by February 2015 and sustained through spring 2018.

The success of the “Breastmilk = Medicine” project is in its multidisciplinary approach. Transport teams initially deliver the “Breastmilk = Medicine” message to recuperating postpartum mothers at the birth hospital. 

Soon after admission to the NICU in Pittsburgh, a neonatologist or advance practice provider contacts the new mother at the birth hospital to update her on her baby’s condition and review the benefits of breast milk. UPMC Children’s staff nurses assist mothers to continue pumping, when they arrive, with a pump in each patient room, and provide meal tickets to assure adequate maternal hydration and nutrition. Two International Board Certified Lactation Consultants (IBCLCs) with NICU nursing experience and 15 CBC counselors (CBC) offer consistent support and encouragement while also trouble shooting with latching and pumping concerns.

Leveraging Technology to Eliminate Breast Milk Errors

With the increase in numbers of mothers providing breast milk, there was an increased potential for the administration of incorrect breast milk. The existing system for labeling, identification, and administration of breast milk was targeted for a quality improvement initiative to eliminate the potential for the administration of the wrong breast milk to infants during their stay and at the time of discharge.

According to Dr. Brozanski, under the leadership of NICU Unit Directors, Diane Ankney, MSN, RN, NEA-BC, and Carrie Rubino MSN, RN, CCRN, the solution implemented was a protocol similar to positive patient identification used when administering medications and the labeling of lab samples. Orders are placed in the EMR indicating breastfeeding for the mother and her baby. Barcoded labels are generated for milk bottles and tied to each patient through the EHR. Labeled bottles are scanned prior to giving them to the family. They are rescanned to verify the codes match when the mother gives milk to the staff for storage. During feedings, the milk is brought to the bedside and scanned prior to feeding to ensure a match with the patient. Bottles going home at the time of discharge also are scanned prior to distribution to ensure they are going to the correct family.

Decreasing Length of Stay in Cases of Gastroschisis

In 2013, UPMC Children’s began an initiative to reduce the length of stay for these patients. “We benchmarked our length of stay (LOS) for our patients with gastroschisis against the mean LOS seen in the CHNC partners, and we realized that we had room for improvement at our own institution,” says Dr. Brozanski.

A multidisciplinary group included neonatology, neonatal APPs, pediatric surgery, maternal fetal medicine, nursing and respiratory therapy reviewed best practices, developed and implemented consensus management to decrease the LOS by nearly 50 percent, from 58 days to 31 days. “We’ve been able to sustain these improvements year after year with fewer ventilator days and less exposure to pain medications,” says Dr. Brozanski.

Ongoing Postoperative Pain Reduction QI Initiative

Currently in progress at UPMC Children’s is the development of a postoperative pain reduction protocol for NICU patients. This project is designed to identify the type of postoperative pain control and medication necessary for babies before the surgery. “Our goal is to decrease consecutive high pain scores, eliminate excessive sedation, use non-pharmacologic pain therapy whoever possible, and involve families in identification of postoperative pain,” says Dr. Brozanski.

This initiative is ongoing and quality metrics are underway for analysis of program efficacy. The Newborn Medicine Program is proud to be a division that targets Quality Improvement to provide evidenced-based care to the most fragile patient population.

References

1 Piazza A, Brozanski B, Provost L, Grover T, Chuo J, Smith J, Mingrone T, Moran S, Morelli L, Zaniletti I, Pallotto EK. SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction. Pediatrics. 2016; 137(1): 1-12. 23. Epub 2015 Dec 23. PMID: 26702032.

2 Pallotto E, Piazza P, Smith J, Grover T, Chuo J, Provost L, Mingorne T, Holston M, Moran S, Morelli L, Zaniletti I, Brozanski B. Sustaining SLUG Bug CLABSI Reduction: Does Sterile Tubing Change Technique Really Work? Pediatrics. 2017 Oct;140(4). pii: e20163178. doi: 10.1542/ peds.2016-3178. PMID: 28951441.