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Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods.

Patel AL, Trivedi S, Bhandari NP, Ruf A, Scala CM, Witowitch G, Chen Y, Renschen C, Meier PP, Silvestri JM - J Perinatol (2014)

Bottom Line: The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU.

View Article: PubMed Central - PubMed

Affiliation: Section of Neonatology, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT

Objective: Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.

Study design: In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).

Result: The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.

Conclusion: QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.

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Related in: MedlinePlus

The incidence of NEC stage 2 or 3 and surgical NEC in VLBW infants from January 2005 - December 2011. The solid black line represents the observed percentage of VLBW infants that developed NEC stage 2 or 3. The dashed black line represents the observed percentage of VLBW infants that developed surgical NEC. NEC, necrotizing enterocolitis; VLBW, very low birth weight
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Figure 3: The incidence of NEC stage 2 or 3 and surgical NEC in VLBW infants from January 2005 - December 2011. The solid black line represents the observed percentage of VLBW infants that developed NEC stage 2 or 3. The dashed black line represents the observed percentage of VLBW infants that developed surgical NEC. NEC, necrotizing enterocolitis; VLBW, very low birth weight

Mentions: Through use of quality improvement methodologies, including PDSA cycles, we successfully targeted a NEC epidemic in our NICU.(Figure 3) Whereas, our findings may not serve as the solution to NEC-related outbreaks in other institutions, the QI process by which we addressed this problem is generalizable to other centers when they evaluate their own practices that may potentially be related to NEC in their institutions. For example, previous findings have demonstrated the effectiveness of standardized feeding regimens in reducing NEC rates,49,65 and we anticipated that our QI phase 1 standardized feeding protocol would reduce the incidence of NEC in our NICU. However, when our NEC incidence did not decline between Baseline and QI phase 1, we searched for additional risk factors. We found that the new NG feeding tube system had been initiated approximately one month prior to the introduction of the standardized feeding protocol in QI phase 1, and likely confounded the impact of the standardized feeding protocol. This highlights the unintended consequences that can result from a seemingly unrelated decision that was felt to be cost effective and would decrease handling of infants, and the importance of multidisciplinary communication. Attention to the potential impact of the new NG tube change procedure on NEC rates occurred as a result of multiple unrelated situations: attendance at a PAS 2010 seminar, neonatologists’ bedside observations of residual fluid in NG extension tubing, and review of relevant literature. We quickly implemented quality initiatives which included more frequent NG tube changes and expanded parental education about hygienic handling and cleaning of breast pumps. By the end of QI phase 2, these combined changes resulted in a reduction in NEC rates. These processes illustrate the importance of multidisciplinary collaboration in QI processes in the NICU.


Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods.

Patel AL, Trivedi S, Bhandari NP, Ruf A, Scala CM, Witowitch G, Chen Y, Renschen C, Meier PP, Silvestri JM - J Perinatol (2014)

The incidence of NEC stage 2 or 3 and surgical NEC in VLBW infants from January 2005 - December 2011. The solid black line represents the observed percentage of VLBW infants that developed NEC stage 2 or 3. The dashed black line represents the observed percentage of VLBW infants that developed surgical NEC. NEC, necrotizing enterocolitis; VLBW, very low birth weight
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4216600&req=5

Figure 3: The incidence of NEC stage 2 or 3 and surgical NEC in VLBW infants from January 2005 - December 2011. The solid black line represents the observed percentage of VLBW infants that developed NEC stage 2 or 3. The dashed black line represents the observed percentage of VLBW infants that developed surgical NEC. NEC, necrotizing enterocolitis; VLBW, very low birth weight
Mentions: Through use of quality improvement methodologies, including PDSA cycles, we successfully targeted a NEC epidemic in our NICU.(Figure 3) Whereas, our findings may not serve as the solution to NEC-related outbreaks in other institutions, the QI process by which we addressed this problem is generalizable to other centers when they evaluate their own practices that may potentially be related to NEC in their institutions. For example, previous findings have demonstrated the effectiveness of standardized feeding regimens in reducing NEC rates,49,65 and we anticipated that our QI phase 1 standardized feeding protocol would reduce the incidence of NEC in our NICU. However, when our NEC incidence did not decline between Baseline and QI phase 1, we searched for additional risk factors. We found that the new NG feeding tube system had been initiated approximately one month prior to the introduction of the standardized feeding protocol in QI phase 1, and likely confounded the impact of the standardized feeding protocol. This highlights the unintended consequences that can result from a seemingly unrelated decision that was felt to be cost effective and would decrease handling of infants, and the importance of multidisciplinary communication. Attention to the potential impact of the new NG tube change procedure on NEC rates occurred as a result of multiple unrelated situations: attendance at a PAS 2010 seminar, neonatologists’ bedside observations of residual fluid in NG extension tubing, and review of relevant literature. We quickly implemented quality initiatives which included more frequent NG tube changes and expanded parental education about hygienic handling and cleaning of breast pumps. By the end of QI phase 2, these combined changes resulted in a reduction in NEC rates. These processes illustrate the importance of multidisciplinary collaboration in QI processes in the NICU.

Bottom Line: The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU.

View Article: PubMed Central - PubMed

Affiliation: Section of Neonatology, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT

Objective: Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.

Study design: In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).

Result: The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.

Conclusion: QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.

Show MeSH
Related in: MedlinePlus