A Multifaceted Approach to Improving Outcomes in the NICU: The Pediatrix 100 000 Babies Campaign

Abstract

BACKGROUND AND OBJECTIVE: Despite advances in neonatal medicine, infants requiring neonatal intensive care continue to experience substantial morbidity and mortality. The purpose of this initiative was to generate large-scale simultaneous improvements in multiple domains of care in a large neonatal network through a program called the “100,000 Babies Campaign.” METHODS: Key drivers of neonatal morbidity and mortality were identified. A system for retrospective morbidity and mortality review was used to identify problem areas for project prioritization. NICU system analysis and staff surveys were used to facilitate reengineering of NICU systems in 5 key driver areas. Electronic health record–based automated data collection and reporting were used. A quality improvement infrastructure using the Kotter organizational change model was developed to support the program. RESULTS: From 2007 to 2013, data on 422 877 infants, including a subset with birth weight of 501 to 1500 g (n = 58 555) were analyzed. Key driver processes (human milk feeding, medication use, ventilator days, admission temperature) all improved (P < .0001). Mortality, necrotizing enterocolitis, retinopathy of prematurity, bacteremia after 3 days of life, and catheter-associated infection decreased. Survival without significant morbidity (necrotizing enterocolitis, severe intraventricular hemorrhage, severe retinopathy of prematurity, oxygen use at 36 weeks’ gestation) improved. CONCLUSIONS: Implementation of a multifaceted quality improvement program that incorporated organizational change theory and automated electronic health record–based data collection and reporting program resulted in major simultaneous improvements in key neonatal processes and outcomes.

Surgical necrotizing enterocolitis

“…In this review, the overall incidence of NEC decreased from 6.6% in 2007 to 3.9% in 2013 ( p < 0.0001), with a decrease in both medical (4.4–2.8%, p < 0.0001) and surgical (2.2–1.2%, p < 0.0001) NEC. 23 This suggests that although the incidence of NEC decreased, the proportion of neonates with NEC requiring surgical intervention remained stable over time (approximately 30%).…”

“…They performed a retrospective cohort study and noted a decrease in incidence of NEC from 12% in both 1986–1987 and 1992–1993 to 6% in 1998–1999. 22 Similarly, a more recent (2016) study 23 of approximately 60,000 VLBW neonates during a 7-year time period noted a decrease in the incidence of NEC after instituting the “100,00 Babies Campaign,” a quality improvement program that incorporated education and restructuring of Neonatal Intensive Care Unit (NICU) care on a large scale within the Pediatrix Neonatal Network. In this review, the overall incidence of NEC decreased from 6.6% in 2007 to 3.9% in 2013 ( p < 0.0001), with a decrease in both medical (4.4–2.8%, p < 0.0001) and surgical (2.2–1.2%, p < 0.0001) NEC.…”

The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project

“…1, 2, 3, 4 We have provided a transparent, concise yet broad, EBM guideline that contains most potential therapies thought to reduce the burden of the nine major VLBW infant morbidities. A succinct four category PBP classification schema (Table 2 and updated in Supplementary Table S1) and detailed compliance checks (Table 3 and updated in Supplementary Table S2) has, to our knowledge, never been published.…”

“…Nevertheless, there are multiple sensible strategies to reduce some major morbidities, PBPs of little risk to the NICU provider, for example, hand washing, breast milk, fewer ventilator days and limiting unnecessary medications. 1, 2, 3, 4 …”

“…The reduction of certain neonatal intensive care unit (NICU) morbidities driven by evidence-based principles of CQI is encouraging. 1, 2 The Vermont Oxford Network (VON) has championed multidisciplinary collaboration and potentially better practice (PBP) sharing within its membership achieving significant reductions over the past 25 years in any late infection and retinopathy of prematurity in very low-birth-weight (VLBW) infants. 1 VON CQI tools are particularly enticing for NICUs with comparatively high morbidity rates, because adopting fundamental CQI techniques reliably reduces unfavorable rates to at least average percentiles.…”