Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants

Abstract

OBJECTIVE: To reduce the incidence of necrotizing enterocolitis (NEC) among very low birth weight (VLBW) infants admitted to 8 intensive care nurseries from a 2010 baseline of 8.0% to <4.0% by 2012 and sustain for 6 months using quality improvement (QI) methodology. METHODS: A multidisciplinary NEC QI team used the Vermont Oxford Network definition of NEC and the Institute for Healthcare Improvement model. The specific aims were evidenced based and included (1) standardized early human milk feedings, (2) conservative feeding guidelines during blood transfusions and indomethacin treatment, and (3) restriction of ranitidine use in VLBW infants. Inclusion criteria included VLBW infants admitted within the study period without NEC. Exclusion criteria included established NEC or spontaneous intestinal perforation unrelated to NEC. The incidence of NEC and NEC-related surgery were tracked using statistical process control methodology. RESULTS: The baseline NEC rate in 2010 was 8% (27 NEC cases in 335 VLBW infants). After initiation of early human-milk feeding and conservative feeds during blood transfusions guidelines in November 2011, only 3.1% (19 of 606 VLBW infants) had developed NEC through December 2013 (P = .001). Special cause variation was noted in June 2012 establishing a new centerline at 3.1%. NEC-related mortality decreased from a 2010 baseline mean of 2.7% to a new baseline mean of 0.9% from January 2011 to December 2013. CONCLUSIONS: Implementation of QI initiatives decreased the NEC rate from 8.0% to <4.0%. Early human milk feedings and conservative feeding during blood transfusion policies appear to have significant impact on NEC reduction.

Newborn infants’ hair cortisol levels reflect chronic maternal stress during pregnancy

“…Since stress during pregnancy has negative consequences for the fetus and newborn infant, the main challenge is to ensure early identification and prevention of high stress levels [ 52 – 54 ]. Although there is evidence that postnatal care can help neonates at risk [ 55 , 56 ], prenatal assessment of stress levels and maintenance of optimal levels remain important. Collecting data on cortisol levels and psychological well-being may help early detection of problems that could affect the intrauterine relationship between mother and fetus, which is fundamental for the future health of both.…”

Transient effects of transfusion and feeding advances (volumetric and caloric) on necrotizing enterocolitis development: A case-crossover study

“…Services are distributed among 5 level III NICU and 3 level II special care units. All neonatal units at NCH employed standardized feeding protocols that emphasized early feedings and the use of human breast milk [12]. Infants <28 weeks’ gestation were given trophic feeds of 10 mL/kg/day every 6 hours for the first 3 days.…”

Necrotising Enterocolitis - epidemiology and imaging

“…14 The risk of NEC may also be increased by direct effects of H2-blockers on the immune system and decreased intestinal motility. 161,188 Prevention Quality improvement projects including scheduled feeding and the use of human milk, 189,190 conservative feeding guidelines during blood transfusions, and indomethacin treatment, and restrictive use of H2-blockers 190 seem to be able to reduce the incidence of NEC in institutions. As each program included a combination of preventive measures, it is, however, difficult to discern which ones had effect.…”