BACKGROUND AND OBJECTIVE: Despite advances in neonatal medicine, breed acute neonatal accelerated affliction abide to acquaintance abundant anguish and mortality. The purpose of this action was to accomplish all-embracing accompanying improvements in assorted domains of affliction in a ample neonatal arrangement through a affairs alleged the “100,000 Babies Campaign.”
METHODS: Key drivers of neonatal anguish and bloodshed were identified. A arrangement for attendant anguish and bloodshed assay was acclimated to analyze botheration areas for activity prioritization. NICU arrangement assay and agents surveys were acclimated to facilitate reengineering of NICU systems in 5 key disciplinarian areas. Cyberbanking bloom record–based automatic abstracts accumulating and advertisement were used. A affection advance basement appliance the Kotter authoritative change archetypal was developed to abutment the program.
RESULTS: From 2007 to 2013, abstracts on 422 877 infants, including a subset with bearing weight of 501 to 1500 g (n = 58 555) were analyzed. Key disciplinarian processes (human milk feeding, medication use, chase days, acceptance temperature) all bigger (P < .0001). Mortality, necrotizing enterocolitis, retinopathy of prematurity, bacteremia afterwards 3 canicule of life, and catheter-associated infection decreased. Survival afterwards cogent anguish (necrotizing enterocolitis, astringent intraventricular hemorrhage, astringent retinopathy of prematurity, oxygen use at 36 weeks’ gestation) improved.
CONCLUSIONS: Accomplishing of a able affection advance affairs that congenital authoritative change access and automatic cyberbanking bloom record–based abstracts accumulating and advertisement affairs resulted in above accompanying improvements in key neonatal processes and outcomes.
Despite advances in neonatal medicine, breed acute neonatal accelerated affliction abide to acquire abundant anguish and mortality.1,2 Unexplained variations in aftereffect amid alone NICUs abide a bind for neonatal networks gluttonous to analogously advance outcomes.3 Single-center and collaborative affection advance (QI) initiatives accept accustomed to abatement aberration and advance outcomes, but after-effects accept been mixed.4–6
QI collaboratives frequently focus on a distinct analytic problem, rather than the best accepted accumulation of problems that drive poor bloom outcomes.5,7,8 Such collaboratives generally crave big-ticket abstracts accumulating and advertisement systems that may not be readily available. These limitations actualize cogent barriers to all-embracing advance in neonatal affliction and outcomes.
The cold of this action was to pragmatically reengineer the charge of neonatal accelerated affliction in a ample neonatal arrangement with the ambition of accompanying multidimensional improvements in action and outcome. We accepted that a structured access to arrangement appraisal and reengineering of neonatal accelerated affliction in assorted key action areas would crop abiding advance in neonatal anguish and mortality.
Pediatrix Medical Accumulation (PDX) is a civic accumulation of clinicians that provides neonatal accelerated affliction casework for ∼20% of the newborns in the United States who crave accelerated care. These clinicians convenance in a assorted accumulation of settings, from baby association hospitals to ample children’s hospitals, and abide in 34 states added Puerto Rico.
This assay is a anecdotic assay of abstracts from breed in the PDX network, composed of 330 NICUs that augment abstracts into the PDX Analytic Abstracts Barn (CDW). PDX clinicians acclimated a proprietary software arrangement (BabySteps; MEDNAX, Inc, Sunrise, FL). Infant abstracts are added and adapted by providers in BabySteps during their circadian assessments. These abstracts are acclimated to accomplish the medical affidavit (eg, admission, progress, and acquittal notes), announcement worksheets, and the CDW abstracts set. To aerate validity, abstracts for the CDW are extracted at the end of the infant’s NICU stay, so providers accept assorted opportunities to assay and verify the documentation. These abstracts are deidentified, stored in a circumscribed civic abstracts set, and are adjustable with the Bloom Insurance Portability and Accountability Act of 1996 regulations.9 The Western Institutional Assay Board accustomed the use of this deidentified abstracts barn for this study.
From 2007 to 2009, the authors authentic key disciplinarian processes based on abstract assay and use of nominal accumulation address methods.10 Emphasis was placed on anecdotic analytic processes that were adjustable and had abundant appulse on the primary drivers of poor bloom outcomes8,11–20 (Fig 1).
Driver diagram of the 100 000 Babies Attack anecdotic the aims, outcomes, key drivers, and action changes targeted in the program. CPAP, connected absolute airway pressure; IV, intravenous.
John Kotter’s 8-step archetypal for arch authoritative change was acclimated for the architecture and accomplishing of our attack (Fig 2).21,22 The appellation “100 000 Babies Campaign” was acclimated because of its affinity to the Institute for Healthcare Improvement’s “100 000 Lives Campaign,” which auspiciously targeted key botheration areas in affliction with the ambition of extenuative 100 000 lives.23,24 We accustomed to reengineer the affliction of 100 000 breed with the achievement that the accompanying targeting of key disciplinarian processes would construe into bigger outcomes.
Adaption of the Kotter authoritative change archetypal to the anatomy of the 100 000 Babies Campaign.
Various aspects of the 100 000 Babies Attack were alien artlessly from 2007 to 2009, with academic barrage of the affairs in 2009. The affairs congenital on our antecedent QI successes in convalescent advance and abbreviation retinopathy of prematurity (ROP).25,26 Accord was not mandated, but was acerb encouraged. A key affair of the action was a adjustable and adjustable access to convalescent affliction aural the ambience of the alone NICU’s microsystem. A array of approaches to problems were provided, with the apprehension that anniversary NICU would acclimate the interventions to their specific environment. Reliance on automatic axial abstracts accumulating via the cyberbanking bloom almanac (EHR) rather than all-encompassing bounded abstracts accumulating was emphasized to aish barriers to accord in the affairs and to ensure the best reliable and reproducible aftereffect information.
NICUs were asked to assay their outcomes for several years to appraise their achievement in the disciplinarian areas and in analytic outcomes. The CDW was acclimated for NICU self-assessment and for allegory with PDX arrangement benchmarks.
NICUs were provided with a arrangement assay worksheet to adviser assay of their system’s adeptness to abutment the targeted activity goals.
NICUs were provided with a assay to appraise the attitudes, adeptness base, and biases of their analytic staff. Allegory of responses from physicians, assistant practitioners, and NICU nurses was emphasized to ascertain aberration in adeptness gaps and attitudes aural a NICU. These adeptness gaps and variations were acclimated to acquaint their specific educational needs and activity strategies.
After assay of surveys, outcomes, and arrangement analysis, the NICU aggregation acclimated a activity prioritization cast to actuate specific ambition areas for advancing advance efforts. Multidisciplinary activity teams were again designated, with alternative for assorted baby teams rather than 1 ample aggregation that did all projects.
A activity administration apparatus (QualityStepsTM MEDNAX, Sunrise, FL) was acclimated to facilitate tracking of anniversary project, to advice alike the QI aggregation efforts, and to accredit affidavit that acquiesce participants to access American Board of Pediatrics Part 4 Aliment of Certification (MOC) credit. It independent activity advance notes, educational materials, and templates.
To facilitate a adeptness of advance and to accommodate associate support, PDX provided “Quality Summit” conferences 3 times per year. The class covered activity selection, Pareto charts, basis account analysis, multidisciplinary aggregation building, change concepts, plan-do-study-act cycles, basal abstracts analysis, and use of run charts. Workshops included baby accumulation contest that provided befalling to administer QI methods to specific analytic problems and emphasized aggregate botheration analytic with clinicians from assorted backgrounds.27,28 QI activity presentations were a above affection of the program, and were acclimated to appearance assorted approaches to analytic problems and to actualize a ambience that accent the assignment of high-performing NICUs. To aish barriers to accord and to accent the organization’s charge to convalescent accommodating care, allotment for biking and affair costs was provided by PDX with the apprehension that participants would booty the acquired abilities aback to their practices and administer them aural their own NICU’s QI infrastructure.
The CDW was acclimated as the primary apparatus for activity abstracts advertisement at the bounded level. Abstracts from the BabySteps EHR arrangement were automatically extracted and adapted into a real-time analytic affection letters of assorted processes and outcomes. Abstracts letters included arrangement akin comparisons to NICUs of agnate volume. These letters did not crave any specific abstracts accumulating or extraction.
Estimated gestational age (EGA) was authentic as the best appraisal of the neonatologist of EGA, based on obstetric history, prenatal ultrasound, and postnatal concrete examinations.
For anniversary medication appear in all tables, we authentic acknowledgment to that specific medication as any address at any time during the NICU stay. Aboriginal ampicillin was authentic as acknowledgment to ampicillin on the day of bearing (day 0) or day 1 or 2 afterwards birth. Ampicillin continuance of >3 canicule with abrogating cultures was the admeasurement of breed in whom the claret adeptness was abrogating who were advised with ampicillin for >3 days’ duration.
Daily abstracts on diet were captured by appliance a comestible abutment aces list. Any address of animal milk (donor or maternal) during the hospital break was advised acknowledgment to animal milk. Animal milk at acquittal was any address of animal milk in the day of acquittal feedings.
The affliction provider is appropriate to address the amount of oxygen abutment and the blazon of abutment anniversary day. We counted the absolute cardinal of canicule anniversary accommodating was on a chase and afflicted the average canicule of ventilatory abutment for anniversary year. Hypothermia was authentic as a NICU acceptance temperature of >36°C.
In breed who had arch imaging reported, we afflicted the admeasurement of breed who had a brand 3 or 4 intraventricular drain (IVH). The accomplished amount of severity was based on the following: brand 3, ventricles are connected by the accumulated blood; and brand 4, bleeding extends into the academician tissue about the ventricles. In breed with a address of an eye examination, we afflicted the admeasurement with astringent (stage 3, 4, or 5) ROP. The accomplished amount of severity was acclimated based on the following: date 3, acutely aberrant claret barge growth; date 4, partially alone retina; date 5 absolutely alone retina.
The advice analogue for necrotizing enterocolitis (NEC) is that breed with NEC should accept ≥1 of the afterward analytic signs: ailing belly aspirate or emesis, belly distention, or claret in stool afterwards affirmation of a abdominal fissure; and had ≥1 of the afterward radiographic findings: pneumatosis intestinalis, hepatobiliary gas, or pneumoperitoneum. NEC-medical is assay with antibiotics, bowel rest, and admiring affliction and NEC-surgical is back anaplasty is additionally required. Abiding lung ache (CLD) was authentic as actuality on added than allowance air at 36 weeks postmenstrual age (PMA). The ante of NEC and CLD were based on the denominator of all breed (survived to acquittal or died). We authentic late-onset sepsis as any absolute claret adeptness appear afterwards 3 canicule of age. Breed were advised to accept survived with no anguish if they were absolved from the hospital with no address of astringent IVH (grade 3 or 4), astringent ROP (stages 3, 4, or 5), NEC (medical or surgical), or CLD. Weight accretion (g/day) over the hospital break was afflicted (discharge bare bearing weight disconnected by the age at acquittal for survivors).
Infants were categorized by year of acquittal for the anecdotic tables. The P ethics appear in the tables are based on trend analyses over the absolute time aeon and are not simple comparisons of 2007 with 2013. For detached absolute variables, we acclimated Cochran-Armitage trend tests to actuate if there were cogent changes over time. Connected variables (EGA, bearing weight, affectionate age, chase days, age at discharge) were evaluated by appliance a 1-way assay of about-face (ANOVA) and beeline corruption to actuate if there were cogent changes over time. If the P amount was <.01, we compared anniversary year to 2007 (control) by appliance Dunnett’s adjustment in JMP. Nonparametric abstracts were adjourned with Kruskal-Wallis ANOVA. Statistical analyses were performed by appliance JMP 11 (SAS Institute, Cary, NC).
For catheter-associated bloodstream infection calculations, an algorithm that is agnate to the 2012 Centers for Ache Ascendancy and Blockage analogue for axial line–associated bloodstream infection (CLABSI) was developed and activated to the absolute abstracts set for constant description of CLABSI over the abstraction period. This algorithm did not accommodate provider-driven estimation of the algorithm, but was based on cold abstracts components, such as adeptness results, timing, and attendance of a axial band about to time of absolute cultures. This archetypal acceptable overestimates the CLABSI amount to a baby degree, as added primary causes of infection may not accept been articular and could be misattributed as a CLABSI.29
A statistical action ascendancy blueprint assay was done by appliance accepted rules to ascertain appropriate account variation. The beggarly (center line) and high and lower ascendancy banned were afflicted and displayed as ±3 SD of the beggarly by appliance QI Macros for Excel (KnowWare International, Inc, Denver, CO).30,31
Between January 1, 2007, and December 31, 2013, we provided affliction to 574 158 breed accepted for neonatal accelerated care; 490 539 (85%) were congenital and 422 877 (74%) were cared for at a distinct hospital. Tables 1 and 2 address on the subset of this citizenry that had bearing weights amid 501 and 1500 g (n = 58 555, 14%). A abstracts table on the absolute citizenry is in the Supplemental Information.
Results for Action Measures for Breed With Bearing Weight of 501–1500 g
Results for Aftereffect Measures for Breed With Bearing Weight of 501–1500 g
There was no change over time in average gestational age (29 weeks), bearing weight (1.1 kg), admeasurement of macho breed (50%), charge by cesarean (76%), or assorted gestations (28%). There was a slight access in average affectionate age from 27 to 28 years old (P < .001). Antenatal corticosteroid use decidedly added over time from a 2007 baseline of 78.8% to 85.0% in 2013 (P < .001).
Exposure to animal milk and use of animal milk use at acquittal added (Table 1). Acknowledgment to medications that were targeted for abridgement (dexamethasone, H2 blockers, metoclopramide, and cefotaxime) was decreased. The absolute admeasurement of breed advised with aboriginal empiric ampicillin and the admeasurement of breed with abrogating cultures who were advised for >3 canicule decreased. The admeasurement of breed advised with automatic blast decreased as did the average canicule of chase support. Hypothermia at acceptance to the NICU decreased.
Mortality, NEC, astringent and surgical ROP, and bacteremia afterwards 3 canicule of activity decreased (Table 2). Use of added than allowance air abutment at 36 weeks’ PMA decreased slightly. Astringent IVH showed a nonsignificant decrease. Survival afterwards cogent anguish (NEC, astringent IVH, astringent ROP, oxygen use at 36 weeks) improved. The weight at time of acquittal and advance acceleration bearing to acquittal was hardly increased. Age at acquittal of survivors was increased.
Human milk use increased, and use of targeted medications decreased (Supplemental Table 4). Aboriginal use of ampicillin decreased. Assay with ampicillin for added than 3 canicule in breed with abrogating claret cultures decreased. Beneath breed were advised with automatic ventilation. Acceptance hypothermia, backward access sepsis, mortality, and NEC decreased.
Statistical action ascendancy blueprint assay (Fig 3) showed a connected abatement in CLABSI amount from a baseline of 6 CLABSI/1000 band canicule to 2.6 CLABSI/1000 band days. The connected advance triggered appropriate account aberration and recalculation of ascendancy banned 2 added times, advertence connected advance throughout the abstraction period.31
Statistical action ascendancy chart, CLABSI per 1000 band days, account abstracts from 2007 through 2013. Abiding abatement in CLABSI amount with appropriate account aberration apparent over 3 time periods afterwards accomplishing of the initiative. Ascendancy banned were adapted with anniversary appropriate account event. CTL, centermost band (mean); LCL, lower ascendancy limit; UCL, high ascendancy limit.
In this ample arrangement of NICUs, the accomplishing of the 100 000 Babies Attack was associated with accompanying advance in the key disciplinarian processes and outcomes. Backward access sepsis, catheter associated infections, ROP, NEC, and bloodshed decreased. Survival afterwards anguish increased. Growth, astringent IVH, and oxygen use at 36 weeks’ PMA were abiding or hardly improved.
Our allegation are agnate to antecedent analyses of NICU networks. Stoll et al32 showed an access in antenatal corticosteroid use and decreased use of intubation and surfactant in agnate subgroups of abortive breed from 2003 to 2007. Horbar et al2 showed a abatement in anguish and bloodshed in breed belief 501 to 1500 g in the Vermont Oxford Arrangement from 2000 to 2009. It is accessible our improvements mirror improvements apparent in non-Pediatrix NICUs; however, we targeted and showed abiding advance in assorted key action measures.
Our allegation are constant with NICU QI collaboratives that address advance back a systemwide appliance of evidence-based practices is allowable and authentic over time.4,5,7,8,14,33,34 The 100 000 Babies Attack was different in that it was auspiciously conducted aural a ample neonatal arrangement with automatic abstracts collection, and bigger assorted processes and outcomes simultaneously, rather than targeting a distinct action or morbidity.
The anatomy of our attack has limitations. No ancillary ascendancy accumulation was used. We accede that statistical associations are not agnate to establishing causality. The businesslike access to our accommodating citizenry bound the adeptness to anon aggregate some data, such as axial band aliment array compliance. The capacity of activity selection, prioritization, modification, and accomplishing were larboard to the acumen of the alone practices and may accept been suboptimal. Some analytic after-effects could accept been afflicted by inconsistent cyberbanking documentation. To action this deficiency, educational sessions were provided to assimilate affidavit and BabySteps was added to accommodate reminders and affected functions to enhance authentic documentation.
Multiple factors contributed to the success of our campaign. Use of Kotter’s model21 for arch change was an important account of auspiciously alteration behavior in a assorted neonatal network. An important footfall to creating transformative change is to “create urgency.” We produced this ambiance through the accouterment of a CDW that enabled clinicians to considerately see and analyze their outcomes adjoin added NICUs. Large, collaborative affection conferences were acclimated to highlight these differences and actualize associate groups. Analytic practices that approved the “quality chasm” in neonatology were emphasized, to appearance evidence-based practices that were not actuality absolutely implemented. Attendance at the Affection Summit (Table 3) demonstrates accretion accord in the affairs and use of the CDW during the abstraction period. The American Board of Pediatrics’ claim to complete QI projects for MOC created added urgency. From March 2011 to December 2013, American Board of Pediatrics MOC acclaim for QI assignment was accustomed for 414 projects.
Quality Summit Attendance and CDW Utilization
We brainstorm that our attack will accept after absolute furnishings on accepted bloom outcomes. The improvements in animal milk appliance and antibacterial administration accept important ramifications for accessible bloom and ache prevention. Unneeded biologic acknowledgment increases the accident of adverse biologic events, opportunities for error, and consumes added nursing and pharmacy resources.35 Compared with baseline appliance in 2007, ∼1 000 000 beneath doses of ampicillin, metoclopramide, and H2 blockers were accustomed than expected. We appraisal a accumulative amount accumulation of $58 000 000 associated with the abridgement in catheter-associated claret beck infection.36 Based on changes in mortality, we appraisal that over the advance of our attack there were 1885 beneath deaths than expected.
Implementation of the 100 000 Babies Attack resulted in above improvements in key processes and outcomes. The structured reengineering of NICU care, with a admiring basement to affect ample calibration authoritative change was auspiciously acclimated in a ample and assorted neonatal network. We brainstorm that use of authoritative change theory, targeting of key drivers of adverse bloom outcomes, automatic abstracts collection, and advertisement by appliance a specialty-specific EHR arrangement could be broadly acclimated in bloom affliction to accredit ample calibration improvements in accommodating bloom and advance the amount of analytic care.
FINANCIAL DISCLOSURE: The authors accept adumbrated they accept no banking relationships accordant to this commodity to disclose.
FUNDING: This assignment was authentic by Pediatrix Medical Group. No alfresco honorarium, grant, or added anatomy of acquittal was accustomed to anyone to aftermath the manuscript.
POTENTIAL CONFLICT OF INTEREST: All authors are active by Pediatrix and assignment aural The Centermost for Research, Education and Quality. Dr Ursprung additionally letters he serves as a affiliate of the Vermont Oxford Arrangement Database Advisory Committee.
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