Elimination of admission hypothermia in preterm very low-birth-weight infants by standardization of delivery room management

Abstract

Context: Temperature instability is a serious but potentially preventable morbidity in preterm infants. Admission temperatures below 36°C are associated with increased mortality and late onset sepsis.

Objective: The goal of our quality-improvement effort was to increase preterm infants' admission temperatures to above 36°C by preventing heat loss in the immediate postnatal period.

Design: This quality-improvement initiative used the rapid-cycle Plan-Do-Study-Act approach. Preterm infants born at less than 33 weeks' gestation with very low birth weight less than 1500 g who were born at a Regional Level III Neonatal Intensive Care Unit (NICU) in San Jose, CA, were enrolled. Our intervention involved standardizing the management of thermoregulation from predelivery through admission to the NICU. Data on admission temperature were collected prospectively.

Main outcome measures: The primary outcome measure was hypothermia, defined as temperature below 36°C on admission to the NICU.

Results: The hypothermia rate was reduced from 44% in early 2006 to 0% by 2009. There was a slight increase to 6% in 2010. Subsequently, with further real-time feedback, we were able to sustain 0% hypothermia through 2011. Our hypothermia rate remained substantially lower than state and national hypothermia benchmarks that have shown moderate improvement over the same period.

Conclusion: We reduced hypothermia in very low-birth-weight infants using a standardized protocol, multidisciplinary team approach, and continuous feedback. Sustaining improvement is a challenge that requires real-time progress evaluation of outcomes and ongoing staff education.

Figure 1.

Implementation timeline. Admit = admission; CPQCC = California Perinatal Quality Care Collaborative; DCC = delayed umbilical cord clamping; DR = delivery room; Neowrap = polyethylene occlusive wrap (NeoWrap, Fisher & Paykel Healthcare, Irvine, CA); NRP = Neonatal Resuscitation Program; Porta warmer = chemical warming mattress (Cardinal Health, McGaw Park, IL); Von = Vermont Oxford Network.

Figure 2.

Thermal equipment used for resuscitation.

Figure 3.

Risk-adjusted hypothermia rates for inborn infants at our center, trend chart, 2006 to 2012.^{a a} Dots represent our unit risk-adjusted rate of hypothermia and the lines with the error bars show the 95% confidence limits for the risk-adjusted rate. The horizontal reference line is the California Perinatal Quality Care Collaborative (CPQCC) hypothermia rate. Risk adjustment model included gestational age, small for gestational age, congenital anomalies, 5-minute Apgar score, multiple gestations, male sex, maternal race, and no prenatal care. Data for 2012 shown in gray zone are ongoing and incomplete. Reprinted with permission from the California Perinatal Quality Care Collective.

Figure 4.

Risk-adjusted hypothermia rates for inborn infants at our center compared with other regional NICUs in California, 2009 to 2011.^{a a} Each bar represents a regional center NICU participating in CPQCC. Dots represent the 3-year (2009 to 2011) aggregate risk-adjusted rate of hypothermia, and the bars extend up to the 95% confidence limits for the risk-adjusted rate for each center. Our center is the solid bar. The horizontal reference line is the average rate of hypothermia for all regional NICUs in CPQCC. CPQCC = California Perinatal Quality Care Collaborative; NICU = neonatal intensive care unit. Reprinted with permission from the California Perinatal Quality Care Collective.

Figure 5.

Risk-adjusted survival rates without serious morbidity for inborn infants at our center, trend chart, 2004 to 2012.^{a a} Dots represent our unit risk-adjusted rate of survival without serious morbidity, and the lines with the error bars show the 95% confidence limits for the risk-adjusted rate. The horizontal reference line is the average rate of survival without serious morbidity in the California Perinatal Quality Care Collaborative (CPQCC). Risk adjustment model included gestational age, small for gestational age, congenital anomalies, 5-minute Apgar score, multiple gestations, male sex, maternal race, and no prenatal care. Data for 2012 shown in gray zone are ongoing and incomplete. Reprinted with permission from the California Perinatal Quality Care Collective.

Figure 6.

Risk-adjusted survival rates without serious morbidity for inborn infants at our center compared with other regional NICUs in California, 2009 to 2011.^{a a} Each bar represents a regional center NICU participating in CPQCC. Dots represent the 3-year (2009 to 2011) aggregate risk-adjusted rate of survival without severe intraventricular hemorrhage, severe retinopathy of prematurity, chronic lung disease, necrotizing enterocolitis, or nosocomial infection, and the bars extend up to the 95% confidence limits for the risk-adjusted rate for each center. Our center is the solid bar. The horizontal reference line is the average rate of survival without serious morbidity for all regional NICUs in CPQCC. CPQCC = California Perinatal Quality Care Collaborative; NICU = neonatal intensive care unit. Reprinted with permission from the California Perinatal Quality Care Collective.