A Quality Improvement Initiative to Improve Perioperative Hypothermia Rates in the NICU Utilizing Checklists

Abstract

Premature infants are at high risk for heat loss. Infants undergoing surgical procedures outside of the neonatal intensive care unit have an increased risk of hypothermia. Hypothermia can lead to delayed recovery, hypoglycemia, metabolic acidosis, sepsis, and emotional stress for the parents. We aimed to reduce the incidence of hypothermia for infants undergoing surgical procedures from a baseline of 44.4% to less than 25% over 3 years (2016-2018) with the utilization of a checklist and education.

Methods: We conducted a retrospective chart review for all infants undergoing surgical procedures from 2014 to 2015 and prospective data for 2016-2018. Next, we created a multidisciplinary team, educated staff members, and instituted a checklist comprising 9 tasks. We conducted Plan-Do-Study-Act cycles quarterly and audited checklist compliance monthly.

Results: From 2014 to 2015, the total incidence of perioperative hypothermia was 44.4% (n = 54). After the initiation of the checklist, the overall incidence of hypothermia decreased to 23.4% (n = 124, P = 0.007). Hypothermia occurred most frequently while the patient was in the operating room. Furthermore, we noticed that hypothermia was significantly associated with neonates requiring emergency procedures. There was an inverse correlation between overall compliance with checklist usage and the incidence of hypothermia.

Conclusion: A checklist is a useful and simple tool for maintaining an optimal temperature for postsurgical neonates. Frequent re-education and enforcement of the protocol is necessary. Overall, implementation of the checklist, along with regular education, decreased the total incidence of perioperative hypothermia in the neonatal intensive care unit.

Fig. 1.

Key driver diagram depicting essential checkpoints as well as the interventions aimed at reducing the incidence of perioperative hypothermia in NICU patients. Reducing hypothermia incidence in the perioperative period for NICU infants.

Fig. 2.

A 9-item perioperative NICU transport temperature checklist centered around obtaining core rectal temperatures (unless contraindicated) before transport to the OR (item 1), following completion of the procedure within the OR (item 5), and upon return back to the NICU (item 9).

Fig. 3.

P-chart illustrating quarterly data for the before-and-after incidence rate of hypothermia measured in the OR. Hypothermia was considered as a defect and was measured each month against the number of neonates undergoing a procedure. There is centerline shift and tighter control limits after interventions.

Fig. 4.

A run-chart of quarterly compliance percentage with all checklist items. Checklists that were deficient in any item were regarded as incomplete.