A standardized implementation of multicenter quality improvement program of very low birth weight newborns could significantly reduce admission hypothermia and improve outcomes

Abstract

Background: Admission hypothermia (AH, < 36.5℃) remains a major challenge for global neonatal survival, especially in developing countries. Baseline research shows nearly 89.3% of very low birth weight (VLBW, < 1500 g) infants suffer from AH in China. Therefore, a prospective multicentric quality improvement (QI) initiative to reduce regional AH and improve outcomes among VLBW neonates was implemented.

Methods: The study used a sequential Plan-Do-Study-Act (PDSA) approach. Clinical data were collected prospectively from 5 NICUs within the Sino-Northern Neonatal Network (SNN) in China. The hypothermia prevention bundle came into practice on January 1, 2019. The clinical characteristics and outcomes data in the pre-QI phase (January 1, 2018- December 31, 2018) were compared with that from the post-QI phase (January 1, 2019-December 31, 2020). Clinical characteristics and outcomes data were analyzed.

Results: A total of 750 in-born VLBW infants were enrolled in the study, 270 in the pre-QI period and 480 in the post- QI period, respectively. There were no significant differences in clinical characteristics of infants between these two phases. Compared with pre-QI period, the incidence of AH was decreased significantly after the QI initiative implementation in the post-QI period (95.9% vs. 71.3%, P < 0.01). Incidence of admission moderate-to-severe hypothermia (AMSH, < 36℃) also decreased significantly, manifesting a reduction to 38.5% in the post-QI (68.5% vs 30%, P < 0.01). Average admission temperature improved from after QI (35.5 [Formula: see text] 0.7℃ vs. 36.0 [Formula: see text] 0.6℃, P < 0.01). There was no increase in proportion the number of infants with a temperature of > 37.5 °C or thermal burns between the two groups. The risk ratio of mortality in infants during the post-QI period was significantly lower in the post-QI period as compared to the pre-QI period [adjusted risk ratio (aRR): 0.26, 95% confidence interval (CI): 0.13-0.50]. The risk ratio of late-onset neonatal sepsis (LOS) also significantly lowered in the post-QI period (aRR: 0.66, 95% CI: 0.50-0.87).

Conclusion: Implementation of multicentric thermoregulatory QI resulted in a significant reduction in AH and AMSH in VLBW neonates with associated reduction in mortality. We gained a lot from the QI, and successfully aroused the attention of perinatal medical staff to neonatal AH. This provided a premise for continuous quality improvement of AH in the future, and might provide a reference for implementation of similar interventions in developing countries.

Trial registration: Trial registration number: ChiCTR1900020861 . Date of registration: 21 January 2019(21/01/2019). Prospectively registered.

Keywords: Hypothermia; Neonates; Outcomes; Quality improvement; Very low birth weight.

Fig. 1

Patient Inclusion. A total of 890 in-born infants with a BW < 1500 g were enrolled in the study; 49 infants were excluded because they were out-born; 20 infants were excluded because their mother had a fever during delivery (temperature ≥ 38.4 °C). Additionally, 64infants with redirection of intensive care and 7 infants with missing temperature data were excluded. The remaining 750 VLBWIs were included in this analysis, 270 infants in pre-QI phase and 480 infants in post-QI phase, respectively. (*: limited care (not intensifying medical treatment) or withdrawal of care; Maternal hyperthermia*: mothers had a fever temperature (≥ 38.4 °C) during delivery)

Fig. 2

Month proportion of rectal temperature ≥ 36.5℃ within first hour after admission during the QI phase

Fig. 3

P-chart of monthly AH percentage in January 2018–December 2020. Subdivided into pre-QI period and post-QI period. CL, center line; LCL, lower control limit; UCL, upper control limit. Arrows show change of major interventions including the thermoregulation bundle: Initial Bundles (January 1–March 31, 2019); PDSA Cycle 1 (April 1–May 31, 2019): Using polyethylene occlusive wrap infants without drying instead of drying infants immediately after birth. PDSA Cycle 2 (June 1–August 31, 2019): a heated transport incubator introduction. PDSA Cycle 3 (September 1,2019 – March 31, 2020): Revise admission hypothermia check list to supervise effectively. PDSA Cycle 4 (April 1– December 31, 2020): Various online education lectures monthly to build up confidence, faith and further emphasize heat preservation awareness