A Quality Improvement Initiative to Improve Normothermia While Transitioning Premature Infants to an Open Crib

Abstract

Introduction: Current literature focuses on the optimal lowest weight and incubator temperature to transition an infant to an open crib, with minimal data quantifying the rate of failed attempts or standardizing the process. Due to multiple failed attempts at this institution in 2021, the project aimed to reduce the rate of preterm newborns who failed the crib by 10% in 1 year.

Methods: Interventions, including nursing education, an audit checklist, environmental changes, and a standardized protocol, were implemented after establishing baseline data.

Results: The incidence of failed transitions to an open crib decreased from a baseline of 13.5% failed cribs per monthly transition attempts to 3.3% failed cribs per monthly transition attempts in 18 months, a 76% decrease, where it is currently sustained. Of note, infants born between 32 and 35 weeks gestation had higher failure rates compared with those born <32 weeks.

Conclusions: Compliance with a thermoregulation protocol, utilizing an audit checklist, and standardizing the process improved the success rate of transitioning to an open crib.

Fig. 1.

Key driver diagram detailing key drivers and interventions established for this QI project.

Fig. 2.

Process map utilizing NYU Langone Hospital-Long Island’s established thermoregulation protocol for transitioning preterm infants from an incubator to an open crib.

Fig. 3.

Failed crib audit checklist. An audit checklist to be completed by nursing staff if an infant fails the transition.

Fig. 4.

Statistical process control chart. P chart depicting the percentage of failed crib transitions per total monthly transition attempts: The x axis shows time in months. The data table below each month shows the number of failed cribs and the total attempts for that month. The y axis shows the percentage of failed cribs per total monthly transition attempts. The chart has interventions annotated. October 2021 marks a process change to designate the start of the interventions. Annotations in black represent major interventions. The baseline centerline shows 13.5% failed cribs/monthly transition attempts. The control chart reflects the process remaining in control from October 2021 to August 2023 around new CL at 3.3% failed cribs/monthly transition attempts. Special cause variations were noted in December 2021 and January 2022. CL, centerline; UCL, upper control line.

Fig. 5.

Process and balancing measure run charts. A, Run chart showing the percentage compliance of daily audits to the target room temperature of 23.9 °C (75 °F). The x axis shows the month recorded. The y axis shows the compliance percentage to the goal temperature during the month. B, Run chart showing the readmissions after NICU discharge. The orange line reflects all readmissions to the institution, whereas the blue line reveals the readmissions secondary to hypothermia. The run chart is also annotated with the time of each intervention implementation. The x axis is the month recorded. The y axis is the number of readmissions.