QI Initiatives

Robin Baker, M.D.

Fairfax Neonatal Associates, P.C. (FNA) Current Initiatives in the Inova Fairfax Hospital for Children's Neonatal Intensive Care Unit (NICU)

Over the past 5 years, a multidisciplinary team of caregivers from within the NICU at Inova Fairfax Hospital for Children (IFHC) has focused primarily on improving the care and outcome of low birth weight newborns. To enhance this effort, FNA neonatologists have worked under the guidance of the Vermont Oxford Neonatal Network (VONN) in a national collaborative effort with other neonatal centers to share "best neonatal medical practices" and to benchmark/measure the outcome after implementaion of these potentially better practices. A more focused group called NIC/Q 2000, of which FNA was a member, formed from within VONN to study how to implement and track change. With the help of the VONN, specific initiatives in the care of low birth weight newborns were undertaken and are discussed in the following paragraphs.

Nutrition/Fluid
Our current goals for the first few days of life are to deliver optimal calories to the premature newborn using the least amount of fluid. Restricting the amount of fluid administered in the initial days and weeks of life has been shown to decrease the incidence of patent ductus arteriosis (PDA) and may improve the infant's respiratory outcome. To accomplish these goals, infants are begun on standardized dextrose solutions upon admission to the NICU. When the infant is stabilized (day 1 or 2 after delivery), intravenous nutrition (total parenteral nutrition or TPN) is begun, which contributes baseline calories as well as protein, fat, minerals, and vitamins. In addition, a small amount of breast milk/premature formula is introduced into the GI tract as soon as the infant is hemodynamically stable. The early introduction of this feeding plan is known as minimal enteral nutrition or MEN. A computer program directs and documents the amount of fluid and calories delivered each day to these low birth weight newborns and helps to maximize the daily amount of delivered calories, protein, fat and minerals. By standardizing our fluid administration and changing our (early) feeding practices, the average number of days to first feeds decreased from 12.4 to 4.5 days in the year 2000, while the average TPN days decreased from 36.5 to 33 days in infants with birth weights (BW) < 1251 g. The incidence of complications related to the feeding of these newborns, i.e., necrotizing enterocolitis (NEC), did not change over this interval. After implementing this restricted fluid regimen, the number of infants requiring medical treatment (indomethacin) for a symptomatic PDA decreased from 30% to 18%, surgical treatment (ligation) decreased from 12% to 7%, and infants who received both indomethacin and later ligation decreased from 7.5% to 2%. Our NICU has an active group that meets regularly and is continually evaluating and discussing strategies for the improvement of our nutritional and fluid practices.

Chronic Lung Disease
Comparison data obtained from the Network (VONN) demonstrated that the incidence of chronic lung disease (the need for supplemental oxygen at 36 weeks corrected age) was greater at the IFHC NICU than similar centers within the Network. Accordingly, we (along with seven other centers) reviewed recent information as to the etiology of chronic lung disease, and then developed and implemented a series of best practices designed to improve this outcome. The group of institutions, nicknamed ReLi (for Reduced Lung Injury), evaluated the use of surfactant, NCPAP (nasal continuous positive airway pressure), fluid administration, vitamin A and ventilation practices. After developing a consensus and implementing these practices ,the IFHC NICU noted a decrease in the average length (in days) of of mechanical ventilation from 17 to 10 in the year 2000, and a decrease in the number of days of oxygen supplementation from 47 to 44. We also re-examined the use of dexamethasone for the treatment of chronic lung disease and subsequently reduced the use of this medication in the very low birth weight population. As the use decreased, we did not experience an increase in chronic lung disease.

It is noteworthy that during the implementation of these best practices, the average length of stay within the NICU for this group of newborns with BW <1251 g decreased from 77 to 69 days. In addition, we noted a decrease in the infection rate.

Family Care
In the year 2000, the IFHC NICU began a pilot program of Transitional Intermediate Care (T-IMC). The goal is to incorporate "families" into the daily health care needs of their sick and convalescing infants. A review these efforts elsewhere in the U.S. has demonstrated a decreased length of stay within the NICU, a reduction of family anxiety at discharge, and a reduced re-admission rate to the hospital within the first year of life. The ability of parents to care for their ingants within a private room promotes and increased degree of familiarity with feeding the infant as well as medication administration and monitoring requirements, thus enhancing parental confidence. As the parent's confidence improves, so will their understanding of the infant's requirements for oprimum care after discharge. Initial responses to these efforts have been extremely positive, and in the coming years we are planning to expand this philosophy and culture throughout the NICU.

Finally, our newest initiative is a focus on the reduction of medical errors. A systematic review of the source of errors is ongoing, and one of our goals is to create an organization or system of enhanced checks that will result in a reduction of errors.

We are proud of the above mentioned efforts and accomplishments to date. However, these are only a few of the active committees. Other committees are evaluating infection reduction, pain control, and overall unit culture. We are continually evaluating all areas of our medical practice and strongly believe this is crucial to the maintenance of a state of the art neonatal intensive care unit.