Children's Hospitals Today - Summer 2016 - 25

THEORY INTO ACTION DISTINCTIVE ACHIEVEMENT STANDARDIZING CARE FOR NICU PATIENTS Lessons learned OUTCOMES $5.7 million Necrotizing enterocolitis (NEC) is a disease characterized by damage to estimated cost savings the intestines of premature babies. The cause is not known. While analyzing its outcomes compared to other hospitals, cases of NEC prevented over five years staff members at Cincinnati Children's Hospital Medical Center's NICU noticed they had increasing rates of NEC. They began a project with the goal of decreasing the number of very low birth weight infants (VLBW) diagnosed with NEC by standardizing care with four key drivers. The effort took place in three hospitals and has now expanded to two others in the region. The team reached its goal of reducing NEC from 0.18 (cases per 100 VLBW patient days) to 0.07 in 2014 and achieved a decrease to 0.03 in June 2015. "Earlier last year, I was giving a talk on NEC to the residents and they said, 'Oh, we're so glad you talked about this because we have never seen a case,'" says Amy Nathan, M.D., project lead, medical director, Neonatology and Pulmonary Biology. "I got a huge smile on my face-it's the dream to totally eliminate it. That hasn't happened yet. It may not happen in my lifetime but, to see a resident go through a month or two in the NICU and never see a case was a great feeling." 50 4 key drivers for improved feeding Cincinnati Children's Hospital Medical Center uses these strategies to reduce the number of VLBW infants diagnosed with NEC. Standardize feeding practices. With a standardized feeding protocol, the rates of NEC decrease, regardless of variations. "It's easy to get hung up on how we should feed small babies, but the small details are not as important as long as you're consistent," Nathan says. Use human milk. Nathan says the literature shows human milk as the strongest link to preventing NEC. The team began using donor milk rather than formula for the babies whose mothers could not provide milk. This was the biggest expense associated with the project. Maintain a healthy microbiome. Research has shown that bacteria may be one of the causes of NEC, as removing the intestines' natural bacteria allows "bad" bacteria to take root. One of the three NICUs piloting these drivers had a strong pharmaceutical connection and helped run the antibiotics portion of biome management. Optimize intestinal perfusion. Lack of circulation to the intestines is the other hypothesized cause of NEC, so team members increased the amount of time before the cutting the cord (allowing the baby to get more blood from the placenta) and changed some of the medication they used in an attempt to get more blood to the intestines. The 2015 Pediatric Quality Award category winners share their advice. Levine Children's Hospital at Carolinas Healthcare System Developing future Improvement leaders: experiential QI training in residency  Use non-physician experts such as a QI coach and data analyst.  Look for creative ways to incorporate learning time into resident schedules.  Use the Personal Improvement Project to introduce QI concepts. Doernbecher Children's Hospital at OHSU Reducing radiation exposure: pediatric modified barium swallow studies  Foster curiosity about quality improvement possibilities.  Allow new leaders to surprise you.  Know that success comes in many different forms.  Balancing measures is hard, so come up with a reliable measurement system.  Figure out your way of pursuing improvement of care. Children's of Alabama Decreasing hospital length of stay for postoperative adolescent spinal fusion patients  Help create a cultural paradigm shift.  Create groups of frontline staff with QI leadership experience.  Give staff members a practical education in QI lingo.  Identify what will make a group of providers interested in change. Cincinnati Children's Hospital Medical Center Using quality improvement to reduce necrotizing enterocolitis across hospital systems  Approach the problem from a variety of angles simultaneously.  Examine data in a frequent and accurate manner.  Recognize the limitations of national benchmarking networks.  Create an established protocol to allow for internal consistency. For more information, visit childrenshospitals.org/award. CHILDREN'S HOSPITAL S TODAY Summer 2016 25 http://www.childrenshospitals.org/award

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