Newborn Screening in the NICU: A Process Improvement Initiative Allison Piques, NNP Conflict of Interest None to Disclose 1
Problem Statements Newborn Screens (NBS) are obtained at inconsistent times and the process for follow up is non standardized Despite multiple repeat screens, our patient population remains at risk for loss to follow up complex patients with acute (on chronic) needs variability in practice clinical variables impact results; interpretation challenging Process Improvement Initiative 1. Standardize timing for NBS in NICU 2. Standardize follow up procedures for abnormal NBS 2
Meet BG Repeat 33 weeker NBS drawn on day of life 6. Required a blood transfusion in second week of life. NBS results: First screen ABNORMAL for CAH A Second screen is obtained because the first was abnormal. It reflects Transfusion, but NORMAL for CAH Lab requests Third screen, but not until 8 weeks later. In 2 weeks, Baby Repeat is ready for discharge What s the provider to do? A Obtain a 3rd NBS, hoping it does not reflect a transfusion B C Assign accountability for follow up to community PCP Ignore this situation bc BB Repeat obviously doesn t have CAH, and that s what matters 3
Primary Goals Standardize the timing of Newborn Screens for our specialized population Identify why screens were often being repeated Develop a procedure for a consistent approach to follow up on all NBS Secondary Goal Improve collaboration and communication with VDH to close the case in a timely manner 4
Interventions Developed a NBS protocol to meet the needs of our patient population Disseminated protocol Educated staff re: new guidelines, emphasis on team accountability for the NBS Implemented protocol Protocol Development Review of current practices Literature review Interdisciplinary collaboration Pediatric specialists at CHoR Neonatology Endocrine Genetics/ metabolic, Metabolic dietician: medical nutrition therapy Pulmonology DCLS Laboratory scientists NBS follow up staff at VDH 2013 Hematology (adding Hgb algorithm) 2015 Allergy/Immunology (adding SCID) 5
Two Key Practice Changes Standardized Timing for NBS Dated and timed order rather than Routine or standing DOB +2, 4am Standardized procedures for follow up/ follow through NBS Algorithm Clear pathways for Follow up 6
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Disseminate and Implement Communicate change in protocol NICU nursing staff and patient care tech NICU Faculty, NNPs and Fellows Newborn Screening consultants and VDH Question/Answer period, education Revised unit based nursing policy to reflect new protocol Protocol effective September 2012 8
Initial focus Timing of NBS Evaluation What causes Untimely Newborn Screens? Multifactorial: Early Incorrect order Late Missed order? Incorrect order or NO order? Incorrect order, and missed? Other issues (handling, etc) 9
Reporting Results: Monthly QA/I Meeting How are we doing? 100% RESULTS: NBS Timing over 9 months % Mistimed Newborn Screens 75% 50% Drill down / 25% Post-critical event inquiry Reinforcement from nursing leadership 0% Oct-12 Nov Dec Jan-13 Feb Mar Apr May June 10
100% 75% RESULTS: NBS Timing over 9 months Let me tell you about our protocol for NBS. Here s a copy! % of NBS Mistimed 50% 25% 0% Oct-12 Nov Dec Jan-13 Feb Mar Apr May June Opportunities for Improvement NBS data log > NBS log updated weekly by PCT (enters NBS time, etc) > Drop down menus describe rationale for miss > Monthly audit by staff RN to determine % compliance NICU Power Orders > Changing house staff rely on care sets NICU Admission Order Sets updated Summer 2015 Human-proof, timed orders are pre-populated! 11
First screen obtained on DOB +2 ABNORMAL for CAH Knowing that the baby has since been transfused, what s the provider to do? Consult NBS Algorithm. BG Repeat: Take 2 Obtain 17 ohp, BMP Results are faxed to NBS Nurse at VDH Case / Folder closed. Additional Outcomes to Consider Pre/Post, Interval change: Frequency of repeat NBS # of transfused specimens Cost analysis Loss to follow up/ % case closure Staff perceptions and satisfaction 12
Don t forget my newborn Screen! Please order on admission date of birth + 2, after 4 am 13