Quality Improvement in Neonatology July 27, 2013
Disclosure Nothing to disclose Nothing off label No commercial products No financial affiliation
Objectives Key components of Quality Improvement work Advances in Neonatology
Quality Chasm Between the health care we have and the care we could have lies not just a gap, but a chasm Underuse, Overuse Misuse Variation in practice Medical errors Crossing the Quality Chasm: A new health system for the 21 st century, IOM 2001
Reinvent the System Aim for improvement Redesign, prioritize Engage the stakeholders Change the environment Start now
Quality Improvement In practice Improve outcomes Decrease errors Increase satisfaction Decrease cost Formal process Analysis of performance Systematic efforts to improve performance Shift in health care delivery
QI Key Components Do the right thing Team work Change Evaluate Sustain the improvement
Effective Safe Six Aims of Patient Care Do the right thing Patient-centered Timely Efficient Equitable
Team Work Engaging stakeholders Leadership Frontline
Change How will we know there is improvement? Outcomes Benchmarks Process Measures
Sustained Improvement What changes will result in improvement? Embrace change Test the change Analysis Spread the change
Neonatology Quality Improvement Knowing is not enough, we must apply; willing is not enough, we must do - Goethe
Neonatal ICU Patient population Well-defined Defined conditions Multidisciplinary MD, RN, RT Rehab, dietary, lactation Behavioral health
Neonatal ICU Dynamic complexity Fragile patients Fast paced Unpredictable human factors Essential family involvement Social factors High tech High cost of care
Outcomes Survival Neurodevelopment Major morbidities Chronic lung disease Nosocomial infection Necrotizing enterocolitis Retinopathy of prematurity Intraventricular hemorrhage
Neonatology Chasm Breast milk: Underuse Improved neurodevelopmental outcomes Decreased necrotizing enterocolitis Decreased nosocomial infections Oxygen: Overuse Retinopathy of prematurity Bronchopulmonary dysplasia Antibiotics: Overuse Resistant organisms Fungal infections Increased necrotizing enterocolitis
Modifying Oxygen Practices to Reduce Retinopathy of Prematurity in the Newborn Special Care Unit Specific Aim: Decrease the incidence of ROP in very low birth weight infants
Retinopathy of Prematurity Major morbidity in very low birth weight (VLBW) infants (BW < 1500 gms) 2/3 of VLBW infants develop some form of ROP About 1/5 of VLBW infants progress to moderately severe stage of ROP and 1/3 of those will require surgical intervention
Factors Contributing to ROP Low birth wt High PCO2 Mechanical Ventilation High PaO2 Prematurity Apnea Concurrent illnesses Anemia/ Transfusions Intraventricular Hemorrhage Maternal Risk Factors
History 1950s: need to restrict oxygen Association between unrestricted prolonged oxygen exposure and retrolental fibroplasia (Patz A, Kinsey VE, and Engle MA ) 1960s: not under control more problems Subsequent decrease in O2 administration showed a dramatic reduction in RLF with a concomitant increase in death and cerebral palsy 1970s: need for intervention Improved survival of preterm infants Renamed Retinopathy of prematurity
Pathophysiology of ROP Premature birth Exposed to hyperoxia Suppresses normal vessel growth Creates a relative tissue hypoxia.
Role of oxygen Hypoxia causes increased vascular endothelial growth factor (VEGF) expression Results in abnormal retinal vessel growth Retinopathy of prematurity (ROP)
Specific Aim Decrease the incidence of retinopathy of prematurity in VLBW infants by reducing episodes of hypoxia/hyperoxia
Stakeholders Medical team Neonatologists, residents, fellows, NNPs Nursing Respiratory therapy Administration Ancillary Social work Rehabilitation services Dieticians Parents
Factors Contributing to High PaO2 Nursing Staff Beliefs Respiratory Therapist Beliefs Physician Beliefs Caregiver Personality (compulsive vs. lax) Unit Census Patient Lability Limited Staffing Available Technology
Baseline data Oxygen saturation Orders Alarm settings Patient saturation measures ROP incidence Severe Laser surgery
Ordered O 2 Saturation Parameters 100 95 SATURATIONS 90 85 80 75 70 Oct Nov MONTH Dec Ordered Low er Parameter Ordered Upper Parameter
O 2 Saturation Alarm Settings 100 95 SATURATIONS 90 85 80 75 70 Oct Nov MONTH Dec Low er Alarm Setting Upper Alarm Setting
Ideal O2 Sat Orders and Monitor Parameters SATURATIONS 100 100 95 95 90 90 85 85 80 80 75 75 70 70 Oct Nov MONTH Month Dec Ordered Low er Parameter Ordered Upper Parameter Low er Alarm Setting Upper Alarm Setting
Ordered O 2 Parameters vs. Alarm Settings 100 95 SATURATIONS 90 85 80 75 70 Oct Nov MONTH Dec Ordered Low er Parameter Ordered Upper Parameter Low er Alarm Setting Upper Alarm Setting
Charted O 2 Saturations (12) (34) (47) (19)
Retinopathy of Prematurity (ROP) At risk population for ROP Extremely low birthweight infants (<1000g) Approximately 28-30 wks gestation and below Incidence 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ROP 2003-2005 Laser (%) Stage 3 or 4 (%) <750 751-999 1000-1249 1250-1500 >1500 Birthweight (g)
Interventions Standard orders (EMR) Saturation limits At risk for ROP Not at risk Oxygen guidelines Titration Documentation Education Rationale Feedback
Ordered Oxygen Parameters 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 82-90 82-92 85-92 85-93 85-95 88-92 88-96 92-96 0.0% 7/1/2005 7/2/06 to 12/31/06 1/1 to 12/31/07
Alarm Parameters 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 85-93 85-100 other 7/1/05 to 7/1/06 7/2 to 12/31/06 1/1 to 12/31/07
QI in Neonatology 2013 On-going efforts Central line blood stream infection 2.9% vs 6.6% (1 st quartile VON 2012) Necrotizing enterocolitis 0.7% vs 2.3% Pay for performance Maintenance of certification
QI in Neonatology Databases Vermont Oxford Network (VON) International Neonatal Collaboration Collaboratives VON Neonatal CABSI
QI for me Work in teams Make changes Data, data, data Do the right thing Better outcomes A better way
Other Morbidities Pre (%) Post (%) p value PDA 42 50 0.059 Ligation 14 20 0.496 Chronic lung disease 29 20 0.003 Death 2 1 0.669
QI in the US Vision for the future: 2022 Best practices for better care initiative QI embedded into the continuum of physician development Alignment of clinical and educational missions Quality Improvement work Systematic Data-driven Context-variable Produce immediate, positive changes Improve care now Teaching for Quality Report of an Expert Panel, AAMC, 2012
Central Law of Improvement Every system is perfectly designed to achieve the results it achieves - Donald Berwick
Human Factors Science Analysis of errors Preventive interventions Proactive prevention Improve efficiency, timeliness, accuracy Best or potentially best practices
Systems Systems thinking Simple: bedside monitor Complex: central monitoring Mechanical: pump alarm Adaptive: servo control Complex adaptive: saturation monitoring and oxygen adjustment Tinkering vs system change
Change First order: Tinkering Try harder Be more careful Remember Effort-based changes Second order: systems change Resign the system Not rely on individual effort Sustained improvement
QI Strategies Failure modes and effects analysis Plan-Do-Study-Act Six Sigma Lean Root cause analysis
Action Plan Change Apply the evidence Share information Align payment with quality Prepare the workforce Impact ABMS certification State medical boards JACHO Pay for performance Malpractice premium incentives Public awareness