Improving the Breastfeeding Practices in Healthy Neonates During Hospital Stay Using Quality Improvement Methodology

Objective

To demonstrate the applications of the principles of Quality Improvement (QI) in a tertiary-care centre with the aim to improve the breastfeeding practices during hospital stay.

Methods

An operational team was formulated to identify the reasons for low proportion of exclusive breast feeding (EBF) in healthy neonates. Reason specific solutions were proposed, discussed, prioritized and tested using Plan-Do-Study-Act Cycle (PDSA Cycle). Strategies included clear departmental policy plan and creation of Breastfeeding support package (BFSP). PDSA cycles were tested and implemented over 6 weeks period and its sustainability was measured monthly for five months duration.

Results

After implementation of PDSA cycles, the proportion of neonates receiving early breastfeeding within one hour of birth increased from 55% to 95%, and the proportion of neonates on EBF during hospital stay increased from 72% to 98%.

Conclusion

Quality Improvement principles are feasible and effective to improve breastfeeding practices in the hospital setting.

     

Target Oxygen Saturation Among Preterm Neonates on Supplemental Oxygen Therapy: A Quality Improvement Study

Objective

To avoid excessive oxygen exposure and achieve target oxygen saturation (SpO₂) within intended range of 88%–95% among preterm neonates on oxygen therapy.

Methods

20 preterm neonates receiving supplemental oxygen in the first week of life were enrolled. The percentage of time per epoch (a consecutive time interval of 10 hours/day) spent by them within the target SpO₂ range was measured in phase 1 followed by implementation of a unit policy on oxygen administration and targeting in phase 2. In phase 3, oxygen saturation histograms constructed from pulse-oximeter data were used as daily feedback to nurses and compliance with oxygen-targeting was measured again.

Results

48 epochs in phase 1 and 69 in phase 3 were analyzed. The mean (SD) percent time spent within target SpO₂ range increased from 65.9% (21.4) to 76.5% (12.6) (P=0.001).

Conclusion

Effective implementation of oxygen targeting policy and feedback using oxygen saturation histograms may improve compliance with oxygen targeting.

     

A Quality Improvement Initiative for Early Initiation of Emergency Management for Sick Neonates

Objective

To determine efficacy of Point-of-care Quality improvement (POCQI) in early initiation (within 30 minutes) of emergency treatment among sick neonates.

Design

Quality improvement project over a period of twenty weeks.

Setting

Special Newborn Care Unit (SNCU) of a tertiary care center of Eastern India.

Participants

All consecutive sick neonates (≥ 28 wk gestation) who presented at triage during morning shift (8 am to 2 pm).

Intervention

We used a stepwise Plan-do-study-act (PDSA) approach to initiate treatment within 30 min of receiving sick newborns. After baseline phase of one month, a quality improvement (QI) team was formed and conducted three PDSA cycles (PDSA I, PDSA II and PDSA III) of 10 d each, followed by a post-intervention phase over 3 months.

Main outcome measure(s)

Percentage of sick babies getting early emergency management at SNCU triage.

Results

309 neonates were enrolled in the study (56 in baseline phase, 88 in implementation phase and 212 in post-intervention phase). Demographic characteristics including birthweight and gestational age were comparable among baseline and post intervention cohorts. During implementation phase, successful early initiation of management was noted among 47%, 69% and 80% neonates following PDSA I, PDSA II and PDSA III, respectively. In comparison to baseline phase, the percentage of neonates receiving treatment within 30 minutes of arrival at triage increased from 20% to 76% (P<0.001) and the mean (SD) time of initiation of treatment decreased from 80.8 (21.0) to 19.8 (5.6) min (P<0.001) during post-implementation phase. Hospital mortality (33% vs 15%, P=0.004) and need for ventilator support (44% vs 18%, P<0.001) were also significantly lower among post intervention cohort in comparison to baseline cohort.

Conclusion

Stepwise implementation of PDSA cycles significantly increased the percentage of sick newborns receiving early emergency management at the SNCU triage, thereby resulting in better survival.

     

Improving First-hour Breastfeeding Initiation Rate After Cesarean Deliveries: A Quality Improvement Study

Objective

To improve the rates of first hour initiation of breastfeeding in neonates born through cesarean section from 0 to 80% over 3 months through a quality improvement (QI) process.

Design

Quality improvement study.

Setting

Labor Room-Operation Theatre of a tertiary care hospital.

Participants

Stable newborns ≥35 weeks of gestation born by cesarean section under spinal anesthesia.

Procedure

A team of nurses, pediatricians, obstetricians and anesthetists analyzed possible reasons for delayed initiation of breastfeeding by Process flow mapping and Fish bone analysis. Various change ideas were tested through sequential Plan-Do- Study-Act (PDSA) cycles.

Outcome measure

Proportion of eligible babies breast fed within 1 hour of delivery.

Results

The rate of first-hour initiation of breastfeeding increased from 0% to 93% over the study period. The result was sustained even after the last PDSA cycle, without any additional resources.

Conclusions

A QI approach was able to accomplish sustained improvement in first-hour breastfeeding rates in cesarean deliveries.

     

National Quality Improvement Initiative in Home Visiting Services Improves Breastfeeding Initiation and Duration

Objective

To improve breastfeeding through home visiting.

A Quality Improvement Initiative to Improve Attention-Deficit/Hyperactivity Disorder Follow-Up Rates Using School-Based Telemedicine

ObjectivePatients with a new diagnosis of attention-deficit/hyperactivity disorder (ADHD) who are prescribed stimulant medication need regular follow-up. Guidelines recommend follow-up within 30 days of stimulant initiation or change but this goal is seldom achieved. This quality improvement (QI) study in an urban academic outpatient practice aimed to: 1) assess whether use of school-based telemedicine increases rates of follow-up within 30 days and decreases the number of days to follow-up for ADHD, and 2) compare rates of 30-day follow-up via in-person vs telemedicine visits.MethodsWe performed three Plan-Do-Study-Act cycles over a 12-month period: QI interventions included clinic wide education, paper prompts for clinicians, and creation of a database to track ADHD patients. We measured days from the index visit to the follow-up visit, and the mode of both visits (in-person or telemedicine). Data were collected for 6 months pre-intervention and 12 months post-intervention.ResultsFollow-up within 30 days increased from 19% (of 191 visits) to 33% (of 661 visits) (P < .001). The time to follow-up decreased from 67 to 34 days (P < .001). Follow up visits by telemedicine were more also more likely to be within 30 days (62% vs. 32%, P < .001).DiscussionA QI intervention for ADHD care increased rates of follow-up within 30 days, particularly when telemedicine was used, and decreased the number of days to follow-up. This intervention could serve as a model to improve follow-up for ADHD in other settings.     

Improving Duration of Kangaroo Mother Care in a Tertiary-care Neonatal Unit : A Quality Improvement Initiative

Objectives

To increase the duration of Kangaroo mother care (KMC) in preterm infants from an average of 3 hours/day to at least 6 hours/day over 7 weeks through a Quality improvement (QI) approach in a tertiary-care neonatal unit.

Methods

Preterm mother-infant dyads who were admitted in the Neonatal intensive care unit and KMC ward were enrolled in this study. A QI team comprising of nurses, nurse educators, resident physicians and nursing-in-charge of unit was formed. The potential barriers for prolonged KMC were evaluated using fish bone analysis. A variety of measures (allowing family members including male members during night for doing KMC, making KMC an integral part of treatment order, introducing the concept of weekly KMC champions, etc.) were introduced and subsequently tested by multiple Plan-do-study-act (PDSA) cycles. Data on duration of KMC per day was measured by bedside nurses on daily basis.

Results

20 eligible mother-infant dyads were studied during implementation period (50 d). The mean (SD) weight and gestation of infants were 1199 (356) g and 31.1 ( 2.3) wks, respectively. We achieved our goal by step-wise implementation of changes through construction of 3 PDSA cycles. The duration of KMC increased to 6 hours-a-day over a period of 7 weeks. Evaluation at 6 and 12 months in the post-implementation phase suggested sustenance of improved KMC duration up to 9 h/day in the unit.

Conclusions

Ongoing quality improvement measures increased the duration of KMC from a baseline of 3 h to 6 h in eligible preterm infants, and the results were sustained at 6–12 month.

     

Comparison of Different Rates of Artificial Ventilation in Preterm Neonates with Respiratory Distress Syndrome

The effectiveness of three different ventilator rates of artificial ventilation (30, 60 and 120/min) was studied in 32 preterm infants, all of whom were suffering from the Respiratory Distress Syndrome (16 were paralysed). Ventilator pressures, I: E ratio and MAP were kept constant at each rate. Increase in rate from 30 to 60 and to 120/min was well tolerated and not associated with episodes of hypotension. The only significant improvement in oxygenation was amongst the non-paralysed infants and at a rate of 120/min ( p <0.01) this was associated with synchronous respiration. Two different ventilators were used in the study and a significant change in Pa_co2, (reduction) occurred only in non-paralysed infants ventilated at a rate of 120/min by Sechrist ventilators ( p <0.05). This difference may be a direct reflection of differences in ventilator performance at fast rates.     

Reducing Healthcare-associated Infections in Neonates by Standardizing and Improving Compliance to Aseptic Non-touch Techniques: A Quality Improvement Approach

Objective

To standardize and improve compliance to Aseptic non-touch techniques (ANTT) for commonly performed procedures in Neonatal intensive care unit (NICU) through application of Model for improvement, and study its impact on Healthcare-associated infection (HCAI) rates.

Design

Quality improvement project utilizing multiple Plan-Do-Study-Act (PDSA) cycles.

Setting

Tertiary-care neonatal unit.

Participants

All resident doctors and nurses working in neonatal unit were subjects for assessment of compliance to ANTT. All admitted neonates staying in hospital for more than 48 hours were subjects for HCAI data collection.

Procedure

Most frequently performed procedures in NICU were identified and pictorial Standard Operating Procedures (SOP) were developed. Implementation and uptake was reinforced by means of PDSA cycles. Compliance to ANTT was assessed as proportion of components to which adherence was documented. Trend of HCAI rates in unit were analyzed using process control charts.

Main outcome measure

Change in compliance to ANTT for most frequently performed procedures.

Results

Significant improvement in compliance to ANTT practices was observed, specifically in use of procedure tray/ trolley (16% to 49%, P=0.001), iv hub scrubbing (0% to 60%, P=0.001), local skin cleaning (33% to 67%, P=0.004), personal protective equipment use (55% to 80%, P=0.02) and disposal (27% to 51%, P=0.03), use of non-touch technique (50% to 70%, P=0.001) and reduction in key part contamination (45% to 31%, P=0.03). A modest decrease in HCAI rates was seen in the short period of observation after implementation.

Conclusions

Substantial improvements in compliance to aseptic non-touch techniques can be ensured by adopting a combination of initial intensive teaching and sustaining through multiple PDSA cycles, targeting specific areas revealed by audits.

     

母乳喂养教育材料对6个月内婴儿纯母乳喂养的影响

目的了解2007-2008年石河子市6个月内纯母乳喂养率,探讨发放母乳喂养教育材料对6个月内婴儿纯母乳喂养的影响。方法采用队列研究对2007-2008年石河子市人民医院、石河子大学医学院第一附属医院、石河子市妇幼保健院分娩的347例产妇进行单盲随机问卷调查,在奇数月份分娩的产妇发放母乳喂养教育材料,作为干预组;偶数月份分娩的产妇不发放教育材料,作为对照组。出院后分别在婴儿0.5、1.5、2.5、3.5、4.5、6.0个月时,电话随访其喂养和健康状况。应用生存分析计算纯母乳喂养率,Kaplan-Meier过程比较纯母乳喂养持续时间。结果1.干预组各月龄纯母乳喂养率显著高于对照组(P<0.05)。2.干预组纯母乳喂养持续时间显著长于对照组(P<0.05)。结论发放母乳喂养教育材料可提高纯母乳喂养率和延长纯母乳喂养持续时间。     

A Quality Improvement Initiative to Increase HPV Vaccine Rates Using an Educational and Reminder Strategy With Parents of Preteen Girls

IntroductionA quality improvement project was undertaken to determine if an evidence-based educational brochure and reminder system can increase human papillomavirus (HPV) vaccine uptake and dose completion rates.MethodDevelopment of a brochure to promote HPV vaccine uptake was based on predictors of parental acceptance and Health Belief Model concepts. Electronic alerts prompted telephone reminders for dose completion. This quality improvement project utilized a quasi-experimental design with 24 parents of preteen girls from a private pediatric practice and a historical control group of 29 parents. HPV vaccine rates were compared between the groups.ResultsA significant difference in HPV vaccine uptake (χ² = 11.668, P = .001; odds ratio [OR] = 9.429, 95% confidence interval [CI] = 2.686-33.101) and dose completion (χ² = 16.171, P < .001; OR = 22.500, 95% CI = 4.291-117.990) rates were found between the historical control and intervention groups. Parents who received the clinical protocol were 9.4 times and 22.5 times more likely to have HPV vaccine uptake and dose completion, respectively.DiscussionLow national HPV vaccine rates demonstrate the need for theory-based vaccine delivery programs. These results show that an evidence-based educational brochure and reminder system appeared to improve HPV vaccine uptake and dose completion rates at this private pediatric practice.     

Achieving Early Mother-baby Skin-to-skin Contact in Caesarean Section: A Quality Improvement Initiative

Objective

To improve rate of skin-to-skin contact for early initiation of breastfeeding at birth on operation table among healthy term and late pretem babies born by caesarean sections from 0% to 80% in eight weeks.

Methods

A quality improvement initiative was undertaken at maternity-newborn care unit of a tertiary-care hospital. A team involving Neonatologists/Pediatricians, Obstetricians, Anaesthesiologists, and Nurses in concerned areas identified problem areas using Fish bone analysis. Situational analysis was done through process flow mapping. Three Plan-do-study-act cyles were undertaken. Firstly, sensitization of personnel was done and a written policy was made. Secondly, maternal counselling and procedural modifications were done. Lastly, efforts were made to improve duration of contact.

Results

Rate of early skin-to-skin contact after Plan-do-study-act cycle 1, 2 and 3, respectively was 87.5%, 90% and 83.3%. It was 100% after sustainability phase after four months.

Conclusion

Early skin-to-skin contact was achievable through sensitization of all persons involved and simple procedural changes. Prolonging duration of contact remained a challenge.

     

Improving Preterm Motor Control:

No abstract available for this article.     

Reducing Waiting-time of Preterm Babies at a Retinopathy of Prematurity Clinic: A Quality Improvement Project

Objective

To decrease the waiting time for preterm babies visiting the Retinopathy of prematurity clinic in a tertiary eye hospital.

Design

Interventional study.

Setting

Tertiary eye care hospital.

Patients

All preterm babies reporting for screening and follow up at Retinopathy of prematurity clinic.

Intervention/Procedure

A quality improvement team comprising of a faculty (team leader), two senior residents, two junior residents, one nursing officer, and a registration staff was constituted. Fish bone analysis was done to understand various reasons for the high waiting time for preterm babies. Baseline data was collected followed by multiple Plan-Do-Study-Act (PDSA) cycles.

Main outcome measures

Average waiting-time, maximum waiting-time, and last baby entry-time were measured.

Results

The median average waiting-time, maximum waiting-time and last baby entry-time at baseline were 90.5 min (range 74.1 to 118.8 min), 177.5 min (range 160 to 190 min) and 111 min (90 to 118 min), respectively. At the end of 3rd PDSA cycle, these reduced to 77.6 min (range 55.2 to 94.3 min), 122 min (range 110 to 135 min), and 60 min (range 45 to 80 min), respectively and were sustained; the decrease from baseline being 14.3%, 31.2%, and 46%, respectively.

Conclusion

The time spent in the waiting area at the Retinopathy of Prematurity clinic was significantly reduced by simple changes in the process flow.

     

Quality Improvement Collaborative for Preterm Infants in Healthcare Facilities

Across all healthcare settings, it is important not only to provide safe and effective healthcare, but also to ensure that it is timely, patient-centered, efficient and equitable. There is a wide variability in neonatal and perinatal outcomes in India and other developing countries, with certain units demonstrating clinical outcomes that match the developed world, while others showing higher than expected mortality and morbidity. Collaborative quality improvement initiatives offer a pragmatic way to improve performance of healthcare delivery within and between neonatal units. Variations in application of evidence-based healthcare process and dependent health outcomes can be identified and targeted for improvement in quality improvement cycles. We herein describe the concept of Collaborative quality improvement, and the success stories of the best-known Collaborative quality improvement initiatives across the world. We also highlight the process and progress of creating Collaborative quality improvement in our country.