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 expectedmortality and morbidity. Collaborative quality improvement initiatives offer a pragmatic way to improve performance of healthcaredelivery within and between neonatal units. Variations in application of evidence-based healthcare process and dependent healthoutcomes can be identified and targeted for improvement in quality improvement cycles. We herein describe the concept ofCollaborative quality improvement, and the success stories of the best-known Collaborative quality improvement initiatives across theworld. We also highlight the process and progress of creating Collaborative quality improvement in our country.

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

Objective: To determine efficacy of Point-of-care Qualityimprovement (POCQI) in early initiation (within 30 minutes) ofemergency treatment among sick neonates.Design: Quality improvement project over a period of twentyweeks.Setting: Special Newborn Care Unit (SNCU) of a tertiary carecenter 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 sicknewborns. After baseline phase of one month, a qualityimprovement (QI) team was formed and conducted three PDSAcycles (PDSA I , PDSA II and PDSA III) of 10 d each, followedby a post-intervention phase over 3 months.Main outcome measure(s): Percentage of sick babies gettingearly emergency management at SNCU triage.Results: 309 neonates were enrolled in the study (56 inbaseline phase, 88 in implementation phase and 212 in post-intervention phase). Demographic characteristics includingbirthweight and gestational age were comparable amongbaseline and post intervention cohorts. During implementationphase, successful early initiation of management was notedamong 47%, 69% and 80% neonates following PDSA I, PDSA IIand PDSA III, respectively. In comparison to baseline phase, thepercentage of neonates receiving treatment within 30 minutesof arrival at triage increased from 20% to 76% (P<0.001) andthe mean (SD) time of initiation of treatment decreased from80.8 (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 alsosignificantly lower among post intervention cohort in comparisonto baseline cohort.Conclusion: Stepwise implementation of PDSA cyclessignificantly increased the percentage of sick newborns receivingearly emergency management at the SNCU triage, therebyresulting in better survival.

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 earlyinitiation of breastfeeding at birth on operation table amonghealthy term and late pretem babies born by caesarean sectionsfrom 0% to 80% in eight weeks.Methods: A quality improvement initiative was undertaken atmaternity-newborn care unit of a tertiary-care hospital. A teaminvolving Neonatologists/Pediatricians, Obstetricians,Anaesthesiologists, and Nurses in concerned areas identifiedproblem areas using Fish bone analysis. Situational analysis wasdone through process flow mapping. Three Plan-do-study-actcyles were undertaken. Firstly, sensitization of personnel wasdone and a written policy was made. Secondly, maternalcounselling and procedural modifications were done. Lastly,efforts were made to improve duration of contact.Results: Rate of earlyskin-to-skin contact after Plan-do-study-act cycle 1, 2 and 3, respectively was 87.5%, 90% and 83.3%. Itwas 100% after sustainability phase after four months.Conclusion: Early skin-to-skin contact was achievable throughsensitization of all persons involved and simple proceduralchanges. Prolonging duration of contact remained a challenge.

Decreasing Central Line-associated Bloodstream Infections through Quality Improvement Initiative

Objectives: To study the impact of a quality improvement (QI)initiative using care bundle approach on Central-line associatedbloodstream infections (CLABSI) rates.Methods: A QI team for infection control in NICU was formed in atertiary-care neonatal intensive care unit (NICU) from June 2015to August 2016. Baseline data were collected over first 3 monthsfollowed by the intervention period of 1 year. Measures withrespect to strengthening hand hygiene and central line bundlecare were implemented during the intervention period. Auditsassessing the compliance to hand hygiene and CLABSI bundleprotocols were used as process indicators. Multiple PDSA cycleswere used to strengthen the practices of proposed interventions,documentation of data and audits of the processes during thestudy period.Results: The QI initiative achieved a 89% reduction in CLABSIfrom the baseline rate of 31.7 to 3.5 per 1000 line-days. The bloodstream Infections reduced from 7.3 to 2.3 per 1000 patient-days.The overall mortality showed a reduction from 2.9% to 1.7 %during the intervention period. There was a significantimprovement in compliance with hand hygiene protocol andcompliance with CLABSI protocols.Conclusion: This study demonstrated that simple measuresinvolving hand hygiene and strengthening of the care bundleapproach through quality improvement could significantly reducethe blood stream Infections and CLABSI rates

Impact of Quality Improvement Program on Expressed Breastmilk Usage in Very Low Birth Weight Infants

Objective: To improve the usage of expressed breast milk invery low birth weight infants admitted in the neonatal intensivecare unit of a tertiary centre in India.Methods: Between April 2015 and August 2016, various Plan-do-act-study cycles were conducted to test change ideas likeantenatal counselling including help of brochure and video, post-natal telephonic reminders within 4-6 hours of birth,standardization of Kangaroo mother care, and non-nutritivesucking protocol. Data was analyzed using statistical processcontrol charts.Results: 156 very low birth weight infants were deliveredduring the study period, of which 31 were excluded due tovarious reasons. Within 6 months of implementation, theproportion of very low birth weight infants who receivedexpressed breast milk within 48 hours improved to 100% from38.7% and this was sustained at 100% for next 8 months. Themean time of availability and volume of expressed breast milkwithin 48 hours, improved gradually from 73.3 h to 20.9 h and 4.7mL to 15.8 mL, respectively. The mean proportion of expressedbreast milk once infant reached a feed volume of 100 mL/kg/dayalso improved from 61.3% to 82.3%.Conclusion: Quality improvement interventions showedpromising results of increased expressed breast milk usage invery low birth weight infants.