Evaluation and development of potentially better practices for the prevention of brain hemorrhage and ischemic brain injury in very low birth weight infants.

OBJECTIVE: Neonatal care providers from 5 institutions formed a multidisciplinary focus group with the purpose of identifying potentially better practices, the implementation of which would lead to a reduction in the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants. METHODS: Practices were analyzed, 4 benchmark neonatal intensive care units were identified and evaluated, and the literature was assessed using an evidence-based approach. The work was also reviewed by a nationally respected expert. RESULTS: Ten potentially better clinical practices were identified. In addition, variability in cranial ultrasound practice, related to both procedural process and interpretation, was identified as a confounding problem in evaluating quality. Using the same process, potentially better cranial ultrasound practices were also identified. CONCLUSIONS: Implementation of these practices will improve clinical outcomes as well as the reliability of sonogram interpretation, the basis for evaluating the quality of the team's work.

Implementation of potentially better practices for the prevention of brain hemorrhage and ischemic brain injury in very low birth weight infants.

OBJECTIVE: Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants. METHODS: Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone. RESULTS: Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process. CONCLUSIONS: The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia.