Preventing Pressure Injuries in Neonates Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: An Interprofessional Quality Improvement Project.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) can be caused by multiple factors including pressure, shear, friction, moisture/incontinence, device-related pressure, immobility, inactivity, and nutritional deficits. Along with immobility, medical device-related (MDR) HAPIs are a primary cause of pressure injury in neonates, as the clinical practice setting has become increasingly technologically advanced. It is estimated that up to 50% of HAPIs are MDR in pediatric patients. Neonates are at particular risk for HAPI because of their specific anatomical, physiological, and developmental vulnerabilities. A specific example of confluent factors that may increase risk for HAPI is the application of therapeutic hypothermia (TH) and continuous electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy (HIE). INTERVENTIONS: An interprofessional team collaborated to expand upon existing evidence-based standards of care to address the needs of this specific population within the neonatal intensive care unit (NICU). Interventions centered on revision of current protocols, with efforts to optimize product selection, hardwire assessment practices, and refine documentation of patient care and outcomes. METHODS: The team primarily utilized plan-do-study-act (PDSA) cycles to test and refine specific methods and strategies to reduce HAPIs. Tested solutions were adopted, adapted, or abandoned. RESULTS: A sustained zero HAPI rate in the HIE population resulted. The team continues to collect, report, and utilize near-miss data to continue to refine the process as new risks are identified. IMPLICATIONS FOR PRACTICE: Recognizing the unique skin protection needs of special populations within the NICU, such as those undergoing TH, is crucial. When evidence-based standards of care fail to adequately meet such needs, a collaborative approach to identifying, testing, and implementing population-specific solutions is essential. IMPLICATIONS FOR RESEARCH: A paucity of literature regarding the unique skin protection needs for babies undergoing TH exists. Work should be done to better describe the influence of TH on skin integrity, with the goal of identifying population-specific protective measures.

Got (the Right) Milk? How a Blended Quality Improvement Approach Catalyzed Change.

BACKGROUND: The expression, storage, preparation, fortification, and feeding of breast milk are common ongoing activities in many neonatal intensive care units (NICUs) today. Errors in breast milk administration are a serious issue that should be prevented to preserve the health and well-being of NICU babies and their families. PURPOSE: This paper describes how a program to improve processes surrounding infant feeding was developed, implemented, and evaluated. METHODS: The project team used a blended quality improvement approach that included the Model for Improvement, Lean and Six Sigma methodologies, and principles of High Reliability Organizations to identify and drive short-term, medium-term, and long-term improvement strategies. FINDINGS/RESULTS: Through its blended quality improvement approach, the team strengthened the entire dispensation system for both human milk and formula and outlined a clear vision and plan for further improvements as well. The NICU reduced feeding errors by 83%. IMPLICATIONS FOR PRACTICE: Be systematic in the quality improvement approach, and apply proven methods to improving processes surrounding infant feeding. Involve expert project managers with nonclinical perspective to guide work in a systematic way and provide unbiased feedback. Create multidisciplinary, cross-departmental teams that include a vast array of stakeholders in NICU feeding processes to ensure comprehensive examination of current state, identification of potential risks, and "outside the box" potential solutions. IMPLICATIONS FOR RESEARCH: As in the realm of pharmacy, the processes involved in preparing feedings for critically ill infants should be carried out via predictable, reliable means including robust automated verification that integrates seamlessly into existing processes. The use of systems employed in pharmacy for medication preparation should be considered in the human milk and formula preparation setting.