A quality improvement initiative to reduce necrotizing enterocolitis in high-risk neonates.

OBJECTIVE: Prompted by an acute increase in necrotizing enterocolitis (NEC) rates, we aimed to decrease the rate of stage 2 or greater NEC in infants born at <1500 grams or <30 weeks gestational age from 19.5% to less than 9.7% (a 50% reduction) within 18 months, without adversely affecting central line-associated bloodstream infection (CLABSI) rates. STUDY DESIGN: We utilized Define, Measure, Analyze, Improve, and Control (DMAIC) as our improvement model. Informed by our key driver diagram and root cause analyses, six Plan-Do-Study-Act cycles were completed. RESULTS: 147 infants in the QI initiative had a median gestational age of 28.1 weeks and a median birthweight of 1070 grams. NEC rates decreased from the QI baseline of 19.5% to 6% (p = 0.03). Oral care administration increased, and maximal gavage tube dwell time decreased. CONCLUSION: NEC rates decreased during this QI initiative through a combination of multidisciplinary interventions aimed at reducing dysbiosis.

Reducing Opioid Exposure in a Level IV Neonatal Intensive Care Unit.

INTRODUCTION: Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project's primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months. METHODS: A multidisciplinary care team used Define, Measure, Analyze, Improve, Control methodology to identify root causes of the quality gap including: (1) inconsistent reporting of objective pain scales; (2) variable provider prescribing patterns; and (3) variable provider bedside assessment of pain. These root causes were addressed by two interventions: (1) standardized reporting of the premature infant pain profile scores and (2) implementation of an analgesia management pathway. RESULTS: Mean opioid exposure, measured in morphine equivalents, in infants less than 1,250 g at birth during their first 14 days of life decreased from 0.64 mg/kg/d (95% confidence interval 0.41-0.87) at baseline to 0.08 mg/kg/d (95% confidence interval 0.03-0.13) during the postintervention period (P < 0.001). There was no statistical difference in rates of days to full feedings, unintentional extubations, or central line removals between epochs. CONCLUSIONS: Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.

Increased RhoA translocation in renal cortex of diabetic rats.

RhoA, a member of the Rho small G protein family, mediates multiple intracellular signaling pathways, and is highly expressed in renal cortex. RhoA translocation is associated with RhoA activation. This study was undertaken to examine the relation of translocation of RhoA in the renal cortex with diabetic renal injury in streptozotocin (STZ)-induced diabetic rats. Male Sprague-Dawley rats were divided into control and diabetic groups and were studied at 8 weeks after STZ-injection (55 mg/kg, i.v). We found that the kidney weight and urinary protein excretion were significantly increased in diabetic rats. Diabetic glomerulopathy was confirmed by mesangial matrix expanding and glomerular basement membrane thickening. The ratio of membrane-bound RhoA verses cytosolic RhoA is 1.8 fold higher (p < 0.01) in diabetic group, indicating an enhanced RhoA translocation. There was no significant difference in total RhoA protein expression and RhoA mRNA expression between diabetic and control groups. These data suggest that RhoA translocation might be involved in diabetic renal injury.