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NYSPQC Perinatal Quality Collaborative: Neonatal Initiatives

Enteral Nutrition Improvement Project

The New York State Perinatal Quality Collaborative (NYSPQC) Enteral Nutrition Improvement Project aims to reduce the percentage of newborns <31 weeks gestational age who are discharged from a Regional Perinatal Center (RPC) Neonatal Intensive Care Unit (NICU) below the tenth percentile for growth on Fenton scales for weight and head circumference. The project addresses a problem revealed by a review of NYSDOH NICU Module admission and discharge data. High rates of extrauterine growth restriction by time of hospital discharge have been identified at most RPCs. Similar findings were reported more than a decade ago by the 12 National Institute of Child Health and Human Development Neonatal Research Network centers. The same group has identified a significant effect of NICU growth velocity on neurodevelopmental and growth outcomes at 18 to 22 months’ corrected age.

There is reason to believe that standardizing the approach to enteral nutrition within a NICU can improve nutritional outcomes and also further decrease central line (CL) use. Therefore, the NYSPQC is encouraging and assisting RPCs to standardize – at the level of the individual NICU – their enteral nutrition practices and, together with the NYSDOH, to monitor nutritional outcomes. Data will be available to evaluate the effect of standardized practices within one and one-half to two years.

This intervention will be disseminated to all RPC network affiliate hospitals with NICU-level care. This population-based, statewide program will promote critical review of evidence-based practice and inform questions concerning sustainability, performance variation among hospitals, and potentially better practices among the various standardized approaches.

CLABSI Reduction Project

In 2008, NYS’s 18 RPCs participated in an intervention specifically focused on reducing central line associated blood stream infections (CLABSIs) in NICU patients. Through this initiative, the RPCs demonstrated that use of standardized central line care bundles and central line maintenance checklists led to a significant statewide decline in these infections. (Joseph Schulman, et al, “Statewide NICU Central-Line Associated Bloodstream Infection Rates Decline after Bundles and Checklists,” Pediatrics, 127.3 (March 2011): 436.)

As a result of the RPC CLABSI reduction initiative, central and umbilical line infection rates among participating RPCs decreased 67% statewide between 2008 and 2010. By comparison, these infection rates have remained higher among NYS’s Level III NICUs. Further, comparison of data for RPCs and Level III hospitals from the 2010 HAI Program’s Pre-Audit Hospital survey revealed a variety of differences in protocols and practices between RPCs and Level III NICU sites in NYS.

Based on these results, the NYSPQC has expanded the intervention to include hospitals with NYS DOH Level III perinatal designations.

The 2008 RPC-led intervention focused on reducing central line associated blood stream infections. Progress was monitored based on data concerning infections acquired in their NICUs that NYS RPCs and Level III hospitals must report to the NYSDOH Hospital Acquired Infections (HAI) program via the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Using the same data source, the new, expanded initiative is focusing on both central and umbilical line associated blood stream infections in accordance with changes in the HAI program’s data reporting which now combines these infections into one category.

This initiative seeks to establish uniform care practices for a defined aspect of NICU care across NYS and monitor population-based effectiveness along with remaining institutional performance variation, thereby informing ongoing improvement.