Quality-Improvement Effort to Christine Andrews, MD, MPH, a Colleen Whatley, MSN, CNS-BC, RNC-OB,b Meaghan Smith, MSN, RN-BC, c ReduceEmily Caron Brayton, RN, Hypothermia ADN, b Suzanne Simone, BSN, b Alison Volpe AmongHolmes, MD, MPHa, b High- Risk Infants on a Mother-Infant Unit BACKGROUND AND OBJECTIVE: abstract – Neonatal hypothermia is common in low birth ’ weight (LBW) (<2500 g) and late-preterm infants (LPIs) (34 0/7 36 6/7 weeks gestation).‍ It can be a contributory factor for newborn admission to a NICU, resulting in maternal-infant separation and increased resource use.‍ Our objective was to study the efficacy of a quality-improvement bundle aDepartment of Pediatrics, Hasbro Children’s Hospital, Providence, Rhode Island; bChildren’s Hospital at of hypothermia preventive measures for LPIs and/or LBW infants in a Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, METHODS: mother-infant unit.‍ Lebanon, New Hampshire; and cDepartment of Women’s and Children’s Services, Elliot Health System, Manchester, We conducted plan-do-study-act (PDSA) cycles aimed at decreasing New Hampshire environmental hypothermia for LPIs and/or LBW infants in a mother-infant Dr Andrews reviewed and collected patient data, unit with no other indications for NICU-level care.‍ Interventions included conducted the data analysis, drafted initial versions using warm towels after delivery, a risk identification card, an occlusive of the abstract and manuscript, and reviewed and hat, delayed timing of first bath, submersion instead of sponge-bathing, and revised the manuscript; Mrs Whatley participated in the project team meetings as a newborn nursery conducting all assessments under a radiant warmer during the initial hours perinatal clinical specialist and reviewed and of life.‍ We implemented these interventions in 3 PDSA cycles and followed revised the manuscript; Mrs Smith participated in RESULTS: hypothermia rates by using statistical process control methods.‍ the project team meetings as a newborn nursery nurse manager and reviewed and revised the The baseline mean monthly hypothermia rate among mother-infant manuscript; Mrs Brayton participated in the project − P unit LPIs and/or LBW infants was 29.‍8%.‍ Postintervention, the rate fell to team meetings as a newborn nursery nurse, directly participated in the implementation of 13.‍3% ( 16.‍5%; = .‍002).‍ This decrease occurred in a stepwise fashion − P targeted interventions in the mother-infant unit, and in conjunction with the PDSA cycles.‍ In the final, full-intervention period, reviewed and revised the manuscript; Mrs Simone the rate was 10.‍0% ( 19.‍8%; = .‍0003).‍ A special-cause signal shift was participated in the project team meetings as a CONCLUSIONS: observed in this final period.‍ newborn nursery nurse and reviewed and revised the manuscript; Dr Holmes conceptualized and Targeted interventions can significantly reduce hypothermia designed the improvement initiative and the plan of in otherwise healthy LPIs and/or LBW newborns and allow them to safely study, led the project team meetings, and reviewed and revised the manuscript; and all authors remain in a mother-infant unit.‍ If applied broadly, such preventive practices approved the final manuscript as submitted and could decrease preventable hypothermia in high-risk populations.‍ agree to be accountable for all aspects of the work. This work was presented at the Academic Pediatric – – Association Regional Meeting; March 14, 2016; 11 Boston, MA; Pediatric Hospital Medicine 2016; Newborn hypothermia is associated surface area to body mass ratios.‍ July 28-31, 2016; Chicago, IL; and the Pediatric with an increased risk of neonatal Interventions that reduce neonatal Academic Societies 2017 Meeting; May 6-9, 2017; San Francisco, CA. hypoglycemia,– respiratory distress, hypothermia include immediate DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1214 sepsis,1 metabolic9 acidosis, and drying, head caps, early skin-to-skin– death.‍ The prevalence of neonatal placement, occlusive plastic wraps, ° 2, 10 13 Accepted for publication Sep 18, 2017 hypothermia, defined 10as a rectal and immersion tub-bathing.‍ temperature <36.‍0 C, is increased Combining these thermoregulation To cite: Andrews C, Whatley C, Smith M, et al. in low birth weight (LBW) (<2500 g) strategies is most effective because – ’ Quality-Improvement Effort to Reduce Hypothermia and late-preterm infants (LPIs) together they target all the Among High-Risk Infants on a Mother-Infant Unit. (34 36 6/7 weeks gestation) mechanisms of heat loss: radiation, Pediatrics. 2018;141(3):e20171214 because of decreased intrinsic evaporation,9, 11,conduction,14, 15 and thermoregulation and higher convection.‍ Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 141, number 3, March 2018:e20171214 QUALITY REPORT TABLE 1 Outline of the PDSA Bundles Implemented in the Mother-Infant Unit PDSA 1 PDSA 2 PDSA 3 To date, studies of newborn July 2015 August 2015 December 2015 hypothermia have been restricted to the NICU population, omitting Population: All Newborns Population: LPIs and LBW Newborns Population: All Newborns the much larger population of LPIs Immediately towel dry after birth High-risk crib card ID All baths delayed >12 h and higher weight categories of Occlusive hat Submersion baths LBW newborns, many of whom Delay bath >12 h Assessments under radiant warmer are cared for in mother-infant ID, identification. units rather than NICUs.‍ At our institution, mother-infant unit LPIs ’ include infants between 35 and METHODS 36 6/7 weeks gestation, whereas Context of the PDSA bundles, an e-mail was mother-infant unit LBW infants sent out to all the providers working include those between 1750 and in the mother-infant unit, and the 2500 g.‍ Because mother-infant units This QI project was implemented charge nurse played an active role have more variable environments ’ in the mother-infant unit at the in disseminating the new policies.‍ than NICUs and generally do not Biweekly audits were done by a use extrinsic heat sources, such Children s Hospital at Dartmouth- Hitchcock (CHaD), a 63-bed, medical student and reported back as radiant warmers and isolettes, ’ to the hypothermia team to ensure interventions that enhance newborn Children's Hospital Association- accredited children s hospital within that all the interventions were being thermoregulation may be even implemented.‍ more effective in these settings.‍ a 396-bed, tertiary-care center (Dartmouth-Hitchcock Medical Additionally, neonatal hypothermia ’ ∼ The first PDSA bundle occurred in in a mother-infant unit requires Center) in Lebanon, New Hampshire.‍ July 2015 and involved thoroughly active management, including the use CHaD s mother-infant unit has 1200 drying all infants immediately after of equipment, testing, and staffing inborn deliveries annually and is birth with towels before mother- needs that can result in transfers to composed of 22 Labor, Delivery, infant skin-to-skin contact.‍ Before the NICU.‍ Precluding hypothermia Recovery, and Postpartum (LDRP) this, drying at birth was implemented in this higher-risk population in beds and 19 bassinettes with mother with nonabsorbing, soft blankets.‍ and infant residing in the same room.‍ a mother-infant unit could ease ≥ The second PDSA bundle occurred in Otherwise-healthy infants remain in provider workload and prevent ’ ≥ August 2015 and specifically targeted the mother-infant unit if they are 35 unnecessary and costly escalation known mother-infant unit LPIs and weeks gestation and weigh 1750 g of care.‍ LBW infants and consisted of the at birth.‍ Per CHaD policy, infants who ° following:• have a confirmed rectal temperature We noted a hypothermia rate of <36 C should be transferred to the • Use of a plastic-lined, knit hat; 29.‍1% for mother-infant unit LPIs NICU.‍ and/or LBW newborns and 9.‍5% for Interventions Delaying baths until at least all newborns in our mother-infant • 12 hours after birth; unit at an academic, tertiary-care Conducting all provider hospital with an adjacent level A small team of health care providers assessments in the first 12 hours of 3 regional NICU.‍ Hypothermia met bimonthly to identify areas • life under a radiant warmer; and correction was consuming significant of care improvement to prevent nursing and physician time and newborn hypothermia.‍ The team Identifying LPIs and/or LBW effort leading to laboratory testing consisted of a pediatric hospitalist, a infants with a crib card containing and potential NICU transfers.‍ Our nurse manager, the unit clinical nurse a reminder to implement these hypothesis was that most newborn specialist, several mother-infant unit practices.‍ hypothermia was due to improvable nurses (including charge nurses), and Before this bundle, there were no environmental factors and was a medical student.‍ These meetings specific thermoregulation protocols therefore preventable.‍ The aim resulted in the development of in place for mother-infant unit LPIs of this quality-improvement (QI) care practice standards that were and/or LBW births.‍ There was no project was to reduce the incidence implemented across 3 plan-do- standardization of hat use, the timing of neonatal hypothermia in a mother- study-act (PDSA) bundles and of baths, or the location of newborn infant unit by implementing multiple rolled out to physician and nursing physical assessments.‍ Bathing thermoregulation strategies with a staff by using the usual methods of occurred between 2 and 3 hours of particular project