Quality Improvement – NeoPed Quality

Newborns treated in NICUs tend to have a high percentage of complications, and some of them die or have poor developmental outcomes in their future lives. That, in turn, leads to many lawsuits filed against neonatologists, nurses, and healthcare institutions. Some estimate that no less than 60% of neonatologists were part of at least one lawsuit during their career. In my separate article, I described the most common diagnoses and situations associated with medico-legal cases. This article is directed to parents, neonatologists, NICU nurses, administrators, and lawyers. I will discuss basic strategies that can be instituted in the NICU to improve patient outcomes and decrease liability risks. Controlling external factors The NICU is not an isolated environment in a hospital. Doctors and nurses interact with other hospital departments every day. For each of our patients, we use imaging services, laboratories, pharmacies, and IT. Their performance will impact the quality of care provided to our tiny patients. If a significant delay or error occurs in any of those ancillary departments, the consequences for the baby may be grave. Diagnosis may be delayed or wrong, treatment may be delayed, or the wrong medication may be administered to the patient. Providing blood testing or radiological services to neonates differs significantly from providing these services to adults. Therefore, personnel need additional training and ongoing supervision. Also, many NICUs do not treat extremely premature babies regularly, and due to low exposure to such cases, skills among staff deteriorate. Medical directors and charge nurses need to be constantly aware of skill levels among staff and in ancillary departments and remedy any deficiencies. Ensuring that staff has all necessary licenses and certifications All professionals working in a hospital are expected to hold specific certificates and licenses. Some of them expire yearly or every 2-5 years. Although having a certificate does not guarantee competence, having personnel who did not renew their licenses or certificates exposes an institution to liability. Ensuring ongoing education and training I explained above that ongoing training and practice are crucial to maintaining appropriate skill levels. In small hospitals, neonatal emergencies may occur only once a year or even less frequently. Some of these situations are listed below: Birth of a 23-weeker in a level 1 or 2 Hospital A baby with severe pneumothorax A baby with severe blood loss during labor requiring urgent blood transfusion A baby with severe bleeding due to coagulopathy A cyanotic heart disease A baby with HIE If a level 1 or 2 hospital has only 800 births a year, a severe case of pneumothorax may occur only once in 3 years. Diagnosis of pneumothorax and subsequent treatment requires special skills in neonatologists and staff. Knowing the location of needed equipment and being trained on how to use it is crucial. During my practice, especially in small or underserved area hospitals, I happened to be in situations where staff could not locate a chest tube or did not know how to connect negative pressure suction to the chest tube after I had inserted it (steps during treatment of pneumothorax). Regular training and performance testing using skill stations can help to avoid all such situations. Although many hospitals organize such trainings, I think they do not conduct them frequently enough. Providing proper staffing according to severity and number of patients Staffing needs in the NICU depend on the number of treated babies and their acuity level. Sometimes, rural nurseries have only one or two patients at a time. On occasion, their administrators keep only one nurse on site and another on call. Unfortunately, this is not a safe practice because a sadden neonatal emergency may occur in the labor room or emergency room, and there will not be enough skilled nurses to take care of such a patient in a timely manner. Nursing staffing plans should take into account not only current nursery occupancy but also the possibility of an emergency. In addition, relying on nurses being moved from other hospital departments to the nursery and pretending that it solves a problem can be a very unsafe practice. Regular review of policies and training staff on their application Each hospital department has multiple policies on performing specific procedures or acting when XYZ occurs. Examples of such policies are listed below: Hypoglycemia protocol Evaluating baby for possible infection Evaluating baby for jaundice Administration of Surfactant Administration of prophylactic medications to a baby right after its birth Assessments needed to be done before discharge home Each policy or protocol should be assessed regularly for its accuracy and relevance. In addition, medical and nursing directors should institute regular training and ensure compliance with departmental policies. Deviations from policies are allowed as they are only guidelines, and certain patient-specific conditions may occur. However, doctors and nurses must properly document why policies have not been followed to avoid potential liability. Following quality indicators Each medical director, in collaboration with the unit director and hospital quality director, must decide which quality indicators are relevant to their institution and patient population. For NICUs, I list some examples below: Mortality rates by gestational age and birth weight Number of late infections Number of accidental extubations Number of medication errors Number of readmissions within a month after discharge home Percentage of babies with specific diagnoses: NEC, ROP, IVH, BPD, PDA Number of babies receiving breast milk Average number of days on ventilator and oxygen by gestational age and diagnosis Quality improvement activities Each hospital and each healthcare manager and director should design the most appropriate plans to review and improve the quality of healthcare services provided to patients served in the hospital, in our case, the NICU. Some of the available tools are briefly described below. Getting active feedback from parents and staff Administrative directors need to seek frequent feedback from parents and their staff. An open-door policy and anonymous mailboxes to solicit feedback are helpful. Gathering complaints and suggestions to improve practices are necessary activities in each NICU. Neonatal Chart reviews Chart reviews serve multiple purposes in a hospital environment. Administrators, medical directors, utilization committees, peer review committees, and risk management managers review medical charts regularly to fulfill their mandates. The most frequent reasons for which we review charts are listed below: review of physicians' performance for hospital credentialing purposes Ensuring that policies are followed ensuring proper coding and billing by professionals preventing overuse of laboratory and radiological services Patients complain about the quality of care. Following various quality indicators and ensuring that optimal care was provided to patients (review of deaths, transfers, hospital-acquired infections, readmissions, falls, medication errors, delays in diagnosis and treatment) If you would like my help reviewing a neonatal chart please follow this link. Initiatives to improve lagging quality indicators Doctors and hospital administrators need to understand that there is always room for improvement in healthcare quality. We are not perfect; medical knowledge is constantly changing, and patients' needs evolve over time. Some quality improvement initiatives conducted by multiple states in the USA exemplify the best approach to such an improvement. Numerous NICUs within a state (North Carolina or Illinois are just two examples) conducted organized efforts to help each other in nonthreatening and professional environments. In those collaborations, each NICU strived to improve its quality of care, and at the same time shared its results and methods. The best-known initiatives are listed below, and you can find more details about them on the internet at PQCNC for North Carolina and at ILPQC for Illinois: Reducing Early Elective Deliveries Mothers and Babies Affected by Opioids Neonatal CABSI (preventing central line infections) Improving Rates of Breast Feeding Improving Care of Late Preterm Baby There are multiple opportunities for NICUs to join quality improvement initiatives on local, regional, or state levels. Medical and nursing directors should determine where their unit is lagging the most and how to improve it. Random quality checks in the NICU Random quality checks are like random TSA checks in an airport. They occur unexpactedly for the passengers and in our case for the staff. As a director, I can have a box with 15 items to survey, and each day I pick one on which to focus during my "quality rounds" in the unit. For example, on Monday, I can check if monitor alarms are correctly set; on Tuesday, if Newborn Screens are being performed on time and documented well; and on Wednesday, whether nurses provide enough education to parents regarding the benefits of breastfeeding. Depending on the results, I will remove or add certain items to my random quality checks each month. Summary: I hope I proved to you that continuous improvement in healthcare quality is a must and is possible. This article is general. However, I wanted to introduce at least some "healthcare quality concepts" to parents, healthcare professionals, and lawyers, showing that such efforts are necessary and should be expected in each hospital and NICU setting.