Chronic lung disease (CLD) is a common morbidity for infants born prematurely. CLD — also known as bronchopulmonary dysplasia — is defined as a need for supplemental oxygen or ventilator support at 36 weeks gestational age. CLD affects roughly two thirds of extremely low birth weight infants.
The rate of incidence of CLD has driven many hospitals to implement strategies to reduce its frequency in NICU patients. One popular strategy is to benchmark against Vermont Oxford Network (VON) data. The VON is a nonprofit collaboration of healthcare professionals working together to improve outcomes and increase the quality, safety and value of newborn care. The VON maintains a clinical database of information about extremely low birth weight infants and releases reports to its members with data and strategies for care improvement.
Beginning in 2008, Sheridan Healthcare undertook an improvement project aimed at reducing the incidence of CLD at its hospitals, using VON recommended practices and benchmarking data. Sheridan’s commitment to best-in-class care for premature babies and increased emphasis on teamwork have resulted in a significant drop in the rate of CLD across all NICUs in the Sheridan network.
Tackling Chronic Lung Disease in Preemies
Beginning in the second half of 2008, Sheridan began preparing for the quality improvement initiative by collecting baseline data from each of its NICUs. After a year and a half of project planning and prep work, Sheridan’s neonatology team sent out communications asking each NICU to selected one of four “potentially better practices” (PBPs) to implement (the VON prefers the term “potentially better practice” to “best practice” because it recognizes that one strategy may not work best at all hospitals). The four PBPs that Sheridan NICUs could choose from were evidence-based strategies for reducing the risk of CLD among newborns:
- Early caffeine treatment for babies less than 1Kg (10 grams)
- Oxygen saturation targeting at 88-95% fir babies less than 1.5Kg
- Room air challenge testing at 32, 34 and 36 postmenstrual age
- Antenatal steroids for babies at 23-33 weeks gestation age
NICUs implemented one PBP from Q1 of 2010 through the end of 2011 and reported their outcomes. At the start of 2012, NICUs were asked to implement all four of the PBPs. Sheridan collected data on the CLD rate and conformance rates among practices by querying their PremiEHR clinical database. The results were quantified and were then shared with each NICU in a quarterly Quality Management report. PremiEHR helped Sheridan NICUs collect the data, and the software also helped NICU nurses, doctors and therapists monitor an infant’s documented oxygen level, respiratory support and medication, and provided reminders when infants were due for challenge testing under the program.
In addition to collecting and analyzing the PremiEHR data, Sheridan’s neonatology team also conducted quality site visits. The site visits incorporated team building exercises to align the nurses, respiratory therapists and physicians. Ensuring consistent understanding of the program, goals and division of new responsibilities across the care team was critical to the success of the program. Sheridan’s team also worked with its hospitals to create an environment conducive to teamwork. For example, Sheridan encouraged hospitals to send out weekly communications to notify care teams of patients nearing CLD criteria. The increased communication ensured all care team members were informed of a patient’s status and fostered more effective distribution of care responsibilities.
Sheridan’s neonatal improvement project was extremely successful in lowering the incidence of CLD in newborns. During the five-year-long project, Sheridan was able to drop its incidence of CLD well below VON’s mean — VON’s data shows 24 percent of extremely low birth weight infants at member NICUs are affected by CLD, while just 16 percent of Sheridan patients are affected. The baseline CLD rate for all NICUs in the Sheridan neonatal network was 37 percent in 2008, so Sheridan was able to decrease its CLD rate by nearly 57 percent.
Beyond the improved care outcomes, Sheridan’s NICUs also experienced tremendous cost savings. According to the Journal of Pediatrics, the incremental cost of a CLD patient is $31,562 (as of 2013). Altogether, Sheridan NICUs were able to save 800 cases of CLD, resulting in averted costs of $25 million for Sheridan hospitals.
Sheridan’s employment of VON’s PBPs and its dedication to collaboration between NICU care team members significantly improved care for infants at risk of CLD. To learn more about Sheridan’s neonatal services, visit our neonatology page.