Neonatal Nurse Practitioner Children’s WI Slinger, Wisconsin, United States
Background: Occurrences in the first hour of life impact morbidity and mortality for extremely premature infants. Evidence recommends following predetermined and standardized processes during the first 60 minutes of an infant’s life. Within our unit we have noted significant delays in the admission of extremely premature infants, particularly in the time to initiation of intravenous fluids (IVF) with resultant hypoglycemia. Objective: We aim to decrease the time to dextrose containing IVF and improve hypoglycemia rates for extremely preterm infants by standardizing and optimizing admission. Design/Methods: This work took place in our 70 bed Level 4 NICU which admits about 35 infants with gestational age under 28 weeks from an attached delivery unit annually. The quality improvement team consisted of physicians, nurse practitioners, nurses, respiratory therapists, pharmacists, and leadership. We developed a driver diagram (Figure 1). In 2023 we implemented a standard approach to small baby admission tasks. We encouraged teams to initiate dextrose containing IVF quickly, generally via an unconfirmed umbilical line before final securement. We created reference binders containing flow diagrams which subsequently transitioned to checklists, photos, and additional resources. We created a new admission order set specially for this population.
The outcome measures were the time to dextrose containing IVF initiation and percentage of infants with glucose less than 35g/dL on admission. Process measures included time from birth to arrival in the NICU and time to x-ray confirmation of line placement.
Balancing measures included lines dislodged during line placement and failure to achieve central venous and arterial access. Results: Since implementation in February 2023, we have admitted 17 qualifying infants. There was a decrease in time to IVF (Figure 2). Hypoglycemia rates improved from 26% to 11%. There was also a decreased time to confirmatory x-ray (88 minutes to 77 minutes of age). Time of arrival to NICU was stable at 27 minutes of age. There have been no documented cases of line dislodgement during admission, all umbilical central venous lines were placed successfully, and 13 of 17 central umbilical arterial lines were successful.
Conclusion(s): With the implementation of standard work for extremely premature admissions, we saw an improvement in the time to initiation of IVF and a reduction in hypoglycemia. Next steps include evaluating delivery room efficiencies as well as other outcomes including time to medication delivery and time to incubator closure. Small baby Driver Diagram.jpeg
