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  • Quality Improvement Article
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Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project

Journal of Perinatology volume 39, pages 143–151 (2019)Cite this article

Subjects

Abstract

Objective

Our specific, measurable, attainable, relevant, and time-limited (SMART) aim was to reduce the incidence of severe intracranial hemorrhage (ICH) among preterm infants born <30 weeks’ gestation from a baseline of 24% (January 2012–December 2013) to a long-term average of 11% by December 2015.

Study design

We instituted an ICH bundle consisting of elements of the “golden hour” (delayed cord clamping, optimized cardiopulmonary resuscitation, improved thermoregulation) and provision of cluster care in the neonatal intensive care unit (NICU). We identified key drivers to achieve our SMART aims, and implemented quality improvement (QI) cycles: initiation of the ICH bundle, education of NICU staff, and emphasis on sustained adherence. We excluded infants born outside our facility and those with congenital anomalies.

Results

Using statistical process control analysis (p-chart), the ICH bundle was associated with successful reduction in severe ICH (grade 3–4) in our NICU from a prebundle rate of 24% (January 2012–December 2013) to a sustained reduction over the next 4 years to an average rate of 9.7% by December 2017. Results during 2016–2017 showed a sustained improvement beyond the goal for 2014–2015. Over the same interval, there was improvement in admission temperatures [median 36.1 °C (interquartile range: 35.3–36.7 °C) vs. 37.1 °C (36.8–37.5 °C), p < 0.01] and a decrease in mortality rate [pre: 16/117 (14%) vs. post: 16/281 (6%), P < 0.01].

Conclusion

Our multidisciplinary QI initiative decreased severe ICH in our institution from a baseline rate of 24% to a lower rate of 9.7% over the ensuing 4 years. Intensive focus on sustained implementation of an ICH bundle protocol consisting of improved delivery room management, thermoregulation, and clustered care in the NICU was temporally associated with a clinically significant reduction in severe ICH.

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Acknowledgments

We thank all our collaborators and NICU staff; Dr. R. Donald Garrison for his leadership, building the foundation that has become the ICH bundle; Dr. Philipp Aldana for encouraging us to report our findings; and Dr. Matt Garber for his expertize on quality improvement. Lastly, we thank all our infants who continually inspire us; and their families who have trusted us not only to do what is right but also to improve on our best efforts.

Author information

Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA

    Nicolas Chiriboga, Josef Cortez, Adriana Pena-Ariet, Kartikeya Makker & Mark L. Hudak

  2. Center for Health Equity and Quality Research, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA

    Carmen Smotherman & Shiva Gautam

  3. Department of Women’s and Children’s Nursing Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA

    Allison Blair Trikardos & Mark Yeoman

  4. Department of Rehabilitation Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA

    Holly Knight

  5. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA

    Erin Burnett

  6. Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA

    Alexandra Beier

  7. Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA

    Inbal Cohen

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  1. Nicolas Chiriboga
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Correspondence to Josef Cortez.

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Chiriboga, N., Cortez, J., Pena-Ariet, A. et al. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project. J Perinatol 39, 143–151 (2019). https://doi.org/10.1038/s41372-018-0257-x

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