Abstract
Objective
Prompted by an acute increase in necrotizing enterocolitis (NEC) rates, we aimed to decrease the rate of stage 2 or greater NEC in infants born at <1500 grams or <30 weeks gestational age from 19.5% to less than 9.7% (a 50% reduction) within 18 months, without adversely affecting central line-associated bloodstream infection (CLABSI) rates.
Study design
We utilized Define, Measure, Analyze, Improve, and Control (DMAIC) as our improvement model. Informed by our key driver diagram and root cause analyses, six Plan-Do-Study-Act cycles were completed.
Results
147 infants in the QI initiative had a median gestational age of 28.1 weeks and a median birthweight of 1070 grams. NEC rates decreased from the QI baseline of 19.5% to 6% (pā=ā0.03). Oral care administration increased, and maximal gavage tube dwell time decreased.
Conclusion
NEC rates decreased during this QI initiative through a combination of multidisciplinary interventions aimed at reducing dysbiosis.
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Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
References
Sharma R, Hudak ML. A clinical perspective of necrotizing enterocolitis: past, present, and future. Clin Perinatol. 2013;40:27ā51.
Neu J. Necrotizing enterocolitis. Pediatr Clin North Am. 1996;43:409ā32.
Mowitz ME, Dukhovny D, Zupancic JAF. The cost of necrotizing enterocolitis in premature infants. Semin Fetal Neonatal Med. 2018;23:416ā9.
Bazacliu C, Neu J. Necrotizing enterocolitis: long term complications. Curr Pediatr Rev. 2019;15:115ā24.
Rose AT, Patel RM. A critical analysis of risk factors for necrotizing enterocolitis. Semin Fetal Neonatal Med. 2018;23:374ā9.
Cacho NT, Parker LA, Neu J. Necrotizing enterocolitis and human milk feeding. Clin Perinatol. 2017;44:49ā67.
Xiong T, Maheshwari A, Neu J, Ei-Saie A, Pammi M. An overview of systematic reviews of randomized-controlled trials for preventing necrotizing enterocolitis in preterm infants. Neonatology. 2020;117:46ā56.
Denning NL, Prince JM. Neonatal intestinal dysbiosis in necrotizing enterocolitis. Mol Med. 2018;24:4.
Pammi M, Cope J, Tarr PI, Warner BB, Morrow AL, Mai V, et al. Intestinal dysbiosis in preterm infants preceding necrotizing enterocolitis: a systematic review and meta-analysis. Microbiome. 2017;5:31.
Bazacliu C, Neu J. Pathophysiology of necrotizing enterocolitis: an update. Curr Pediatr Rev. 2019;15:68ā87.
Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990;336:1519ā23.
Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawƶger R, Kiechl-Kohlendorfer U, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatrics. 2010;156:562ā7.
Morgan RL, Preidis GA, Kashyap PC, Weizman AV, Sadeghirad B. Probiotics reduce mortality and morbidity in preterm, low-birth-weight infants: a systematic review and network meta-analysis of randomized trials. Gastroenterology. 2020;159:467ā80.
Cotten CM, Taylor S, Stoll B, Goldberg RN, Hansen NI, SĆ”nchez PJ, et al. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009;123:58ā66.
Greenwood C, Morrow AL, Lagomarcino AJ, Altaye M, Taft DH, Yu Z, et al. Early empiric antibiotic use in preterm infants is associated with lower bacterial diversity and higher relative abundance of Enterobacter. J Pediatr. 2014;165:23ā29.
Romaine A, Ye D, Ao Z, Fang F, Johnson O, Blake T, et al. Safety of histamine-2 receptor blockers in hospitalized VLBW infants. Early Hum Dev. 2016;99:27ā30.
Ma A, Yang J, Li Y, Zhang X, Kang Y. Oropharyngeal colostrum therapy reduces the incidence of ventilator-associated pneumonia in very low birth weight infants: a systematic review and meta-analysis. Pediatr Res. 2021;89:54ā62.
Garofalo NA, Caplan MS. Oropharyngeal motherās milk: state of the science and influence on necrotizing enterocolitis. Clin Perinatol. 2019;46:77ā88.
Patel AL, Trivedi S, Bhandari NP, Ruf A, Scala CM, Witowitch G, et al. Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods. J Perinatol. 2014;34:850ā7.
Yee WH, Soraisham AS, Shah VS, Aziz K, Yoon W, Lee SK. Incidence and timing of presentation of necrotizing enterocolitis in preterm infants. Pediatrics. 2012;129:e298āe304.
Battersby C, Santhalingam T, Costeloe K, Modi N. Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018;103:F182ā9.
Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am. 1986;33:179ā201.
Moreno-Fernandez J, SĆ”nchez-MartĆnez B, Serrano-LĆ³pez L, MartĆn-Ćlvarez E, Diaz-Castro J, PeƱa-Caballero M, et al. Enhancement of immune response mediated by oropharyngeal colostrum administration in preterm neonates. Pediatr Allergy Immunol. 2019;30:234ā41.
Quigley M, Embleton ND, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2019;7:1465ā858.
American Society for Quality. The Define, Measure, Analyze, Improve, Control (DMAIC) Process. [Accessed June 20, 2022]. Available from: https://asq.org/quality-resources/dmaic
Pyzdek T, Keller PA. The Six Sigma Handbook: A Complete Guide for Green Belts, Black Belts, and Managers at All Levels, Third edn. McGraw Hill: New York, NY, 2010.
Michie S, Van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.
NeoMed. NeoConnect Feeding Tubes for ENFit Instructions for Use. 2018. [Accessed June 11, 2020]. Available from: https://www.neomedinc.com/wp-content/uploads/2019/06/NeoConnect-Feeding-Tubes-for-ENFit-Instructions-for-Use.pdf
Patel AL, Meier PP, Canvasser J. Strategies to increase the use of motherās own milk for infants at risk of necrotizing enterocolitis. Pediatr Res. 2020;88:21ā24.
Meier PP, Johnson TJ, Patel AL, Rossman B. Evidence-based methods that promote human milk feeding of preterm infants. Clin Perinatol. 2017;44:1ā22.
Miracle DJ, Meier PP, Bennett PA. Mothersā decisions to change from formula to mothersā milk for very-low-birth-weight infants. J Obstet Gynecol Neonatal Nurs. 2004;33:692ā703.
Meier PP, Engstrom JL, Patel AL, Jegier BJ, Bruns NE. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010;37:217ā45.
Committee on nutrition, Section on breastfeeding, Committee on fetus and newborn, Daniels S, Corkins M, de Ferranti S, et al. Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics. 2017;139:e20163440.
Montgomery DC. Introduction to Statistical Quality Control. John Wiley & Sons, Inc., 2013.
Hurrell E, Kucerova E, Loughlin M, Caubilla-Barron J, Hilton A, Armstrong R, et al. Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae. BMC Infect Dis. 2009;9:146.
van den Akker CHP, van Goudoever JB, Shamir R, Domellƶf M, Embleton ND, Hojsak I, et al. Probiotics and preterm infants: a position paper by the European society for paediatric gastroenterology hepatology and nutrition committee on nutrition and the European society for paediatric gastroenterology hepatology and nutrition working group for probiotics and prebiotics. J Pediatr Gastroenterol Nutr. 2020;70:664ā80.
Bafeta A, Koh M, Riveros C, Raaud P. Harms reporting in randomized controlled trials of interventions aimed at modifying microbiota. Ann Intern Med. 2018;169:240ā7.
Esaiassen E, Cavanagh P, Hjerde E, Simonsen GS, StĆøen R, Klingenberg C. Bifidobacterium longumSubspeciesinfantisBacteremia in 3 Extremely Preterm Infants Receiving Probiotics. Emerg Infect Dis. 2016;22:1664ā6.
Vermeulen MJ, Luijendijk A, Toledo L, Kaam AH, Reiss IKM. Quality of probiotic products for preterm infants: Contamination and missing strains. Acta Paediatrica. 2020;109:276ā9.
Poindexter B, Cummings J, Hand I, Adams-Chapman I, Aucott SW, Puopolo KM, et al. Use of probiotics in preterm infants. Pediatrics. 2021;147:e2021051485.
Kaplan HC, Provost LP, Froehle CM, Margolis PA. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf. 2012;21:13ā20.
Larson CE, Larson C, LaFasto FMJ, Fasto FML. Teamwork: What Must Go Right/What Can Go Wrong. SAGE Publications, 1989.
Gray KD, Messina JA, Cortina C, Owens T, Fowler M, Foster M, et al. Probiotic use and safety in the neonatal intensive care unit: a matched cohort study. J Pediatr. 2020;222:59ā64.e51.
Javidi D, Wang Z, Rajasekaran S, Hussain N. Temporal and seasonal variations in incidence of stage II and III NECāa 28-year epidemiologic study from tertiary NICUs in Connecticut, USA. J Perinatol. 2021;41:1100ā9.
Acknowledgements
The authors would like to thank Roxanne Torgerson, RN and Angela Giese, RN for their advocacy in promoting QI interventions in the NICU during this project.
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SCM: Conceptualization, methodology, formal analysis, investigation, data curation, visualization, writing- original draft. CMG: Conceptualization, methodology, investigation, writing- review & editing. MM, DLH, BNS, RCS: Methodology, writing- review & editing. MMM and LAS: Methodology, investigation, writing- review & editing. VSS: Project administration, writing- review & editing. JLF: Conceptualization, methodology, formal analysis, supervision, writing- review & editing.
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Mavis, S.C., Gallup, M.C., Meyer, M. et al. A quality improvement initiative to reduce necrotizing enterocolitis in high-risk neonates. J Perinatol 43, 97ā102 (2023). https://doi.org/10.1038/s41372-022-01476-5
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DOI: https://doi.org/10.1038/s41372-022-01476-5