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Prevention of severe brain injury in very preterm neonates: A quality improvement initiative



To determine the impact of neuroprotection interventions bundle on the incidence of severe brain injury or early death (intraventricular hemorrhage grade 3/4 or death by 7 days or ventriculomegaly or cystic periventricular leukomalacia on 1-month head ultrasound, primary composite outcome) in very preterm (270/7 to ≤ 296/7 weeks gestational age) infants.

Study design

Prospective quality improvement initiative, from April 2017-September 2019, with neuroprotection interventions bundle including cerebral NIRS, TcCO2, and HeRO monitoring-based management algorithm, indomethacin prophylaxis, protocolized bicarbonate and inotropes use, noise reduction, and neutral positioning.


There was a decrease in the incidence of the primary composite outcome in the intervention period on unadjusted (N = 11/99, pre-intervention to N = 0/127, intervention period, p < 0.001) and adjusted analysis (adjusted for birthweight and Apgar score <5 at 5 min, aOR = 0.042, 95% CI = 0.003–0.670, p = 0.024).


Neuroprotection interventions bundle was associated with significant decrease in severe brain injury or early death in very preterm infants.

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Fig. 1: Key driver diagram.
Fig. 2: Statistical process control chart showing incidence of severe brain injury or early death during the study period.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.


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We acknowledge the significant assistance of nurses and respiratory therapists in the neonatal intensive care unit at the University of Alabama Hospital for their contribution to this work, and the parents and infants in the RNICU.


No external funding was sought for the current study. We would like to thank the Perinatal Health and Human Development Research Program of the University of Alabama at Birmingham and the Children’s of Alabama Centennial Scholar Fund for supporting the divisional research projects.

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Authors and Affiliations



AK, MR, VS, WC, and NA, and were involved in the conceptualization of this study and in implementation of quality improvement initiatives. AB, SW, SY, AK, and VS were responsible for collecting data through chart review for this study. AFR, VS, MR were responsible for data analysis. All authors were involved in drafting and revising the paper and agree to be accountable for all aspects of the work and final approval of the version to be published. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Vivek V. Shukla or Manimaran Ramani.

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Shukla, V.V., Klinger, A., Yazdi, S. et al. Prevention of severe brain injury in very preterm neonates: A quality improvement initiative. J Perinatol (2022).

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