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A quality improvement initiative to reduce necrotizing enterocolitis in high-risk neonates



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.


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% (p = 0.03). Oral care administration increased, and maximal gavage tube dwell time decreased.


NEC rates decreased during this QI initiative through a combination of multidisciplinary interventions aimed at reducing dysbiosis.

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Fig. 1: Key driver diagram summarizing the improvement theory.
Fig. 2: Annotated P-chart of necrotizing enterocolitis (NEC) rate during the quality improvement (QI) initiative.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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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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Authors and Affiliations



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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Correspondence to Stephanie C. Mavis.

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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 (2022).

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