Cleveland Clinic Children's Outcomes
The Use of Human Milk and Breastfeeding in the Neonatal Intensive Care Unit
Cleveland Clinic Children's: Human Milk at Discharge (2019)
Human milk provides many specific health benefits to the vulnerable infant, both during the hospital stay and following discharge. These benefits include a lower incidence and severity of hospital-acquired infections, and a lower incidence of necrotizing enterocolitis (NEC). Infants who are fed human milk have improved visual acuity and higher scores on tests of neurocognitive and developmental outcomes. Furthermore, studies demonstrate that there is a dose response effect of human milk on the development of white matter in the brain. Our department conducted an A3 quality project to enhance and sustain maternal breast milk feeding at discharge.
Cleveland Clinic's target benchmark for 80% of infants to receive human milk at discharge is consistent with top Children's hospitals as measured by U.S. News and World Report.
CDC. (2019). Breastfeeding report card. https://www.cdc.gov/breastfeeding/data/reportcard.htm
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(1):217-245. doi:10.1016/j.clp.2010.01.013
Reduction of Chronic Lung Disease (CLD) by Implementing Bubble CPAP (b-CPAP) Into Clinical Practice
Chronic lung disease (CLD) is a common complication encountered in premature infants, especially those supported by mechanical ventilation. Incidence of CLD is higher in infants born before 30 weeks of gestation and with birth weight less than 1,500 grams. CLD is associated with poor growth and worse neurodevelopmental outcomes. In February 2018, a bubble CPAP (b-CPAP) strategy was implemented for respiratory support of premature infants born at Cleveland Clinic Children’s Hospital. The goal was to reduce the incidence on CLD in preterm infants by avoiding intubation and invasive respiratory support when possible, in combination with using b-CPAP.
Initially, b-CPAP was introduced at the Cleveland Clinic Fairview NICU, which resulted in the reduction of CLD incidence from 22% to 8.6%, after a year of implementation. In 2019, b-CPAP was implemented at the Cleveland Clinic Hillcrest NICU, which resulted in the reduction of CLD incidence from 30% to 14%. Overall, at CCC’s NICUs, implementation of b-CPAP resulted in the reduction of CLD incidence from 26.3% in 2017 to 8.8% by the end of 2019. Future opportunities for 2020 include extension of the b-CPAP program to the Cleveland Clinic Main Campus NICU.
Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Preterm Birth: Causes, Consequences, and Prevention. Washington (DC): National Academies Press (US); 2007. 10, Mortality and Acute Complications in Preterm Infants. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11385/ https://www.ncbi.nlm.nih.gov/books/NBK11385/
VON = Vermont Oxford Network
QI= Quality Improvement
Newborn Nursery Antibiotic Utilization Rate
2018 - 2019
Antibiotics are the most commonly prescribed medications in the neonatal population throughout the country, especially in well appearing infants in the first few days of life. Many undesirable consequences have been associated with unnecessary sepsis evaluations and antibiotic exposure. A quality improvement project was conducted utilizing validated multivariate risk assessment tools (Sepsis Risk Calculator) combined with clinical assessment and close monitoring. The project was started in June 2018 for babies with sepsis risk factors. As a result, we were able to significantly decrease antibiotic utilization rates and NICU admissions without compromising balancing measures for late onset sepsis or readmissions after discharge.
Unplanned Extubation Rate
2015 - 2019
Unplanned Extubation (UE) in mechanically ventilated infants can place infants at risk for significant complications. In 2019, the CCC’s Neonatology Department implemented a number of steps in an effort to reduce the UE rate of 1.49 per 100 non-tracheostomy invasive ventilation days in 2018, to less than 1.0. This benchmark is based on other initiatives cited in the literature to reduce UE. A multidisciplinary NQC-UE team was formed with the goal to standardize a preventive bundle and share good practices across the enterprise's NICUs. The major preventive elements that were implemented during 2019 include:
- Two licensed caregivers are present for routine securing, repositioning, and/or manipulating of ETT, with one caregiver dedicated to holding the ETT during movement and repositioning.
- No traction applied to ETT at any time.
- In August 2019, a UE preventive bundle reliability audit was inititated.
- In December 2019, new guidelines for prevention of UE were approved.
The UE rate at the CCC’s Neonatology Enterprise has decreased from 1.49 in 2018 to 0.66 per 100 non-tracheostomy invasive ventilation days by the end of 2019.