407 - REST - Rapid Evaluation and Stabilization of Tiny Infants: A Quality Improvement Initiative

Poster Number: 407
Publication Number: 407.436

Lisa Grady, Women & Infants Hospital of Rhode Island, Providence, RI, United States; Giulia Molinaro, Crozer Keystone Health System, Media, PA, United States; Richard Tucker, Women & Infants Hospital of Rhode Island, Providence, RI, United States; Mara G. Coyle, Women & Infants Hospital of Rhode Island, Providence, RI, United States

Background:
The term “Golden Hour” has been used to describe the critical first hour of treatment in the care of preterm infants. Previous research shows care during the first hours of life can impact short-term morbidities associated with prematurity including hypo/hyperthermia, hypoglycemia, and sepsis. In addition to addressing these short-term issues, efficient stabilization can also impact long term morbidities, specifically IVH, BPD, and neurodevelopmental impairment.

Objective:
To decrease the time required to stabilize infants born at ≤28 6/7 weeks gestation or with a birth weight ≤1000g upon arrival to the NICU at Women and Infants Hospital. The quality improvement initiative was named the REST Project for the Rapid Evaluation and Stabilization of Tiny Infants.

Design/Methods:
A REST protocol was developed with a multidisciplinary team and involved the education of over 220 staff members with identified champions from each discipline to facilitate education.  Figure 1 demonstrates the driver diagram developed for the implementation of the REST protocol. A pre-delivery checklist was made to ensure equipment was available and a specialized REST team identified to stabilize each infant upon admission.

A retrospective chart review (Nf25) three months prior to the start of the project was collected and prospective data (Nf62) collected for 1 year. Inclusion criteria: gestational age ≤28 6/7 weeks or birth weight ≤1000g; exclusion criteria: stillbirth, death within two hours of birth and patients requiring additional procedures precluding timely stabilization. Comparisons between the retrospective and prospective groups were made using Wilcoxon tests for continuous data and chi-square tests for categorical data.

Results:
As shown in Table 1, implementation of the REST project resulted in a statistically significant decrease in time to incubator top closure and time to central line placement. While the time to placement of a PIV was significantly shorter for the retrospective group, the percent of patients with hypoglycemia and requiring a PIV was significantly less for the prospective group. There was no difference in percentage of normothermia at time of admission, time of incubator top down or time to administration of antibiotics.
Conclusion(s):
After the introduction of the REST protocol to the NICU at Women and Infants Hospital, there was a significant decrease in the time required to stabilize extremely premature infants.The REST quality improvement project illustrates the benefit of an educational program to prioritize the importance of timely stabilization of infants in the first hours of life.

Figure 1: Driver Diagram for Implementation of REST Project
Table 1: Comparison of Pre- vs Post-REST project implementation*P < 0.05, **P < 0.01; Data is shown as mean +/- sd or percent (n)