231 - The outcome of a Severe Intraventricular haemorrhage prevention bundle, in very low birth weight infants. Application of a modified Quality improvement methodology.

Poster Number: 231
Publication Number: 231.127

Thowfique K. Ibrahim, KK women's and Children's Hospital, Singapore, N/A, Singapore; Arpan Agarwal, KK Women's and Children's Hospital, Singapore, N/A, Singapore; Darolyn Tan, -, Singapore, N/A, Singapore; Abdul Alim Abdul Haium, Duke-NUS Medical School, Singapore, Singapore, N/A, Singapore; Sharifah Bte Sarjono, KKH Women & Children Hospital Pte.Ltd, Singapore, N/A, Singapore; Maria Chona Badillo, KKhospital, Singapore, N/A, Singapore; Nirmal Visruthan Kavalloor, KK Women's and Children's hospital, Singapore, N/A, Singapore; Rehena Sultana, Duke-NUS Medical School, Singapore, N/A, Singapore; Victor Samuel Rajadurai, KK Women's and Children's Hospital, Singapore, N/A, Singapore

Background: Severe intraventricular haemorrhage (IVH)  can lead to significant risk of death and neurodevelopmental delay in Very Low Birth Weight (VLBW, ≤ 1.5 kg) infants.

Objective: The objective of this study was to ascertain the outcome of the implementation of a severe IVH prevention bundle, to reduce the incidence of severe IVH in VLBW infants in a tertiary Neonatal Intensive Care Unit (NICU), and to determine the validity of a modified quality improvement methodology applied in this study.

Design/Methods: All VLBW infants born from 2013 to 2019 in a tertiary care centre were categorised into two periods a) Intervention period (2013 to 2017) and study period (2018 to 2019). A total of 5 interventions were instituted during the intervention period, namely a) neutral head position and developmental care b) administration of antenatal steroid at least 48 hrs before delivery in ≤ 24 weeks gestational age infants at birth c) administration of antenatal magnesium sulphate for neuronal protection d) implementation of hypothermia prevention protocol e) Implementation of PDA management and Prophylactic indomethacin for IVH prevention, protocols. All infants, who developed severe IVH were audited with a structured checklist by a QI committee and recommendations were implemented. IVH was diagnosed with a cranial ultrasound scan by the radiologists. Papile's classification was used to classify the severity of the IVH. Univariate and multivariate analyses were conducted. An incidence run chart was configured. The data on compliance with interventions were captured. The Compliance data on the neutral head position and developmental care was lost in storage. 

Results:
A total of 1370 VLBW Infants were involved in the study, 1000 infants in the intervention period and 370 infants in the study period. The mean gestational age of infants was 28.6 weeks in the intervention and study period. 11 key recommendations from the severe IVH QI Audit committee were implemented. The Compliance with interventions was a) 80% for PDA and IVH prophylaxis protocol b) 92.4% for hypothermia protocol c) 97% for antenatal steroid protocol. 56% of mothers of VLBW infants received Magnesium Sulphate. A non-random variation was noted on the run chart. The Incidence of severe IVH in the intervention period and the study period was 4.4 and 1.9% (adjusted OR 0.266,  p= 0.006, 44/1000 vs 7/370) respectively.
Conclusion(s):
The bundle has significantly reduced the rate of severe IVH to less than 2% in the study population. The modified quality improvement methodology was found to be effective in decreasing the severe IVH burden in VLBW infants.

Figure 1: Flow diagram of study cohort representing infants in Epoch 1 period (Intervention period) and Epoch 2 period (post intervention period) with incidence of severe IVH in the corresponding periods.Infant recruitment
Table 2: Summary of Infant CharacteristicsInfant Characteristics