Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management
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Katherine Carlton
Abstract
Objectives
Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines.
Methods
A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied.
Results
We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score.
Conclusions
Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient’s EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.
Funding source: National Center for Research Resources
Funding source: National Center for Advancing Translational Sciences
Funding source: National Institutes of Health
Award Identifier / Grant number: UL1TR001436
Funding source: Medical College of Wisconsin
Acknowledgments
This study was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number UL1TR001436. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. We would like to thank the MCW Division of Neonatology and the members of the CHW Neonatal Neurocritical Care Program for their support.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Ethical approval: Approval was granted through Children’s Wisconsin Institutional Review Board with waiver of informed consent.
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Supplementary Material
The online version of this article offers supplementary material (https://doi.org/10.1515/jpm-2020-0095).
© 2020 Walter de Gruyter GmbH, Berlin/Boston
Artikel in diesem Heft
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- Original Articles – Obstetrics
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- Initial review of pregnancy and neonatal outcomes of pregnant women with COVID-19 infection
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Artikel in diesem Heft
- Frontmatter
- Review
- Clinical evaluation of labor: an evidence- and experience-based approach
- Original Articles – Obstetrics
- How fever is defined in COVID-19 publications: a disturbing lack of precision
- Initial review of pregnancy and neonatal outcomes of pregnant women with COVID-19 infection
- Usefulness of COVID-19 screen-and-test approach in pregnant women: an experience from a country with low COVID-19 burden
- Clinical chorioamnionitis at term X: microbiology, clinical signs, placental pathology, and neonatal bacteremia – implications for clinical care
- Cytokine profiling: variation in immune modulation with preterm birth vs. uncomplicated term birth identifies pivotal signals in pathogenesis of preterm birth
- Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome
- A novel technique for prediction of preterm birth: fetal nasal flow Doppler
- Pregnant women’s knowledge and behaviour to prevent cytomegalovirus infection: an observational study
- Reference intervals and reliability of cavum septi pellucidi volume measurements by three-dimensional ultrasound between 19 and 24 weeks’ gestation
- First-trimester presentation of ultrasound findings in trisomy 13 and validation of multiparameter ultrasound-based risk calculation models to detect trisomy 13 in the late first trimester
- Pre-operative tranexemic acid vs. etamsylate in reducing blood loss during elective cesarean section: randomized controlled trial
- External validation of a prediction model on vaginal birth after caesarean in a The Netherlands: a prospective cohort study
- The influence of race on cervical length in pregnant women in Brazil
- Original Articles – Fetus
- A 24-segment fractional shortening of the fetal heart using FetalHQ
- Original Articles – Neonates
- Antenatal corticosteroids and short-term neonatal outcomes in term and near-term infants of diabetic mothers. Analysis of the Qatar PEARL-peristat registry
- Acute respiratory effect of transpyloric feeding for respiratory exacerbation in preterm infants
- Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management
- Letter to the Editor
- Cross transmission of SARS-CoV-2 and obstetric ultrasound
- ‘Getting to zero’ cross transmission of SARS-CoV-2 in obstetric ultrasound during COVID-19 pandemic
