Caregiver Innovations to Reduce Harm in Neonatal Intensive Care

Principal Investigator: Eric J. Thomas, M.D., University of Texas, Houston, TX
AHRQ Grant No.: HS24459
Project Period: 09/30/15–09/29/21
Description: The goal of the University of Texas Patient Safety Learning Laboratory was to create an environment of collaborative learning focused on reducing all-cause preventable harm by 50 percent in the neonatal intensive care unit (NICU).

The specific aims were to:

1. Increase parent engagement.
2. Improve staff training on nutrition and respiratory care in neonates.
3. Decrease central line-associated bloodstream infections.

This learning lab’s three cores of multidisciplinary experts engaged NICU caregivers to develop a multimethod trigger-based, prospective clinical surveillance system to detect all-cause preventable harm. More specifically, the following provides examples of individual core accomplishments.

• The measurement core developed causal-loop diagrams and a simulation model to help identify various individual-, team-, and unit/organizational-level factors associated with harms and quality improvement (QI)-related outcomes. This model showed how policies designed to affect those factors resulted in changes to outcomes.¹ The measurement core also created a tool to assess the processes and teamwork during QI team meetings and a new survey to measure stakeholder attitudes about QI interventions.
• The electronic health record (EHR) core identified and developed the Safer Dx Trigger Tools Framework that enables health systems to develop and implement e-trigger tools.^2,3 They also identified nine challenges to help healthcare organizations, health information technology developers, researchers, policymakers, and funders focus their efforts on health information technology-related patient safety. As of August 2021, the Centers for Medicare & Medicaid Services requires eligible hospitals to attest to having completed an annual self-assessment of their EHR using SAFER guides.
• The parent engagement core used an observational, mixed-methods design of field observations, interviews, and surveys with parent advisors, clinicians, and leaders involved with the NICU. This core obtained data to detect preventable harms in the NICU and the impact of parent engagement on QI initiatives. They found that parents of hospitalized infants in the NICU observe and can report problems/harms, if asked. Through this work, researchers describe a stepwise approach to implementing a QI-based parent advisory council that could be applicable to any hospital or ambulatory unit.⁴ 

A product from this lab resulted in a debriefing tool designed for use after each unplanned extubation (UPE) to help entire care teams understand events leading to UPEs. This tool led to a 100 percent capture of UPEs and reduced the number of unknown UPEs since it was implemented.⁴ 

Another intervention is “Nutrition Goal-Based Rounding,” a new feeding protocol to fill gaps in nutritional deficits that offers new rounding with more thorough documentation.⁴ Early results showed a slight increase in average calories and protein intake among neonates but no change in growth deficits.

In addition, the lab designed and implemented a Robust Process Improvement® (RPI) training program to increase organizational improvement capacity. They empowered clinical and operational leadership and frontline workers with the tools and authority to identify, implement, and evaluate change at the bedside in partnership with patients and families.⁴ Leaders, staff, and parent participants applied their RPI training to improvement initiatives, which resulted in improvements of UPEs, very low birth weight infant nutrition, and central line-associated blood stream infections.⁵

This lab’s work has resulted in at least 13 peer-reviewed journal publications.

Publications

2021

• Fris E,  et al. Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS). BMJ Open Quality 2021;10:e001332.
• Nether, K. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual 2022 Jan-Feb 01;44(1):23-30.

2020

• Singh H, Sittig DH. A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework. Ann Intern Med 2020;172(11 Suppl):S92-100.
• Sittig DF, et al. Current challenges in health information technology-related patient safety. Health Informatics J 2020;26(1):181-9.

2019

• Murphy DR, et al. Application of electronic trigger tools to identify targets for improving diagnostic safety. BMJ Qual Saf 2019;28:151-9.
• Ottosen MJ, et al. An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit. Adv Neonatal Care 2019;19(6):500-8.

2018

• Sedlock EW, et al. Assessing Quality Improvement Team Processes - A Meeting Observation Tool. SCITS Conference: Thematic Paper Sessions/Panels. 2018. https://sts.memberclicks.net/assets/2018_SciTS_docs/2018SciTSAbstracts_Final.pdf.
• Sedlock EW, et al. Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit. J Patient Saf Risk Manag 2018;23(4):167-75.
• Sittig DF, et al. Adherence to recommended electronic health record safety practices across eight health care organizations. J Am Med Inform Assoc 2018;25(7):913-8.
• Sittig DF, et al. Improving the safety of health information technology requires shared responsibility: it is time we all step up. Healthc (Amst) 2018;6(1):7-12.

2017

• Robinson JR, et al. Measuring the value of a clinical practice guideline for children with perforated appendicitis. Ann Surg 2017 Jul;266(1):195-200.

2016

• Russo E, et al. Challenges in patient safety improvement research in the era of electronic health records. Healthc (Amst) 2016 Dec;4(1):285-90.

References

1. Fris E, et al. Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS). BMJ Open Quality 2021;10(4):e001332.
2. Murphy DR, et al. Application of electronic trigger tools to identify targets for improving diagnostic safety. BMJ Qual Saf 2019 Feb;28(2):151-9.
3. Singh H, Sittig DF. A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework. Ann Intern Med 2020 Jun;172(11 Suppl):S92-100.
4. Thomas EJ. Progress Report:  Caregiver Innovations To Reduce Harm in Neonatal Intensive Care. Houston: University of Texas Health Science Center; 2018.
5. Nether KG, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual 2022 Jan-Feb 01;44(1):23-30.