MANUSCRIPT CITATION

Andrews C, Whatley C, Smith M, et al. Quality-Improvement Effort to Reduce Hypothermia Among High-Risk Infants on a Mother-Infant Unit. Pediatrics. 2018;141(3):e20171214. PMID: 29444816

REVIEWED BY

Alexander Howes, Paediatric Basic Trainee
Department of Neonatal Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia

Amy Keir, Consultant Neonatologist
Department of Neonatal Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia
Healthy Mothers, Babies and Children Theme, South Australian Health and Medical Institute, North Adelaide, South Australia
Robinson Research Institute and the Adelaide Medical School, the University of Adelaide, Adelaide, South Australia

TYPE OF INVESTIGATION

Quality improvement

QUESTION

In low birthweight and late preterm infants on mother-infant units, do multi-faceted preventive interventions compared to usual care reduce the rates of hypothermia?

METHODS

• Design: Quality improvement study using Plan-Do-Study- Act (PDSA) cycles
• Allocation: Not applicable
• Blinding: Not applicable
• Follow-up period: Not applicable
• Setting: Mother-infant unit at the Children’s Hospital at Dartmouth-Hitchcock Medical Centre in Lebanon, New Hampshire, USA. This is a 83 bed Children’s Hospital Association accredited children’s hospital within a 396 bed tertiary centre.
• Patients: All infants born at Dartmouth-Hitchcock Medical Centre who remained within the mother-infant unit at time of delivery ≥ 35⁺⁰ weeks and ≥ 1750 grams (g) admitted to mother-infant unit. The subgroup of interest were the late preterm (35⁺⁰ – 36⁺⁶ weeks’ gestational age) and/or low birth weight (1750 – 2500 g) infants admitted to this unit.
• Exclusions: Deceased infants, stillbirths or infants transferred to neonatal intensive care unit (NICU) within the first 24 hours of life for a reason other than hypothermia.
• Included patients:
  • All infants fitting the inclusion criteria were included. Of note, infants transferred with a hypothermic event (as defined by a rectal temperature of <36.0 °C in the first 24 hours of life) with a concurrent reason for transfer, such as hypoglycaemia, sepsis or hyperbilirubinemia were also included.
• Intervention: Three PDSA cycles as follows –
  • First PDSA cycle: All newborns July 2015 admitted to the mother-infant unit –
    • Thoroughly drying all infants immediately after birth with towels before mother-infant skin-to-skin contact.
  • Second PDSA cycle: Late preterm infants (LPI) and low birth weight (LBW) only in August 2015 –
    • Use of a plastic-lined, knit hat;
    • Delaying baths until at least 12 hours after birth;
    • Conducting all provider assessments in the first 12 hours of life under a radiant warmer; and
    • Identifying LPIs and/or LBW infants with a crib card containing a reminder to follow these practices.
  • Third PDSA cycle: All infants December 2015 admitted to the mother-infant unit –
    • Delayed baths for all newborns until at least 12 hours of age and standardized submersive bathing
• Outcomes:
  • Primary outcome: Monthly proportion of newborns who became hypothermic within the first 24 hours of life.
  • Secondary outcomes: Monthly proportion of newborns who became hyperthermic (as defined by a rectal temperature of >37.5°C in the first 24 hours of life) within the first 24 hours of life
• Analysis and Sample Size:
  • No sample size calculation was performed
  • Changes in monthly percentages of newborns with hypothermia events were measured using traditional (boxpots and t tests) and statistical process control (SPC) methods. For the SPC methods, P-charts (control charts) were used to compare the monthly percentages of hypothermic events over the 27 month study period
• Patient follow-up: Not applicable

MAIN RESULTS

This quality improvement study investigating the use of evidence-based hypothermia prevention strategies, using three PDSA cycles, found that the rates of hypothermia were sequentially reduced. The study was conducted over a 27 month study period (July 2014 to September 2016) with 2570 eligible births with 2161 meeting the eligibility criteria. In the pre-intervention months, prior to the commencement of the PDSA intervention cycles, the hypothermia rate was three times higher in low birthweight (LBW) and late pre-term infants (LPIs) compared to all mother-infant unit infants. A total of 1003 mother-infant births occurred in the pre-intervention group with 110 having hypothermic events (11%). Post intervention, after the conclusion of the third and final PDSA intervention cycle, the average monthly hypothermia rates was reduced from a pre-intervention rate of 29.8% to 13.3%. A total of 1158 infants were included in the post intervention group, with 114 having hypothermic events (9.8%). Across the three time periods, hypothermia rates reduced from 29.8% to 19.2% to 10.0% respectively.

CONCLUSION

The proportion of hypothermic events in the mother-infant unit, in a subgroup of LBW and LPIs, was successfully reduced through the implementation of multiple strategies supported by repeat PDSA cycles.

COMMENTARY

Hypothermia, especially in low birthweight (LBW) and late preterm infants (LPIs), is associated with neonatal mortality and morbidity.(1, 2) This quality improvement study investigated the use of multiple thermoregulation interventions to prevent hypothermia in this population. Previous clinical trials have shown evidence for the use of multiple combined thermoregulation interventions compared to individual interventions in isolation.(3, 4) In this study, several thermoregulatation strategies were implemented, including of a plastic-lined knit hat, delaying baths until at least 12 hours of age, conducting all assessments in the first 12 hours of life under a radiant warmer and the clear identification of at risk infants. It showed that these strategies decreased the hypothermic rates in LBW and LPIs sequentially over the three PDSA cycles. These results strength the evidence base that multiple thermoregulation interventions are superior to single intervention approaches in the prevention of neonatal hypothermia. This study is of importance as LBW and LPIs are an understudied group, in particular in the area of quality improvement activities. Most studies to date surrounding the prevention of hypothermia have been restricted to neonatal intensive care units.(3)

This study is, however, limited in its generalisability, as the study was performed in a small hospital nursery unit where the strategies were easily communicated amongst the relatively small numbers of staff. This may be more difficult to implement in larger institutions where there is a greater turnover of nursery staff. The study did not take into account seasonal variations, which may have had an effect in the environmental temperatures affecting the rates of hypothermia, as well as other potential unmeasured differences. The study did not report timing of temperature measurements, numbers of times per day temperatures were routinely measured and the environment in which the infant was in when identified as hypothermic e.g. during kangaroo care or in a cold room. Collection of data around medical interventions precipitated by the diagnosis of hypothermia would have strengthened the study. There were also a number of benefits identified in this study. The results from the third PDSA cycle, implementing several thermoregulations strategies in combination, significantly decreased the rates of hypothermia in the study population subgroup (LBWs and LPIs). The implementation of these simple, low-cost strategies had a clinically meaningful decrease in hypothermic rates. In other highly resourced settings, these approaches may have a similar effects on hypothermia rates in LBW and LPIs. This has the potential to decrease further medical complications in this group, e.g. hypoglycaemia, decrease the likelihood of maternal-infant separation, and reduce healthcare costs.

Further large, multi-centre trials are warrented in the area of thermoregulation strategies in the population of LBW and LPIs. This could go on to further develop universal strategies to be implemented throughout mother-infant nurseries to significantly reduce hypothermic rates in newborn infants, thereby decreasing morbidity and reducing healthcare costs.

REFERENCES

1. Leadford AE, Warren JB, Manasyan A, Chomba E, Salas AA, Schelonka R, et al. Plastic bags for prevention of hypothermia in preterm and low birth weight infants. Pediatrics 2013; 132 1:e128-34.
2. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival. BMC Med 2013; 11:24.
3. McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2018; 2.
4. Russo A, McCready M, Torres L, Theuriere C, Venturini S, Spaight M, et al. Reducing hypothermia in preterm infants following delivery. Pediatrics 2014; 133 4:e1055-62.