Reducing intraventricular hemorrhage following the implementation of a prevention bundle for neonatal hypothermia

Sustained Reduction in Severe Intraventricular Hemorrhage in Micropremature Infants: A Quality Improvement Intervention

BACKGROUND

Quality improvement (QI) interventions may reduce the incidence and severity of Intraventricular Hemorrhage (IVH) in the population of inborn micropremature infants (born at ≤26 weeks' gestation) with the goal of improving outcomes in this high-risk population.

METHODS

A multidisciplinary team reviewed the current literature to develop a site-specific brain protective bundle. Baseline data were collected from June 2014 to February 2015, with interventions occurring from March 2015 to December 2015. The period of sustainability was assessed from January 2016 to December 2023. Control charts were used to analyze the effect of the interventions. Outcome measures included all grades of IVH, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), and spontaneous intestinal perforations (SIP).

RESULTS

Brain care initiatives decrease the rate of severe IVH in the inborn micropremature infant population from a baseline of 21% to 6.45% with a sustained rate of 4.5% with no change to balancing measures.

CONCLUSIONS

Brain-protective initiatives such as midline head positioning and minimal handling are associated with a significant and sustained reduction in severe IVH among inborn micropremature infants.

Quality Improvement Interventions to Prevent Intraventricular Hemorrhage: A Systematic Review

OBJECTIVES

Quality improvement may reduce the incidence and severity of intraventricular hemorrhage in preterm infants. We evaluated quality improvement interventions (QIIs) that sought to prevent or reduce the severity of intraventricular hemorrhage.

METHODS

PubMed, CINAHL, Embase, and citations of selected articles were searched. QIIs that had reducing incidence or severity of intraventricular hemorrhage in preterm infants as the primary outcome. Paired reviewers independently extracted data from selected studies.

RESULTS

Eighteen quality improvement interventions involving 5906 infants were included. Clinical interventions in antenatal care, the delivery room, and the NICU were used in the QIIs. Four of 10 QIIs reporting data on intraventricular hemorrhage (IVH) and 9 of 14 QIIs reporting data on severe IVH saw improvements. The median Quality Improvement Minimum Quality Criteria Set score was 11 of 16. Clinical intervention heterogeneity and incomplete information on quality improvement methods challenged the identification of the main reason for the observed changes. Publication bias may result in the inclusion of more favorable findings.

CONCLUSIONS

QIIs demonstrated reductions in the incidence and severity of intraventricular hemorrhage in preterm infants in some but not all settings. Which specific interventions and quality improvement methods were responsible for those reductions and why they were successful in some settings but not others are not clear. This systematic review can assist teams in identifying potentially better practices for reducing IVH, but improvements in reporting and assessing QIIs are needed if systematic reviews are to realize their potential for guiding evidence-based practice.

Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants

INTRODUCTION

Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited.

METHODS

Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed.

RESULTS

Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71).

CONCLUSION

Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.