Perspectives on Safety

First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit

By Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD

Nine years ago, Maci [not her real name] was born at 23 weeks and a birth weight of 520 grams. Her skin was gelatinous, her eyelids fused, her lungs too immature to breathe, her gut too immature to tolerate food, and her immune system too immature to effectively fight infections. Maci received neonatal intensive care for 128 days from a finely tuned multidisciplinary care team to keep her alive and allow her to grow and develop. She experienced mechanical ventilation, intravenous nutrition, and blood transfusions. Nine years later, Maci is now a generally healthy young girl.

By all accounts, Maci's story is one of the successes of state-of-the art neonatal intensive care. But buried in her story are many opportunities for improvement that should help inform the future of patient safety in the neonatal intensive care unit (NICU). To keep Maci alive, the NICU team delivered care that was both outstanding and routine in NICUs across the United States. For example, they frequently checked routine blood laboratories (e.g., blood gases, electrolytes, nutritional metrics, or hematocrits) and radiographs (e.g., daily chest radiograph when intubated). This cultural approach, which derives from an assumption of pathology and aims to protect against the worst possible case, provides everyone—including clinicians and parents—with a sense of safety. However, many of these tests and treatments originate from a time when drugs, nutrition support (total parenteral nutrition [TPN]), and technology (ventilators, humidified isolettes, noninvasive monitoring) were less refined, and today may represent examples of overtreatment and overtesting.

Providers often underappreciate that these routine interventions, purported to keep patients safe, in fact, carry significant risk (blood loss, pain, infections, etc.). This risk may outweigh their utility. Maci experienced more than 1200 separate interventions, many of them painful, that conferred risk to her. Risks of overuse include the transfusion-related sequelae, infections, excessive antibiotics, and most concerningly, an association of painful stimuli with poor long-term neurodevelopmental outcomes.(1)

Newborn intensive care has delivered incremental but steady improvements in outcomes over the past few decades.(2) These improvements have led many NICUs to actively provide care for more complex infants at ever younger gestational ages (in some NICUs, newborns as preterm as 22 weeks gestation).(3) Despite very similar patient populations, significant variation in care and outcomes have been observed between NICUs.(4) At the same time, many of the "routine" interventions experienced by patients are common across NICUs. Despite being an expected part of NICU care, such routine interventions may not be supported by evidence, may no longer be necessary given progress in noninvasive methods of monitoring, and may cause more harm than good. 

Changing the "routine care" paradigm requires a cultural shift and a reorientation of thinking focused on value for the newborn and the family (Figure 1). Value-based patient safety is achieved via a collaborative, interdisciplinary team approach with a flat hierarchy. The team develops and executes care plans that are fiercely focused on minimizing interventions that are unlikely to drive therapeutic modification, thus protecting infants from the harms of overuse. Examples of this approach include eliminating unnecessary routine blood draws, judicious use of central lines, line entry, and removal, converting from intravenous to oral medications (or stopping medications) as soon as possible, and use of placental blood rather than infants' blood on admission.(5) 

This approach uses a daily count of interventions (POKEs) to be discussed on rounds and a daily plan that only allows for those interventions that will add value. This requires leadership reinforcement, psychological safety among care team members, and engagement of the entire team. Expectations for unit safety behavior and accountability for use of standard safety tools (readback, SBAR) is set by medical and nursing leadership, promoted in morning huddles (Video), and then reinforced throughout the day. Every member of the care team is expected to participate in all safety activities. Care team concerns are surfaced, and everyone participates in developing solutions to fix the systems issues. All effective solutions are rapidly disseminated via huddles and newsletters. Importantly, this approach promotes provider engagement and reduces burnout and staff turnover.(6)

Team-based rounds are family-centered, ensuring that the voice of the family is validated. After the family speaks, each member of the team presents data and recommendations for care. POKE scores are discussed by the bedside nurse. Therefore, every intervention and painful care experience is surfaced, contributing to the shared pool of understanding on care team rounds. The neonatologist synthesizes the recommendations into the care plan.(7)

This care model is not a distant utopia, rather the norm at Intermountain Healthcare's Dixie Regional Medical Center NICU in St. George, a level 3, 24-bed (48-patient capacity) unit serving southern Utah. Adoption of this approach has led to substantial reduction of key neonatal morbidities and costs of care (Figure 2). Over the past 10 years, patients have enjoyed a 50% reduction in POKEs (11,000 per year), a 28% reduction in cost of care, a 21% reduction in the length of stay for the most preterm infants, and the elimination of hospital-acquired infections (central line–associated bloodstream infections and ventilator-associated pneumonia).(E. Ridout, unpublished data, 2019) Caregivers enjoy a culture of recognition and respect, a culture in which all have a voice.

A review of the care experience of two infants from a single family, a daughter (Abi) cared for prior to implementation of this model of care and then her younger brother (Cam) cared for following implementation, exemplifies the approach. Abi and Cam [not real names] again were both born 13 weeks early with similar birthweight and equivalent issues of prematurity. Abi experienced 734 separate interventions, many painful, while Cam experienced 500 fewer interventions (the omitted interventions were each identified as being nonvalue added). His length of stay was 17 days (22%) shorter.

The future of NICU care is already here. We believe that the approach taken at Dixie Regional provides a template for other NICUs across the country and other health care settings. More interventions do not necessarily mean better care, and at times they not only add unnecessary costs but harm as well.

Jochen Profit, MD, MPH 
Associate Professor of Pediatrics 
Director, Perinatal Health Systems Research 
Stanford University
Perinatal Epidemiology and Health Outcomes Research Unit
Division of Neonatology
Department of Pediatrics
Stanford University School of Medicine and Lucile Packard Children's Hospital
California Perinatal Quality Care Collaborative
Palo Alto, CA

Annette Scheid, MD
Attending Neonatologist and Director of Physician Wellbeing
Department of Pediatric Newborn Medicine
Brigham and Women's Hospital
Boston, MA

Erick Ridout, MD
Medical Director, Neonatal Transport
Medical Director, Quality and Patient Safety
Dixie Regional Center
Department of Pediatrics
Division of Neonatology
Intermountain Healthcare
St. George, UT

References

1.    Vinall J, Miller SP, Bjornson BH, et al. Invasive procedures in preterm children: brain and cognitive development at school age. Pediatrics. 2014;133:412-421. [go to PubMed]
2.    Horbar JD, Edwards EM, Greenberg LT, et al. Variation in performance of neonatal intensive care units in the United States. JAMA Pediatr. 2017;171:e164396. [go to PubMed]
3.    Norman M, Hallberg B, Abrahamsson T, et al. Association between year of birth and 1-year survival among extremely preterm infants in Sweden during 2004-2007 and 2014-2016. JAMA. 2019;321:1188-1199. [go to PubMed]
4.    Profit J, Gould JB, Bennett M, et al. Racial/ethnic disparity in NICU quality of care delivery. Pediatrics. 2017;140:e20170918. [go to PubMed]
5.    Baer VL, Lambert DK, Carroll PD, Gerday E, Christensen RD. Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions. J Perinatol. 2013;33:363-365. [go to PubMed]
6.    Sexton JB, Sharek PJ, Thomas EJ, et al. Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. BMJ Qual Saf. 2014;23:814-822. [go to PubMed]
7.    Huddle DRMC NICU Bedside Rounds [Video]. YouTube. Published September 24, 2019.

Figures

Figure 1. Conceptual Model of Value-based Patient Safety in the NICU.
The patient is at the center of all efforts. A flat hierarchy interdisciplinary team conducts safety-centered huddles and patient-centered rounds. The approach is reinforced through servant leadership fostering and environment of psychological safety and accountability. Efforts are aligned with health system priorities and strategies sought with payers to ensure better care is not financially disadvantageous. The approach protects harm from health care workers and infants.

Figure 1
 

Figure 2. Actual and Predicted Central Line–associated Bloodstream Infection (CLABSI) Rates Among All NICU Admissions.

Figure 2