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Background: Informed consent is necessary to preserve patient autonomy and shared decision-making, yet compliant consent documentation is suboptimal in the intensive care unit (ICU). We aimed to increase compliance with bundled consent documentation, which provides consent for a predefined set of common procedures in the neonatal ICU from 0% to 50% over 1 year. Methods: We used the Plan-Do-Study-Act model for quality improvement. Interventions included education and performance awareness, delineation of the preferred consenting process, consent form revision, overlay tool creation, and clinical decision support (CDS) alert use within the electronic health record. Monthly audits categorized consent forms as missing, present but noncompliant, or compliant. We analyzed consent compliance on a run chart using standard run chart interpretation rules and obtained feedback on the CDS as a countermeasure. Results: We conducted 564 audits over 37 months. Overall, median consent compliance increased from 0% to 86.6%. Upon initiating the CDS alert, we observed the highest monthly compliance of 93.3%, followed by a decrease to 33.3% with an inadvertent discontinuation of the CDS. Compliance subsequently increased to 73.3% after the restoration of the alert. We created a consultant opt-out selection to address negative feedback associated with CDS. There were no missing consent forms within the last 7 months of monitoring. Conclusions: A multi-faceted approach led to sustained improvement in bundled consent documentation compliance in our neonatal intensive care unit, with the direct contribution of the CDS observed. A CDS intervention directed at the informed consenting process may similarly benefit other ICUs.

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Hospital noise is associated with adverse effects on patients and staff. Communication through overhead paging is a major contributor to hospital noise. Replacing overhead paging with smartphones through a clinical mobility platform has the potential to reduce transitory noises in the hospital setting, though this result has not been described. The current study evaluated the impact of replacing overhead paging with a smartphone-based clinical mobility platform on transitory noise levels in a labor and delivery unit. Transitory noises were defined as sound levels greater than 10 dB above baseline, as recorded by a sound level meter. Prior to smartphone implementation, 77% of all sound levels at or above 60 dB were generated by overhead paging. Overhead pages occurred at an average rate of 3.17 per hour. Following smartphone implementation, overhead pages were eliminated and transitory noises decreased by two-thirds (P < 0.001). The highest recorded sound level decreased from 76.54 to 57.34 dB following implementation. The percent of sounds that exceeded the thresholds recommended by the Environmental Protection Agency and International Noise Council decreased from 31.2% to 0.2% following implementation (P < 0.001). Replacement of overhead paging with a clinical mobility platform that utilized smartphones was associated with a significant reduction in transitory noise. Clinical mobility implementation, as part of a noise reduction strategy, may be effective in other inpatient settings.

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INTRODUCTION: Therapeutic hypothermia (TH) is a time-sensitive, efficacious treatment for newborns who experience perinatal hypoxic-ischemic encephalopathy. Optimal management of patient temperatures during TH may improve newborn outcomes and reduce side effects. We noted that patients undergoing TH were often outside of the target temperature range during treatment. This project sought to improve the timely initiation of effective treatment and temperature stability during TH through system-based changes in practice. METHODS: Measures include the time to target temperature, the percentage of core temperatures outside of the target range, and the absolute difference between core and peripheral temperatures over 41 months. System-based changes in the TH protocol included changing from passive to active hypothermia on transport and utilizing a delivery mode that uses more gradual temperature fluctuations during TH. We compared measures of health status and side effects as balancing measures. RESULTS: The TH protocol changes resulted in a significant reduction of time to goal temperature from 1.67 to 0.49 hours, in the percentage of temperature readings outside goal range from 12.6% to 6.3%, and the average absolute difference between core and peripheral temperatures from 1.78°C to 1.47°C. No adverse health outcomes were detected. We observed decreases in vasopressor use with each protocol change. CONCLUSIONS: This study demonstrates that detailed attention to the method of delivery of TH has an impact on ensuring effective delivery of therapy and minimizing the risks of treatment. The protocol changes were not associated with an increase in adverse events and were associated with a reduction in vasopressor use.

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Smartphones increasingly are used to facilitate the delivery of healthcare. Earlier studies assessing patient perceptions on smartphone use were performed before the emergence of broad clinical mobility platforms, and these studies did not distinguish potential differences related to smartphone device types. The current study evaluated the perceptions of neonatal intensive care unit parents on two different smartphone devices (personal phone and industrial phone) in the setting of an established clinical mobility platform. A total of 59 parents completed a multiple-choice survey exploring respondents' beliefs regarding whether smartphones could help care for their child, concerns regarding privacy/security, and perceived functionality of each smartphone. For both devices, most participants believed that smartphones were clearly used to help in the care of their child. However, respondents reported greater comfort with the industrial phone (P < 0.05). Respondents were more likely to express concern that the personal phone could compromise their child's personal/private information (P < 0.05). Respondents were more likely to believe that the industrial phone could receive emergency alerts/alarms compared with the personal phone (P < 0.05). Parental perceptions of smartphones generally were positive; however, perceived differences were found between devices, and smartphone functionality was underestimated. This suggested that education interventions addressing the value of smartphones for clinical mobility are warranted.

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In-hospital neonatal falls are increasingly recognized as a postpartum safety risk, with maternal fatigue contributing to these events. Recommendations to support rooming-in may increase success with breastfeeding; however, this practice may also be associated with maternal fatigue. We report a cluster of in-hospital neonatal falls associated with a hospital program to improve breastfeeding, which included rooming-in practices. Metrics related to breastfeeding were prospectively collected by chart audit or patient survey while ongoing efforts to improve breastfeeding occurred (September 2015-August 2017). Falls were identified through the hospital adverse event reporting system from January 2011 to February 2018. Medical records were reviewed to determine factors associated with the falls, including time of event, pain medication administration, hours of life at fall, method of delivery, or other notable factors that may have contributed to the fall event. Three fall events occurred within 1 year of commencing improvement efforts as process and outcome metrics associated with breastfeeding improved. All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am Falls occurred from 38.0 to 75.7 hours after birth. No sedating pain medications were administered within 4 hours of any event. In 2 of 3 cases, mothers experienced notable ongoing social stressors. Rooming-in was the most significant change involved in our health care delivery during the programmatic effort to improve breastfeeding. Monitoring for in-hospital neonatal falls may be needed during projects aimed at improving breastfeeding, particularly if rooming-in practices are involved.

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Implementation Lessons 1. Mobile telephony use in the hospital setting is complex and sub-optimal implementation of mobile communication technology can create inefficiencies in clinical workflow 2. Objective measurement of mobile technology's impact on clinical communication workflow is necessary to identify and remediate associated inefficiencies in real-time 3. Functionality between mobile applications and devices should be evaluated when implementing technology, particularly when an application is non-native to a device 4. Continual collaboration between front-line clinicians and technical teams allows for early identification of adverse impacts from, and optimization of, mobile communication technology implementation.

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BACKGROUND: Inhaled nitric oxide (INO) reduces extracorporeal membrane oxygenation (ECMO) use in term and near-term neonates with persistent pulmonary hypertension of the newborn; however, its overutilization is increasing. We hypothesized that implementing a shared baseline protocol would safely improve evidence-based INO use in a Level IV neonatal ICU. METHODS: Through several plan-do-study-act cycles, a shared baseline protocol for initiation and weaning of INO was developed and implemented starting in August 2014. Based on user feedback, the shared baseline protocol was amended and re-evaluated at regular intervals. Significant changes for process and outcome measures related to utilization of INO were detected using statistical process control, bivariate analyses using t test or nonparametric Wilcoxon rank-sum test as appropriate, and chi-square and Fisher exact testing as appropriate. Comparisons between the pre-plan-do-study-act group (January 2012 to July 2014) and post-plan-do-study-act group (August 2014 to October 2015) were made. RESULTS: One hundred sixteen INO courses in 95 subjects were administered during the pre-plan-do-study-act period, and 44 episodes were initiated in 39 subjects during the post-plan-do-study-act period. Process control charts demonstrate significant reductions in the percentage of INO doses > 20 ppm and the percentage of prolonged (>4-d) INO courses. Prolonged INO courses decreased from 67.9 to 40% (P = .032), whereas the median duration of INO per course decreased from 8 to 4 d (P < .001). The percentage of INO courses that exceeded the dose of 20 ppm decreased from 18.1 to 2.3% (P = .009). Very delayed INO weaning (weaning at FIO2 ≤ 0.40) decreased from 41.9 to 21.2% (P = .038). There were no differences in the percentage of INO courses administered to non-sedated subjects or the percentage of INO courses administered to preterm infants. There was no difference for death or ECMO between groups. CONCLUSIONS: Implementation of a shared baseline protocol to encourage appropriate INO initiation and weaning safely decreased INO exposures. Focused efforts on reducing unapproved INO use in preterm infants are warranted.

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Handoffs for neonatal resuscitation involve communicating critical delivery information (CDI). The authors sought to achieve ≥95% communication of CDI during resuscitation team requests. CDI included name of caller, urgency of request, location of delivery, gestation of fetus, status of amniotic fluid, and indication for presence of the resuscitation team. Three interventions were implemented: verbal scripted handoff, Spök text messaging, and Engage text messaging. Percentages of CDI communications were analyzed using statistical process control. Following implementation of Engage, the communication of all CDI, except for indication, was ≥95%; communication of indication occurred 93% of the time. Control limits for most CDI were narrower with Engage, indicating greater reliability of communication compared to the verbal handoff and Spök. Delayed resuscitation team arrival, a countermeasure, was not higher with text messaging compared to verbal handoff ( P = 1.00). Text messaging improved communication during high-risk deliveries, and it may represent an effective tool for other delivery centers.

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To improve hospital access for expectant women and newborns in the state of Maryland, a quality improvement team reviewed the patient flow characteristics of our neonatal intensive care unit. We identified inefficiencies in patient discharges, including delays in patient transports. Several patient transport delays were caused by late preparation and delivery of the patient transfer summary. Baseline data collection revealed that transfer summaries were prepared on-time by the resident or nurse practitioner only 41% of the time on average, while the same transfer summaries were signed on-time by the neonatologist 5% of the time on average. Our aim was to improve the rate of on-time transfer summaries to 50% over a four month time period. We performed two PDSA cycles based on feedback from our quality improvement team. In the first cycle, we instituted a daily huddle to increase opportunities for communication about patient transports. In the second cycle, we increased computer access for residents and nurse practitioners preparing the transfer summaries. The on-time summary preparation by residents/nurse practitioners improved to an average of 72% over a nine month period. The same summaries were signed on-time by a neonatologist 26% of the time on average over a nine month period. In conclusion, institution of a daily huddle combined with augmented computer resources significantly increased the percentage of on-time transfer summaries. Current data show a trend toward improved ability to accept patient referrals. Further data collection and analysis is needed to determine the impact of these interventions on access to hospital care for expectant women and newborns in our state.