RESUMEN
Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Enterocolitis Necrotizante , Lactante , Femenino , Recién Nacido , Humanos , Cuidado Intensivo Neonatal , Recien Nacido Prematuro , Enterocolitis Necrotizante/diagnóstico , Enterocolitis Necrotizante/prevención & control , Enterocolitis Necrotizante/epidemiología , Flujo de TrabajoRESUMEN
BACKGROUND: Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%. PURPOSE: This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC. METHODS: A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs. RESULTS: NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003). IMPLICATIONS FOR PRACTICE: Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount. IMPLICATIONS FOR RESEARCH: Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.