A Quality Improvement Initiative to Reduce Cranial Deformities in Very Low Birth Weight Infants

Purpose/Objectives: In the neonatal intensive care units (NICU), infants are placed on their backs for prolonged periods which increases their risk of developing an asymmetrical head shape (plagiocephaly), particularly in very low birth weight (VLBW) infants (weight less than 1500 grams and/or gestational age less than 32 weeks at birth). This positional plagiocephaly can be of various types with brachycephaly and dolicocephaly being the most common. In our NICU, we observed several VLBW infants developing plagiocephaly during the hospital stay.
Our specific, measurable, attainable, relevant, and time-limited aim was to reduce the incidence of any cranial deformity in VLBW infants from our baseline incidence of 47% (Oct-Dec 2019) to less than 35% by December 2020 (25% reduction).

Design/Methods: We developed a team consisting of occupational therapists, nurse champions, quality leaders, and providers and identified primary drivers to achieve our goals.
Cranial deformity was diagnosed by calculation of cranial index using cranial measurements.
PDSA 1: We organized interdisciplinary meetings and brain storming sessions. We realized that we did not have a standardized method for cranial measurements leading to inter-provider variability. Our team of occupational therapists started using standardized calipers in order to decrease variability.
PDSA 2: We started using gel pillows for all eligible low birth weight infants. Laminated information sheets were placed at bedside with instructions on how an infant’s head should be placed on the gel pillow.
PDSA 3: In order to monitor compliance with usage of gel pillows, team members performed random audits during rounds and monitored if the eligible infants were placed appropriately on gel pillows. We tracked compliance with gel pillow usage as our process measure.
PDSA 4: We identified that despite bedside instruction sheets, infants were not consistently placed on gel pillows. We performed bedside nurse education sessions and organized nursing skills fair to improve their awareness and knowledge regarding consistent and appropriate use of gel pillows.

Results: Following the use of standardized calipers, we observed an initial increase in incidence of cranial deformities to 53% (Jan-Mar 2020). After we started using gel pillows, the incidence gradually decreased to 39% by Sep 2020. With further nursing education, we were able to decrease the incidence of cranial deformities in very low birth weight infants to 35.5% by December 2020. We saw a consistent increase in usage of gel pillows over the period from June 2020 to March 2021. We used this as our process measure and were able to sustain usage rate around 85%.

Conclusion/Discussion: With improved nursing education and consistent usage of gel pillows, we were able to gradually decrease the incidence of cranial deformities in very low birth weight infants. We will continue reinforcing the provider and nursing education to monitor for a sustained improvement.