PC1243: A Quality Improvement Project to Reduce Variation of Practice Patterns Surrounding Apnea of Prematurity Management

Purpose/Objectives: Apnea of prematurity is a common problem in most neonatal intensive care units (NICU). At our level III NICU, we experienced variation in practice patterns surrounding apnea of prematurity, leading to confusion and frustration among staff and families. At baseline, only 17% of staff survey respondents felt the unit was consistent in management and only 10% felt documentation was clear. We aimed to improve reported consistency in management and clarity of documentation in the electronic medical record (EMR) each to at least 50% in one year.

Design/Methods: In this IRB exempt quality improvement initiative, a multi-disciplinary team was assembled to evaluate the problem and identify primary and secondary drivers. Documentation surrounding apnea of prematurity was found to be a primary driver of the problem. Interventions including education, editing of EMR nursing flowsheet of apnea events, and designation of event determination in the EMR.
The outcome measure was percentage of respondents answering positively on a follow up internal survey. Process measures included percentage of documentation completion. Balancing measures included length of stay (LOS) and post-menstrual age (PMA) at discharge for premature infants. Analysis was done using statistical process control (SPC) charts where applicable. Baseline data were collected starting July 2020, with the initial survey sent September 2020. Interventions were carried out during January 2021-September 2021. The follow up survey was completed September 2021. Data collected through December 2021. We looked at infants born prematurely, birth gestation < 35 weeks, who were discharged from our NICU. We excluded infants with major congenital anomalies.

Results: 172 premature infants were discharged from our unit from September 2020 through December 2021. On post-intervention survey of unit staff, providers, and respiratory therapists, n=33 with 75% of respondents being nurses, compared with pre-intervention survey n=55. The percentage of respondents answering that unit management was “very consistent” or “somewhat consistent” increased from 17% to 48%. The percentage of respondents answering documentation was “very clear” or “somewhat clear” increased from 10% to 81% (Figure 1). Documentation completeness surrounding events improved from a mean of 58% of items documented pre-intervention to 82% post-intervention (Figure 2). SPC chart analysis showed this was special cause variation. Mean PMA at discharge did not increase, nor did mean LOS.

Conclusion/Discussion: In this QI project, we found that by improving the nursing flowsheet surrounding apnea of prematurity documentation completeness improved. This, along with education and documenting the provider decision of the event, reduced variation in practice patterns surrounding apnea of prematurity without increasing the time to discharge.