PC1268: Implementing Teleneonatology in a Community Newborn Medicine Network: A Quality Improvement Initiative

Purpose/Objectives: Neonatal morbidity and mortality is strongly influenced by the quality of resuscitation. Neonatal mortality is higher at community hospitals with low delivery volumes, and morbidity and mortality rates are higher for outborn infants requiring transfer to a higher level of care. In community hospitals with low delivery volumes, practitioner NRP comfort and skills can be variable. Previous studies suggest teleneonatology (TN), teleconferencing with a neonatologist during delivery room resuscitation, improves neonatal resuscitation and community practitioner support.

Design/Methods: The Tufts Neonatal Intensive Care Unit in Boston, MA has a network of 5 community level II delivery services and special care nurseries (SCN). In a needs assessment survey, all respondents recognized the need for TN at high-risk deliveries in the community setting. We are implementing TN within our network utilizing a quality improvement framework. Our SMART aims are: over 6 months: a) achieve utilization of TN services for 70% of level II neonatal resuscitations, b) improve time to return of spontaneous circulation (ROSC) by 20% of baseline, c) improve median 10-minute Apgar score by 2 points from baseline, d) decrease time to advanced airway placement by 20%, e) decrease the need for chest compressions by 20%. A Logic model was created and Plan-Do-Study-Act QI methodology is being used for process flow. Process, outcome, and balancing measures will be tracked. AAP Telehealth guidelines were used for hardware and connectivity.

Results: Baseline outcome measures over 24 months for infants requiring advanced resuscitation show mean time to advanced airway placement (6.1 ± 5.0 min), initiation and duration of positive pressure ventilation (PPV) (start time of 1.4 ± 1.6 min; duration 5.4 ± 5.2 min, initiation and duration of chest compressions (start 3.8 ± 2.2 min; duration 5.9 ± 6.0 min), APGAR score at 5 and 10 min of life (5 and 7, respectively). Baseline data were also collected for all infants who were eligible for a TN consult, showing 94% were transferred to a higher level of care. Multiple PDSA cycles have occurred for equipment and connectivity.

Conclusion/Discussion: Phase I is being implemented at our largest affiliate, and will inform expansion to other sites during Phase II. Phase III will continue tracking QI measures and apply changes through PDSA cycles as needed. An implementation bundle includes online modules, role specific handouts, call activation flow chart, and troubleshooting. Immediate post resuscitation surveys, six-month cumulative feedback, and chart data will be obtained to assess satisfaction, identify process issues, and track QI measures. QI measures will be tracked dynamically using process control charts and run charts with a monthly data interval collection. Less frequent outcome measures will be analyzed as pre-post data using t-test or ANOVA.