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At TIPQC Annual Meetings, hospitals and practices select projects for development and pilot testing for future statewide projects.

Current State Wide Projects

NICU - Human Milk for the NICU Infant

Complications associated with initiation of enteral feedings in very low birth weight (VLBW) babies & all NICU babies are a widely recognized source of excess morbidity, mortality, costs, and length of stay in the neonatal intensive care unit. Multiple reports have documented the efficacy of human breast milk in reducing NICU feeding morbidity. This project is being led under the direction of Dr. Reddy Dhanireddy and Dr. Steven McElroy with pilot member hospitals developing the project including The Med, Parkridge East, and Monroe Carell Jr. Children’s Hospital at Vanderbilt & East Tennessee Children’s Hospital.

Aim:
The 2012 aim approved by the teams at the Annual Meeting, is to improve the health of infants admitted to the NICU in Tennessee by increasing initiation and sustainment of enteral nutrition with human milk. Clearly there exist some contraindications and barriers to achieving total use of human milk for all NICU infants. Thus, we seek to increase the rate of human milk feeding by 10% by December 2012.

Resources:
Additional information on this project is available in past e-zines at:
August 2010 Ezine
July 2010 Ezine

or via webinars:
HM4NICU Webinar 1
HM4NICU Webinar 2
To view the talks given by Dr. Robert Lawrence at the 2011 Annual Meeting, see:
http://tipqc.org/meetings/annual-meetings/2011-annual-meeting/

May Update:
Over 6400 Tennessee infants admitted to the NICU have been involved in this project from 17 NICU hospital teams. Overall improvement is being shown with state aggregate data showing a 20% increase in the rate of initiation of feeding with human milk in TN NICUs. Evidence suggests that increasing the use of human milk will further reduce hospital acquired infections as well as the frequency of catastrophic intestinal complications of prematurity potentially avoiding an additional $2-4 million dollars in hospital charges per year in Tennessee. Huddle #14 will be on May 8, 2012 at 2:00 PM CST/3:00 PM ET

OB - Reduce Elective Deliveries Before 39 Weeks

This project was piloted in Davidson County, under the leadership of Dr. Frank Boehm. Late preterm and near-term infants experience increased neonatal, infant and lifetime morbidity compared to infants born at term. Many scheduled deliveries are necessary and avert both maternal and infant morbidity. However, a variable fraction of scheduled deliveries appear to be elective. The pilot project in Davidson County demonstrated this group could be reduced through a quality improvement approach. The first state-wide webinar was held in September, with 9 hospitals, with over 9000 mothers and infants involved in the project. The 39 Week Elective Delivery Reduction project continues to be redefined with state-wide spread as the Tennessee Hospital Association’s Hospital Engagement Network (HEN) embraces and joins the project.

Aim:
Using a collaborative quality improvement approach, this project seeks to report the rate and indications for scheduled deliveries before 39 weeks of gestation at the time of scheduling for all scheduled deliveries in Tennessee.

Resources:

May Update:
The 39 week elective delivery reduction group have captured data on over 9,000 Tennessee deliveries. This project remains open to all hospitals across the state, as well as collaborating with the THA HENs. With over 93 folks on our last call, we are looking forward to great collaboration and accomplishments. The next joint webinar will be on May 29 at 10 AM CT/11 ET.

OB - Breastfeeding Promotion

At the 2009 meeting, the Obstetric community voted to develop a project to promote breast milk feeding. A project development group was convened to review Tennessee’s progress toward the Healthy People 2020 goals, identify locally successful strategies to promote breast milk feeding, and develop a project to improve the rates of breast milk feeding across the state. The project is now open for state-wide enrollment. For the application and IRB information, please email Brenda.Barker@TIPQC.org.

Resources:

Click here to view the talks given by Dr. Robert Lawrence at the 2011 Annual Meeting.

Aim:
The aim of this project is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting breastfeeding at prenatal care visits. While barriers to successful breastfeeding exist in multiple settings, we will focus on high reliability (>90%) implementation of processes that promote breastfeeding in the prenatal clinic. Thus, we seek to increase the fraction of infants who are fed breast milk at the maternal post-partum visit by 50% by March 2012.

May Update:
The TIPQC Breastfeeding Promotion continues piloting in Memphis and Johnson City, and has captured 540 women at their 6-week postpartum visit. This project is now open for statewide enrollment. Please contact the TIPQC office for an application and more details, as well as see the lead article in last month’s e-zine.

NICU-Family Involvement Team

Aim: The aim of this project is to build greater resources and to develop a statewide qualitative step-wise improvement effort to support families who have children in the NICU.

May Update:
Under the state leadership of Rochelle Nelson and Mark Anderson, MD the group will met on May 17 to learn more about engaging families. This project is open to the state. Please contact the TIPQC office to receive additional log in information for this webinar.

NICU—Undetected Critical Congenital Heart Disease Registry

Congenital heart disease occurs in 7 to 9 of 1000 live births in the United States. One-fourth of these infants have critical congenital heart disease (CCHD) which is defined as severe and life-threatening disease requiring surgical or catheter intervention in the first year of life. Diagnosis places the infant at risk for hemodynamic compromise secondary to hypoxia, acidosis, and shock. Because of these missed cases, mandatory universal screening of all asymptomatic newborns is being considered by both the federal and state government.

Aim:
To determine the incidence of undetected CCHD in TN in 2010 and 2011 in order to decide if there are enough cases to warrant initiation of universal screening.

This project is under the direction of Dr. Bill Walsh, and includes: Memphis-Jean Ballweg, Marilyn Robinson-Lebonheur, ETSU-Mike Devoe, Rajani Anand, Ehrlanger-Nisha Surenderanath, Knoxville-Jeff Jennings, Mike Liske, Vanderbilt-Jessica Mouledoux,and the State Birth defects registry-David Law.

May Update:
The goal of the registry for the past year was to identify infants discharged from the nursery who return within the first month of life with a diagnosis of critical congenital heart disease (congenital heart disease requiring surgical or catheter based intervention within the first month of life). With your help, we have identified 11 infants who were initially discharged from the hospital without a diagnosis of CCHD. In addition, we are aware of three additional infants presenting with congenital heart disease requiring intervention at more than 30 days of life. TIPQC will continue to partner with us to keep track of these undiagnosed infants in 2012 prior to the implementation of pulse oximetry screening.

Given the recommendation of the Secretary of the Department of Health and Human Services (HHS) to add CCHD to the Recommended uniform Screening Panel, the HHS Health Resources and Services Administration has released grant funding to “support the development, dissemination and validation of screening protocols and newborn screening infrastructure for point of care screening specific to CCHD.” Dr. Walsh and Dr. Mouledoux have been assisting the Tennessee Department Maternal and Child Health in applying for this grant in hopes of securing funding to implement a successful CCHD screening program in the state of Tennessee with particular attention to education of parents and providers and data collection to evaluate the efficacy and cost of screening. TIPQC will likely play an instrumental part in the data collection with initiation of pulse oximetry screening until the state is able to take over data collection and follow-up of infants with a positive screen.

On February 27, 2012, the Tennessee House of Representatives passed the identical bill that the Senate passed directing the GAC to establish universal screening using the pulse oximeter, by January 2013, making TN the third state to do so.

Projects Being Piloted

For these projects, teams of state leaders and pilot hospitals have been developing these projects and a fully implementable change package. These committees are formed from volunteers across the state, and their first task involved reviewing the literature, available guidelines and best practices for testing prior to inclusion in the change package. This group of volunteer subject matter experts will serve as consultants to assist the project teams who are building and testing the interventions on the local level. Volunteers are TIPQC members who can commit time to project development activities and who bring specific expertise in the subject area to the committee.

NICU - Neonatal Follow Up Work

An opportunity exists in Tennessee to expand communication with NICUs across the state who are interested in providing follow-up to their graduates, explore opportunities to improve communication and engagement of primary care providers with resources for high-risk follow up of NICU graduates, and to consider development of a statewide QI project aimed at optimizing high-reliability follow up for high-risk NICU graduates using an ultra-thin data set.

Aim:
The aim of this project is to improve access to and utilization of follow up for NICU graduates in Tennessee.
Immediate AIM: Gather baseline data on TN NICU follow up care.

This project is under the direction of Nathalie Maitre, MD and Lucky Vogt, RN with pilot hospitals being East Tennessee Children’s Hospital, Jackson Madison County General Hospital, Johnson City Medical Center, Monroe Carell Jr. Children’s Hospital and University of Tennessee Medical Center at Knoxville.

May Update:
Statewide IRB approval has been received! Teams are submitting their applications, data agreements & local IRB or quality council approvals. Data collection will begin in May.

Hospital - Breastfeeding Promotion

At the 2009 meeting, the Obstetric community voted to develop a project to promote breast milk feeding. A project development group was convened to review Tennessee’s progress toward the Healthy People 2020 goals, identify locally successful strategies to promote breast milk feeding, and develop a project to improve the rates of breast milk feeding across the state. The original project was divided into three components: antenatal, hospital, and post-natal.

Resources:

Aim: The aim of this project is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting and supporting breastfeeding in the delivery setting. While barriers to successful breastfeeding exist in multiple settings, we will focus on high reliability (>90%) implementation of processes that promote and support breastfeeding in the delivery setting.
Immediate aim: Thus, we seek to increase the fraction of infants who are exclusively fed breastmilk at hospital discharge by 10% by March 2013.
Long term aim: To eliminate barriers in birthing facilities to achieving the Healthy People 2020 goal.

May Update:
An informational webinar was held on April 25th. The second informational webinar will be held on June 1, with a statewide “face-to-face” meeting being planned for July 20 in Nashville. All teams that are interested in joining this project utilizing the TIPQC tool kit, which will be available to teams June 1, and includes the USBFC and the JC perinatal core measures should attend. For information & to register for the webinar or the project, please contact the TIPQC Office. Pilot teams have begun submitting their application, data agreement & IRB or quality council approvals.

Projects Being Developed

For these projects, teams of state leaders and pilot hospitals have been developing these projects and a fully implementable change package. These committees are formed from volunteers across the state, and their first task involved reviewing the literature, available guidelines and best practices for testing prior to inclusion in the change package. This group of volunteer subject matter experts will serve as consultants to assist the project teams who are building and testing the interventions on the local level. Volunteers are TIPQC members who can commit time to project development activities and who bring specific expertise in the subject area to the committee.

NICU - Golden Hour

This project was nominated by The Med and was voted on by the membership to develop for TIPQC, focusing on the first critical hour of life for neonates.

Click here to see the talk given by Dr. Gautham Suresh at the 2011 Annual Meeting.

May Update:
The tool kit and data forms should be completed and submitted to IRB this month. Soon the development teams of The Med, Baptist-Nashville, Methodist-Germantown will begin data collection. The next webinar is scheduled for May 30 at 12:00 NOON CT for REDCap data entry training. The statewide kick off for this project is scheduled in Nashville for September 12. Make plans to join us!

OB - Maternal Mortality Review

Tennessee ranks 38th for maternal deaths in the nation, with 11.7 deaths per 100,000 live births. Twenty-one states currently have maternal mortality review committees, but Tennessee does not. This project will first work with the TN legislature to establish a maternal mortality review committee. Once established, data can be collected from reviews of individual cases. The committee will seek to identify patterns in preventable deaths with a goal of reducing and preventing the number of deaths related to pregnancy, birth and the puerperium.

For more on this project, see Dr. William Callaghan’s talk at the 2011 TIPQC Annual Meeting: http://tipqc.org/assets/306/maternalmortalityCALLAGHAN.pdf

The project leaders are David Adair, MD, Connie Graves, MD and Janice Whitty, MD.

May Update:
Several new state leaders have been added to this group. They have begun assessing the process of setting up a Maternal Mortality Review, and have zeroed in on post-partum hemorrhage as a first target for a statewide QI effort to address contributors to Maternal Mortality in Tennessee. The next Huddle of the state leaders will be on May 22, 9 AM CDT/10 EDT.

NICU — Neonatal Abstinence

Preliminary Aim: Develop a treatment plan to treat Neonatal Abstinence Syndrome (NAS) that will: consistently evaluate the presence and severity of withdrawal symptoms; initiate appropriate non-pharmacological interventions and pharmacotherapy to control symptoms; wean the opioid-dependent infant as quickly as possible while providing good control of withdrawal symptoms.

This project is being led by East Tennessee Children’s Hospital under the direction of Terry King, Pharm.D with pilot hospital University of Tennessee at Knoxville.

May Update:
The development teams met at the annual meeting, and will continue work on the tool kit and data collection for this project. The next development huddle is June 8 at Noon CTS.

NICU — Central Line Associated Blood Stream Infection, Phase 2

May Update:
The CLABSI Reduction group selected to develop a Phase 2 project centered around all BSIs at the annual meeting. To begin Phase 2 development, we need two physician leaders, as well as 2-3 teams. To volunteer please contact the TIPQC office.

Projects in Sustainment

NICU - Central Line Associated Blood Stream Infection

Central Line Associated Blood Stream Infections are a recognized source of excess morbidity, mortality, costs, and length of stay. Multiple reports have described successful reduction in CLABSI rates by systematic application of evidence-based practice in the context of a collaborative, multi-center quality improvement project. This project was developed by the pilot centers: East Tennessee Children’s Hospital, Jackson-Madison County General Hospital, Johnson City Medical Center, and TC Thompson Children’s Hospital along with the TIPQC team. The state-wide project began in January 2010.

Resources:
Click here for additional information on this project available via webinar.

Click here for the workshop led by Dr. Gautham Suresh at our 2011 Annual Meeting.

http://www.nichd.nih.gov/news/resources/spotlight/021811-CME-CE-program.cfm

http://www.nichd.nih.gov/ncmhep/about/operations/index.cfm

CLABSI Reduction Toolkit

Aim:
To eliminate central line associated blood stream infections in participating NICU’s. Reduction in CLABSI episode frequency is clearly possible, and the immediate aim of this project is to reduce the frequency of CLABSI episodes in participating NICUs by 50% within the first year. (GOAL WAS MET!)

May Update:
Eleven NICU teams are participating in the Central Line Associated Blood Stream Infection Reduction project, with over 4800 babies captured. Due to the work of each team, state aggregate data continues to show remarkable improvement having achieved a 75% reduction in life-threatening and costly infections in Tennessee NICUs. The Dept. of Health has independently verified this statewide change noting that the rate of these events has decreased from over twice the national average to less than half the national average resulting in an estimated attributable cost averted of $2 million per year in Tennessee. Approximately half of the teams went into sustainment December 2011. This project has gone into sustainment. Congratulations to all the teams! Sustainment teams were encouraged to continue monitoring data, having a process owner (and a back up), determining when to monitor the data and report structure, continuing education, reminders, and hardwiring changes throughout the sustainment period! Please continue to use the TIPQC forum as a way to collaborate and share, across town or across the state. The next sustainment webinar will be on October 25.

ABP MOC for this project has been extended with additional credits available! Physicians should visit the TIPQC CLABSI Forum to learn more, since this project just entered sustainment and will close for MOC credit on March 30, 2013, physicians must be actively involved for one year to ensure credit can be given before MOC closeout for this project. For more information, please see last month’s ezine.

Please see the 12 month Progress Report and the state aggregate, released at the annual meeting 2011.

NICU - Admission Temperature

This is the first improvement project for neonatology (NICU) which was launched at the Annual Meeting on March 5-6, 2009. Thermal management prior to admission to the NICU is a recognized challenge, especially for sick and premature infants.

Aim:
Improve thermal management in participating NICUs to reduce the number of infants whose admission temperature is less than 36C. Teams will focus on improving pre-delivery environmental factors, optimizing thermal management during resuscitation, and improving temperature regulation during transport to NICU.

For the state aggregate please see 12 Month Sustainment.

ABP MOC for this project is available! This is TIPQC’s first project and it remains in sustainment. Active participation in the sustainment phase had to have begun no later than September 30, 2011 to claim credit in order to meet the one year participation requirement. All participants seeking MOC part 4 credit must turn in their Attestation Forms to TIPQC by September 23, 2012 in order to ensure credit can be given before MOC closeout for this project! Visit the TIPQC temperature forum to learn more.

May Update:
Hypothermia has long been associated with excess morbidity and mortality in infants, and is very difficult to avoid in the first critical minutes of life. Twenty-three NICUs and almost 4000 Tennessee infants admitted to the NICU were involved in this project, which reduced the rate of admission hypothermia in Tennessee in half, and has successfully sustained the improvement after completion of the first TIPQC project.

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