Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths

Abstract

Objective The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants.

Study Design A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality.

Results Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change.

Conclusion A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC.

Key Points

• QI reduces surgical necrotizing enterocolitis.

• Reduction in NEC rate improves mortality.

• Human milk does not change SIP incidence.

Keywords

necrotizing enterocolitis - prematurity - quality improvement - very low birth weight

Authors' Contributions

G.G. conceptualized and designed the study, designed the data collection instruments, collected data, performed the initial analyses, was the drafter of the initial paper, and reviewed and revised the paper. K.M. conceptualized and designed the study, designed the data collection instruments, collected data, performed the initial analyses, and reviewed and revised the paper. A.P. collected data and reviewed and revised the paper. T.J. performed the final statistical analyses and reviewed and revised the paper. J.W. and A.N. were involved in the care of the infants described in this study and were involved in reviewing and revising the submitted paper. M.H. and B.P. conceptualized and designed the study and were involved in reviewing and revising the submitted article. All authors approved the final article as submitted and agreed to be accountable for all aspects of the work.

Publication History

Received: 26 March 2020

Accepted: 30 April 2020

Article published online:
08 June 2020

• References

• 1 Robinson JR, Rellinger EJ, Hatch LD. et al. Surgical necrotizing enterocolitis. Semin Perinatol 2017; 41 (01) 70-79
• 2 Kim JH. Necrotizing enterocolitis: the road to zero. Semin Fetal Neonatal Med 2014; 19 (01) 39-44
• 3 Nathan AT, Ward L, Schibler K, Moyer L, South A, Kaplan HC. A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems. J Perinatol 2018; 38 (06) 742-750
• 4 Ellsbury DL, Clark RH, Ursprung R, Handler DL, Dodd ED, Spitzer AR. A multifaceted approach to improving outcomes in the NICU: the Pediatrix 100,000 babies campaign. Pediatrics 2016; 137 (04) e20150389
• 5 Kantorowska A, Wei JC, Cohen RS, Lawrence RA, Gould JB, Lee HC. Impact of donor milk availability on breast milk use and necrotizing enterocolitis rates. Pediatrics 2016; 137 (03) e20153123
• 6 Patel AL, Panagos PG, Silvestri JM. Reducing incidence of necrotizing enterocolitis. Clin Perinatol 2017; 44 (03) 683-700
• 7 Patel AL, Trivedi S, Bhandari NP. et al. Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods. J Perinatol 2014; 34 (11) 850-857
• 8 Talavera MM, Bixler G, Cozzi C. et al. Quality improvement initiative to reduce the necrotizing enterocolitis rate in premature infants. Pediatrics 2016; 137 (05) e20151119
• 9 Bell MJ, Ternberg JL, Feigin RD. et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978; 187 (01) 1-7
• 10 Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am 1996; 43 (02) 409-432
• 11 Struijs MC, Diamond IR, de Silva N, Wales PW. Establishing norms for intestinal length in children. J Pediatr Surg 2009; 44 (05) 933-938
• 12 Pyle AK, Shabanova V, Cleary MA. et al. Variable management strategies for NEC totalis: a national survey. J Perinatol 2019; 39 (11) 1521-1527
• 13 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
• 14 Bode L. Human milk oligosaccharides in the prevention of necrotizing enterocolitis: a journey from in vitro and in vivo models to mother-infant cohort studies. Front Pediatr 2018; 6: 385
• 15 Silano M, Milani GP, Fattore G, Agostoni C. Donor human milk and risk of surgical necrotizing enterocolitis: a meta-analysis. Clin Nutr 2019; 38 (03) 1061-1066
• 16 Ward L, Auer C, Smith C. et al. The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants. Breastfeed Med 2012; 7: 234-240
• 17 Delfosse NM, Ward L, Lagomarcino AJ. et al. Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals. J Perinatol 2013; 33 (06) 446-451