Newborn Hypoglycemia Prevention

and Care
Learning Session II
October 14, 2019
 Welcome!!!

• Recognizing Excellence: the 2019 PQCNC Quality Improvement

Award
• NHPC
– Review
– Data update
– Progress to date
– Going Forward
• JC updates
 PQCNC 2019 Quality Improvement Award
• The PQCNC Quality Improvement Award recognizes a North
Carolina delivery unit that has made a measurable and sustained
positive change in a major perinatal quality improvement
indicator/issue through the implementation of quality improvement
activities within the previous three years.
• Projects reviewed for design, team development, adherence to QI
principles, documentation and reporting of PDSAs, identifying clear
aims for the project, tracking and reacting to key process and
outcome measures designed to achieve initiative aim
• Winner in 2018 was Atrium Health Cabarrus, home of the Jeff
Gordon Childrens Hospital and its outstanding NICU team for their
work on Antibiotic Stewardship and Newborn Sepsis
 This Years Winner

• A goal of reducing antibiotic usage in their NICU by 20% from a mean of 285
days per 1000 patient days to 228 days or less
• Were leaders in the PQCNC ASNS initiative
• Organized a multidisciplinary team including parents, pharmacists, nurses, docs
(Neos and NBN), Infection Control and Administration
• Leadership team developed a key driver diagram identifying challenges,
opportunities and recommended changes in practice
• Incorporated Kaiser sepsis calculator, and developed a sepsis algorithm for
infants < 34 weeks
• Automatic stops for antibiotics at 36 hours were created
• Created an education document for families (5 Questions to ask your doctor
about antibiotics)
• Incorporated an antibiotic time out into NICU rounds
• Tracked AUR, periodic audits incorporated into data review
• And…6% reduction in NICU admits, AUR from 285 to 167 days (41% reduction),
antibiotic exposure of newborns from 2.1 to 0.2%, 70% reduction in Vancomycin
use, 36% reduction in B-lactams
 The Winner of the PQCNC 2019 Quality Improvement
Award…..

Atrium Health Levine Childrens Hospital NICU

Jamie Jones, Michelle Suggs, Melissa Tyo, Rupal Patel, Adam Blake, Usha
Ramkumar, Jennifer Barnes, Jeanne Forrester, David Fisher, Alisa Dent, Drew
Herman, Gail Harris, Meghan Elliot, Della Wrightson, Jenna Anderson,
NHPC Engagement
 NHPC Babies

• 46 hospitals
• 5100 babies
• While some variability, at baseline
– 30% of all deliveries at risk for hypoglycemia
– 30% of these get hypoglycemic
– 20% of these require IVF/elevation in care
 Keep Moms and Newborns Together

Non-breastmilk Sustainability IV Infusions

Supplementation

20% 25% 25%

Standardized Transfers to
Protocol SCN/NICU
 47%

NBN
Currently use to treat asymptomatic newborns with
The hypoglycemia

Snapshot
36%
Glucose Gel
NICU
Currently use to treat asymptomatic newborns with
hypoglycemia
 5%

The NBN

Snapshot Currently have an IV weaning protocol

IV Weaning 8%

Protocol
NICU
Currently have an IV weaning protocol
The 52%

Snapshot
NBN
PC05 Average NC breastfeeding rates at discharge

Breastfeeding
Rates
February 2019…Your State NHPC Protocol
 Percentage of Newborns STS
100

90
84 84
82 82
79 78 79
80

70
4%
60

50

40

30

20

10

0
February March April May June July August
 Percentage of Newborns BF in first 60 Min
100

90

80

70

60
53
51
49 48
50 47 46
45

40

30

20

10

0
February March April May June July August
 Percentage of Newborns receiving only Breastmilk
for last 3 feeds prior to discharge
100

90

80

70

60

50 46 46 47
45 44 44 43

40

30

20

10

0
February March April May June July August
 Percentage of Newborns received Formula
100

90

80

70 69
67 66 66
64 64
62
60

50
7%
40

30

20

10

0
February March April May June July August
 Percentage of Newborns that received Glucose
Gel
50

45

40

35
31
30
25
25
22
20
20 18
16
15
22%
15

10

0
February March April May June July August
GEL Update…November!
 Lessons in Glucose Gel

• Gel is not a silver bullet

• If you give gel but don’t continue to encourage regular feeding, you
risk hypoglycemia
• Availability of gel
– If hypoglycemic and gel immediately available give gel and feed
the baby
– If gel not on the floor…ordered…feed the baby
– Do not leave the baby hypoglycemic for 5-10-45 minutes while
waiting for gel
 Percentage of Newborns Transferred to Higher
Level of Care
25

20

15

26%
10 8.6 8.2
7.6 7.4
6.2 6.5 6.4

0
February March April May June July August
 Percentage of Newborns Received IV fluids
25

20

15

10

6.7 42%
4.8
5 4.1 4.4
3.9
3.4 3.2

0
February March April May June July August
 Percentage of NBN Families Educated
100

90

80

70

60

50 46 46
41
40 37 37
35

30
29
59%
20

10

0
February March April May June July August
 Percentage of Newborns weaned with IV
weaning Protocol
100

90

80
71
70
62 62
58
60

162%
51
50

40
32
30 27

20

10

0
February March April May June July August
 IVF for Hypoglycemic Infants in the NICU

Hypoglycemic Infants Receiving IVF in the NICU

100

90

80

70

60

50

40

30

20

10

0
Mar '19 Apr '19 May '19 Jun '19 Jul '19 Aug '19
 NICU LOS for Hypoglycemia

NICU LOS Hours Hypoglycemia

160

140

120

100

80

60

40

20

0
Feb '19 Mar '19 Apr '19 May '19 Jun '19 Jul '19 Aug '19
Average Minutes of IVF for NICU Hypoglycemic Babies

Average Minutes of IVF for NICU Hypoglycemic Babies

4000

3500
2.4 2.4
3000
2 1.9 1.8
2500

1.8
2000 1.6
1500
1.2
1000

500

0
Feb '19 Mar '19 Apr '19 May '19 Jun '19 Jul '19 Aug '19 Sep '19
 A Tale of Two NBN Initiatives

• Enrolling Only • Enrolling All At Risk and

Hypoglycemic Infants
– Large Regional Center with
4096 annual births, YTD 145
enrolled
– Directly reports
hypoglycemic infants and
reduction in IV/transfers
– Smaller denominator means
less overall impact on
collaborative reporting
– Allows us to assess
reductions in number of
hypoglycemic infants as a
result of STS/Early feeding
1. Who is enrolling all at risk infants?
2. If so are you also tabulating infants monthly that are actually hypoglycemic?
Hypoglycemic Infants
– Large Regional Center with
3096, YTD 546 enrolled
– Challenging…variable at risk
criteria
– No direct measure of
number hypoglycemic
– Transfers/IVF would
hopefully reduce over time
but a very indirect measure
of hypoglycemic infants
– Large number meaning
process measure like
glucose gel much lower
percentage
 Comparing Populations

Percent Early BF

59% 58%
53% 53% 51%
49%
46% 47% 48% 46%
45% 44% 44% 43%

February March April May June July August

TOTAL Early BF HYPO Early BF
 Comparing Populations

STS

86% 86%
83%
81% 83% 81% 79%
82%
80%
77% 78% 78% 77%
74%

February March April May June July August

TOTAL STS HYPO STS
 Comparing Populations

BF @ DC
52% 53%
50% 51% 50%
48%
45%

45% 44% 46%

43% 43%
41% 41%

February March April May June July August

TOTALBFDC HYPO BFCD
 Comparing Populations

Gel Use

48%

41%

33%
31% 31%
26%

20%
25%
21%
17%
14%
12% 12% 12%

February March April May June July August

TOTALGEL HYPOGEL
 Comparing Populations

IVF in NBN

7%

6%
5%
5%
5% 4% 5%
4%
4%
3% 4%
3% 3%

2%

February March April May June July August

TOTAL IVFNBN HYPO IVFNBN
 Comparing Populations

Percent Infants Transferred To a Higher Level of Care or Another

Facility
18%

15%
13%
11%
10%
10%

7%
7%
6% 6%
5% 5% 5% 5%

February March April May June July August

TOTAL Transfer HYPO Transfer
 A Tale of Two NBN Initiatives
• While we are recommending STS, early (breast) feeding, a new
intervention we identified as an Expert Team was the introduction of gel
• In creating this initiative we used Sugar Babies as a model
• Gel will only possibly be used in hypoglycemic infants and we need to
know how many infants are hypoglycemic to understand if gel is being
used effectively
• We are now 10 months in…
• We have 24 centers reporting hypoglycemic infants
• Our primary NBN aim is a 25% reduction in hypoglycemic infants
needing IVF or transfer/elevation of care
• We recommend all of us go forward reporting on just hypoglycemic
infants
• We all have been engaged in this work whether reporting At Risk or just
hypoglycemics so it is not as if we are introducing new teams to the
data pool
• We will maintain the ability to analyze data separately as well as pool
data as we go forward, and later consider how we report final results as
a collaborative
• As a hospital team continue to make the work you are doing even more
incredible!
Data Reporting
 TJC PC05
1991
Exclusive Breastfeeding

Baby
Friendly

Severe Maternal Morbidity

 PC05
Exclusive Breastfeeding
 PC05
Exclusive Breastfeeding
 JC PC-06:Unexpected Newborn Complications

• Lack of metrics that assess the health outcomes of term infants who
represent over 90% of all births
• This measure addresses this gap and gauges adverse outcomes
resulting in severe or moderate morbidity in otherwise healthy term
infants without preexisting conditions.
• Serve as a balancing measure for other maternal measures such as
NTSV Cesarean rates and early elective delivery rates.
• Exclusions…<37 weeks, multiples, < 2500 gms, drug exposure,
genetic and prenatally diagnosed infant conditions
 Inclusions PC 06: Severe Complications

• Death
• Transfer to a another acute care facility
• 11.36 Severe Birth Trauma
• 11.37 Severe Hypoxia/Asphyxia
• 11.38 Severe Shock and Resuscitation
• 11.39 Neonatal Severe Respiratory Complications
• 11.40 Neonatal Severe Infection
• 11.41 Neonatal Severe Neurological Complications
• 11.42 Severe Shock and Resuscitation Procedures
• 11.43 Neonatal Severe Respiratory Procedures
• 11.44 Neonatal Severe Neurological Procedures
• Patients with Length of Stay greater than 4 days AND an ICD-10-CM
Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for Sepsis
as defined in Appendix A, Table 11.45 Neonatal Severe Septicemia
 Inclusions PC 06 Moderate Complications
• 11.46 Moderate Birth Trauma
• 11.47 Moderate Respiratory Complications
• 11.48 Moderate Respiratory Complications Procedures
• ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A,
Table 11.20.2 Single Liveborn Newborn-Vaginal AND Length of Stay greater than 2 days
• OR
• ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A,
Table 11.20.3 Single Liveborn Newborn-Cesarean AND Length of Stay greater than 4 days
• AND ANY
• ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS
Principal Procedure Code or ICD-10-PCS Other Procedure Codes for moderate
complications as defined in Appendix A, Tables:
• 11.49 Moderate Birth Trauma with LOS
• 11.50 Moderate Respiratory Complications with LOS
• 11.51 Moderate Neurological Complications with LOS Procedures
• 11.52 Moderate Respiratory Complications with LOS Procedures
• 11.53 Moderate Infection with LOS
• Patients with Length of Stay greater than 5 days and NO ICD-10-CM Principal Diagnosis
Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-
10-PCS Other Procedure Codes for jaundice or social indications as defined in Appendix A,
Tables:
• 11.33 Neonatal Jaundice
• 11.34 Phototherapy
• 11.35 Social Indications
Does Anyone Out There Know How Hard We Are
Working?...And Why We Do It?

YES!!!!