Central line-associated blood stream infections (CLABSIs), unplanned extubations (UEs) and increasing opioid use are just some of the many challenges faced by critically ill patients in neonatal ICUs across the country. At the Level IV NICU at Children’s Health, Children’s Medical Center Dallas, we are committed to tackling these challenges as we strive to provide the best care for our patients and their families.

We’ve made significant strides in these areas, thanks to a culture that encourages every team member – from nurses to physicians – to ask hard questions and lead the search for answers.

“Quality improvement methodology involves a rigorous, data-driven evaluation of processes that are continually measured, refined and then sustained in an attempt to deliver the best care to our patients. Our quality initiatives have helped us achieve many things, like making our central line infection rates among the best within level IV NICUs across the nation,” says Vedanta Dariya, M.D., Neonatologist at Children’s Health℠ and Assistant Professor at UT Southwestern. “We’re eager to share our solutions and collaborate with other centers to make care even better.”

A Team Approach to Preventing Infections

CLABSIs are often at highest risk of occurring at the time of dressing changes. The traditional approach to care of the central line involved the bedside nurse changing the dressing for their own patients. We were part of a large, national trial that showed significantly improved outcomes when a select team of nurses is responsible for the care of all central lines. We were quick to adapt our staffing needs to provide the support needed to meet these recommendations. And our BSI team was born.

This team follows a strict two-person process: One nurse performs all tasks that need to be sterile, such as changing caps, while the second nurse does all non-sterile tasks, such as opening the incubator.

“This has been a huge success,” says Lisa Wulz, RN, who manages our neonatal-perinatal quality improvement programs. “Before creating this team, our rate was 1.7 infections per 1,000 line days – and now it’s down to and stays at 0.3.”

Preventing Unplanned Extubations in the NICU

Babies that experience unplanned extubations can have complications such as airway trauma, code events, hypoxemia and increased length of stay. These can be especially hard to prevent in small, critically ill neonates. Nationally, NICUs average approximately one UE for every 100 ventilator days. The rate in our NICU is currently around half the national average, thanks to a series of new practices. These include a standardized method of securing our tubes, a rigorously enforced team approach to moving intubated babies and daily discussions of tube position on medical rounds

“Our rates first started coming down when we standardized the method of securing the endotracheal tubes in all patients,” says Whitney Lewis, RN, clinical manager of the NICU. “It solves the problem of having tape come loose because of oral secretions.”

Our team also posts signs to indicate which patients have a higher UE risk, such as babies who weigh under 1,000 grams or those with a history of a previous UE. And whenever a baby is moved, two nurses are assigned to the job – one to move the child and one to manage the tube. 

We’ve also taken extra steps to minimize UE risk during kangaroo care. 

“Our team fits the parent with a cushioned device that keeps the baby in position, and we provide a handout for parents with instructions such as not using their phones while holding their child,” Whitney says. “Parents having direct contact with their babies is so important, we do everything we can to enable it while protecting their airway and keeping the babies intubated.”

Reducing Opioid Use in the NICU

Adequate pain control during painful procedures is beneficial to the developing nervous system of the newborn. However, medical opioid use has increased in NICUs across the country and carries risks for patients. We recently launched a quality improvement initiative to strike the balance between adequate pain control and decreased opioid use for our patients after surgery. As part of this, one of our NICU nurse practitioners developed a clinical algorithm that guides the team through an objectively determined evaluation of pain and strictly monitored pharmacological and non-pharmacological support after minor surgeries.

“With the help of this tool, we have a pain management plan before the baby leaves the operating room,” Whitney says.

“It’s another way we’re standardizing pain management and avoiding opioids unless they’re absolutely necessary,” says Lebanon David, who developed the tool based on practices and results from other children’s hospitals as part of a large national, multicenter initiative through the Children’s Hospital Neonatal Consortium.

Nurses Take the Lead

The essence of quality improvement is not a system that assigns errors to individuals and seeks punitive reform, but one that fosters the engagement of invested, dedicated hard-working healthcare professionals and identifies how the system can better support staff to provide the highest quality care to patients

In addition to a monthly safety meeting strictly for nurses, Lisa leads a monthly meeting that involves leaders from several teams – from social work to speech therapy – to troubleshoot problems and find better ways to work together in the NICU.

“The multidisciplinary approach works for safety just like it does for providing care: We draw on all perspectives to find the best solutions,” Lisa says.

Nurses also play a key role in identifying important questions – and in leading the search for answers. We kickstart this process by requiring all first-year nurses to identify a quality improvement project, research potential solutions and propose one to our team.

“This creates an atmosphere where nurses feel empowered to ask hard questions, which is the critical first step toward improving care,” Whitney says.

To solicit ideas more widely, the NICU installed a “solution board” in a hallway. This is a large display onto which anyone – from nurses and providers to clinical techs – can post a comment about something that would improve their work. We have found that even the “smallest suggestion” has the potential to vastly improve workflow, efficiency and satisfaction.

“The solution board does wonders for staff engagement – which leads to higher performance and better care for our patients,” Whitney says.

The Texas Department of State Health Services cited our safety record and commitment to quality when we were recently redesignated with Level IV status. Dr. Dariya says the supportive and solution-oriented culture of the NICU extends from its ties to UT Southwestern. 

“We’re a teaching institution,” he says, “which also means we’re a learning institution. If someone has an idea that might protect a baby’s health or make our teams more effective – we’re open to it.”

Learn more about the innovative care and research at Children’s Health.

Addendum: Sadly, Lisa Wulz passed away shortly after this article was written. Lisa dedicated her life to providing quality care for babies. She had her fingerprints throughout the organization, making a difference in the lives of many, many children and families. She will be sorely missed.