Purpose for the Program
Cozy Cuties is a multidisciplinary performance improvement team convened to address hypothermia from birth to admission to the neonatal intensive care unit among inborn preterm infants at less than 31 weeks gestational age. Review of facility data over the past 5 years showed that the initial admission temperatures of these infants were significantly lower than average in our neonatal intensive care unit (NICU) than the benchmark of 850 NICUs within the Vermont Oxford Network. Across this time period, 61% of the infants who were less than 31 weeks gestational age had body temperatures less than 36°C at admission and were classified as hypothermic using the World Health Organization definition. Two large studies of infants from 23 weeks to 30 completed weeks of gestation, suggested that when infants are admitted to the NICU with hypothermia, their chances of survival decrease by approximately 10% for every degree below 36°C, independent of any disease conditions. In addition, late onset sepsis is increased by 11% and odds of death are increased by 28%.
Root cause analysis using fish bone techniques was conducted on the first five cases of admission of hypothermia for each calendar month over the 12-month period prior to project inception. Literature was reviewed to establish potential causes. A facility tour determined how many potential causes existed and coupled the potential cause with evidence-based interventions. A thermal intervention bundle was developed and implemented. The bundle included a timeout-style thermal checklist, increased room temperature, proper radiant warmer preheat and use, shortened infant time at point of delivery for both vaginal birth and cesarean birth, change in transfer technique of newborn to a warmer from point of delivery, effective use of polyethylene wrap, attention to application of pulse oximetry, warming of surfactant, and warming of caregiver hands. Aggressive clinical staff education in labor and delivery and NICU was conducted using a variety of methods, including video and social media. Post-implementation, infants who were less than 31 weeks gestational age were prospectively followed and the incidence of the outcome variables was collected.
Implementation, Outcomes, and Evaluation
Data were analyzed, and findings showed that our admission hypothermia rates have been reduced from 61% over the past 5 years to approximately 18% over the past 6 months. Ongoing monitoring for sustained improvement is now in place.
Implications for Nursing Practice
A multidisciplinary team can be an extremely effective agent of change. It is important to bring key stakeholders in a project to realize gains. Clinicians are obligated to benchmark practices that may contribute silently to patient illness. Body temperature should never be taken for granted. The goal should always be to keep a warm infant warm, not to rewarm a cold infant.