Improving Newborn Preventive Services at the Birth Hospitalization: A Collaborative, Hospital-Based Quality-Improvement Project
OBJECTIVE. The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization.
METHODS. All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital.
RESULTS. Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of ≥20% in ≥1 newborn preventive service.
CONCLUSIONS. A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.
Comprehensive preventive health care for children begins with adequate obstetric and pediatric prenatal care.1,2 For pediatricians, the prenatal visit serves to initiate a trusting relationship with the parents and to establish the infant's medical home. Preventive health care services such as anticipatory guidance on pertinent parenting issues and screenings for identification of high-risk situations can also occur at the prenatal visit.3 Although it is endorsed by the American Academy of Pediatrics and supported by pediatricians, as few as 11% of parents are seen for the pediatric prenatal visit.4 The birth hospitalization may be the first encounter new parents have with the pediatric health care practitioner.
When pediatric practitioners initiate health care services during the birth hospitalization, they work closely with hospital nursing staff members responsible for postpartum and newborn care. The Guidelines for Perinatal Care5 state that such nursing care should include initial and ongoing assessment, newborn care education, support for the attachment process, preparation for healthy parenting, and preparation for discharge and follow-up monitoring of the mother and her newborn. The recommended nurse/patient ratio for normal mother-newborn couplet care is 1 nurse for every 3 or 4 mother-newborn couplets.
In 2004, the American Academy of Pediatrics recommended a set of initial health care services to be provided, and minimal criteria to be met, before hospital discharge for well newborns.6 Newborn preventive health care services, including assessment for immunization, metabolic and hearing screenings, anticipatory guidance, risk assessment, and counseling, were among this inventory of recommendations for care during the birth hospitalization.
Over the past several decades, the length of the birth hospitalization has become increasingly short. In 2003, the National Committee for Quality Assurance Health Plan Employer Data Information Set reported the median length of birth hospital stay for well newborns to be 2.2 days.7 Extensive work has been performed to examine the impact of decreased length of stay for well term newborns, although that work was largely limited to a focus on rehospitalizations8–11 or outpatient follow-up services.12–14 Despite well-documented variability and deficiencies in the delivery of preventive care in pediatric settings,15–17 we found no literature about the completeness of preventive health care services for well newborns during the birth hospitalization.
Quality improvement (QI) collaboratives offer a method for improving the delivery of appropriate health care services. In pediatrics, national and state QI collaboratives have focused on improving the quality and safety of care for premature infants and their families in the NICU18 and term infants in the pediatric office setting.19–21 However, health care services provided to well newborns during the birth hospitalization were not included in that work.
The current intervention implements QI methods modified from the Institute for Healthcare Improvement Breakthrough Series (BTS) Collaborative,22,23 incorporating shared learning, coaching from a team of experts, provider education, measurement, and feedback. The aim of this study was to examine the effects of a QI intervention on the delivery of newborn preventive health care services during the birth hospitalization in a statewide sample of community hospitals delivering obstetric care.
Study Setting and Design
All Vermont hospitals with obstetric services were recruited to participate. The project principal investigator (Dr Mercier) met with the chief executive officer or designee from each hospital, explained the goals of the project, and described the responsibilities and resources required for hospital participation. Each hospital signed a consent form committing to participation in the project. Hospitals participated in the project for an 18-month period. Hospital participation was initiated on a rolling basis, beginning in May 2002. All hospitals completed the study by June 2004. Audits of 30 newborn medical charts were performed at each hospital for each preintervention and postintervention measurement of preventive health care service delivery. Medical charts were selected at random from lists generated using hospital discharge records for newborns delivered in the previous 6 months. Data on predefined preventive health care service variables were abstracted by a team of trained chart abstractors from the Vermont Child Health Improvement Program.24
The selection of newborn preventive services was generally drawn from the American Academy of Pediatrics policy statement on the hospital stay for healthy term newborns7 and the American Academy of Pediatrics periodicity schedule.25 The mixture of newborn preventive services included sensory screening, general procedure, and anticipatory guidance services. For anticipatory guidance, the risk assessment and counseling tasks of the service were counted as separate services. For example, sleep position assessment and sleep position counseling were treated as 2 distinct preventive services. Each of the newborn preventive services was supported by a professional guideline or health policy statement.26–35
Selected newborn preventive services are defined in Table 1. Services included hepatitis B immunization; assessment of breastfeeding adequacy; assessment of risk of hyperbilirubinemia; performance of newborn metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. Services were defined as having been delivered on the basis of documentation in the newborn medical chart. Interrater agreement, defined as the proportion of items coded identically by 2 chart auditors, was established with a random sample of 20% of the charts from each hospital for each measurement period and exceeded 95%. The study was approved by the institutional review board of the University of Vermont. All data were collected before the implementation of the Federal Health Insurance Portability and Accountability Act.
The population consisted of hospital-born, healthy, newborn infants. There were no gestational age or birth weight limitations; multiple births as well as singleton infants were included. Infants transferred into or out of their birth hospital were excluded.
Thirteen hospital-based newborn preventive health care services were targeted for the QI intervention. The intervention was based on a modified BTS Collaborative model.22,23 Each hospital received a performance report of the preintervention measurement (feedback session) for 13 hospital-based newborn preventive health care services. The feedback session was presented at a facilitated, multidisciplinary, peer-protected, on-site meeting. The report identified opportunities to improve performance in the delivery of these hospital-based newborn services. After the report, each hospital was encouraged to form a multidisciplinary (nurse, physician, and quality specialist) hospital-improvement team. Teams were provided guideline- and literature-based references for each of the 13 newborn preventive health care services. Table 2 lists the measurable aims for newborn preventive health care services that teams were offered and could choose to adapt to their specific clinical practice. Teams were encouraged to attend 4 face-to-face statewide meetings (learning sessions), participate in self-measurement activity, submit monthly progress reports, and participate in coaching calls on process improvement methods with project staff members. Continuing medical education and nursing contact hours were provided for both feedback and learning sessions.
Learning sessions focused on planning for outpatient follow-up care, assessment of risk for hyperbilirubinemia, and assessment of exposure to domestic violence. These 3 topics were chosen because of the complexity of organizational and operational issues involved in implementing current guideline recommendations. At the learning sessions, invited experts reviewed the current literature supporting guideline recommendations, and parents or family members presented personal experiences. Hospital teams reviewed potentially effective strategies to improve delivery of these preventive services and received coaching on process improvement, based on the plan-do-study-act cycle method.36 Each learning session designated facilitated time for hospital teams to review their preintervention data, to identify gaps in performance, to identify potential changes in their practice that could improve performance, and to develop strategies to test these changes. Hospital teams were also encouraged to choose ≥1 other preventive health care service for targeted improvement work. Modifications to the BTS model included a longer time frame (18 months) during which the intervention was conducted, a greater number of learning sessions (4 sessions) in which hospital teams participated, clinical topic-based presentations at the learning sessions, a greater number of one-on-one coaching telephone calls to team leaders by the project director, systematic sharing of deidentified hospital-level data among improvement teams, and no facilitated conference calls between participating hospitals.
The primary outcome measure was the aggregate preintervention to postintervention change in delivery of newborn preventive health care services during the birth hospitalization. Improvement in the delivery of preventive services at each individual hospital was also examined.
The data analysis compared preintervention and postintervention measures of the delivery of newborn preventive health care services. The data were aggregated across hospitals and examined with regard to assumptions of statistical normality. Logistic regression models were used for analysis of preintervention versus postintervention changes for each preventive service variable. In one set of logistic regressions, the models included terms for time (preintervention versus postintervention) and were adjusted to account for changes in Medicaid eligibility (Medicaid or Medicaid eligible versus privately insured) and short length of stay (<48 hours versus ≥48 hours). Models that were not adjusted were also run. For each measure, odds ratios (ORs) for the logistic regression model were generated and evaluated by using a Wald statistic; α was .05. The 95% confidence intervals (CIs) of the ORs were adjusted for clustering of patients within hospitals.
All Vermont hospitals with obstetric services participated (n = 12; see “Acknowledgments”). All hospitals formed project-improvement teams, and all hospital teams attended each learning session, participated in self-measurement activity, submitted monthly progress reports, and participated in coaching calls on process-improvement methods from project staff members. The median number of health care preventive services for which hospital teams conducted formal process-improvement work (including plan-do-study-act cycles) was 5 (range: 4–9 services).
In all, medical charts of 719 newborns were reviewed (359 for the preintervention measurement and 360 for the postintervention measurement), representing ∼9% of the hospital births that occurred in Vermont during the study period. Table 3 shows the characteristics of the preintervention and postintervention samples. Samples did not differ in the characteristics of average maternal age, birth weight, gestational age, length of hospital stay, or proportions of primiparous births, cesarean sections, or singleton births.
Table 4 shows the results for the aggregate changes in delivery of the 13 newborn preventive health care services at participating hospitals. Numbers in the unadjusted columns reflect the ORs, the 95% CIs for the ORs, and the P values obtained by using logistic regression analyses without adjustment for changes in Medicaid eligibility or short length of stay. Numbers in the adjusted columns reflect the ORs, the 95% CIs for the ORs, and the P values obtained by using logistic regression analyses with adjustment for changes in Medicaid eligibility or short length of stay. Medicaid status data were not obtained for 1 hospital in the preintervention measurement; we used the median insurance status value from the postintervention data for that hospital in the logistic regression equation for the 30 affected cases of preintervention data. In 19 cases in which data on length of stay were not available, the hospital- and measurement-specific (preintervention versus postintervention) median value from the other cases was substituted for the missing data.
Adjustment of the regression models for Medicaid eligibility and short length of stay did not have an impact on the analysis of the findings. Significant increases in the delivery of newborn preventive health care services were identified for the assessment of breastfeeding adequacy (49.4% vs 80.6%; P = .03), assessment of risk of hyperbilirubinemia (14.4% vs 23.4%; P = .04), performance of newborn hearing screens (74.1% vs 97.4%; P = .01), assessment of infant sleep position (12.7% vs 55.7%; P = .02), observation of car safety seat fit (41.8% vs 71.0%; P = .04), counseling on tobacco smoke exposure (22.7% vs 52.6%; P = .03), and counseling on car safety seat fit (37.6% vs 74.7%; P = .02). No significant changes were noted for the performance of hepatitis B immunization (45.3% vs 29.7%; P = .19), performance of newborn metabolic screens (98.0% vs 98.2%; P = .89), assessment of tobacco smoke exposure (52.5% vs 66.7%; P = .17), assessment of domestic violence (27.1% vs 36.2%; P = .51), counseling on infant sleep position (46.4% vs 68.3%; P = .08), or planning for outpatient follow-up care (80.3% vs 71.4%; P = .38).
To describe the variability of improvement among individual hospitals, we calculated a hospital improvement quotient. The improvement quotient was the number of newborn preventive health care services for which there was a ≥20% increase from preintervention measurement to postintervention measurement, divided by the total number of services for which an improvement of ≥20% was possible for a given hospital. Figure 1 shows hospital improvement quotients.
Improvement quotients varied among hospitals, ranging from 0.25 at hospitals 8 and 11 to 0.82 at hospital 5. Hospitals with greater numbers of services for which improvement was possible had greater numbers of improved services (r = 0.692; P = .013).
Whether improvement in infant assessment was related to improvement in family counseling for a specific preventive service was also examined. We evaluated infant assessment for and family counseling on tobacco smoke exposure, infant sleep position, and car safety seat fit, using 20% as the minimum for a change to be considered an improvement. Of 6 hospitals that had the opportunity to improve both assessment of and counseling on tobacco smoke exposure, 1 hospital did so. Of 8 hospitals that had the opportunity to improve both assessment of and counseling on infant sleep position, 3 hospitals did so. Of 7 hospitals that had the opportunity to improve both assessment of and counseling on infant car safety seat fit, 5 hospitals did so. Whether improvement in one area of family counseling correlated with improvement in other counseling preventive services was examined for tobacco smoke exposure, infant sleep position, and care safety seat fit. When these were examined as combinations of counseling services, 6 hospitals had the opportunity to improve (>20%) in all 3 areas, and 3 did so. At the level of the individual infant, 12.2% of families received all 3 counseling services at preintervention measurement and 44.4% of families received all 3 at postintervention measurement (adjusted OR: 5.71; 95% CI: 3.87–8.44; P = .01).
We engaged 12 hospitals in a QI collaborative targeting newborn preventive services during the birth hospitalization. Significant improvements were seen in the assessments of breastfeeding adequacy, the risk of hyperbilirubinemia, infant sleep position, and car safety seat fit. The performance of newborn hearing screens and counseling on tobacco smoke exposure and car safety seat fit also improved. Hospitals with more areas to improve demonstrated a greater number of improvements. More research is needed to understand the predictors of a hospital's success in improvement work.
The preventive services audited did not include all newborn preventive services appropriate for the birth hospitalization. Furthermore, the preventive services chosen for this work neither indicated our prioritizing of services nor suggested a standard of medical care. Finally, the mixture of preventive services focused exclusively on newborn care and safety. In general, routine obstetric prenatal care, such as maternal screening for syphilis or HIV infection, which ultimately could affect the health status of the newborn, was not included in this work. The one exception was the assessment of maternal tobacco use.
Measurement of preintervention and postintervention newborn preventive services relied exclusively on medical chart audits performed by study personnel. None of the medical charts selected for either the preintervention or postintervention audit was found to be missing or unavailable or was judged as incomplete by study personnel. Although study personnel had no affiliation with a hospital whose medical charts were audited, those individuals were aware of the project objectives.
Audits of newborn medical charts reflected documentation in the medical charts. It is possible that changes in the delivery of preventive services occurred as a result of changes in documentation and not actual improvements. This was of particular concern when counseling services were assessed. However, our chart auditors routinely found evidence of standardized tools that either scripted counseling or served as triggers prompting review of several parental teaching points.
Documentation of newborn preventive services in the mothers' medical charts would not have been discovered in our audits. It is possible that exclusion of the mothers' medical charts from the auditing process affected the results of the intervention. This was of particular concern when exposure to domestic violence was assessed. Hospital staff members admitted that, when the father of the infant was alleged as the perpetrator of domestic violence, anxiety about his access to the newborn medical chart was a specific barrier to documentation of assessment. It is likely that this barrier had an impact on our ability to measure changes in the assessment of maternal exposure to domestic violence across the intervention period.
Eleven of 12 hospitals that participated in this project exclusively offered basic (level 1) obstetric services to their communities. The numbers of licensed beds in these level 1 hospitals ranged from 25 to 188; 4 hospitals had <50 beds. In 2003, the numbers of births in these level 1 hospitals ranged from 213 to 570. All 11 level 1 hospitals were actively engaged in a regionally coordinated system of perinatal health care services that supported interhospital patient transfer to a subspecialty (level 3) perinatal health care center, as well as professional nurse and physician continuing education. As a part of this regional system, birth center nurse managers at all 11 level 1 hospitals routinely met as a group, semiannually, to discuss issues related to managing obstetric and birthing center units. At least 1 pediatric practice serving each hospital had previous experience participating in a statewide, office-based, QI project targeting preventive services.21 Each hospital also had a representative from the Vermont Department of Health affiliated with the hospital and participating in the project team.
The true total cost is difficult to define. We estimate that the cost of conducting the project, including all personnel and operating costs, was $350000, or approximately $29000 per hospital. An additional unmeasured cost is that of the staff time devoted by each hospital in carrying out the QI work. With ∼5900 well newborn infants per year born in the state and the estimate that this project affected 97% of that population, the cost per infant over the period of this intervention was approximately $41.
The effect of our modified BTS intervention was assessed at the end of an 18-month intervention period. The ideal time to assess the effect of an intervention is not clear.37 Notable changes in practice patterns could have occurred within the 18-month project period and, independent of our intervention, affected the delivery of newborn preventive services. Such changes were possibly associated with the decrease in hepatitis B immunization rates during the intervention period. The recommendation for hepatitis B vaccination at birth, before discharge from the hospital, was well established before the initiation of this project.38 During the intervention period, the US Food and Drug Administration licensed a combined diphtheria, tetanus toxoids, acellular pertussis absorbed, hepatitis B (recombinant), and inactivated poliovirus vaccine (Pediarix; SmithKline Beecham Biologicals, Rixensart, Belgium) for use for infants 2, 4, and 6 months of age.39 This event likely contributed to the decrease in the postintervention immunization rate to 29.7%.
Hospital-based birthing center teams were able to identify opportunities for improvement, to support a single set of improvement goals, to learn to apply basic QI methods, and, in doing so, to improve the quality of newborn care provided at a statewide level. Performance-based feedback, education on evidence-based practice, and parental testimony each made important contributions to the success of hospital team efforts. Leadership from the state department of health and an experienced QI team based in an academic medical center was important to hospital-based team success.
Participating hospitals were as follows: Brattleboro Memorial Hospital, Brattleboro, Vermont; Central Vermont Medical Center, Barre, Vermont; Copley Hospital, Morrisville, Vermont; Gifford Medical Center, Randolph, Vermont; North Country Hospital, Newport, Vermont; Northeastern Vermont Regional Hospital, St Johnsbury, Vermont; Northwestern Medical Center, St Albans, Vermont; Porter Medical Center, Middlebury, Vermont; Rutland Regional Medical Center, Rutland, Vermont; Southwestern Vermont Medical Center, Bennington, Vermont; Springfield Hospital, Springfield, Vermont; Vermont Children's Hospital at Fletcher Allen Health Care, Burlington, Vermont.
We thank the team members at the 12 Vermont hospitals for their voluntary participation in this study, which made this research possible. We thank Rachael Beddoe and Mary Ingvoldstad for work as the study data abstractors, Joseph Carpenter for assistance with development of the chart-auditing tool, Gary Badger for assistance with data analysis, and Lewis First for support of this work.
- Accepted April 23, 2007.
- Address correspondence to Charles E. Mercier, MD, Smith 578, Fletcher Allen Health Care-Medical Center Hospital of Vermont Campus, 111 Colchester Ave, Burlington, VT 05401. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
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