Help! I'm Cold...Improving the Warmth of Our Newborns

Braithwaite, Pamela

Purpose for the program: Cozy Cuties is a multidisciplinary performance improvement team convened to address birth to admission hypothermia among inborn preterm infants < 31 weeks gestation. Review of facility data over the past 5 years showed that the initial admission temperatures of these babies were significantly lower than average in our NICU as compared to 850 benchmark NICU ‘s within the Vermont Oxford Network. Across this time period, 61% of our babies in this gestational range had body temperatures <36⁰C at admission and were classified as hypothermic, using the WHO definition. Two large N studies of infants 23 to 30 completed weeks gestation, suggest that when infants are admitted to NICU with hypothermia, their chances of survival decrease by approximately 10% for every degree below 36⁰C, independent of any disease conditions. In addition, late onset sepsis is increased by 11% while odds of death are increased by 28%.

Proposed change: Root cause analysis using fish bone techniques was conducted on the first 5 cases of admission hypothermia for each calendar month x 12 months 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 & use, shortened infant time at point of delivery for both vaginal and cesarean births, 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 L&D and NICU was conducted using a variety of methods including video and social media. Post-implementation, infants < 31 weeks were prospectively followed and the incidence of the outcome variables was collected.

Implementation, outcomes and evaluation: Data collected were analyzed, findings showed that our admission hypothermia rates have been reduced from 61% over past 5 years to ~ 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 in order 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 baby warm, not to rewarm a cold baby.

Keywords: Preterm, hypothermia, fishbone diagram, root-cause analysis, morbidity, mortality, polyethylene.