Reducing Necrotising Enterocolitis in VLBW Infants- a Quality Improvement Initiative

Reducing Necrotising Enterocolitis in VLBW Infants- a Quality Improvement Initiative

Becher JC, Freer Y, McCormick J, Menon G.The Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Scotland, UK. Primary author: Dr Julie-Clare Becher, FRCPCH MD MBChB

Email: Tel: 0044 131 2422567

Keywords: necrotising enterocolitis, breast milk, antimicrobial stewardship

Background: Necrotising enterocolitis (NEC) affects around 5% of very low birthweight infants and is associated with high mortality and morbidity, including adverse neurodevelopmental outcome. Acquisition of an abnormal gut microflora is recognised in the pathogenesisof NEC and factors such as a lack of feeding with human breast milk and prolonged antibiotics are established risks.

Aim: In 2012 we aimed to reduce the rate of NEC from 14.1%to 5% in our Vermont Oxford Network (VON) population (<1501g or <30weeks) by optimising gut health in three quality improvement initiatives: (1) by improving early mother’s own breast milk (MOM) administration within 72hours to 100%(2) by reducing early formula milk (FM) exposure in a subset of infants <1000g to 0% and (3) by reducing exposure to antibiotics in the context of negative cultures by 50%.

Setting:The Neonatal Unit (NNU) has 39 cots and is a tertiary centre for babies requiring intensive care from the south east of Scotland. The regional birth rate is approximately 15000/annum with the NNU admitting approximately 1000 infants, of which 100-130 are inborn and VLBW. The NNU has a clinical staff complement of around 150 people comprising senior and junior doctors, nurses and allied health professionals. Donor breast milk (DBM) is sourced from the National Milk Bank in Glasgow, Scotland.

Mechanism:Mother’s own breast milk is protective against NEC and we identified in 2011 that only 58% of infants received their mother’s own milk (MOM) in the first 24 hours of life while 22% were exposed to formula milk in the first 14 days of life. Antibiotics also alter the gut microbiome and prolonged antibiotics in the face of negative cultures increases the risk for NEC. In 2011 we identified that over 80% of infants with negative blood cultures received >48 hours of antibiotics and that this was due both to a delay and uncertainty in the decision-making process.

Methods:Following a high rate of NEC 2007-2011, ‘Improving Gut Health’ was made a priority of the Newborn Care Collaborative, a multidisciplinary machine (including parents) for improvement change within the Lothian Neonatal Service. Staged implementation of quality improvement measuresoccurred between 2012-2014.

(1) A programme of change was formulated to optimise support for mothers in establishing early lactation (Table 1) (2) A guideline was introduced at the start of 2012 for the administration of DBM in infants <1000g where MOM was insufficient (3) The use of an Automatic Stop Order (ASO) was introduced in 2012 as an option at the initiation of antibiotic therapy to curtail the course to 48h in the face of negative cultures. A single CRP measurement at 36h was introduced in late 2012 and an ASO was made mandatory on all prescriptions in 2014.

Measures:

(1) NEC in inborn VON infants was defined strictly according to VON criteria and calculated as an annual percentage of inborn VON admissions 2011-2014.

(2) Human Milk: Measures were collected monthlyfrom Aug 2013-Jun 2015 and expressed as a percentage.

1. Numerator:inborn VONinfants receiving any MOM24h. Denominator: inborn VON infants
2. Numerator: inborn VONinfants receiving any MOM72h. Denominator: inborn VON infants
3. Numerator: alladmissions<1000g receiving FM in first 14 days. Denominator: admissions<1000g

(3) ASO: Measures were collected in four cycles of audit (2011-2014) and expressed as percentage.

1. Numerator: inborn infants receiving >48 h antibiotics. Denominator: inborn infantsreceiving antibiotics.
2. Numerator: number of prescriptions using anASO. Denominator: all antibiotic prescriptions.

Data/Results:The rate of NEC fell steadily from 14.1% (2011) to 4.6% (2014) (Figure 3). The number of VON infants receiving MOM within 24h increased from 58% to 90% (Figure 1) and within 72h increased from 85% to 100% (Figure 2).The number of infants <1000g receiving FM in the first 14 days of life fell from 22% (2011) to 3.6%, 0% and 0% in 2012, 2013 and 2014 respectively. The number of infants receiving greater than 48h of antibiotics in the context of negative cultures decreased from 81% to 28% (p<0.0001) as the use of anASOand single CRP measurement became a standard of care.

Discussion:Simple measures to optimise gut health can have a positive impact on necrotising enterocolitis rates in very low birthweight infants.

Team acknowledgement:We thank all of the staff and parents of the neonatal unit who have contributed to this quality improvement work over the past 2 years.

Table 1:Drivers of change to support early administration of MOM (2012-14)

Figure 1. Percentage of infants with negative cultures who receive >48h of antibiotics (4 month periods of audit of consecutive admissions)

Figure 2. Percentage of inborn VON infants receiving early MOM (<24h and <72h)

Figure 1. Percentage of inborn VON infants with NEC (SCRH vs VON Type B Units)