Reducing Necrotizing Enterocolitis in Very Low Birth Weight Infants Using Quality Improvement Methods

OBJECTIVE: Due to a rise in necrotizing enterocolitis (NEC, stage ≥2) among very low birth weight (VLBW, birth weight <1500g) infants from 4% in 2005-6 to 10% in 2007-8, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants. STUDY DESIGN: In September 2009 we developed a NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ≥2. In May 2010 we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (Jan 2008-Nov 2009, n219), QI phase 1 (Dec 2009-May 2010, n62), and QI phase 2 (June 2010-Nov 2011, n170). RESULT: The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%), but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC. CONCLUSION: QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.