Pausing TPN to Decrease Abnormal Newborn Screens: A NICU Quality Initiative

Detection of metabolic and genetic disorders via the newborn screen (NBS) remains a great diagnostic achievement in medicine. Unfortunately, many false positives for neonates due to acute illness lead to repeat testing. For example, the rate of abnormal NBS in very low birth weight (VLBW) neonates at the University of Virginia was 66%, with 23% due to total parenteral nutrition (TPN) on the amino acid profile. METHODS: This study describes a quality improvement (QI) initiative completed in the NICU at a quaternary care center. The primary and secondary outcomes were the percentage of abnormal NBSs in VLBWs and all admissions. The intervention required a pause in TPN, and a dextrose-containing fluid ran for 4 hours before collecting the NBS. During PDSA cycle 1, the TPN pause occurred at 1400, and the collection of the NBS occurred at 1800. During PDSA cycle 2, we aimed to decrease the number of blood draws per neonate and, thus, paused the TPN at 0000 to enable NBS collection at 0400 with routine morning laboratory work. RESULTS: The rate of abnormal screens in VLBWs decreased from 66% to 49%; P < 0.006; 95% CI, 0.04–0.27, and the rate of abnormal screens in all admissions dropped from 45.2% to 28.8%; P < 0.0001; 95% CI, 0.06–0.51. Hospital costs decreased from $244.79 to $170.86 per patient in the cost of the NBS cards alone. CONCLUSION: By pausing TPN for 4 hours before drawing the NBS, we decreased the number of abnormal NBS in all admissions while also decreasing hospital costs.