P2C067: Implementation of a NEC Prevention Bundle to Decrease the Incidence of NEC in Preterm And/or VLBW Infants in a Level III NICU

Purpose/Objectives: Necrotizing Enterocolitis (NEC) is one of the most common gastrointestinal emergencies in preterm infants. The incidence of NEC has been reported to be 2-7.5% in very low birth weight (VLBW) infants, contributing to significant morbidity and mortality in the neonatal intensive care unit (NICU). The implementation of standardized protocols and checklists has been shown to decrease the incidence of NEC at many centers. We conducted a Quality Improvement (QI) initiative at a Level III NICU that aimed to reduce the incidence of NEC by 20% over a 2-year period, from January 1st, 2021, to December 31st, 2022.

Design/Methods: Infants with gestational age < 32 weeks and/or weight < 1500g at birth were included. The QI Model for Improvement and Key Driver Diagram were used to build the NEC prevention bundle that comprised of a 9-point checklist. We studied 5 interventions during the initiative: 1) Use of mother’s own milk or donor human milk, 2) Adherence to the unit feeding protocol, 3) Discontinuation of antibiotics within 48 hours of negative blood cultures, 4) No routine checking of gastric residuals, 5) Removal of central lines at 100 ml/kg/day of feeding volume. Compliance with items on the checklist was ensured and barriers to successful implementation identified and addressed by 2 independent investigators. The infants enrolled in the study were followed bi-weekly until discharge. The primary outcome measure was the incidence of clinically proven NEC and the process measure was adherence to the NEC bundle.

Results: We conducted 2 PDSA (Plan-Do-Study-Act) cycles over a 2-year period. There were 74 infants who met the inclusion criteria. The adherence rates to our process measure improved from 97% to 100% for use of human milk, 68% to 83% for adherence to the feeding protocol, 81% to 88% for antibiotic discontinuation at 48 hours, 76% to 94% for not checking gastric residuals and 71% to 92% for central line removal. Our outcome measure of incidence of NEC decreased from 7% at baseline to 5.3% at the end of the first PDSA cycle. Following the second PDSA cycle, the incidence of NEC decreased from 5.3% to 2.8%. This was a 60% reduction from baseline.

Conclusion/Discussion: Implementation of the NEC prevention bundle reduced the incidence of NEC by 60% in our NICU. Reduction in NEC rate decreases overall morbidity and mortality and leads to improved long-term neurodevelopmental outcomes and quality of life in preterm and VLBW infants.