P2C066: Improving the Rate of Necrotizing Enterocolitis in the NICU

Purpose/Objectives: Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal (GI) tract in newborns. Strategies for the prevention of NEC include: 1) standardized feeding protocols; 2) human milk diet; 3) antibiotic stewardship; 4) limiting antacid use. Since 2017, the baseline median NEC rate in our level 4 NICU was 4.3%, above the benchmark of ~2% for similar centers. Using QI methodology, we sought to reduce our NEC rate by 10% over 2 years.

Design/Methods:

Aim: To decrease rate of NEC by 10% between Dec 1, 2020 and Dec 31, 2022.
Interventions included:
1) Establishment of a feeding protocol
2) Formation of a breast milk work group with the goal of improving human milk use
3) Establishment of an NEC work group.

Results: 1. Feeding Protocol
We introduced a feeding protocol in Sept 2020. Compliance with the protocol was measured based on “self-reporting” using a data collection tool. Training on the protocol occurred from Jan 2021 to Jan 2022. Copies were posted by computer work-stations (Jan 2021) and on an online share-drive (Jan 2022). In Jan 2022, NICU dieticians gained privileges to modify feeding orders. Our baseline compliance improved to 100% compliance by March, 2022 (figure 1).

2. Breastmilk at Discharge
We monitored breast milk rates at NICU discharge to assess if breast milk use was sustained through discharge. The median breast milk at discharge rate was 64.7%. In Aug 2022, a work group was created to improve breast milk use. We saw a trend towards improved breast milk rates at the end of 2022 (100% x 2 months).

3. Primary outcome: NEC rate
The baseline median NEC rate since 2017 was 4.3%. The NEC rate decreased to 1.6% and to 0.9% in 2021 and 2022 respectively (figure 2). Prior to 2019, infants with congenital heart disease (CHD) were admitted to the NICU pre-operatively and transferred to CVICU post-operatively. NEC data prior to 2019 includes infants with CHD that were admitted to NICU and later transferred to CVICU. After 2019, infants with CHD were admitted directly to CVICU and are not included in the NICU NEC data. This change in hospital practice may have impacted the NICU NEC data. However, the NEC rate remained at 4% in 2019 and 2020 despite this change in practice, and therefore unlikely had any major influence. In 2021, a NEC multi-disciplinary work group was formed. The focus of the group is to review best practice guidelines for NEC prevention.

Conclusion/Discussion: Using best practice interventions, we improved our NEC rate from 4.3% to 0.9%. NEC carries a high morbidity and mortality; survivors of NEC are more likely to develop long-term neurodevelopmental impairment. By decreasing NEC, we are improving long-term patient outcomes and reducing the cost of NICU care.