Improving Newborn Preventive Services at the Birth Hospitalization: A Collaborative, Hospital-Based Quality-Improvement Project
Improving Newborn Preventive Services at the Birth Hospitalization: A
Collaborative, Hospital-Based Quality-Improvement Project
Charles E. Mercier, Sara E. Barry, Kimberley Paul, Thomas V. Delaney, Jeffrey D.
Horbar, Richard C. Wasserman, Patricia Berry and Judith S. Shaw
Pediatrics 2007;120;481-488
DOI: 10.1542/peds.2007-0233
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/120/3/481
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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ARTICLE
Improving Newborn Preventive Services at the Birth
Hospitalization: A Collaborative, Hospital-Based
Quality-Improvement Project
Charles E. Mercier, MDa, Sara E. Barry, MPHa, Kimberley Paul, BSNa, Thomas V. Delaney, PhDa, Jeffrey D. Horbar, MDa,b,
Richard C. Wasserman, MD, MPHa, Patricia Berry, MPHc, Judith S. Shaw, RN, MPHa
a
Department of Pediatrics, University of Vermont, Burlington, Vermont; bVermont Oxford Network, Burlington, Vermont; cVermont Department of Health, Burlington,
Vermont
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
OBJECTIVE. The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to
healthy newborns during the birth hospitalization.
METHODS. All Vermont hospitals with obstetric services participated. The qualityimprovement collaborative (intervention) was based on the Breakthrough Series
Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia;
performance of metabolic and hearing screens; assessment of and counseling on
tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to
domestic violence; and planning for outpatient follow-up care. The effect of the
intervention was assessed at the end of an 18-month period. Preintervention and
postintervention chart audits were conducted by using a random sample of 30
newborn medical charts per audit for each participating hospital.
RESULTS. Documented rates of assessment improved for breastfeeding adequacy
(49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position
(13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of
counseling improved for tobacco smoke exposure (23% vs 53%) and car safety
seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs
97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco
smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%),
assessment of exposure to domestic violence (27% vs 36%), or planning for
outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of ⱖ20% in ⱖ1 newborn preventive
service.
www.pediatrics.org/cgi/doi/10.1542/
peds.2007-0233
doi:10.1542/peds.2007-0233
Key Words
preventive services, quality improvement,
infant, newborn, birthing centers, hospital
Abbreviations
BTS—Breakthrough Series
OR— odds ratio
CI— confidence interval
QI— quality improvement
Accepted for publication Apr 23, 2007
Address correspondence to Charles E. Mercier,
MD, Smith 578, Fletcher Allen Health CareMedical Center Hospital of Vermont Campus,
111 Colchester Ave, Burlington, VT 05401.
E-mail: charles.mercier@vtmednet.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
American Academy of Pediatrics
CONCLUSIONS. A statewide, hospital-based quality-improvement project targeting
hospital staff members and community physicians was effective in improving
documented newborn preventive services during the birth hospitalization.
PEDIATRICS Volume 120, Number 3, September 2007
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481
C
OMPREHENSIVE PREVENTIVE HEALTH care for children
begins with adequate obstetric and pediatric prenatal care.1,2 For pediatricians, the prenatal visit serves to
initiate a trusting relationship with the parents and to
establish the infant’s medical home. Preventive health
care services such as anticipatory guidance on pertinent
parenting issues and screenings for identification of
high-risk situations can also occur at the prenatal visit.3
Although it is endorsed by the American Academy of
Pediatrics and supported by pediatricians, as few as 11%
of parents are seen for the pediatric prenatal visit.4 The
birth hospitalization may be the first encounter new
parents have with the pediatric health care practitioner.
When pediatric practitioners initiate health care services during the birth hospitalization, they work closely
with hospital nursing staff members responsible for postpartum and newborn care. The Guidelines for Perinatal
Care5 state that such nursing care should include initial
and ongoing assessment, newborn care education, support for the attachment process, preparation for healthy
parenting, and preparation for discharge and follow-up
monitoring of the mother and her newborn. The recommended nurse/patient ratio for normal mother-newborn
couplet care is 1 nurse for every 3 or 4 mother-newborn
couplets.
In 2004, the American Academy of Pediatrics recommended a set of initial health care services to be provided, and minimal criteria to be met, before hospital
discharge for well newborns.6 Newborn preventive
health care services, including assessment for immunization, metabolic and hearing screenings, anticipatory
guidance, risk assessment, and counseling, were among
this inventory of recommendations for care during the
birth hospitalization.
Over the past several decades, the length of the birth
hospitalization has become increasingly short. In 2003,
the National Committee for Quality Assurance Health
Plan Employer Data Information Set reported the median length of birth hospital stay for well newborns to be
2.2 days.7 Extensive work has been performed to examine the impact of decreased length of stay for well term
newborns, although that work was largely limited to a
focus on rehospitalizations8–11 or outpatient follow-up
services.12–14 Despite well-documented variability and
deficiencies in the delivery of preventive care in pediatric
settings,15–17 we found no literature about the completeness of preventive health care services for well newborns
during the birth hospitalization.
Quality improvement (QI) collaboratives offer a
method for improving the delivery of appropriate health
care services. In pediatrics, national and state QI collaboratives have focused on improving the quality and safety
of care for premature infants and their families in the
NICU18 and term infants in the pediatric office setting.19–21 However, health care services provided to well
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MERCIER et al
newborns during the birth hospitalization were not included in that work.
The current intervention implements QI methods
modified from the Institute for Healthcare Improvement
Breakthrough Series (BTS) Collaborative,22,23 incorporating shared learning, coaching from a team of experts,
provider education, measurement, and feedback. The
aim of this study was to examine the effects of a QI
intervention on the delivery of newborn preventive
health care services during the birth hospitalization in a
statewide sample of community hospitals delivering obstetric care.
METHODS
Study Setting and Design
All Vermont hospitals with obstetric services were recruited to participate. The project principal investigator
(Dr Mercier) met with the chief executive officer or
designee from each hospital, explained the goals of the
project, and described the responsibilities and resources
required for hospital participation. Each hospital signed
a consent form committing to participation in the
project. Hospitals participated in the project for an 18month period. Hospital participation was initiated on a
rolling basis, beginning in May 2002. All hospitals completed the study by June 2004. Audits of 30 newborn
medical charts were performed at each hospital for each
preintervention and postintervention measurement of
preventive health care service delivery. Medical charts
were selected at random from lists generated using hospital discharge records for newborns delivered in the
previous 6 months. Data on predefined preventive
health care service variables were abstracted by a team of
trained chart abstractors from the Vermont Child Health
Improvement Program.24
The selection of newborn preventive services was
generally drawn from the American Academy of Pediatrics policy statement on the hospital stay for
healthy term newborns7 and the American Academy
of Pediatrics periodicity schedule.25 The mixture of
newborn preventive services included sensory screening, general procedure, and anticipatory guidance services. For anticipatory guidance, the risk assessment
and counseling tasks of the service were counted as
separate services. For example, sleep position assessment and sleep position counseling were treated as 2
distinct preventive services. Each of the newborn preventive services was supported by a professional
guideline or health policy statement.26–35
Selected newborn preventive services are defined in
Table 1. Services included hepatitis B immunization;
assessment of breastfeeding adequacy; assessment of risk
of hyperbilirubinemia; performance of newborn metabolic and hearing screens; assessment of and counseling
on tobacco smoke exposure, infant sleep position, car
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TABLE 1 Definition of Data Variables
Variable
Hepatitis B immunization
Assessment of breastfeeding adequacy
Assessment of risk for hyperbilirubinemia
Performance of newborn metabolic screen
Performance of newborn hearing screen
Assessment of tobacco smoke exposure
Assessment of infant sleep position
Assessment of car safety seat fit
Assessment of domestic violence
Counseling on tobacco smoke exposure
Counseling on infant sleep position
Counseling on car safety seat fit
Planning for outpatient follow-up care
Definition
Hepatitis B immunization given
Suck or latch, audible swallow, and position for holding infant documented
Total serum bilirubin sample drawn or transcutaneous measurement
performed
Performance of newborn metabolic screen documented
Performance of newborn hearing screen documented
Maternal tobacco smoking assessment documented
Infant sleep position observed and documented
Infant fit in car safety seat observed and documented
Maternal exposure to domestic violence documented
Counseling on risk of infant tobacco smoke exposure documented
Counseling on proper infant sleep position documented
Counseling on proper infant fit in car seat documented
Day or date of planned newborn follow-up assessment documented
safety seat fit, and exposure to domestic violence; and
planning for outpatient follow-up care. Services were
defined as having been delivered on the basis of documentation in the newborn medical chart. Interrater
agreement, defined as the proportion of items coded
identically by 2 chart auditors, was established with a
random sample of 20% of the charts from each hospital
for each measurement period and exceeded 95%. The
study was approved by the institutional review board of
the University of Vermont. All data were collected before
the implementation of the Federal Health Insurance
Portability and Accountability Act.
TABLE 2 Measurable Aims for Newborn Preventive Health Care
Services
Population
The population consisted of hospital-born, healthy,
newborn infants. There were no gestational age or birth
weight limitations; multiple births as well as singleton
infants were included. Infants transferred into or out of
their birth hospital were excluded.
Newborn infants
Hepatitis B immunizations will be given to or planned for 90% of infants.
Adequacy of breastfeeding will be assessed for 100% of breastfeeding infants.
Assessment of risk of hyperbilirubinemia will be performed for 90% of infants.
Newborn metabolic screens will be performed for 100% of infants.
Newborn hearing screens will be performed for 100% of infants.
Risk of tobacco smoke exposure will be assessed for 100% of infants.
Sleep position will be assessed for 100% of infants.
Car safety seat fit will be observed for 100% of infants.
Risk of exposure to domestic violence will be assessed for 100% of infants.
Planning for outpatient follow-up care will be documented for 90% of infants.
Mothers/parents
Mother/parent counseling on the risk of infant exposure to tobacco smoke will
be performed for 90% of families.
Mother/parent counseling on appropriate infant sleep position will be
performed for 90% of families.
Mother/parent counseling on appropriate car safety seat fit will be performed
for 90% of families.
Counseling will be provided to 100% of women with a positive risk assessment
for exposure to domestic violence.
QI Intervention
Thirteen hospital-based newborn preventive health care
services were targeted for the QI intervention. The intervention was based on a modified BTS Collaborative
model.22,23 Each hospital received a performance report
of the preintervention measurement (feedback session)
for 13 hospital-based newborn preventive health care
services. The feedback session was presented at a facilitated, multidisciplinary, peer-protected, on-site meeting.
The report identified opportunities to improve performance in the delivery of these hospital-based newborn
services. After the report, each hospital was encouraged
to form a multidisciplinary (nurse, physician, and quality specialist) hospital-improvement team. Teams were
provided guideline- and literature-based references for
each of the 13 newborn preventive health care services.
Table 2 lists the measurable aims for newborn preventive health care services that teams were offered and
could choose to adapt to their specific clinical practice.
Teams were encouraged to attend 4 face-to-face state-
wide meetings (learning sessions), participate in selfmeasurement activity, submit monthly progress reports,
and participate in coaching calls on process improvement methods with project staff members. Continuing
medical education and nursing contact hours were provided for both feedback and learning sessions.
Learning sessions focused on planning for outpatient
follow-up care, assessment of risk for hyperbilirubinemia, and assessment of exposure to domestic violence. These 3 topics were chosen because of the complexity of organizational and operational issues involved
in implementing current guideline recommendations. At
the learning sessions, invited experts reviewed the current literature supporting guideline recommendations,
and parents or family members presented personal experiences. Hospital teams reviewed potentially effective
strategies to improve delivery of these preventive services and received coaching on process improvement,
based on the plan-do-study-act cycle method.36 Each
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483
learning session designated facilitated time for hospital
teams to review their preintervention data, to identify
gaps in performance, to identify potential changes in
their practice that could improve performance, and to
develop strategies to test these changes. Hospital teams
were also encouraged to choose ⱖ1 other preventive
health care service for targeted improvement work.
Modifications to the BTS model included a longer time
frame (18 months) during which the intervention was
conducted, a greater number of learning sessions (4
sessions) in which hospital teams participated, clinical
topic-based presentations at the learning sessions, a
greater number of one-on-one coaching telephone calls
to team leaders by the project director, systematic sharing of deidentified hospital-level data among improvement teams, and no facilitated conference calls between
participating hospitals.
Outcomes
The primary outcome measure was the aggregate preintervention to postintervention change in delivery of
newborn preventive health care services during the birth
hospitalization. Improvement in the delivery of preventive services at each individual hospital was also examined.
Data Analysis
The data analysis compared preintervention and postintervention measures of the delivery of newborn preventive health care services. The data were aggregated
across hospitals and examined with regard to assumptions of statistical normality. Logistic regression models
were used for analysis of preintervention versus postintervention changes for each preventive service variable.
In one set of logistic regressions, the models included
terms for time (preintervention versus postintervention)
and were adjusted to account for changes in Medicaid
eligibility (Medicaid or Medicaid eligible versus privately
insured) and short length of stay (⬍48 hours versus ⱖ48
hours). Models that were not adjusted were also run. For
each measure, odds ratios (ORs) for the logistic regression model were generated and evaluated by using a
Wald statistic; ␣ was .05. The 95% confidence intervals
(CIs) of the ORs were adjusted for clustering of patients
within hospitals.
RESULTS
All Vermont hospitals with obstetric services participated
(n ⫽ 12; see “Acknowledgments”). All hospitals formed
project-improvement teams, and all hospital teams attended each learning session, participated in self-measurement activity, submitted monthly progress reports,
and participated in coaching calls on process-improvement methods from project staff members. The median
number of health care preventive services for which
hospital teams conducted formal process-improvement
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MERCIER et al
work (including plan-do-study-act cycles) was 5 (range:
4 –9 services).
In all, medical charts of 719 newborns were reviewed
(359 for the preintervention measurement and 360 for
the postintervention measurement), representing ⬃9%
of the hospital births that occurred in Vermont during
the study period. Table 3 shows the characteristics of the
preintervention and postintervention samples. Samples
did not differ in the characteristics of average maternal
age, birth weight, gestational age, length of hospital stay,
or proportions of primiparous births, cesarean sections,
or singleton births.
Table 4 shows the results for the aggregate changes in
delivery of the 13 newborn preventive health care services at participating hospitals. Numbers in the unadjusted columns reflect the ORs, the 95% CIs for the ORs,
and the P values obtained by using logistic regression
analyses without adjustment for changes in Medicaid
eligibility or short length of stay. Numbers in the adjusted columns reflect the ORs, the 95% CIs for the ORs,
and the P values obtained by using logistic regression
analyses with adjustment for changes in Medicaid eligibility or short length of stay. Medicaid status data were
not obtained for 1 hospital in the preintervention measurement; we used the median insurance status value
from the postintervention data for that hospital in the
logistic regression equation for the 30 affected cases of
preintervention data. In 19 cases in which data on length
of stay were not available, the hospital- and measurement-specific (preintervention versus postintervention)
median value from the other cases was substituted for
the missing data.
Adjustment of the regression models for Medicaid
eligibility and short length of stay did not have an impact
on the analysis of the findings. Significant increases in
the delivery of newborn preventive health care services
were identified for the assessment of breastfeeding adequacy (49.4% vs 80.6%; P ⫽ .03), assessment of risk of
hyperbilirubinemia (14.4% vs 23.4%; P ⫽ .04), performance of newborn hearing screens (74.1% vs 97.4%; P
⫽ .01), assessment of infant sleep position (12.7% vs
55.7%; P ⫽ .02), observation of car safety seat fit (41.8%
vs 71.0%; P ⫽ .04), counseling on tobacco smoke exposure (22.7% vs 52.6%; P ⫽ .03), and counseling on car
TABLE 3 Demographic Measures for the Preintervention and
Postintervention Samples
Characteristic
Preintervention
Postintervention
Maternal age, mean (range), y
Birth weight, mean (range), g
Gestational age, median (range), wk
Primipara, %
Cesarean section, %
Singleton, %
Length of stay, mean (range), h
27.5 (15–43)
3488 (2142–5090)
39.4 (35–42)
35.6
21.7
98.7
49.9 (11–172)
27.9 (15–43)
3420 (1735–4575)
39.2 (34–43)
35.3
20.6
96.7
50.0 (2–293)
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TABLE 4 Preintervention Versus Postintervention Results, Unadjusted and Adjusted for Clustering of Patients at Hospitals
Variable
Proportion, %
Adjusteda
Unadjusted
Preintervention
Postintervention
Change
OR (95% CI)
P
OR (95% CI)
P
45.3
49.4
14.4
98.0
74.1
52.5
12.7
41.8
27.1
22.7
46.4
37.6
80.3
29.7
80.6
23.4
98.2
97.4
66.7
55.7
71.0
36.2
52.6
68.3
74.7
71.4
⫺15.6
⫹31.2
⫹9.0
⫹0.2
⫹23.3
⫹14.2
⫹43.0
⫹29.2
⫹9.1
⫹29.9
⫹21.9
⫹37.1
⫺8.9
0.51 (0.22–1.19)
4.24 (1.16–15.46)
1.83 (1.08–3.11)
0.98 (0.20–4.95)
13.38 (3.17–56.46)
1.77 (0.91–3.44)
8.81 (1.62–47.90)
3.41 (1.18–9.82)
1.43 (0.60–3.41)
3.71 (1.29–10.66)
2.49 (0.99–6.29)
4.99 (1.41–17.59)
0.61 (0.25–1.51)
.12
.03c
.03c
.99
.01c
.09
.01c
.02c
.42
.02c
.06
.02c
.31
0.51 (0.37–0.70)
4.49 (3.04–6.62)
1.96 (1.31–2.95)
1.14 (0.39–3.33)
14.31 (7.05–29.06)
1.77 (1.31–2.41)
9.08 (6.21–13.28)
3.42 (2.51–4.67)
1.43 (1.04–1.96)
3.75 (2.72–5.19)
2.56 (1.88–3.47)
5.07 (3.67–7.01)
0.60 (0.43–0.86)
.19
.03c
.04c
.89
.01c
.17
.02c
.04c
.51
.03c
.08
.02c
.38
Hepatitis B immunization
Assessment of breastfeeding adequacyb
Assessment of risk for hyperbilirubinemia
Metabolic screening
Hearing screening
Assessment of smoke exposure
Assessment of sleep position
Assessment of car safety seat fit
Assessment of domestic violence
Counseling on smoke exposure
Counseling on sleep position
Counseling on car safety seat fit
Planning for follow-up care
a Adjusted
on the basis of insurance status (Medicaid versus non-Medicaid) and length of stay of ⬍48 hours.
on numbers of breastfed infants (preintervention: n ⫽ 271; postintervention: n ⫽ 278).
c P ⬍ .05.
b Based
safety seat fit (37.6% vs 74.7%; P ⫽ .02). No significant
changes were noted for the performance of hepatitis B
immunization (45.3% vs 29.7%; P ⫽ .19), performance
of newborn metabolic screens (98.0% vs 98.2%; P ⫽
.89), assessment of tobacco smoke exposure (52.5% vs
66.7%; P ⫽ .17), assessment of domestic violence
(27.1% vs 36.2%; P ⫽ .51), counseling on infant sleep
position (46.4% vs 68.3%; P ⫽ .08), or planning for
outpatient follow-up care (80.3% vs 71.4%; P ⫽ .38).
To describe the variability of improvement among
individual hospitals, we calculated a hospital improvement quotient. The improvement quotient was the
number of newborn preventive health care services for
which there was a ⱖ20% increase from preintervention
measurement to postintervention measurement, divided
by the total number of services for which an improvement of ⱖ20% was possible for a given hospital. Figure
1 shows hospital improvement quotients.
Improvement quotients varied among hospitals,
ranging from 0.25 at hospitals 8 and 11 to 0.82 at hospital 5. Hospitals with greater numbers of services for
which improvement was possible had greater numbers
of improved services (r ⫽ 0.692; P ⫽ .013).
Whether improvement in infant assessment was related to improvement in family counseling for a specific
preventive service was also examined. We evaluated
infant assessment for and family counseling on tobacco
smoke exposure, infant sleep position, and car safety
seat fit, using 20% as the minimum for a change to be
considered an improvement. Of 6 hospitals that had the
opportunity to improve both assessment of and counseling on tobacco smoke exposure, 1 hospital did so. Of 8
hospitals that had the opportunity to improve both assessment of and counseling on infant sleep position, 3
hospitals did so. Of 7 hospitals that had the opportunity
to improve both assessment of and counseling on infant
FIGURE 1
Hospital improvement quotients.
Proportion of preventive
services increased by ≥20%
1.0
0. 9
0. 8
0. 7
0. 6
0. 5
0. 4
0. 3
0. 2
0. 1
0.0
1
2
3
4
5
6
7
8
9
10
11
12
Hospital
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485
car safety seat fit, 5 hospitals did so. Whether improvement in one area of family counseling correlated with
improvement in other counseling preventive services
was examined for tobacco smoke exposure, infant sleep
position, and care safety seat fit. When these were examined as combinations of counseling services, 6 hospitals had the opportunity to improve (⬎20%) in all 3
areas, and 3 did so. At the level of the individual infant,
12.2% of families received all 3 counseling services at
preintervention measurement and 44.4% of families received all 3 at postintervention measurement (adjusted
OR: 5.71; 95% CI: 3.87– 8.44; P ⫽ .01).
DISCUSSION
We engaged 12 hospitals in a QI collaborative targeting
newborn preventive services during the birth hospitalization. Significant improvements were seen in the assessments of breastfeeding adequacy, the risk of hyperbilirubinemia, infant sleep position, and car safety seat
fit. The performance of newborn hearing screens and
counseling on tobacco smoke exposure and car safety
seat fit also improved. Hospitals with more areas to
improve demonstrated a greater number of improvements. More research is needed to understand the predictors of a hospital’s success in improvement work.
The preventive services audited did not include all
newborn preventive services appropriate for the birth
hospitalization. Furthermore, the preventive services
chosen for this work neither indicated our prioritizing of
services nor suggested a standard of medical care. Finally, the mixture of preventive services focused exclusively on newborn care and safety. In general, routine
obstetric prenatal care, such as maternal screening for
syphilis or HIV infection, which ultimately could affect
the health status of the newborn, was not included in
this work. The one exception was the assessment of
maternal tobacco use.
Measurement of preintervention and postintervention newborn preventive services relied exclusively on
medical chart audits performed by study personnel.
None of the medical charts selected for either the preintervention or postintervention audit was found to be
missing or unavailable or was judged as incomplete by
study personnel. Although study personnel had no affiliation with a hospital whose medical charts were audited, those individuals were aware of the project objectives.
Audits of newborn medical charts reflected documentation in the medical charts. It is possible that changes in
the delivery of preventive services occurred as a result of
changes in documentation and not actual improvements. This was of particular concern when counseling
services were assessed. However, our chart auditors routinely found evidence of standardized tools that either
scripted counseling or served as triggers prompting review of several parental teaching points.
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MERCIER et al
Documentation of newborn preventive services in the
mothers’ medical charts would not have been discovered
in our audits. It is possible that exclusion of the mothers’
medical charts from the auditing process affected the
results of the intervention. This was of particular concern when exposure to domestic violence was assessed.
Hospital staff members admitted that, when the father of
the infant was alleged as the perpetrator of domestic
violence, anxiety about his access to the newborn medical chart was a specific barrier to documentation of
assessment. It is likely that this barrier had an impact on
our ability to measure changes in the assessment of
maternal exposure to domestic violence across the intervention period.
Eleven of 12 hospitals that participated in this project
exclusively offered basic (level 1) obstetric services to
their communities. The numbers of licensed beds in
these level 1 hospitals ranged from 25 to 188; 4 hospitals
had ⬍50 beds. In 2003, the numbers of births in these
level 1 hospitals ranged from 213 to 570. All 11 level 1
hospitals were actively engaged in a regionally coordinated system of perinatal health care services that supported interhospital patient transfer to a subspecialty
(level 3) perinatal health care center, as well as professional nurse and physician continuing education. As a
part of this regional system, birth center nurse managers
at all 11 level 1 hospitals routinely met as a group,
semiannually, to discuss issues related to managing obstetric and birthing center units. At least 1 pediatric
practice serving each hospital had previous experience
participating in a statewide, office-based, QI project targeting preventive services.21 Each hospital also had a
representative from the Vermont Department of Health
affiliated with the hospital and participating in the
project team.
The true total cost is difficult to define. We estimate
that the cost of conducting the project, including all
personnel and operating costs, was $350 000, or approximately $29 000 per hospital. An additional unmeasured
cost is that of the staff time devoted by each hospital in
carrying out the QI work. With ⬃5900 well newborn
infants per year born in the state and the estimate that
this project affected 97% of that population, the cost per
infant over the period of this intervention was approximately $41.
The effect of our modified BTS intervention was assessed at the end of an 18-month intervention period.
The ideal time to assess the effect of an intervention is
not clear.37 Notable changes in practice patterns could
have occurred within the 18-month project period and,
independent of our intervention, affected the delivery of
newborn preventive services. Such changes were possibly associated with the decrease in hepatitis B immunization rates during the intervention period. The recommendation for hepatitis B vaccination at birth, before
discharge from the hospital, was well established before
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the initiation of this project.38 During the intervention
period, the US Food and Drug Administration licensed a
combined diphtheria, tetanus toxoids, acellular pertussis
absorbed, hepatitis B (recombinant), and inactivated poliovirus vaccine (Pediarix; SmithKline Beecham Biologicals, Rixensart, Belgium) for use for infants 2, 4, and 6
months of age.39 This event likely contributed to the
decrease in the postintervention immunization rate to
29.7%.
CONCLUSIONS
Hospital-based birthing center teams were able to identify opportunities for improvement, to support a single
set of improvement goals, to learn to apply basic QI
methods, and, in doing so, to improve the quality of
newborn care provided at a statewide level. Performance-based feedback, education on evidence-based
practice, and parental testimony each made important
contributions to the success of hospital team efforts.
Leadership from the state department of health and an
experienced QI team based in an academic medical center was important to hospital-based team success.
ACKNOWLEDGMENTS
Participating hospitals were as follows: Brattleboro Memorial Hospital, Brattleboro, Vermont; Central Vermont
Medical Center, Barre, Vermont; Copley Hospital, Morrisville, Vermont; Gifford Medical Center, Randolph,
Vermont; North Country Hospital, Newport, Vermont;
Northeastern Vermont Regional Hospital, St Johnsbury,
Vermont; Northwestern Medical Center, St Albans, Vermont; Porter Medical Center, Middlebury, Vermont;
Rutland Regional Medical Center, Rutland, Vermont;
Southwestern Vermont Medical Center, Bennington,
Vermont; Springfield Hospital, Springfield, Vermont;
Vermont Children’s Hospital at Fletcher Allen Health
Care, Burlington, Vermont.
We thank the team members at the 12 Vermont
hospitals for their voluntary participation in this study,
which made this research possible. We thank Rachael
Beddoe and Mary Ingvoldstad for work as the study data
abstractors, Joseph Carpenter for assistance with development of the chart-auditing tool, Gary Badger for assistance with data analysis, and Lewis First for support of
this work.
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19.
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Rep. 2003;52:203–204
BROWN’S MEDICAL SCHOOL GETS BIG GIFT
“Retail entrepreneur Warren Alpert’s foundation has donated $100 million to
Brown University’s medical school in a major boost to the Ivy League institution’s effort to expand the school. Brown, in Providence, RI, is renaming its
medical school after Mr. Alpert in honor of the gift, the largest in the medical
school’s history. University and foundation officials plan to announce the
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more in recent years. The largest gift to a US university was a $600 million
donation to the California Institute of Technology in 2001 from Intel Corp
cofounder Gordon Moore and his wife, Betty.”
Tomsho R. Wall Street Journal. January 29, 2007
Noted by JFL, MD
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MERCIER et al
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Improving Newborn Preventive Services at the Birth Hospitalization: A
Collaborative, Hospital-Based Quality-Improvement Project
Charles E. Mercier, Sara E. Barry, Kimberley Paul, Thomas V. Delaney, Jeffrey D.
Horbar, Richard C. Wasserman, Patricia Berry and Judith S. Shaw
Pediatrics 2007;120;481-488
DOI: 10.1542/peds.2007-0233
Updated Information
& Services
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Collaborative, Hospital-Based Quality-Improvement Project
Charles E. Mercier, Sara E. Barry, Kimberley Paul, Thomas V. Delaney, Jeffrey D.
Horbar, Richard C. Wasserman, Patricia Berry and Judith S. Shaw
Pediatrics 2007;120;481-488
DOI: 10.1542/peds.2007-0233
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/120/3/481
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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ARTICLE
Improving Newborn Preventive Services at the Birth
Hospitalization: A Collaborative, Hospital-Based
Quality-Improvement Project
Charles E. Mercier, MDa, Sara E. Barry, MPHa, Kimberley Paul, BSNa, Thomas V. Delaney, PhDa, Jeffrey D. Horbar, MDa,b,
Richard C. Wasserman, MD, MPHa, Patricia Berry, MPHc, Judith S. Shaw, RN, MPHa
a
Department of Pediatrics, University of Vermont, Burlington, Vermont; bVermont Oxford Network, Burlington, Vermont; cVermont Department of Health, Burlington,
Vermont
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
OBJECTIVE. The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to
healthy newborns during the birth hospitalization.
METHODS. All Vermont hospitals with obstetric services participated. The qualityimprovement collaborative (intervention) was based on the Breakthrough Series
Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia;
performance of metabolic and hearing screens; assessment of and counseling on
tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to
domestic violence; and planning for outpatient follow-up care. The effect of the
intervention was assessed at the end of an 18-month period. Preintervention and
postintervention chart audits were conducted by using a random sample of 30
newborn medical charts per audit for each participating hospital.
RESULTS. Documented rates of assessment improved for breastfeeding adequacy
(49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position
(13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of
counseling improved for tobacco smoke exposure (23% vs 53%) and car safety
seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs
97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco
smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%),
assessment of exposure to domestic violence (27% vs 36%), or planning for
outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of ⱖ20% in ⱖ1 newborn preventive
service.
www.pediatrics.org/cgi/doi/10.1542/
peds.2007-0233
doi:10.1542/peds.2007-0233
Key Words
preventive services, quality improvement,
infant, newborn, birthing centers, hospital
Abbreviations
BTS—Breakthrough Series
OR— odds ratio
CI— confidence interval
QI— quality improvement
Accepted for publication Apr 23, 2007
Address correspondence to Charles E. Mercier,
MD, Smith 578, Fletcher Allen Health CareMedical Center Hospital of Vermont Campus,
111 Colchester Ave, Burlington, VT 05401.
E-mail: charles.mercier@vtmednet.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
American Academy of Pediatrics
CONCLUSIONS. A statewide, hospital-based quality-improvement project targeting
hospital staff members and community physicians was effective in improving
documented newborn preventive services during the birth hospitalization.
PEDIATRICS Volume 120, Number 3, September 2007
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481
C
OMPREHENSIVE PREVENTIVE HEALTH care for children
begins with adequate obstetric and pediatric prenatal care.1,2 For pediatricians, the prenatal visit serves to
initiate a trusting relationship with the parents and to
establish the infant’s medical home. Preventive health
care services such as anticipatory guidance on pertinent
parenting issues and screenings for identification of
high-risk situations can also occur at the prenatal visit.3
Although it is endorsed by the American Academy of
Pediatrics and supported by pediatricians, as few as 11%
of parents are seen for the pediatric prenatal visit.4 The
birth hospitalization may be the first encounter new
parents have with the pediatric health care practitioner.
When pediatric practitioners initiate health care services during the birth hospitalization, they work closely
with hospital nursing staff members responsible for postpartum and newborn care. The Guidelines for Perinatal
Care5 state that such nursing care should include initial
and ongoing assessment, newborn care education, support for the attachment process, preparation for healthy
parenting, and preparation for discharge and follow-up
monitoring of the mother and her newborn. The recommended nurse/patient ratio for normal mother-newborn
couplet care is 1 nurse for every 3 or 4 mother-newborn
couplets.
In 2004, the American Academy of Pediatrics recommended a set of initial health care services to be provided, and minimal criteria to be met, before hospital
discharge for well newborns.6 Newborn preventive
health care services, including assessment for immunization, metabolic and hearing screenings, anticipatory
guidance, risk assessment, and counseling, were among
this inventory of recommendations for care during the
birth hospitalization.
Over the past several decades, the length of the birth
hospitalization has become increasingly short. In 2003,
the National Committee for Quality Assurance Health
Plan Employer Data Information Set reported the median length of birth hospital stay for well newborns to be
2.2 days.7 Extensive work has been performed to examine the impact of decreased length of stay for well term
newborns, although that work was largely limited to a
focus on rehospitalizations8–11 or outpatient follow-up
services.12–14 Despite well-documented variability and
deficiencies in the delivery of preventive care in pediatric
settings,15–17 we found no literature about the completeness of preventive health care services for well newborns
during the birth hospitalization.
Quality improvement (QI) collaboratives offer a
method for improving the delivery of appropriate health
care services. In pediatrics, national and state QI collaboratives have focused on improving the quality and safety
of care for premature infants and their families in the
NICU18 and term infants in the pediatric office setting.19–21 However, health care services provided to well
482
MERCIER et al
newborns during the birth hospitalization were not included in that work.
The current intervention implements QI methods
modified from the Institute for Healthcare Improvement
Breakthrough Series (BTS) Collaborative,22,23 incorporating shared learning, coaching from a team of experts,
provider education, measurement, and feedback. The
aim of this study was to examine the effects of a QI
intervention on the delivery of newborn preventive
health care services during the birth hospitalization in a
statewide sample of community hospitals delivering obstetric care.
METHODS
Study Setting and Design
All Vermont hospitals with obstetric services were recruited to participate. The project principal investigator
(Dr Mercier) met with the chief executive officer or
designee from each hospital, explained the goals of the
project, and described the responsibilities and resources
required for hospital participation. Each hospital signed
a consent form committing to participation in the
project. Hospitals participated in the project for an 18month period. Hospital participation was initiated on a
rolling basis, beginning in May 2002. All hospitals completed the study by June 2004. Audits of 30 newborn
medical charts were performed at each hospital for each
preintervention and postintervention measurement of
preventive health care service delivery. Medical charts
were selected at random from lists generated using hospital discharge records for newborns delivered in the
previous 6 months. Data on predefined preventive
health care service variables were abstracted by a team of
trained chart abstractors from the Vermont Child Health
Improvement Program.24
The selection of newborn preventive services was
generally drawn from the American Academy of Pediatrics policy statement on the hospital stay for
healthy term newborns7 and the American Academy
of Pediatrics periodicity schedule.25 The mixture of
newborn preventive services included sensory screening, general procedure, and anticipatory guidance services. For anticipatory guidance, the risk assessment
and counseling tasks of the service were counted as
separate services. For example, sleep position assessment and sleep position counseling were treated as 2
distinct preventive services. Each of the newborn preventive services was supported by a professional
guideline or health policy statement.26–35
Selected newborn preventive services are defined in
Table 1. Services included hepatitis B immunization;
assessment of breastfeeding adequacy; assessment of risk
of hyperbilirubinemia; performance of newborn metabolic and hearing screens; assessment of and counseling
on tobacco smoke exposure, infant sleep position, car
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TABLE 1 Definition of Data Variables
Variable
Hepatitis B immunization
Assessment of breastfeeding adequacy
Assessment of risk for hyperbilirubinemia
Performance of newborn metabolic screen
Performance of newborn hearing screen
Assessment of tobacco smoke exposure
Assessment of infant sleep position
Assessment of car safety seat fit
Assessment of domestic violence
Counseling on tobacco smoke exposure
Counseling on infant sleep position
Counseling on car safety seat fit
Planning for outpatient follow-up care
Definition
Hepatitis B immunization given
Suck or latch, audible swallow, and position for holding infant documented
Total serum bilirubin sample drawn or transcutaneous measurement
performed
Performance of newborn metabolic screen documented
Performance of newborn hearing screen documented
Maternal tobacco smoking assessment documented
Infant sleep position observed and documented
Infant fit in car safety seat observed and documented
Maternal exposure to domestic violence documented
Counseling on risk of infant tobacco smoke exposure documented
Counseling on proper infant sleep position documented
Counseling on proper infant fit in car seat documented
Day or date of planned newborn follow-up assessment documented
safety seat fit, and exposure to domestic violence; and
planning for outpatient follow-up care. Services were
defined as having been delivered on the basis of documentation in the newborn medical chart. Interrater
agreement, defined as the proportion of items coded
identically by 2 chart auditors, was established with a
random sample of 20% of the charts from each hospital
for each measurement period and exceeded 95%. The
study was approved by the institutional review board of
the University of Vermont. All data were collected before
the implementation of the Federal Health Insurance
Portability and Accountability Act.
TABLE 2 Measurable Aims for Newborn Preventive Health Care
Services
Population
The population consisted of hospital-born, healthy,
newborn infants. There were no gestational age or birth
weight limitations; multiple births as well as singleton
infants were included. Infants transferred into or out of
their birth hospital were excluded.
Newborn infants
Hepatitis B immunizations will be given to or planned for 90% of infants.
Adequacy of breastfeeding will be assessed for 100% of breastfeeding infants.
Assessment of risk of hyperbilirubinemia will be performed for 90% of infants.
Newborn metabolic screens will be performed for 100% of infants.
Newborn hearing screens will be performed for 100% of infants.
Risk of tobacco smoke exposure will be assessed for 100% of infants.
Sleep position will be assessed for 100% of infants.
Car safety seat fit will be observed for 100% of infants.
Risk of exposure to domestic violence will be assessed for 100% of infants.
Planning for outpatient follow-up care will be documented for 90% of infants.
Mothers/parents
Mother/parent counseling on the risk of infant exposure to tobacco smoke will
be performed for 90% of families.
Mother/parent counseling on appropriate infant sleep position will be
performed for 90% of families.
Mother/parent counseling on appropriate car safety seat fit will be performed
for 90% of families.
Counseling will be provided to 100% of women with a positive risk assessment
for exposure to domestic violence.
QI Intervention
Thirteen hospital-based newborn preventive health care
services were targeted for the QI intervention. The intervention was based on a modified BTS Collaborative
model.22,23 Each hospital received a performance report
of the preintervention measurement (feedback session)
for 13 hospital-based newborn preventive health care
services. The feedback session was presented at a facilitated, multidisciplinary, peer-protected, on-site meeting.
The report identified opportunities to improve performance in the delivery of these hospital-based newborn
services. After the report, each hospital was encouraged
to form a multidisciplinary (nurse, physician, and quality specialist) hospital-improvement team. Teams were
provided guideline- and literature-based references for
each of the 13 newborn preventive health care services.
Table 2 lists the measurable aims for newborn preventive health care services that teams were offered and
could choose to adapt to their specific clinical practice.
Teams were encouraged to attend 4 face-to-face state-
wide meetings (learning sessions), participate in selfmeasurement activity, submit monthly progress reports,
and participate in coaching calls on process improvement methods with project staff members. Continuing
medical education and nursing contact hours were provided for both feedback and learning sessions.
Learning sessions focused on planning for outpatient
follow-up care, assessment of risk for hyperbilirubinemia, and assessment of exposure to domestic violence. These 3 topics were chosen because of the complexity of organizational and operational issues involved
in implementing current guideline recommendations. At
the learning sessions, invited experts reviewed the current literature supporting guideline recommendations,
and parents or family members presented personal experiences. Hospital teams reviewed potentially effective
strategies to improve delivery of these preventive services and received coaching on process improvement,
based on the plan-do-study-act cycle method.36 Each
PEDIATRICS Volume 120, Number 3, September 2007
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483
learning session designated facilitated time for hospital
teams to review their preintervention data, to identify
gaps in performance, to identify potential changes in
their practice that could improve performance, and to
develop strategies to test these changes. Hospital teams
were also encouraged to choose ⱖ1 other preventive
health care service for targeted improvement work.
Modifications to the BTS model included a longer time
frame (18 months) during which the intervention was
conducted, a greater number of learning sessions (4
sessions) in which hospital teams participated, clinical
topic-based presentations at the learning sessions, a
greater number of one-on-one coaching telephone calls
to team leaders by the project director, systematic sharing of deidentified hospital-level data among improvement teams, and no facilitated conference calls between
participating hospitals.
Outcomes
The primary outcome measure was the aggregate preintervention to postintervention change in delivery of
newborn preventive health care services during the birth
hospitalization. Improvement in the delivery of preventive services at each individual hospital was also examined.
Data Analysis
The data analysis compared preintervention and postintervention measures of the delivery of newborn preventive health care services. The data were aggregated
across hospitals and examined with regard to assumptions of statistical normality. Logistic regression models
were used for analysis of preintervention versus postintervention changes for each preventive service variable.
In one set of logistic regressions, the models included
terms for time (preintervention versus postintervention)
and were adjusted to account for changes in Medicaid
eligibility (Medicaid or Medicaid eligible versus privately
insured) and short length of stay (⬍48 hours versus ⱖ48
hours). Models that were not adjusted were also run. For
each measure, odds ratios (ORs) for the logistic regression model were generated and evaluated by using a
Wald statistic; ␣ was .05. The 95% confidence intervals
(CIs) of the ORs were adjusted for clustering of patients
within hospitals.
RESULTS
All Vermont hospitals with obstetric services participated
(n ⫽ 12; see “Acknowledgments”). All hospitals formed
project-improvement teams, and all hospital teams attended each learning session, participated in self-measurement activity, submitted monthly progress reports,
and participated in coaching calls on process-improvement methods from project staff members. The median
number of health care preventive services for which
hospital teams conducted formal process-improvement
484
MERCIER et al
work (including plan-do-study-act cycles) was 5 (range:
4 –9 services).
In all, medical charts of 719 newborns were reviewed
(359 for the preintervention measurement and 360 for
the postintervention measurement), representing ⬃9%
of the hospital births that occurred in Vermont during
the study period. Table 3 shows the characteristics of the
preintervention and postintervention samples. Samples
did not differ in the characteristics of average maternal
age, birth weight, gestational age, length of hospital stay,
or proportions of primiparous births, cesarean sections,
or singleton births.
Table 4 shows the results for the aggregate changes in
delivery of the 13 newborn preventive health care services at participating hospitals. Numbers in the unadjusted columns reflect the ORs, the 95% CIs for the ORs,
and the P values obtained by using logistic regression
analyses without adjustment for changes in Medicaid
eligibility or short length of stay. Numbers in the adjusted columns reflect the ORs, the 95% CIs for the ORs,
and the P values obtained by using logistic regression
analyses with adjustment for changes in Medicaid eligibility or short length of stay. Medicaid status data were
not obtained for 1 hospital in the preintervention measurement; we used the median insurance status value
from the postintervention data for that hospital in the
logistic regression equation for the 30 affected cases of
preintervention data. In 19 cases in which data on length
of stay were not available, the hospital- and measurement-specific (preintervention versus postintervention)
median value from the other cases was substituted for
the missing data.
Adjustment of the regression models for Medicaid
eligibility and short length of stay did not have an impact
on the analysis of the findings. Significant increases in
the delivery of newborn preventive health care services
were identified for the assessment of breastfeeding adequacy (49.4% vs 80.6%; P ⫽ .03), assessment of risk of
hyperbilirubinemia (14.4% vs 23.4%; P ⫽ .04), performance of newborn hearing screens (74.1% vs 97.4%; P
⫽ .01), assessment of infant sleep position (12.7% vs
55.7%; P ⫽ .02), observation of car safety seat fit (41.8%
vs 71.0%; P ⫽ .04), counseling on tobacco smoke exposure (22.7% vs 52.6%; P ⫽ .03), and counseling on car
TABLE 3 Demographic Measures for the Preintervention and
Postintervention Samples
Characteristic
Preintervention
Postintervention
Maternal age, mean (range), y
Birth weight, mean (range), g
Gestational age, median (range), wk
Primipara, %
Cesarean section, %
Singleton, %
Length of stay, mean (range), h
27.5 (15–43)
3488 (2142–5090)
39.4 (35–42)
35.6
21.7
98.7
49.9 (11–172)
27.9 (15–43)
3420 (1735–4575)
39.2 (34–43)
35.3
20.6
96.7
50.0 (2–293)
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TABLE 4 Preintervention Versus Postintervention Results, Unadjusted and Adjusted for Clustering of Patients at Hospitals
Variable
Proportion, %
Adjusteda
Unadjusted
Preintervention
Postintervention
Change
OR (95% CI)
P
OR (95% CI)
P
45.3
49.4
14.4
98.0
74.1
52.5
12.7
41.8
27.1
22.7
46.4
37.6
80.3
29.7
80.6
23.4
98.2
97.4
66.7
55.7
71.0
36.2
52.6
68.3
74.7
71.4
⫺15.6
⫹31.2
⫹9.0
⫹0.2
⫹23.3
⫹14.2
⫹43.0
⫹29.2
⫹9.1
⫹29.9
⫹21.9
⫹37.1
⫺8.9
0.51 (0.22–1.19)
4.24 (1.16–15.46)
1.83 (1.08–3.11)
0.98 (0.20–4.95)
13.38 (3.17–56.46)
1.77 (0.91–3.44)
8.81 (1.62–47.90)
3.41 (1.18–9.82)
1.43 (0.60–3.41)
3.71 (1.29–10.66)
2.49 (0.99–6.29)
4.99 (1.41–17.59)
0.61 (0.25–1.51)
.12
.03c
.03c
.99
.01c
.09
.01c
.02c
.42
.02c
.06
.02c
.31
0.51 (0.37–0.70)
4.49 (3.04–6.62)
1.96 (1.31–2.95)
1.14 (0.39–3.33)
14.31 (7.05–29.06)
1.77 (1.31–2.41)
9.08 (6.21–13.28)
3.42 (2.51–4.67)
1.43 (1.04–1.96)
3.75 (2.72–5.19)
2.56 (1.88–3.47)
5.07 (3.67–7.01)
0.60 (0.43–0.86)
.19
.03c
.04c
.89
.01c
.17
.02c
.04c
.51
.03c
.08
.02c
.38
Hepatitis B immunization
Assessment of breastfeeding adequacyb
Assessment of risk for hyperbilirubinemia
Metabolic screening
Hearing screening
Assessment of smoke exposure
Assessment of sleep position
Assessment of car safety seat fit
Assessment of domestic violence
Counseling on smoke exposure
Counseling on sleep position
Counseling on car safety seat fit
Planning for follow-up care
a Adjusted
on the basis of insurance status (Medicaid versus non-Medicaid) and length of stay of ⬍48 hours.
on numbers of breastfed infants (preintervention: n ⫽ 271; postintervention: n ⫽ 278).
c P ⬍ .05.
b Based
safety seat fit (37.6% vs 74.7%; P ⫽ .02). No significant
changes were noted for the performance of hepatitis B
immunization (45.3% vs 29.7%; P ⫽ .19), performance
of newborn metabolic screens (98.0% vs 98.2%; P ⫽
.89), assessment of tobacco smoke exposure (52.5% vs
66.7%; P ⫽ .17), assessment of domestic violence
(27.1% vs 36.2%; P ⫽ .51), counseling on infant sleep
position (46.4% vs 68.3%; P ⫽ .08), or planning for
outpatient follow-up care (80.3% vs 71.4%; P ⫽ .38).
To describe the variability of improvement among
individual hospitals, we calculated a hospital improvement quotient. The improvement quotient was the
number of newborn preventive health care services for
which there was a ⱖ20% increase from preintervention
measurement to postintervention measurement, divided
by the total number of services for which an improvement of ⱖ20% was possible for a given hospital. Figure
1 shows hospital improvement quotients.
Improvement quotients varied among hospitals,
ranging from 0.25 at hospitals 8 and 11 to 0.82 at hospital 5. Hospitals with greater numbers of services for
which improvement was possible had greater numbers
of improved services (r ⫽ 0.692; P ⫽ .013).
Whether improvement in infant assessment was related to improvement in family counseling for a specific
preventive service was also examined. We evaluated
infant assessment for and family counseling on tobacco
smoke exposure, infant sleep position, and car safety
seat fit, using 20% as the minimum for a change to be
considered an improvement. Of 6 hospitals that had the
opportunity to improve both assessment of and counseling on tobacco smoke exposure, 1 hospital did so. Of 8
hospitals that had the opportunity to improve both assessment of and counseling on infant sleep position, 3
hospitals did so. Of 7 hospitals that had the opportunity
to improve both assessment of and counseling on infant
FIGURE 1
Hospital improvement quotients.
Proportion of preventive
services increased by ≥20%
1.0
0. 9
0. 8
0. 7
0. 6
0. 5
0. 4
0. 3
0. 2
0. 1
0.0
1
2
3
4
5
6
7
8
9
10
11
12
Hospital
PEDIATRICS Volume 120, Number 3, September 2007
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485
car safety seat fit, 5 hospitals did so. Whether improvement in one area of family counseling correlated with
improvement in other counseling preventive services
was examined for tobacco smoke exposure, infant sleep
position, and care safety seat fit. When these were examined as combinations of counseling services, 6 hospitals had the opportunity to improve (⬎20%) in all 3
areas, and 3 did so. At the level of the individual infant,
12.2% of families received all 3 counseling services at
preintervention measurement and 44.4% of families received all 3 at postintervention measurement (adjusted
OR: 5.71; 95% CI: 3.87– 8.44; P ⫽ .01).
DISCUSSION
We engaged 12 hospitals in a QI collaborative targeting
newborn preventive services during the birth hospitalization. Significant improvements were seen in the assessments of breastfeeding adequacy, the risk of hyperbilirubinemia, infant sleep position, and car safety seat
fit. The performance of newborn hearing screens and
counseling on tobacco smoke exposure and car safety
seat fit also improved. Hospitals with more areas to
improve demonstrated a greater number of improvements. More research is needed to understand the predictors of a hospital’s success in improvement work.
The preventive services audited did not include all
newborn preventive services appropriate for the birth
hospitalization. Furthermore, the preventive services
chosen for this work neither indicated our prioritizing of
services nor suggested a standard of medical care. Finally, the mixture of preventive services focused exclusively on newborn care and safety. In general, routine
obstetric prenatal care, such as maternal screening for
syphilis or HIV infection, which ultimately could affect
the health status of the newborn, was not included in
this work. The one exception was the assessment of
maternal tobacco use.
Measurement of preintervention and postintervention newborn preventive services relied exclusively on
medical chart audits performed by study personnel.
None of the medical charts selected for either the preintervention or postintervention audit was found to be
missing or unavailable or was judged as incomplete by
study personnel. Although study personnel had no affiliation with a hospital whose medical charts were audited, those individuals were aware of the project objectives.
Audits of newborn medical charts reflected documentation in the medical charts. It is possible that changes in
the delivery of preventive services occurred as a result of
changes in documentation and not actual improvements. This was of particular concern when counseling
services were assessed. However, our chart auditors routinely found evidence of standardized tools that either
scripted counseling or served as triggers prompting review of several parental teaching points.
486
MERCIER et al
Documentation of newborn preventive services in the
mothers’ medical charts would not have been discovered
in our audits. It is possible that exclusion of the mothers’
medical charts from the auditing process affected the
results of the intervention. This was of particular concern when exposure to domestic violence was assessed.
Hospital staff members admitted that, when the father of
the infant was alleged as the perpetrator of domestic
violence, anxiety about his access to the newborn medical chart was a specific barrier to documentation of
assessment. It is likely that this barrier had an impact on
our ability to measure changes in the assessment of
maternal exposure to domestic violence across the intervention period.
Eleven of 12 hospitals that participated in this project
exclusively offered basic (level 1) obstetric services to
their communities. The numbers of licensed beds in
these level 1 hospitals ranged from 25 to 188; 4 hospitals
had ⬍50 beds. In 2003, the numbers of births in these
level 1 hospitals ranged from 213 to 570. All 11 level 1
hospitals were actively engaged in a regionally coordinated system of perinatal health care services that supported interhospital patient transfer to a subspecialty
(level 3) perinatal health care center, as well as professional nurse and physician continuing education. As a
part of this regional system, birth center nurse managers
at all 11 level 1 hospitals routinely met as a group,
semiannually, to discuss issues related to managing obstetric and birthing center units. At least 1 pediatric
practice serving each hospital had previous experience
participating in a statewide, office-based, QI project targeting preventive services.21 Each hospital also had a
representative from the Vermont Department of Health
affiliated with the hospital and participating in the
project team.
The true total cost is difficult to define. We estimate
that the cost of conducting the project, including all
personnel and operating costs, was $350 000, or approximately $29 000 per hospital. An additional unmeasured
cost is that of the staff time devoted by each hospital in
carrying out the QI work. With ⬃5900 well newborn
infants per year born in the state and the estimate that
this project affected 97% of that population, the cost per
infant over the period of this intervention was approximately $41.
The effect of our modified BTS intervention was assessed at the end of an 18-month intervention period.
The ideal time to assess the effect of an intervention is
not clear.37 Notable changes in practice patterns could
have occurred within the 18-month project period and,
independent of our intervention, affected the delivery of
newborn preventive services. Such changes were possibly associated with the decrease in hepatitis B immunization rates during the intervention period. The recommendation for hepatitis B vaccination at birth, before
discharge from the hospital, was well established before
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the initiation of this project.38 During the intervention
period, the US Food and Drug Administration licensed a
combined diphtheria, tetanus toxoids, acellular pertussis
absorbed, hepatitis B (recombinant), and inactivated poliovirus vaccine (Pediarix; SmithKline Beecham Biologicals, Rixensart, Belgium) for use for infants 2, 4, and 6
months of age.39 This event likely contributed to the
decrease in the postintervention immunization rate to
29.7%.
CONCLUSIONS
Hospital-based birthing center teams were able to identify opportunities for improvement, to support a single
set of improvement goals, to learn to apply basic QI
methods, and, in doing so, to improve the quality of
newborn care provided at a statewide level. Performance-based feedback, education on evidence-based
practice, and parental testimony each made important
contributions to the success of hospital team efforts.
Leadership from the state department of health and an
experienced QI team based in an academic medical center was important to hospital-based team success.
ACKNOWLEDGMENTS
Participating hospitals were as follows: Brattleboro Memorial Hospital, Brattleboro, Vermont; Central Vermont
Medical Center, Barre, Vermont; Copley Hospital, Morrisville, Vermont; Gifford Medical Center, Randolph,
Vermont; North Country Hospital, Newport, Vermont;
Northeastern Vermont Regional Hospital, St Johnsbury,
Vermont; Northwestern Medical Center, St Albans, Vermont; Porter Medical Center, Middlebury, Vermont;
Rutland Regional Medical Center, Rutland, Vermont;
Southwestern Vermont Medical Center, Bennington,
Vermont; Springfield Hospital, Springfield, Vermont;
Vermont Children’s Hospital at Fletcher Allen Health
Care, Burlington, Vermont.
We thank the team members at the 12 Vermont
hospitals for their voluntary participation in this study,
which made this research possible. We thank Rachael
Beddoe and Mary Ingvoldstad for work as the study data
abstractors, Joseph Carpenter for assistance with development of the chart-auditing tool, Gary Badger for assistance with data analysis, and Lewis First for support of
this work.
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BROWN’S MEDICAL SCHOOL GETS BIG GIFT
“Retail entrepreneur Warren Alpert’s foundation has donated $100 million to
Brown University’s medical school in a major boost to the Ivy League institution’s effort to expand the school. Brown, in Providence, RI, is renaming its
medical school after Mr. Alpert in honor of the gift, the largest in the medical
school’s history. University and foundation officials plan to announce the
donation today. . . . Universities have seen a surge in gifts of $100 million or
more in recent years. The largest gift to a US university was a $600 million
donation to the California Institute of Technology in 2001 from Intel Corp
cofounder Gordon Moore and his wife, Betty.”
Tomsho R. Wall Street Journal. January 29, 2007
Noted by JFL, MD
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MERCIER et al
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Improving Newborn Preventive Services at the Birth Hospitalization: A
Collaborative, Hospital-Based Quality-Improvement Project
Charles E. Mercier, Sara E. Barry, Kimberley Paul, Thomas V. Delaney, Jeffrey D.
Horbar, Richard C. Wasserman, Patricia Berry and Judith S. Shaw
Pediatrics 2007;120;481-488
DOI: 10.1542/peds.2007-0233
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