Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU

Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outco...

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Bibliographic Details
Published in:	Pediatrics (Evanston) Vol. 150; no. 4; p. 1
Main Authors:	Aurora, Megan, Keyes, Madeline L, Acosta, Julian Garcia, Swartz, Kristen, Lombay, Jesiel, Ciaramitaro, Jason, Rudnick, Ariana, Kelleher, Cassandra, Hally, Suzanne, Gee, Michael, Madhavan, Vandana, Roumiantsev, Sergei, Cummings, Brian M, Nelson, Brett D, Lerou, Paul H, Matute, Juan D
Format:	Journal Article
Language:	English
Published:	United States American Academy of Pediatrics 01-10-2022
Subjects:	Anti-Bacterial Agents - therapeutic use Antibiotics Antifungal Agents Disease management Electronic health records Electronic medical records Enterocolitis Enterocolitis, Necrotizing - diagnosis Enterocolitis, Necrotizing - therapy Female Fetal Diseases Gastrointestinal diseases Humans Infant, Newborn Infant, Newborn, Diseases Inflammatory diseases Intensive care Intensive Care Units, Neonatal Medical records Morbidity Mortality Necrosis Necrotizing enterocolitis Neonatal care Patients Pediatrics Piperacillin Quality control Quality improvement Retrospective Studies Standardization Surgery Tazobactam Variation
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Summary:	Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 These authors contributed equally to this work. These authors co-supervised this work. Drs Matute, Aurora, Keyes, Lerou, Ms Swartz, and Ms Hally conceptualized and designed the study, performed education activities in the NICU, performed data collection, analyzed data, and drafted the manuscript; Mr Garcia Acosta and Drs Lombay, Ciaramitaro, and Rudnick contributed to the acquisition of data, analysis, and interpretation of data; Drs Kelleher, Gee, Madhavan, Cummings, Roumiantsev, and Nelson contributed to the conception and design of the study, analysis, and interpretation of data; and all authors critically revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
ISSN:	0031-4005 1098-4275
DOI:	10.1542/peds.2022-056616