The NICU team and entire division of neonatology at the University of Virginia benchmark key metrics in the VON Annual Report against similar centers. In 2013 and 2014, the team observed that fewer than 40% of very low birth weight infants were admitted to the NICU with normal temperature (36.5-37.5 °C), and in fact, nearly 70% of infants born at less than 35 weeks gestation were hypothermic (<36.5 °C) at admission. Matthew Harer, MD, a second-year fellow at the time, spoke up to say, “We can and should do better.”

Dr. Harer led the quality improvement initiative, which included a multidisciplinary team of nurses, managers, neonatal nurse practitioners and physicians from neonatology, obstetrics, and maternal fetal medicine to drive quality improvement for temperature at admission for VLBW infants.

The team set a QI aim to achieve more than 60% normal admission temperature for all infants born under 35 weeks gestational age by 2015 without increasing hyperthermia (>37.5 °C), and they implemented a plan-study-act-do (PDSA) methodology to achieve the aim.

The 51-bed unit serves approximately 200 infants born at less than 35 weeks gestational age per year. While previous research helped develop a UVA-specific guideline to manage temperature, the team found great value observing a subset of deliveries and resuscitations prior to starting the project. During observations, the team identified three major factors to address: variation in delivery room temperature, lack of infant temperature monitoring prior to transport to the NICU, and inconsistent use of supplemental thermoregulation methods.

The observations also gave the team data to demonstrate to obstetric colleagues how processes in the delivery room correlated to admission temperature. They rounded out the improvement team with several nurse champions who ensured compliance with thermoregulation guidelines in the delivery room.

“The multidisciplinary nature of the team made this project successful,” said Harer. “Everyone involved got on board after seeing how our current admission temperatures compared to the rest of VON and stressing how hypothermia can have other implications, such as respiratory status, glucose status, and potentially long-term outcomes.”

Multiple PDSA cycles at three-month intervals informed changes to the initial guideline and led to incremental measurable improvement. The multidisciplinary team made changes rapidly and was able to focus on vital patient-safety and outcome-based issues.

UVA’s final guideline focused on standardizing delivery room temperature and transportation to the NICU. After implementing the guideline, cases of moderate hypothermia (<36 °C) decreased from 29% to 9% in infants of less than 35 weeks gestational age, which means they were in the lowest quartile for hypothermia in this patient population based on 2015 VON data.

“Without VON data, this project would not have existed,” said Jonathan Swanson, MD. “Since admission temperature is a discrete field in the database, we were able to see the problem without looking for it.”

The team at UVA has recently used their VON data to implement another QI project focused on IVH and report a 50% decrease in severe rates of IVH within one year.