667 - Increasing compliance with metabolic bone disease guidelines for preterm infants at a level IV NICU

Friday, April 28, 2023

5:15 PM – 7:15 PM ET

Poster Number: 667
Publication Number: 667.139

Andrea M. Devaris-Martinez, Yale-New Haven Children's Hospital, New Haven, CT, United States; Noa Fleiss, Yale-New Haven Children's Hospital, New Haven, CT 06510, CT, United States; Sarah N. Taylor, Yale University, MADISON, CT, United States

Presenting Author(s)

Andrea M. Devaris-Martinez, MD (she/her/hers)

Resident Physician PGY2
Yale-New Haven Children's Hospital
New Haven, Connecticut, United States

Background: Preterm infants are at increased risk for low mineral levels secondary to missed placental transfer late in pregnancy, low mineral intake, and increased renal losses. This mineral deficiency increases risk for metabolic bone disease (MBD) of prematurity. The most susceptible infants are those with BW < 1500g, prolonged TPN use, and chronic problems, such as NEC and BPD. At our level IV NICU, an interdisciplinary team (neonatal dietitians, neonatology, pediatric endocrinology) standardized an evidence- and experience-based MBD screening method (Figure 1) which entails obtaining a primary screen at 4 weeks of age, followed by a secondary screen and endocrine consult if primary results are abnormal. While these guidelines are widely available, they are not reliably followed by NICU providers, often leading to excess blood draws and unnecessary subspecialty consultations.

Objective: To establish a quality improvement (QI) initiative in the neonatal ICU that increases compliance with MBD guidelines and improves overall bone health of preterm infants at risk for metabolic bone disease.

Design/Methods: All preterm infants < 32 weeks gestational age admitted to the level IV NICU 1/7/22-8/16/22 were included. To track and record compliance with already established evidence based MBD screening guidelines, baseline data was collected; specifically, time to primary screen draw and whether an appropriate endocrine consult was placed. The interdisciplinary team aimed to increase compliance with guidelines by targeting 4 key drivers (fig. 2) including alignment of the team, education of providers, standardized ordering practices and reliable tracking methods. Data is tracked on a monthly basis using a statistical control chart.

Results:

63 preterm infants who met criteria for MBD screening were reviewed. The centerline mean for compliance with MBD guidelines for these infants was 72% (Figure 3). Only 27% of the infants triggered a secondary screen. Unnecessary blood draws occurred in 18% of these infants in the setting of an erroneous secondary screen or obtaining an early primary screen. Also, data reported that only 78% of the staff appropriately consulted endocrinology.

Conclusion(s):

A NICU-based QI initiative focused on increasing compliance with MBD guidelines to promote preterm infant bone health and avoid unnecessary blood draws. With improved compliance with MBD guidelines, we aim to decrease the percentage of inappropriate blood draws and endocrinology consults.