A Quality Improvement initiative to decrease the hospital-acquired infection in preterm neonates less than 34 weeks in a tertiary neonatal intensive care centre

1 in 10 new borns will be born before the completion of 37 weeks of gestation (premature birth). These babies are at a higher risk for morbidity and mortality due to various causes. Infection and sepsis in preterm infants remain the most significant clinical problem that represents a substantial burden on the parents, caregivers, and the healthcare system and is an important cause of mortality. Many factors predispose premature infants for having the greatest risk of developing and succumbing to infection as compared to all other age groups across the age spectrum. The immune system of preterm infants exhibits distinct, rather than deficient, functions compared to more mature and older humans and the immune function in preterm infants contributes to infection risk. Hand hygiene is the most important and single measure that has been shown to reduce infections in intensive care units, as per WHO. Other most common areas to reduce infections in NICU are staff awareness and education, use of checklists for procedures and maintenance to reduce CLABSI and VAP, having standard protocols, regular audits and team meetings. Although much progress in the treatment of infants born preterm has been made, the incidence of infection and sepsis is still high. In spite of all the known standard prevention and treatment methods, the implementation in different NICUs differs leading to increased infections in preterm neonates. The application of systematic quality improvement methods has the potential to reduce various forms of preventable neonatal morbidity and mortality through reliable and consistent application of existing high-level evidence without depending on new medications, technology, or innovations to be developed. This QI study is being conducted to decrease bloodstream infections in neonates <34 weeks of gestation and the cumulative rate of sepsis. Written consent will be taken from the mother/gaurdian of eligible preterm neonates. An interdisciplinary quality improvement team will be formed including neonatologists, pediatricians, postgraduate students, in-charge nurses, clinical nurse managers, clinical nurse educator, respiratory therapy supervisor, infection control nurses, and group D workers. Point of Care in Quality Improvement (POCQI) approach, including Plan, Do, Study Act cycles will be used to conduct the study. In the first 6week period, the old “bundles” and pre-existing practices regarding hand hygiene, regular glove usage, and checklists for invasive procedures will be retained and applied as is. Outcome data will be standardized to reflect the incidence of blood culture positivity per 1000 patient days, infections per 1000 central venous catheter days, catheter-related complications, rates of ventilator-associated pneumonia, meningitis, NEC. Process indicators, such as compliance to glove usage, compliance to hand hygiene and checklists during invasive procedures, will be checked by using weekly audits. The factors that may be contributing to the incidence of hospital-acquired infection will be analyzed. Fishbone analysis, five whys and the Pareto principle will be used in analyzing the barriers. The NICU interdisciplinary QI team will meet twice monthly to develop strategies for reducing healthcare infections in NICU. On the basis of team consensus, current practice will be evaluated and a detailed plan for improving practices will be developed as per the Point of Care in Quality Improvement (POCQI) approach, including Plan, Do, Study Act cycles. An intervention period, in the form of the PDSA cycle will take place, where educational modules for health care professionals working in NICU, procedure and CLABSI checklists, CLABSI and VAP bundles, hand hygiene compliance, use of clean gloves for regular handling, skin and oral care and other solutions to the barriers identified based on the fishbone analysis will be implemented in PDSA cycles until the target reduction is achieved. Compliance audits of the CLABSI and VAP bundles will be performed once every two weeks to validate the bundle implementation. The collected data will be documented and plotted as run charts and assessed on a weekly basis. Analysis will be done, and changes will be made accordingly through subsequent PDSA cycles. If the goal of reduction in the blood culture positivity rate by 30% is reached, then data collection will continue to the sustenance phase.