Reducing NICU Admission Hypothermia

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Early neonatal hypothermia is associated with delayed adjustment to extrauterine circulation, metabolic acidosis, coagulopathy, intraventricular hemorrhage, late-onset sepsis, and hypoglycemia.  The WHO has recommended that the temperatures of newborns be maintained between 36.5 and 37.5°C.  Admission hypothermia occurs frequently in NICUs despite the conventional approaches of drying and wrapping with pre-warmed towels and resuscitating under radiant warmers.  


Our SMART aim was to reduce initial hypothermia (<36.5°C) of infants admitted to NICU to < 5% by November 30, 2020.    


A multidisciplinary QI team (neonatologists, a fellow, advanced care providers, nursing leaders, and a nurse educator) created a comprehensive practice bundle for the prevention of admission hypothermia.  The bundle was made available on the intranet and in binders.  Several PDSA cycles were conducted to disseminate and implement the bundle elements:  1) mandatory education of NICU and Labor/Delivery staff on the impact of hypothermia and on prevention strategies; 2) roll-out of new EMR documentation of the use of hat, bag, and heating mattress for infants < 1500 g during and after resuscitation; 3) engagement of Ob/Gyn leadership and pre-setting thermostats in ORs to 70⁰F (prior to intervention OR temperatures averaged 65⁰F, Fig 2); 4) protocol to document normothermia of infants in LDR/OR prior to transport to NICU and introduction of an EMR template to facilitate it.  Balancing measures were delayed resuscitation or NICU admission secondary to these interventions and documentation requirements.


Severe admission hypothermia (< 36⁰C) decreased from 12% to 2%.  The centerline for moderate hypothermia (36.0-36.4⁰C) remains at 16% but may be improving as well (Fig. 1).  Process measures demonstrated improving bundle reliability for ambient LDR/OR temperatures and documentation of infants' temperatures in LDR/OR (Fig 2).  Time to resuscitation and admission did not increase.


Implementation of unit-specific evidence-based best practices decreased severe hypothermia in infants admitted to the NICU.  Attention to maintaining and documenting normothermia in the Delivery Room or Operating Room, and transferring infants to NICU only after normothermia is achieved, were the most effective process changes.  Sustaining improvement, and decreasing the incidence of moderate hypothermia, are challenges that will require real-time reinforcement and ongoing evaluation of bundle compliance and outcomes.  

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Cohen Children's Medical Center, Northwell Health
Neonatal-Perinatal Medicine, Cohen Children's Medical center
Cohen Children's Medical Center, Northwell Health
Cohen Children's Medical Center, Northwell Health
COhen CHildren's Medical Center, Northwell Health
Northwell - Cohen Children Hospital

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