Now, for the first time in history, preterm birth has become the number one cause of young children death (1). The risk of mortality and morbidity increase with decreasing gestational age. Extremely preterm infants < 28 weeks gestation and infants with extremely low birth weight at birth are at highest risk of death and major morbidity outcomes (2,3). Variability of management and outcomes for this population have been identified from institution to institution, as evidenced by a difference in rate of major clinical outcomes (4). Variability in the clinical team behavior is a product of varied educational backgrounds and experience (5). Hence, guidelines can increase consistency in providing excellent care of similar patients by the myriad healthcare providers in an ICU setting (6). As a part of the ‘Golden Week’ small baby program, specific order sets were developed to establish consistency, and included admission, respiratory therapy, laboratory, nutrition and medication orders. Phased educational program for the physicians and nurses were created and implemented. The ‘Golden Week’ core committee meets monthly to discuss feedback received from medical and nursing staff, review collected data, discuss individual morbidity and mortality, and identify areas for continued improvement.

The overall hypothesis of this initiative was: “using a standardized and efficient management guideline would improve the mortality and major morbidity of preterm infants born at <28 weeks’ gestation.”

Standardized evidence-based guidelines were created in five broad clinical categories and two non-clinical categories. Each category has related measures identified. The clinical categories/goals were: 1) respiratory support 2) Thermoregulation 3) nutrition and fluid management 4) infection prevention and 5) neurological status. The two non-clinical categories were: 1) parent support and satisfaction and 2) staff/team building.

Several outcome measures are being used for this program. As an example, there has been a focus to reduce severe intracranial hemorrhage or death. As early outcomes such as severe intracranial hemorrhage or death during the first week of life are major determinants of overall outcomes in extremely premature infants, we established our initial outcome measure as:

Phase I (first week outcomes) –(i) severe intracranial hemorrhage (Grade 3-4) at 7 days of life, (ii) death or severe intracranial hemorrhage (Grade 3-4) at 7 days of life. The first PDSA cycle involved Phase 1 only (first week outcomes). Phase II (ongoing) involves long term mortality and other major morbidities at discharge. This is an ongoing program with several phases planned.

The Golden Week Program™ core committee includes:

Program Director (Neonatologist – Charitharth Vivek Lal, M.D.) – Oversees the workflow of the project. Chairs monthly meetings with the core team. Engages leadership at the Divisional (Neonatal and Perinatal Medicine) and Departmental (Pediatrics) level.

Fellow Program Liaison (Fellow Neonatologists – Colm Travers, M.D., Kalsang Dolma, M.D.) – Engages leadership of the Neonatal/Perinatal Fellowship Program and Pediatric Residency Program. Oversees the workflow of the project. Coordinates physician teaching.

Nursing Program Liaison (Registered Nurse- Kimberly Nichols, RN) – Engages leadership at multiple levels including: NICU, Labor & Delivery, Radiology, Pharmacy, and Nursing Informatics. In addition, coordinates the multidisciplinary and educational aspects of this program.

Nursing Program Manager (Nurse Manager- Donna Purvis, RN) – Engages leadership of the University Hospital administration, Quality Department, and Hospital Marketing. Supervises the Nursing Program Liaison, and NICU staff.

Respiratory Therapist (Susan Roberts, RT) – Supervises the NICU respiratory therapy staff and engages in respiratory teaching and protocol development.

Parents are important members of the care team for the neonatal patients. We utilized our ‘RNICU March of Dimes Family Liaison’ to monitor for inclusion of family rights and family participation in care. The Neonatal Fellow Physicians provide each family a detailed predelivery consult to include education and information regarding the ‘Golden Week Program’. A ‘Golden Week’ Logo developed by the hospital marketing department, is placed on each infant incubator and room doors - to remind parents, family members, and clinical staff of the baby enrolment in the ‘Golden Week’ program. A detailed ‘Golden Week’ handout for the families is part of the plan. The family liaison shares information with families during a variety of activities and uses these opportunities to reinforce the Golden Week concepts. Labor and Delivery staff in addition to NICU staff were educated on ‘Golden Week’ program’ guidelines to additionally, help with education of families prior to, and after birth.

• youtube.com/watch?v=EEWLcEDAXho.

• www.uab.edu/news/health/item/8446-new-standardized-clinical-practices-reduce-prematureinfant-morbidity-and-mortality-in-first-week-of-life

• uab.edu/medicine/peds/news/1434-uab-rnicu-golden-week-program-receives-2017-gage-award-honorable-mentio

• al.com/news/birmingham/index.ssf/2017/09/uab_hospital_wins_prestigious.html

• bizjournals.com/birmingham/news/2017/09/18/uab-medicine-receives-two-nationalhospital-awards.html

NeuroNICU-B.R.A.I.N. program is a multidisciplinary program that includes pediatric neurologist, pediatric rehabilitation medicine specialist, and pediatric neuro-radiologist, neonatal nurse practitioners, nurse manager, physical therapist, respiratory therapist, and nurse champions.

This program is intended to

1. prevent and reduce the incidence of intraventricular hemorrhage (IVH) in preterm infants ≤29.6 weeks of gestational age (GA) using standardize bundle of care,

2. avoid abnormal cerebral perfusion in the first week after birth infants < 29.6 weeks GA (using transcutaneous CO₂ [TCO₂] monitors and near-infrared spectroscopy [NIRS]),

3. screen for seizures in high-risk preterm and term infants using EEG, and

4. early identification and treatment of high-risk infants with abnormal neurological examination.

The overall hypothesis of this initiative is that using a standardized and evidence-based management guideline would improve the neurodevelopmental outcome of high-risk preterm (≤29.6 weeks of GA) and term infants

1. incorporation of NIRS and TCO₂ as a routine monitoring in preterm infants ≤29.6 weeks of GA during first 7 days after birth,

2. incorporation of EEG as a routine screening in preterm infants ≤29.6 weeks of GA with grade III and IV IVH,

3. early identification and treatment of hypertonicity in preterm infants ≤29.6 weeks of GA with grade III and IV IVH,

4. incorporation of routine EEG during therapeutic hypothermia for infants with hypoxic-ischemic encephalopathy,

5. parental support and satisfaction

6. staff/team building.

1. severe intracranial hemorrhage (Grade 3-4) at 7 days of life,

2. death or severe intracranial hemorrhage (Grade 3-4) at 7 days of life,

3. incidence of subclinical seizures in infants with grade III and IV IVH,

4. days to full PO feeds infants and reduction in the usage of sedations within high-risk preterm infants hypertonicity,

5. identification of subclinical seizures in infants with hypoxic-ischemic encephalopathy.

This is an ongoing program with two phases planned.

Phase 1: Neuroprotective strategies to prevent brain injury in preterm infants ≤29.6 weeks of GA

Phase 2: Neuroprotective strategies to prevent brain injury in high-risk term infants

Program Director (Manimaran Ramani, M.D.,): Oversees the workflow of the project. Chairs the monthly meetings with the core team and quarterly meeting with all the members of NeuroNICU meetings. Engages leadership at the Divisional (Neonatal and Perinatal Medicine) and Departmental (Pediatrics) level. Rounds on NeuroNICU patient weekly with clinical operational manager,

NNICU Clinical Operational Manager (Angela Barganier, CRNP, Neonatal Nurse Practitioner): Oversee the program. Engages with Guideline Development Lead, neonatal nursing staff, multidisciplinary specialist in standardizing the existing protocols and aids the team in developing new protocols. She co-chairs the monthly and quarterly NeuroNICU meetings. Rounds with program director weekly to assess the compliance and the challenges of the implemented neuroprotective protocols.

NNICU Guideline Development Lead (Andrew Klinger, M.D., Neonatology Fellow): Develops guidelines and protocols. Engages leadership of the Neonatal/Perinatal Fellowship Program and Pediatric Residency Program. Coordinates physician teaching.

NNICU Nursing Program Liaison (Shelly Caldwell, RN): Engages leadership at multiple levels including NICU, Labor & Delivery, Radiology, Pharmacy, and Nursing Informatics. In addition, coordinates the multidisciplinary and educational aspects of this program.

NNICU Nurse Professional Development Specialist (Ashley Pruitt, RN): Develop and implement teaching for nursing staff.

Nursing Program Manager (Donna Purvis, RN): Engages leadership of the University Hospital administration, Quality Department, and Hospital Marketing. Supervises the Nursing Program Liaison, Nurse Professional Development Specialist and NICU staff.

NNICU Respiratory Therapist (Alisha Regelin, RT) – Supervises the NICU respiratory therapy staff and engages in respiratory teaching and protocol development.

NNICU Bioinformatics (Justine Brice, RN): Develops and implement electronic order sets.

Multidisciplinary Specialists:
Pediatric Rehab Medicine (Paola Marie Mendoza-Sengco, MD): Rounds weekly in the NeuroNICU patients to identify and treat abnormal neurological findings seen in our high-risk population,
Pediatric Neurologist (Helen Barken, MD): Dedicated pediatric neurologist who reads screening EEG in high risk preterm infants
Pediatric Neuro-Radiologist (Sumit Singh, MD) Dedicated pediatric neurologist who reads head US and MRI in high risk infants,
Developmental Specialist (Myriam Peralta, MD): Measures and assess the neurological outcomes of NeuroNICU graduates in the newborn follow-up clinic.

Parents are important members of the care team for the neonatal patients. Dr. Ramani utilizes the ‘RNICU March of Dimes Family Liaison’ to monitor for inclusion of family rights and family participation in care. The neonatology fellows provide the mother delivering a preterm infant a detailed consult regarding the ‘NeuroNICU Program’. A ‘B.R.A.I.N.’ Logo developed by the hospital marketing department, is placed on each infant incubator and room doors - to remind parents, family members, and clinical staff of the baby enrolment in the ‘B.R.A.I.N program. A detailed ‘B.R.A.I.N brochure is given to the parents of the infants who are enrolled in B.R.A.I.N program. The family liaison shares information with families during a variety of activities and uses these opportunities to reinforce the neuroprotetice concepts. Labor and Delivery staff in addition to NICU staff were educated on ‘B.R.A.I.N program’ guidelines to additionally, help with education of families prior to, and after birth.

Dr. C. Vivek Lal conceptualized, initiated, implemented, and serves as the Director of the Golden Week Small Baby Program in the RNICU at UAB, and as Chair of the Golden Week Small Baby Program Core Committee. He directs the protocol generation and presides over weekly meetings of committee. With this program, we have provided education to over 200 nurses, residents, fellows, and attending physicians. The program has led to a significant and sustained reduction in severe intraventricular hemorrhage and early mortality in extremely preterm infants. In 2017, the program was selected as an honorable mention recipient for a 2017 Gage Award, a competitive national award given by the America’s Essential Hospitals for significant quality improvement initiative.

About the program:

• youtube.com/watch?v=EEWLcEDAXho.

Dr. Ariel Salas designed and developed the Helping Babies Feed program at UAB. Under his leadership, the Helping Babies Feed program implemented the following quality improvement initiatives:

1. Discontinuation of nursing practices related to routine evaluation of gastric residual volumes in extremely preterm infants

2. Standardization of nursing practices related to selective evaluation of gastric residual volumes in extremely preterm infants

3. Validation of a checklist to assess feeding intolerance in extremely preterm infants

4. Development of a bundle to reduce feeding intolerance in ELBW infants receiving CPAP support.

5. Standardization of orogastric tube insertion length in extremely preterm infants

6. Development of a protocol to standardize enteral feeding during blood transfusion

7. Optimization of oral colostrum for extremely preterm infants

8. Optimization of oral feeding initiation among preterm infants

Dr. Ramani designed, developed and implemented the NeuroNICU-B.R.A.I.N. program at UAB. Under his leadership, the NeuroNICU program developed and implemented the following neuroprotective protocols and strategies:

1. Hypoglycemia Prevention Protocol for extremely preterm infants

2. Hyperglycemia Treatment Protocol for high-risk neonates

3. Intraventricular Hemorrhage (IVH) Prevention Protocol for infants less than <30 weeks of gestational age

4. Implementation of EEG monitoring in infants with Grade III and IV IVH

5. Implementation of Near Infra-Red Spectroscopy monitoring in infants less than <30 weeks of gestational age

6. Incorporation of hypoxic-ischemic encephalopathy examination within the electronic medical record

7. Early identification of abnormal neuro-exam in high-risk neonates

8. Simplified Methadone Weaning Protocol for the infants with Neonatal Abstinence Syndrome

 Dr. Ramani collaborate with other NeuroNICU programs across the country and brings the best evidence-based neuroprotective practices to our units.

Baby NINJA is a national, multi-center quality improvement (QI) collaborative that has been shown to reduce both nephrotoxic medication exposure and related acute kidney injury (AKI) in the non-ICU center. It originated at UAB/Children’s of Alabama NICU through a collaborative relationship between neonatology and pediatric nephrology and the support of a P50 Pilot & Feasibility Grant from the Pediatric Center of Excellence in Nephrology at Cincinnati Children’s Hospital. At its pilot institution at Children’s of Alabama, we were able to show a reduction of high nephrotoxic medication (NTM) exposure by 42% and reduction in high NTM-AKI by 65% (https://pubmed.ncbi.nlm.nih.gov/31761141/). It is now a national, multicenter collaborative led by Christine Stoops, D.O., MPH who is an assistant professor in Division of Neonatology at UAB.

In the Continuing Care Nursery at UAB, Dr. Ramani developed the Kangaroo Mother Care program to raise the awareness about the importance of skin-to-skin contact among the parents and healthcare professionals.

Dr. Hannah Hightower is leading an initiative to standardize debriefing following events in COA NICU such as codes, unplanned extubations, CLABSIs, etc.

The Children’s Hospitals Neonatal Consortium (CHNC), formed in 2006, as a partner of Children’s Health Corporation of America, improves care for high-risk infants by providing a platform to compare quality and outcomes across Level IV neonatal intensive care units (NICUs). CHNC launched the Children’s Hospitals Neonatal Database (CHND) in 2010, with UAB/COA as one of the original 17 member institutions. The CHND was developed to meet the data acquisition and analytics required for comparative quality and outcome measures and resource utilization for the unique population of medically complex neonates and infants treated in Level IV NICU patients at children’s hospitals. With an average 25-day length of stay and multiple services they require after discharge, these infants represent on one of the highest resource utilization groups of any pediatric population. CHND is the largest clinically valid data set for this unique patient population.

Currently, data are collected on general patient outcomes, as well as detailed specialty diagnoses (CDH, NEC, BPD, GI, HIE, and surgical events), allowing for comparisons between institutions and practices. In addition, there are multiple targeted study groups (i.e. post-op surgical outcomes, resuscitation, the small baby) providing opportunities for clinicians to brainstorm and initiate quality improvement projects within their own institutions and collaborations between institutions.

UAB faculty members, Coghill, Black, and Hightower, are all involved in collaborative projects within the CHND.

STEPP IN (Safe Transitions and Euthermia in the Perioperative period in Neonates and the newborn) is a project working to promote safe transitions and stability in the perioperative period. Of the patients at COA, 90 % will have a surgical procedure at some point during admission, and this time period surrounding the surgical procedure is high risk for these patients. Our NICU team, under project leadership by Dr. Black, worked along with the anesthesia and surgical divisions to create a standardized pre and post- operative handoff report document and to create a new work flow and process for NICU patients transported to surgery which includes face to face handoff between NICU NNPS and anesthesia CRNAs or physicians. The project looks at a set of parameters (temperature, pH, PCO2, glucose) within an acceptable range to determine stability. In this post-operative study group, UAB/COA is a leader not only in the number of cases contributed to the multidisciplinary collaborative, averaging 30 cases/month meeting the comprehensive criteria for inclusion but also in improvement in post-op temperatures, glucose and blood gas management. Within 9 months of starting the project, post-operative temperatures improved from 60% to over 90% within the normal range and our percentage of handoffs given from NICU to anesthesia improved from 30% to 100%. Last spring, our team was awarded the Golden Collaborative Award by the CHNC, and our project focusing on the improvements in post -operative temperatures has been accepted for presentation at the 2018 CHNC National Symposium.

ERASE Post Op Pain, another project in collaboration with the CHNC, is the next phase of the STEPP IN Project. It aims to improved pain control in our neonatal patients in the first 24 hours following a procedure. Through the leadership of Dr. Black and collaboration with the NICU pharmacists, nursing educators, physicians, anesthesia team, surgeons and bedside nurses, there is now a standardized way that post- operative pain is reported and documented. The team also developed an algorithm for post -operative pain management. Since development of this algorithm, the amount of post -operative pain failures has decreased by twenty percent with no increase in the need for assisted ventilation. The next phase of this involves a parental survey to assess the parental perception of how well their baby’s pain was controlled in the post-operative period. The team was again awarded the Golden Collaborative Award in August 2020 for their efforts.