P3.S373: Standardized Discharge Recommendations for Neonatal Intensive Care Patients: Quality Improvement Initiative

Purpose/Objectives: There are no national practice guidelines for managing neonatal intensive care unit (NICU) graduates in primary care. Handoffs from the NICU to the outpatient setting are prone to medical errors, wide variability, and suboptimal care ranging from nutrition to appropriate screenings. Standardization in patient handoffs reduces medical errors and improves the quality of care. Our aim is to create a standardized smart-phrase for all NICU discharge summaries that will increase adherence to evidence-based guidelines for NICU graduates, overall improving the outpatient care.

Design/Methods: This project was conducted using the Plan-Do-Study-Act method of quality improvement(figure 1). We created a standardized smart-phrase within our EMR with evidence-based health-care maintenance (HCM) recommendation, including audiology screening, hemodynamic monitoring, nutrition with a feeding regimen and length of fortification, and developmental follow-up that was distributed for use in NICU discharge summaries and outpatient follow-up. A single-center retrospective review of the presence of recommendations in NICU discharge notes and outpatient adherence to these recommendations pre-implementation (PRE) and post-implementation (POST) of the smart-phrase was conducted. The project scope includes all infants admitted to the NICU for >5 days and < 35 weeks' gestation discharged one-year pre-implementation and one-year post-implementation (July 2021 to June 2023). Neonates not discharged from the NICU due to transfer or death were excluded. A Fischer’s exact test is used to determine the association between implementation of the NICU smart-phrase and documentation of HCM recommendations at time of discharge.

Results: Of 75 neonates within the scope of the project, 44 charts (59%) were pre-implementation of the smart-phrase and 31 charts (41%) were post-implementation. Implementation of the standardized smart-phrase showed statistically significant improvement in documentation of fortification length from 2.3% to 90.3% (p < 0.001), hearing follow-up from 0% to 83.9% (p < 0.001), and blood pressure screening from 2.3% to 64.5% (p < 0.001) in NICU discharge summaries. There was a correlation in implementation of the smart-phrase with placement of an audiology referral at 6 months corrected gestational age with an increase from 20.5% to 74.2% (p < 0.001). Completion of blood pressure screenings at 9 months corrected gestation age had minimal improvement from 2.3% pre-implementation to 6.5% post-implementation (p=0.59).

Conclusion/Discussion: NICU graduates have medically complex and extended hospital stays that can significantly burden the patient-centered medical home. There is considerable variation in the quantity and quality of discharge documentation on HCM recommendations. With a standardized smart-phrase that includes HCM recommendations in the discharge summary, there is statistically significant improvement in documentation of nutritional guidelines and fortification, audiology screening, and routine health maintenance recommendations for our NICU patients. Although there were improvements in documentation of recommended health maintenance in NICU discharge summaries, additional work is required to improve completion of recommendations in the outpatient setting, specifically completing blood pressure screenings.