Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project

Objective: Our specific, measurable, attainable, relevant, and time-limited (SMART) aim was to reduce the incidence of severe intracranial hemorrhage (ICH) among preterm infants born <30 weeks’ gestation from a baseline of 24% (January 2012–December 2013) to a long-term average of 11% by December 2015. Study design: We instituted an ICH bundle consisting of elements of the “golden hour” (delayed cord clamping, optimized cardiopulmonary resuscitation, improved thermoregulation) and provision of cluster care in the neonatal intensive care unit (NICU). We identified key drivers to achieve our SMART aims, and implemented quality improvement (QI) cycles: initiation of the ICH bundle, education of NICU staff, and emphasis on sustained adherence. We excluded infants born outside our facility and those with congenital anomalies. Results: Using statistical process control analysis (p-chart), the ICH bundle was associated with successful reduction in severe ICH (grade 3–4) in our NICU from a prebundle rate of 24% (January 2012–December 2013) to a sustained reduction over the next 4 years to an average rate of 9.7% by December 2017. Results during 2016–2017 showed a sustained improvement beyond the goal for 2014–2015. Over the same interval, there was improvement in admission temperatures [median 36.1 °C (interquartile range: 35.3–36.7 °C) vs. 37.1 °C (36.8–37.5 °C), p < 0.01] and a decrease in mortality rate [pre: 16/117 (14%) vs. post: 16/281 (6%), P < 0.01]. Conclusion: Our multidisciplinary QI initiative decreased severe ICH in our institution from a baseline rate of 24% to a lower rate of 9.7% over the ensuing 4 years. Intensive focus on sustained implementation of an ICH bundle protocol consisting of improved delivery room management, thermoregulation, and clustered care in the NICU was temporally associated with a clinically significant reduction in severe ICH.