599 - Enhancing early detection of cerebral palsy: A single center quality improvement initiative to improve early neonatal follow-up in a high-risk delivery center.

Publication Number: 599.4624

Sara K. Neches, University of Washington School of Medicine, Shoreline, WA, United States; Kanika Z. Nallaseth, University of Washington, Redmond, WA, United States; Ron L. Kaplan, University of Washington School of Medicine, Seattle, WA, United States; Kristie F. Bjornson, University of Washington/Seattle Children's Research Institute, Seattle, WA, United States; Paul Gross, Cerebral Palsy Research Network, Greenville, SC, United States; Rachel Byrne, Cerebral Palsy Foundation, New York, NY, United States

Background: Infants born prematurely or with hypoxic-ischemic encephalopathy (HIE) are at risk for neurological impairment, including cerebral palsy (CP). Early detection of CP can improve outcomes. Barriers exist to achieving adequate and sustained neonatal follow-up for the academic neonatal intensive care unit (NICU) and high-risk infant follow-up (HRIF) clinic at the University of Washington (UW), leaving infants at substantial risk for missed diagnoses. A high-risk for CP (HRCP) pathway initiated in the NICU may improve HRIF after discharge.

Objective: A clinical pathway designed to enhance the early detection of CP will improve rates of HRIF at 3-4 months from 57% to 80% within 10 months of implementation.

Design/Methods: A single-center Quality Improvement initiative at the UW NICU and HRIF clinic. Baseline data included patient characteristics, comorbidities, and individual risk factors for CP (Table 1). Process mapping and stakeholder meetings began in June 2024, and a Key Driver Diagram was designed (Fig 1). Process changes began Aug 2024 to improve clinic scheduling, data tracking, provider comfort with early CP diagnosis, and family education on the importance of early intervention and HRIF. Process measures include % of eligible infants receiving at least one inpatient General Movements Assessment (GMA) and % of eligible infants scheduled for a 3-4-month appointment before NICU discharge. Outcome measures include % of eligible infants seen at HRIF at 3-4 months corrected gestational age (cGA) and the number of UW NICU graduates diagnosed with HRCP or CP at < 12 months cGA. Balancing measures include the number of infants who cannot be scheduled for follow-up appointments due to a lack of clinic space or providers.

Results: At baseline, 43 infants met criteria for HRIF and were discharged from UW NICU between Feb 2024 and July 2024; 41(95%) were very premature, GA ≤ 32 weeks and/or birthweight ≤1500g, 1(2%) was extremely premature, GA 22 to 24 weeks 6 days. 42(98%) infants had a GMA before discharge. No infants had cramped synchronized movements. 100% received a referral for HRIF, and 0% were scheduled for a 3-4 month appointment before NICU discharge. The monthly follow-up rate (number of infants seen at 3-4 months cGA / number of eligible infants discharged per month) was 57%. By October 2024, 20 out of 25 (80%) eligible infants were scheduled for HRIF before NICU discharge; Fig 2.

Conclusion(s): A standardized pathway in the NICU for infants with high developmental risk may improve local follow-up rates, resulting in an earlier detection of CP and other neurodevelopmental disabilities.

Table 1. Baseline patient characteristics for infants discharged from the University of Washington NICU between Feb 2024 and July 2024, and meeting criteria for High-Risk Infant Follow-up (a)
Table_1_CPQI_1.1.pdfa) An electronic medical record report tool was developed to track developmental screening for all NICU admissions. Baseline data is derived from infants admitted after this EMR report tool went live on Nov 25, 2023. Before this report, an accurate monthly denominator of neonates eligible for HRIF was unknown.
1) Note that more than one race may have been reported per patient
2) Infants may have more than one NICU comorbidity
3) Baseline follow-up data is calculated based on the number of patients (N=33) who reached eligibility for 3-4 month follow-up by October 2024 based on their corrected gestational age.
4) cGA= corrected gestational age

Fig. 1 Key Driver Diagram
UW= University of Washington, Epic = Electronic Medical Record, GMA= General Movements Assessment, HINE=Hammersmith Infant Neurological Exam, PT= Physical Therapy, LAMBs= Late and Moderately Preterm Baby Clinic.

Fig. 2 Percent of eligible infants scheduled for a 3–4-month High-Risk Infant Follow-up appointment before NICU discharge over time, p-chart
Within three months of initiating process changes at the UW NICU (Aug 2024 through October 2024), the percentage of eligible infants who were scheduled for a 3-4 month High-Risk Infant Follow-up appointment before NICU discharge increased from 0% to 80%.

Table 1. Baseline patient characteristics for infants discharged from the University of Washington NICU between Feb 2024 and July 2024, and meeting criteria for High-Risk Infant Follow-up (a)
Table_1_CPQI_1.1.pdfa) An electronic medical record report tool was developed to track developmental screening for all NICU admissions. Baseline data is derived from infants admitted after this EMR report tool went live on Nov 25, 2023. Before this report, an accurate monthly denominator of neonates eligible for HRIF was unknown.
1) Note that more than one race may have been reported per patient
2) Infants may have more than one NICU comorbidity
3) Baseline follow-up data is calculated based on the number of patients (N=33) who reached eligibility for 3-4 month follow-up by October 2024 based on their corrected gestational age.
4) cGA= corrected gestational age

Fig. 1 Key Driver Diagram
UW= University of Washington, Epic = Electronic Medical Record, GMA= General Movements Assessment, HINE=Hammersmith Infant Neurological Exam, PT= Physical Therapy, LAMBs= Late and Moderately Preterm Baby Clinic.

Fig. 2 Percent of eligible infants scheduled for a 3–4-month High-Risk Infant Follow-up appointment before NICU discharge over time, p-chart
Within three months of initiating process changes at the UW NICU (Aug 2024 through October 2024), the percentage of eligible infants who were scheduled for a 3-4 month High-Risk Infant Follow-up appointment before NICU discharge increased from 0% to 80%.