WIP 28 - Timing is Everything: A Quality Improvement Initiative on Neonatal Asymptomatic Hypoglycemia Protocol Adherence

Publication Number: WIP 28.7639

Sarah M. Bibby, University of Kentucky College of Medicine, Lexington, KY, United States; Paula Concepcion, University of Kentucky College of Medicine, Lexington, KY, United States; Tariq Chaudry, University of Kentucky, Lexington, KY, United States; Wesley T. Smith, University of Kentucky College of Medicine, Lexington, KY, United States; Ashley Olszewski, University of Kentucky College of Medicine, Lexington, KY, United States

Background: Neonatal asymptomatic hypoglycemia (NAH) occurs when a neonate has a low plasma glucose level without symptoms such as tremors, tachypnea, and poor feeding. Our nursery protocol recommends checking the first glucose 30 minutes after the first feed. In review of practice at our institution, we recognized lack of adherence to our protocol, especially in neonates delivered via cesarean section (CS). This prompted a quality improvement (QI) initiative to align practice within our center as it relates to NAH.

Objective: Our SMART aim is to reduce the rate of hypoglycemia in LGA, SGA, IDM, or late preterm infants born ≥ 35 weeks gestational age (GA) via CS by 20% by March 30, 2025.

Design/Methods: Initial data collection occurred over 11 weeks. We assessed first glucose check in 59 neonates (31 CS, 29 vaginal delivery) in relation to time of first feed. Inclusion criteria included neonates born ≥ 35 weeks GA who were at risk for hypoglycemia. No IRB approval was needed for this study based on our institutional policy related to QI initiatives. 63% (37/59) of neonates had a first glucose check prior to first feed. 68% (25/37) of these infants were delivered via CS and 76% (19/25) had a low plasma glucose level (≤ 45). We created a key driver diagram to guide our PDSA cycles. We utilized the Failure Modes and Effects Analysis tool and engaged in the Five Whys method to further identify root causes. Immediate post-partum maternal bonding is significantly reduced in CS deliveries, thus reducing opportunities to feed. Our first PDSA cycle will assess mothers with anticipated at-risk infants' willingness to use donor breast milk if they cannot breast feed initially. Our second PDSA cycle will utilize midwives, who enable early breastfeeding for the midwife service, to support CS mothers. Statistical process control charts will be used to track changes over time. The outcome measure we aim to achieve is reduction in number of infants delivered via CS with hypoglycemia. A process measure we will follow is the number of infants delivered via CS with a pre-prandial first glucose check.