073 - Improving accuracy of length measurements in infants with severe BPD in a level IV NICU

Publication Number: 73.5439

Pamela Griffiths, Phoenix Children's Hospital, Phoenix, AZ, United States; Nisha Patel, Phoenix Children's, Phoenix, AZ, United States; Aasma Hasan, Phoenix Children's Hospital, Phoenix, AZ, United States; Emma Brown, Phoenix Children's Hospital, Phoenix, AZ, United States; Michaela Sylvester, Phoenix Children's Hospital, Phoenix, AZ, United States; Elizabeth Yee, Phoenix Children's Hospital, Phoenix, AZ, United States

Background: Growth is important for long-term respiratory and developmental outcomes of infants with bronchopulmonary dysplasia (BPD). Linear growth is reflective of overall wellness and has been correlated with improved respiratory function and development. While length board is the most accurate and standard of care method for length measurement, use in our NICU is inconsistent and may be contributing to variable and erroneous measurements. Several barriers were identified that lead to poor compliance with length board use.

Objective: SMART Aims
• Decrease variability of length measurements, measured as percent change per week, in infants with Grade 2 and 3 BPD from baseline (3%) to less than < 1.5% within 6 months.
• Improve compliance with using length boards for infants with Grade 2 and 3 BPD from baseline (estimated < 50%, not documented) to 75% within 3 months and to 95% within 6 months

Design/Methods: Interventions
• Create interdisciplinary group of caregivers within nursing, physician, and nutrition teams
• Fishbone diagram to assess barriers to optimal practice
• "Stretchy Sundays" slogan and QR code to video demonstrating length board use (Figure 1)
• Knowledge/barrier survey to staff (Figure 2)
• Education slides distributed to RNs, some hands-on education
• Method for documenting length board use added in EMR
• Placement of length boards in centralized location
• Additional length boards obtained in multiple sizes (preemie, newborn, infant)
• Repeat knowledge/barrier survey
• Change to measurements performed by nutrition and developmental specialist

Results: The baseline rate of length percent change per week was 3%. In Feb 2023, we initiated our first interventions. We saw improvement (2.2%) and a statistical shift by Jun 2024, although not sustained. In Mar 2024, we saw further improvement (1.7%) with statistical shift after change in length measurement practices (Figure 3). Use of length board documentation was 4.8% in Jun 2024 and improved to 42% in Oct 2024. With the current practice of measurement by the dietician, length board use is 100%. The rate of the balancing measure, unplanned extubation, was 0%.

Conclusion(s): Following initial survey and education, improvement in variability was seen, although not sustained at 6 months. Ongoing knowledge gaps and high staff turnover likely contribute to the increase in later variability. A practice change to measure on day shift by consistent individuals has resulted in sustained improved variability. Ultimately, more reliable length measurements will allow for more informed decision-making in the care for infants with severe BPD.

Figure 3. Percent change in length measurement from previous week
The baseline rate of length percent change per week was 3%. In Feb 2023, we initiated our first interventions. We saw improvement (2.2%) and a statistical shift by Jun 2024, although not sustained. In Mar 2024, we saw further improvement (1.7%) with statistical shift after change in length measurement practices.

Figure 1. "Stretchy Sunday" slogan signage
This sign was placed on length boards and infant scales to remind nurses to use length boards for weekly measurements. The QR code links to a video demonstrating correct method for length measurement using the length board.

Figure 2. Examples of responses from initial knowledge and barriers survey
A survey assessing knowledge regarding importance of length board use, current unit practice, and barriers to usage was performed at the beginning of the QI initiative. Shown here are selected responses, indicating inconsistent use and concerns for lack of resources and patient safety.