A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates Free

The QI initiative occurred in a 35-bed level IV tertiary care NICU,²⁵  a New York state-designated regional perinatal center that provides care for a diverse patient population with more than 4000 deliveries annually. Approximately 500 infants are admitted to the unit annually. At our institution, neonates born at less than 35 weeks’ gestation or less than 1800 g are automatically admitted to the NICU. Our facility comprises open bays, each accommodating 8 to 12 babies, with a total of 4 bays; the physical space limitations posed a significant challenge for the implementation of STS care.

Our institutional review board reviewed and approved the study protocol as a QI initiative.

At the outset of our QI project, we collected baseline data from January to June 2021 to understand the status of STS care. According to our baseline data, preterm neonates less than 35 weeks received an average of 13.3 minutes of STS care per eligible patient per day during the first 4 weeks of life. After a period of baseline data collection from January to June 2021, this QI project took place over 19 months, from July 2021 to January 2023. All neonates who were born at less than 35 weeks’ gestation were included. On a daily basis, each infant was determined to be eligible or ineligible for STS that day. Neonates were considered ineligible for STS care if they were within 24 hours of a procedure requiring general anesthesia, had an umbilical or peripheral arterial catheter or chest tube, or were hemodynamically unstable. In addition, infants born at less than 32 weeks’ gestation were considered ineligible for STS care during the first 72 hours of life when they undergo a period of limited handling and clustered care as part of intraventricular hemorrhage (IVH) prevention, a standard practice in our unit.

Key stakeholders formed a multidisciplinary QI team, including RNs, nurse practitioners, physicians, occupational therapists, a patient-care coordinator, a nurse manager, and a parent representative. A Knowledge, Attitude, and Practice (KAP) survey conducted before the QI initiative revealed potential hindrances to implementing STS care in the NICU resulting from knowledge gaps and negative attitudes (Supplemental Fig 6). During the KAP survey, providers mentioned several barriers, including “lack of knowledge of STS eligibility and its positive results,” “lack of education on STS,” “scared parents with unstable babies,” “staffing issues,” “insufficient nursing support,” “lack of physical space for privacy in the unit,” and “maternal discomfort or lack of support with setup.” The KAP survey observations were consistent with other KAP surveys conducted in different NICUs.^26–30 

We developed a key driver diagram (Fig 1) and an Ishikawa cause-and-effect diagram (Supplemental Fig 7) to identify the critical drivers for improving STS. We identified 4 primary drivers: (1) multidisciplinary approach, (2) nursing engagement, (3) family empowerment and education, and (4) positive NICU culture. We identified potential interventions for multiple Plan, Do, Study, Act (PDSA) cycles. Concurrent with the PDSA cycles, data were collected and analyzed using run and statistical control charts. The data informed the subsequent PDSA cycles. The team met every 3 to four 4 to reinforce project goals and ensure proper implementation of related processes.

We implemented 3 interventions during the first PDSA cycle (July 2021–November 2021). During the antenatal and postnatal periods, we offered counseling to parents regarding STS care, providing education on the advantages of STS. We also discussed STS eligibility during rounds to ensure that all staff knew which neonates were eligible for STS and to address any concerns regarding the practice. Additionally, we provided orientation for residents on STS to ensure they were familiar with the procedure and could confidently offer education to parents and caregivers.

Two additional interventions were added during the second PDSA cycle (November 2021–February 2022). The first intervention involved obtaining feedback from RNs every 2 weeks through bedside real-time, in-person interactions. These sessions facilitated discussions regarding STS care documentation and provided an opportunity to address any challenges. The second intervention was the introduction of a kangaroo sticker on the patient's incubator as a visual reminder for providers and parents about the eligibility of the neonate for STS care, aiming to increase awareness and facilitate the implementation of STS care.

Two new interventions were added during the third PDSA cycle (March 2022–June 2022). First, we offered counseling to parents and caregivers regarding STS care via telephonic and in-person consultations to ensure that they received information on the benefits of STS. Second, we included STS education as part of the nurses' monthly conference to ensure that all nurses were up to date with the latest information and could provide education to parents and caregivers.

In the fourth PDSA cycle (July 2022–October 2022), we implemented 2 new interventions to improve STS care duration. The first involved introducing a leaflet for STS containing frequently asked questions to educate parents and caregivers on the benefits of STS. The second intervention included a Quick Response (QR) code, which provided access to additional frequently asked questions and a satisfaction questionnaire related to STS. We provided parent resources in English but ensured inclusivity by using a real-time translation system for each individual's primary language.

During the sustainment phase (November 2022–January 2023), we continued all the interventions to ensure the sustainability of our progress in improving STS care.

The primary outcome measure for our QI project was the mean duration of STS care per eligible patient day, which we monitored monthly to assess the effectiveness of the interventions. The first process measure was the age at first STS. We also observed physician documentation of eligibility for STS care in the electronic medical record (EMR) as a second process measure. To ensure our interventions had no unintended negative consequences, we monitored the number of adverse events per month, including apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tubes during STS care, as a balancing measure. Our QI team abstracted data manually from the EMR, where a preexisting charting feature enabled nurses to document STS duration, adverse events, and reasons for withholding. We collected demographic data on all eligible neonates, including admission date, gestational age, birth weight, sex, and mode of delivery.

We created real-time run charts and statistical process control (SPC) charts using QI Macros for Excel (KnowWare International Inc., Denver, CO) to analyze the data collected during the project. For SPC charts, the control limits were set at 3 sigmas above and below the center line (mean). Through these charts, we gained visual insights into the data, promptly identifying any trends or patterns, which enabled us to make informed decisions and enhance the quality of care given to our neonates. If we detected a sustained special cause variation (SCV), characterized by either 1 data point falling outside the established control limits or more than 8 values exceeding the baseline centerline, we shifted the centerline of the SPC chart.³¹ 

From July 2021 to January 2023, 185 infants, accounting for 24% of total admissions, met inclusion criteria, with a mean gestational age of 29.1 weeks and a mean birth weight of 1090 g. In comparison, baseline data from January 2021 to June 2021 included 59 infants, with a mean gestational age of 29.6 weeks and a mean birth weight of 1120 g. During the QI project, the mean duration of STS per eligible patient day increased from the baseline of 13.3 minutes to 32.4 minutes per eligible patient day. The SPC X-chart in Fig 2 shows that the mean increased to 17.4 minutes per eligible patient day at the onset of the project. During the third PDSA cycle, we observed SCV in April 2022 that shifted the center line to a mean of 32.4 minutes per eligible patient day. During the sustainment phase, our outcome measure remained stable.

Throughout the QI project, we observed an improvement in the mean age at which infants received their first STS care from a baseline of 13.3 days to 9.5 days. SCV was noted during the first PDSA cycle and the improvement was sustained throughout the remainder of the project (Fig 3).

We also aimed to implement physician documentation of STS eligibility in the EMR, a facet nonexistent before our QI project's commencement. We monitored our progress using an SPC P-chart (Fig 4), and in March 2022 (during the third PDSA cycle), there was a shift in the center line of the chart because of SCV, indicating a marked improvement in documentation from a mean of 58.8% to 82.3%.

While tracking for balancing measures, we noted occasional episodes of apnea, bradycardia, and desaturations during STS care (0–2 occurrences per month); however, there were no reported episodes of hypothermia or dislodged technology. STS was not aborted during any of these episodes.

STS care for preterm infants has been proven safe and feasible while conferring numerous benefits.^32,33  Although the advantages of STS care are well-established, its adoption and utilization in NICUs have been inconsistent. Even in facilities where STS care is regularly practiced, the duration of STS care is often suboptimal, particularly for preterm neonates in their first month of life. Before implementing the QI initiative, our baseline data indicated that preterm neonates younger than 35 weeks of gestation received an average of 13.3 minutes of STS care per eligible patient per day within the first 4 weeks.

Perceiving immature gestational age as a hindrance to initiating STS care is further complicated by numerous obstacles, including limited facility resources, safety concerns, insufficient staffing, limited awareness, professionals' hesitance to change, fatigue, limited privacy, and overcrowding in the NICU.^21,34–36  Unlike most QI projects documented in the literature that primarily concentrate on stable neonates,^24,37–40  our QI project focused on all preterm neonates younger than 35 weeks, including those who were extremely preterm intubated on conventional or high-frequency ventilators and with central lines.

Our QI project achieved the objective by increasing the duration of STS care in preterm infants born at less than 35 weeks’ gestation during the first 4 weeks of life above the goal of 30 minutes per eligible patient per day. Our project used a multidisciplinary QI team to implement multiple interventions based on a key driver diagram and Ishikawa cause-and-effect diagram. These interventions included parental counseling, discussion on STS eligibility during rounds, STS education for residents, RN feedback every 2 weeks, and introducing a kangaroo sticker on the neonate's incubator as a reminder for providers and parents. The third PDSA cycle played a crucial role in achieving the QI objective. Incorporating STS education into monthly nursing conferences and providing counseling to parents over the phone and in person was particularly effective in getting staff buy-in, changing the culture, and ultimately increasing the duration of STS. Our QI initiative aligns with existing evidence by demonstrating that antenatal counseling and STS education effectively address the significant barriers of limited awareness and understanding of STS among parents and health care providers.^{24,37,40–42}  The STS leaflets and QR codes in the fourth PDSA cycle helped to sustain this improvement. Feedback from parents via the QR code was positive; they reported feeling satisfied performing STS care and feeling more bonded to their infants. Because of the small number of survey responses, further qualitative analysis was not performed.

Since the project launch, there have been only 2 instances in which the STS rate fell below the baseline. These instances occurred in February and March of 2022 and were attributed to the ο wave of the COVID-19 pandemic when many parents and NICU providers fell ill. COVID-19 visitation restrictions were in place and consistent during the baseline and intervention periods. Because of this, they were unlikely to impact the noted improvement.

In alignment with observations from other QI initiatives, obtaining feedback from nurses every 2 weeks and discussing STS eligibility during rounds were additional interventions that aided in sustaining the improvement by effectively bridging the communication gap.³⁷  Several strategies have been implemented to sustain the improvement, including incorporating QI education and ongoing projects into the NICU resident curriculum, designating a new nurse educator to lead the project, and a podcast.

Despite observing an initial trend toward a younger age for the first STS care, we did not note any further decrease in age at first STS care. This may partly be due to our unit's IVH prevention care and the presence of arterial lines early during the hospital course of the smallest, sickest infants, making them ineligible for STS care.

Physician documentation of STS eligibility improved over the study period. Similar to the primary outcome measure, the STS eligibility documentation also experienced a shift in the center line during the third PDSA cycle, highlighting the impact of the interventions. Notably, incorporating STS education into monthly nurse conferences and providing STS orientation to residents were instrumental in driving this change. In March 2022 and July 2022, we identified 2 outliers that fell below the lower control limit. The outlier observed in March 2022 may have been due to the impact of the ο pandemic on staffing, whereas adding a new batch of residents to the team may have caused the outlier in July 2022.

During implementation, our project encountered several challenges, including the lack of awareness and knowledge among health care providers and parents about the benefits of STS care, restrictions on visitation because of the COVID-19 pandemic, concerns among nurses about neonates with umbilical venous catheters and endotracheal tubes, and the introduction of new resident teams every month. However, our interventions successfully overcame these challenges and increased the duration of STS care. Implementing the interventions for STS care did not result in increased adverse events. This observation is consistent with findings from other published literature.^43–45  During the QI initiative, bedside nurses reminded parents about STS care, and residents provided STS education to parents. Despite monthly resident rotations, we maintained consistency through ongoing training.

The sum of our interventions, encapsulated within the STS bundle, stands as a potential model for other NICUs aiming to enhance the duration of STS care. The comprehensive STS bundle (Fig 5) encompasses parental counseling, provider education, kangaroo stickers, QR codes (parent survey), and STS informational leaflets. STS care benefits families through improved engagement in care, heightened parent satisfaction, early parent–child bonding, and reduced parental stress.

Although this project improved STS care duration in our unit, the generalizability of results may be limited by individual NICU eligibility requirements for STS care. Although the lack of objective measures for neonatal outcomes related to improved STS care duration or dose, such as weight gain, breastfeeding rates, reduction in common NICU morbidities, or shorter NICU stays, is a limitation, it is important to acknowledge that these factors were not within the scope of the QI project.

The QI interventions implemented in our level IV NICU have successfully increased the duration of STS care for preterm neonates without an increase in adverse events, despite several challenges faced, particularly the COVID-19 pandemic, nurses' concerns, and new resident physician teams every month. Our project's success was due to the commitment and collaboration of the QI team, the involvement of parents and caregivers, and the support of the hospital administration. Our project's success highlights the importance of QI initiatives in implementing best practices, improving patient care, and promoting evidence-based practices in neonatal care. Our interventions, encompassed in the STS bundle, can serve as a potential model for other NICUs aiming to increase the duration of STS care.

The authors acknowledge Ms O’Connell's invaluable contributions as a skin-to-skin care champion and parent representative, providing valuable input for our QI initiative.