OBJECTIVES:

Reduce postoperative hypothermia by up to 50% over a 12-month period in children’s hospital NICUs and identify specific clinical practices that impact success.

METHODS:

Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for maintaining perioperative euthermia that included the following: established euthermia before transport to the operating room (OR), standardized practice for maintaining euthermia on transport to and from the OR, and standardized practice to prevent intraoperative heat loss. Process measures were focused on maintaining euthermia during these time points. The outcome measure was the proportion of patients with postoperative hypothermia (temperature ≤36°C within 30 minutes of a return to the NICU or at the completion of a procedure in the NICU). Balancing measures were the proportion of patients with postoperative temperature >38°C or the presence of thermal burns. Multivariable logistic regression was used to identify key practices that improved outcome.

RESULTS:

Postoperative hypothermia decreased by 48%, from a baseline of 20.3% (January 2011 to September 2013) to 10.5% by June 2015. Strategies associated with decreased hypothermia include >90% compliance with patient euthermia (36.1–37.9°C) at times of OR arrival (odds ratio: 0.58; 95% confidence interval [CI]: 0.43–0.79; P < .001) and OR departure (odds ratio: 0.0.73; 95% CI: 0.56–0.95; P = .017) and prewarming the OR ambient temperature to >74°F (odds ratio: 0.78; 95% CI: 0.62–0.999; P = .05). Hyperthermia increased from a baseline of 1.1% to 2.2% during the project. No thermal burns were reported.

CONCLUSIONS:

Reducing postoperative hypothermia is possible. Key practices include prewarming the OR and compliance with strategies to maintain euthermia at select time points throughout the perioperative period.

Newborns and infants are at risk for hypothermia because of a higher body surface to weight ratio, high transepidermal permeability, and decreased thermal insulation due to a lack of subcutaneous fat.1,2  This population is more likely to develop significant metabolic consequences from hypothermia. Infants have a metabolic response to cooling that involves chemical (nonshivering) thermogenesis, initiated through sympathetic nerve discharge of norepinephrine in brown fat leading to local heat production that is then transferred to the rest of the body.3  This process increases oxygen consumption, glucose use, and metabolic rate by two- to threefold and can result in tissue hypoxia, hypoglycemia, and metabolic acidosis.46  The resultant physiologic changes can include lowered arterial blood pressure, decreased cardiac output and brain blood flow, as well as pulmonary vasoconstriction.7,8  Therefore, neonatal and infant hypothermia can be an important cause of increased complications, including infections, increased length of hospitalization, poor neurologic outcome, and death.913 

General and regional anesthesia can affect thermal homeostasis through central thermoregulation mechanisms, which reduce sympathetic tone, inhibit peripheral vasoconstriction, and allow redistribution of body heat from the core to the periphery.14  Most of the literature regarding the negative impact of postoperative hypothermia, including increased need for mechanical ventilation and increased length of stay, has been in the adult population.15  Neonates, however, are at high risk for their core temperature to drop during the intraoperative period.16,17  Morehouse et al18  associated postoperative hypothermia in infants with an increase in respiratory adverse events and the need for cardiac intervention. The Joint Commission’s Surgical Care Improvement Project for 2010,19  the Physician Quality Reporting Initiative,20  and the Association of Perioperative Registered Nurses21  all suggest recommendations for perioperative temperature management and prevention of unplanned hypothermia.

Centers participating in the Children’s Hospitals Neonatal Consortium (CHNC)22  developed a data repository (Children’s Hospitals Neonatal Database [CHND]) for level 423  NICUs. The CHNC Collaborative Initiatives for Quality Improvement was established in 2009 to lead quality improvement (QI) projects in children’s hospital NICUs. The purpose of the collaborative Safe Transitions and Euthermia in the Perioperative Period in Infants and Neonates (STEPP IN) was to provide practice recommendations for neonatal health care professionals to improve perioperative care for infants in the NICU who undergo surgery at CHNC centers. The purpose of this article is to describe the development and implementation of a standardized process to maintain perioperative euthermia. The specific, measurable, attainable, relevant, and time-bound (SMART) aim of STEPP IN was to decrease the incidence of hypothermia by 50%, from a baseline of ∼20% to 10%, by December 2014 and sustain over 12 months.

STEPP IN team leaders assembled an interdisciplinary group of neonatal leaders from CHNC hospitals. The Perioperative Euthermia Clinical Practice Recommendations (CPR) was developed after performing a systematic literature review using the principles of the Appraisal of Guidelines for Research and Evaluation II instrument (CPR in Supplemental Information).24  This CPR guideline included practice recommendations for temperature monitoring, heat loss prevention during transport to and from the operating room (OR), increase in ambient OR temperature, and maintenance of intraoperative euthermia. For the CPR, hypothermia was defined as a core body temperature of ≤36°C, measured as per local team standard.25  A subset of the original group (project management team) developed the collaborative driver diagram (Fig 1) and provided oversight for the QI collaborative. Participation criteria included CHNC membership and agreement to participate for the entire project period. Nineteen CHNC hospital NICUs joined the QI collaborative and committed to reducing perioperative hypothermia.

FIGURE 1

Key driver diagram highlighting the project SMART aim and the 3 areas of focus for management of perioperative euthermia. IV, intravenous; PACU, postanesthesia care unit.

FIGURE 1

Key driver diagram highlighting the project SMART aim and the 3 areas of focus for management of perioperative euthermia. IV, intravenous; PACU, postanesthesia care unit.

After review of the CPR, sites were expected to form an interdisciplinary team to define local practices for the following: measurement of core body temperature, maintenance of euthermia during transport to and from the OR, and maintenance of euthermia during the operation (Tables 1 and 2). Teams were to engage key stakeholders (including representatives from neonatal nursing, neonatal advanced practice nursing, neonatal physicians, anesthesiologists, pediatric surgeons, and OR neonatal nurse leaders) and select those interventions that best fit their local site resources, talents, and needs. The collaborative did not dictate a specific bundle.

TABLE 1

Guideline to Develop Local Site Process to Maintain Euthermia During Transport to and From the OR

Determine plan to prewarm patient to specific set temperature before leaving NICU 
 • If yes, what is the desired temperature? 
Determine standard transport device 
 • Prewarmed transport isolette or warmer 
 • Battery-operated heated bed 
Determine need for specific equipment 
 • Warm hat and/or warm blanket 
 • Chemical heating mattress 
 • Thermal blanket 
 • Plastic wrap 
Determine plan to monitor patient temperature during transport 
 • If yes, define method for temperature measurement 
Determine plan to prewarm patient to specific set temperature before leaving NICU 
 • If yes, what is the desired temperature? 
Determine standard transport device 
 • Prewarmed transport isolette or warmer 
 • Battery-operated heated bed 
Determine need for specific equipment 
 • Warm hat and/or warm blanket 
 • Chemical heating mattress 
 • Thermal blanket 
 • Plastic wrap 
Determine plan to monitor patient temperature during transport 
 • If yes, define method for temperature measurement 

Tables 1 and 2 represent a series of questions and guiding tools to help local sites develop processes to address perioperative euthermia. This table addresses the time of transport to and from the OR.

TABLE 2

Guideline to Develop Local Site Process to Maintain Euthermia During Surgery

Determine plan to prewarm the OR 
 • If yes, what is the desired OR set temperature? 
Determine routine strategies to maintain temperature in the OR 
 • Forced air device 
 • Warming lights 
 • Warmed intravenous fluids 
 • Warmed irrigation fluids 
Determine plan to prewarm the OR 
 • If yes, what is the desired OR set temperature? 
Determine routine strategies to maintain temperature in the OR 
 • Forced air device 
 • Warming lights 
 • Warmed intravenous fluids 
 • Warmed irrigation fluids 

Tables 1 and 2 represent a series of questions and guiding tools to help local sites develop processes to address perioperative euthermia. This table addresses the time in the OR.

Several key components of the Institute for Healthcare Improvement (IHI) breakthrough series collaborative framework facilitated project success. Sessions were focused on team learning and sharing through monthly meetings (webinars), bimonthly huddle calls, an active listserv, and coaching by QI faculty advisors.26  Short educational sessions promoted QI knowledge for participants. On monthly collaborative webinars and huddle calls, teams shared barriers and successes learned through local Plan-Do-Study-Act (PDSA) cycles to stimulate learning and collaboration. Biweekly thirty-minute teleconference huddles to discuss specific STEPP IN topics fostered open discussion for sharing in smaller groups. A certificate was awarded each month to the site with the best record for data collection, and percentage of compliance and/or innovative solutions learned through serial PDSA cycles to overcome barriers promoted friendly competition and collaborative learning.

Individual site postoperative hypothermia rates and their compliance to process facilitated benchmarking, transparency, and further efforts toward improvement were shared monthly. The IHI extranet, a data system for QI collaboratives, was used by the teams for reporting measures, accessing a listserv, and storing project resource documents. Faculty advisors provided additional support to answer questions and monitor monthly site assessment and progress.27 

The primary outcome measure was postoperative hypothermia, defined as the first temperature of ≤36°C obtained within 30 minutes on return to the NICU or within 30 minutes of completing surgery in the NICU. Balancing measures were the occurrence of thermal burns and/or hyperthermia. Postoperative hyperthermia was defined as temperature >38°C, as measured on the first temperature within 30 minutes of return to the NICU or within 30 minutes of completing surgery in the NICU. These postoperative temperature measurements were uniform across sites as defined in the CHNC manual of operations. All NICU surgical time frames were included in the outcome and balancing measures unless the surgical procedure used induced hypothermia.

Process measures included (Table 3) preoperative temperature (measured within 60 minutes of surgery), temperature at OR arrival, compliance with warming strategies during the operative procedure as well as during transfer to and from the OR, and last OR temperature (measured before departure from the OR). Some centers increased the OR ambient temperature as part of the intraoperative warming strategy. Minimum target for compliance with process measures was ≥80%, with an ideal target of >90%. The faculty advisors and project management team met each month to review IHI reporting and team progress and discuss strategies to promote implementation success. Participating centers reported a sampling of all surgical time frames (minimum of 10 per month per site) for process measure compliance. We selected this minimum sampling number of 10 to achieve the greatest precision in gathering meaningful information while maintaining an acceptable level of workload (cost) for participants.28 

TABLE 3

Process Measures

Compliance with local center practice to prevent heat loss on transport to and from the OR 
Compliance with local center practice for active intraoperative warming 
Compliance with local center, define practice for ambient set OR temperature (optional) 
NICU patient temperature within 30 min before transfer to OR or within 30 min of surgical start, if surgical procedure in NICU 
First documented patient temperature in OR 
Last documented patient temperature before leaving OR or immediately after completion of surgery, if surgical procedure in NICU 
Compliance with local center practice to prevent heat loss on transport to and from the OR 
Compliance with local center practice for active intraoperative warming 
Compliance with local center, define practice for ambient set OR temperature (optional) 
NICU patient temperature within 30 min before transfer to OR or within 30 min of surgical start, if surgical procedure in NICU 
First documented patient temperature in OR 
Last documented patient temperature before leaving OR or immediately after completion of surgery, if surgical procedure in NICU 

This is a list of the process measures that centers tracked throughout the project.

Each participating site established baseline hypothermia rates using CHND data from January 2011 to August 2013. Project rollout phase (September 2013 to December 2013) was focused on local team building and process development. During the collaborative study phase (January 2014 to June 2015), teams focused on compliance monitoring and local PDSA cycles to achieve target improvement goals. Specifically, centers were asked to develop a process to keep infants warm in the OR and on transport to and from the OR (Tables 1 and 2). Each center developed their own system for measuring compliance. The most common strategy was a monitoring form (or checklist) that accompanied the patient. Success with implementation of these practices (Table 3) was measured by a record of the patient temperature during the perioperative period. Centers were expected to submit outcome and process measure compliance, which was shared with the full collaborative at the monthly webinars. This system allowed teams to track and graph local data over time and monitor improvement progress through submission of progress reports and IHI team assessment scores.26  We monitored and analyzed collaborative hypothermia rates as a time series outcome variable using statistical process control charts (Shewhart P charts). Signals, indicating special cause, were identified by using standard control chart rules.29  We used multivariable logistic regression analysis (SAS v.9.4; SAS Institute, Inc, Cary, NC) to measure the association of important clinical processes identified in the CPR with rate of hypothermia. These clinical processes included adopting the practice of prewarming the OR (increasing the OR ambient temperature to >74°F) and >90% compliance with the following: use of a NICU temperature protocol before surgery, use of an intraoperative warming protocol, a warming protocol during transport to and from the OR, euthermia at OR arrival, and euthermia at OR departure. We considered P values ≤.05 statistically significant. Ongoing collaboration and data collection continued during the sustain phase (July 2015 to December 2015).

The CHND has institutional review board oversight at all participating centers. The Children’s Mercy Hospital, Kansas City, Missouri, Pediatric Institutional Review Board reviewed this project and determined it did not meet the definition of research involving human subjects. Data submitted and analyzed were unit-based data and contained no patient identifiers.

The 19 participating CHNC level 4 NICUs had an average daily census of 66 (range: 20–114, median: 57). All but 2 of these centers had 24-7 coverage with in-hospital surgical fellows and/or attending physicians and performed an average of 27 surgeries per month (range: 1–83, median: 27). As a collaborative, with an average of 510 surgeries per month, these centers were successful in reducing postoperative hypothermia. The first special cause signal, a decrease in postoperative hypothermia from 20.3% to 13.2%, was noted in October 2013. A subsequent special cause signal was achieved in June 2014 with a further decrease in hypothermia to 10.5% (Fig 2). We achieved our SMART aim to lower postoperative hypothermia by ∼50% from baseline. There was a statistically significant but clinically insignificant increase in the rate of hyperthermia from 1.2% to 2.2%. No thermal burns were reported.

FIGURE 2

Statistical process control P chart for the outcome measure of percentage of postoperative hypothermia. Dotted lines represent control limits. Two special cause signals dropped the percentage of postoperative hypothermia from baseline rate. LCL, lower control limit; UCL, upper control limit.

FIGURE 2

Statistical process control P chart for the outcome measure of percentage of postoperative hypothermia. Dotted lines represent control limits. Two special cause signals dropped the percentage of postoperative hypothermia from baseline rate. LCL, lower control limit; UCL, upper control limit.

We collected process measure compliance and shared these charts at each monthly meeting throughout the project to understand key practices leading to improvement and to assist with adjustments at the local level (Table 3). Figure 3 shows a sample chart with the preoperative temperature shown in relation to the number of surgeries per month. The preoperative patient temperature in the NICU was in the target range on average 95% of the time (range: 88%–99%) throughout the study period. Patient temperatures at the start and end of the OR case were within target temperature on average 83.5% (range: 73%–91%) of the time. Throughout the study period, the average compliance with local heat loss prevention during transport to and from the OR was ∼90.5% (range: 68%–98%), and compliance with local active intraoperative warming strategies was 94% (range: 80%–99%). Compliance with a target ambient OR temperature was not tracked, although some centers did report adopting the practice of maintaining OR ambient temperature to >74°F.

FIGURE 3

Process measure compliance with pre-op NICU temperature (average preoperative NICU temperature for all centers). The left y-axis and the dark gray bars represent the total number of surgeries monitored per month. The right y-axis and the light gray boxes represent the percentage of those surgeries that were compliant with the preoperative target temperature range, obtained within 60 minutes of transport to the OR or within 60 minutes of arrival of the surgical team for surgeries in the NICU.

FIGURE 3

Process measure compliance with pre-op NICU temperature (average preoperative NICU temperature for all centers). The left y-axis and the dark gray bars represent the total number of surgeries monitored per month. The right y-axis and the light gray boxes represent the percentage of those surgeries that were compliant with the preoperative target temperature range, obtained within 60 minutes of transport to the OR or within 60 minutes of arrival of the surgical team for surgeries in the NICU.

Although the collaborative demonstrated an overall decrease in hypothermia by 48%, Fig 4 demonstrates the wide variation in postoperative hypothermia across centers in both baseline and intervention periods as well as individual site improvement. We used multivariable logistic regression to model the center’s percentage of hypothermia against the adherence to process measures to identify the center-level practices most associated with lower hypothermia rates. Centers that adopted the practice of prewarming the OR (P = .05) and centers that achieved >90% euthermia target temperature rates at OR arrival (P < .001) and departure (P = .017) had lower adjusted odds of postoperative hypothermia (Table 4). Unexpectedly, centers achieving >90% compliance with warming protocols in transit to the OR had higher adjusted odds of developing hypothermia (P < .001).

FIGURE 4

Average rates of hypothermia by center. The bars represent postoperative hypothermia rates for the baseline (striped) and intervention periods (solid) by center.

FIGURE 4

Average rates of hypothermia by center. The bars represent postoperative hypothermia rates for the baseline (striped) and intervention periods (solid) by center.

TABLE 4

Outcome: Probability of Postoperative Hypothermia

Effect (Yes Versus No)Odds Ratio (95% CI)P
Adopting the practice of prewarming the OR 0.78 (0.62–1.00) .05a 
>90% compliance with NICU temperature protocol before surgery 0.90 (0.69–1.17) .43 
>90% compliance with warming protocol to the OR 2.43 (1.90–3.09) <.001a 
>90% compliance euthermia at OR on arrival 0.58 (0.43–0.79) <.001a 
>90% compliance with intraoperative warming protocol 0.95 (0.75–1.21) .67 
>90% euthermia at OR departure 0.73 (0.56–0.95) .02a 
Effect (Yes Versus No)Odds Ratio (95% CI)P
Adopting the practice of prewarming the OR 0.78 (0.62–1.00) .05a 
>90% compliance with NICU temperature protocol before surgery 0.90 (0.69–1.17) .43 
>90% compliance with warming protocol to the OR 2.43 (1.90–3.09) <.001a 
>90% compliance euthermia at OR on arrival 0.58 (0.43–0.79) <.001a 
>90% compliance with intraoperative warming protocol 0.95 (0.75–1.21) .67 
>90% euthermia at OR departure 0.73 (0.56–0.95) .02a 

Multivariable logistic regression demonstrating the effect of selected interventions that impact postoperative hypothermia. CI, confidence interval.

a

Represents statistical significance.

This multicenter QI collaborative, conducted over 2 years and involving >13 000 monitored surgeries, achieved a nearly 50% reduction in postoperative hypothermia, a clinically significant decrease in patient harm, and identified clinical practices associated with improvement success. NICU patients with perioperative hypothermia have more respiratory adverse events and are more likely to require cardiac and thermoregulatory interventions than normothermic infants.18  The reduction was sustained after the end of the active project, projecting harm elimination for >50 patients per month across these hospital systems.

We identified euthermia at OR arrival and at OR departure as significant predictors of postoperative euthermia. However, high compliance with warming protocols during patient transport to the OR increased the odds of postoperative hypothermia, a finding that should be interpreted with caution because this association was unexpected and does not seem biologically plausible.30  Eleven centers achieved >90% compliance with their local warming protocol to the OR, and 5 of these centers had the highest rate of postoperative hypothermia. On further investigation, we note that 4 of these 5 centers failed to achieve 90% compliance with euthermia target temperature rates at OR arrival and departure. This suggests that the warming strategies of some centers were more effective at maintaining euthermia target temperatures than others.

A strength of this project is the validity of the outcome measure. The use of the CHND captures both outcome and balancing measures on all patients in participating NICUs. There are clear definitions for each measure, and interrater reliability has been established.22  The clinical practices identified in the CPR served as an important guide for teams to assess risk points within their own systems and define improvements in their local culture (Supplemental Information).

In a collaborative improvement process, Paul Batalden popularized the quote, “Every system is perfectly designed to get the results it gets,” which infers that “if we want different results, we must change (transform) the system.”31  Thus, at the local level, each team must evaluate their own system to identify additional barriers and process change to demonstrate improvement. Further consideration may include examining whether patients experience a temperature drop while waiting in a holding area, which mitigates the benefit of warming strategies during transport to the OR, or whether there are additional intraoperative OR strategies to implement. High-performing teams report active involvement of anesthesia and surgeons and demonstrate success at all process points.

Data transparency during monthly meetings provided benchmarking opportunities to share successful strategies for process change. Teams found value in the monthly meeting format (4 out of 5 on a Likert scale), which included data review, QI education, local team-sharing, and encouragement of open discussion. Participants reflected this value in evaluation comments: “It was helpful to see that other teams were having similar obstacles.” Sites were encouraged to share compliance monitoring data with frontline providers to provide local feedback on changes leading to improvement and use the data to translate into success: “We gathered ideas on how to distribute data on a regular basis. . .with frontline staff.”

STEPP IN huddle calls complemented the monthly webinars, allowing small group discussion and facilitating collaborative success. On average, team members from 9 sites participated in these 30-minute, twice-monthly calls, formatted to promote additional team-sharing. A short presentation on the topic of interest was followed by questions to stimulate conversation. Huddle topics varied and included “Euthermia challenges during transport”; “Hypothermia: which patients are at greater risk”; “Timely data entry: a collaborative responsibility”; and “Keeping STEPP IN up: how to maintain project momentum.” The biweekly format that repeated the same topic each month allowed flexibility for team members to choose to participate in one or both sessions. Teams verbalized that the learning from shared experiences was translated to process improvements at their local center. Implementation examples included when to use a chemical warming mattress for transport to and from the OR; the need to train OR staff on the use of NICU beds; the use of select intraoperative warming strategies, such as warm irrigation fluids; and the importance of anesthesia and OR staff commitment to the improvement process.

Key lessons for success from individual sites included use of additional warming methods for patients at highest risk (eg, chemical mattress and/or battery-operated bed), strong collaboration with the OR team members, and incorporating immediate and regular feedback of outcomes (at least monthly) to frontline team members. Centers without an anesthesia champion had difficulty implementing intraoperative euthermia strategies, whereas centers with engaged interdisciplinary teams that included anesthesia and OR nurses reported less hypothermia. Finally, many teams demonstrated success with use of an intervention checklist that followed the patient to and from the OR to promote compliance to expected processes.

Achieving success in QI, according to the Model for Understanding Success in Quality theory, involves an understanding of multiple contextual factors within an organization that includes the microsystem, macrosystem, and the external environment.32  It is possible that the integration of these principles differed across organizations. Variation in QI capability and culture at the local level likely contributed to center outcome. Understanding the impact of these contextual differences might be as important as the individual process measures but were not evaluated during this collaborative. Top-performing teams reported that the ability to actively engage and motivate an interdisciplinary team of stakeholders at all levels led to both system and process changes.

Some degree of hypothermia may be unavoidable. Temperature drops are an expected physiologic response to the administration of anesthesia.14,16,17  If teams are compliant to maintenance of the euthermia process and still see a temperature drop, then the repercussions could impede buy-in to the project. However, with our results and individual site success, we suggest that engaged interdisciplinary teams can make improvements by working together throughout the process to impact prevention of hypothermia.

Temperature measurement mode (esophageal versus axillary versus rectal) was not mandated and may have varied both across sites and within individual hospital locations. Axillary temperature measurement, common in most NICUs, may vary in reliability at extremes of temperature ranges but provides a good approximation of core body temperature and closely correlates with core temperatures.33  The temperature monitoring method was unlikely to have impacted our improved results. Temperature reporting occurred over an extended period in multiple centers and was consistent at each site.

We have demonstrated that low rates of postoperative hypothermia in a vulnerable NICU patient population is achievable. The key elements for success include interdisciplinary team engagement and high compliance to processes throughout the perioperative period and in transitions of care. Understanding opportunities and barriers within each unique system is imperative to success.

We thank Jeanette M. Asselin, MS, RRT-NPS; Beverly Brozanski; David J. Durand, MD (emeritus); Francine D. Dykes, MD (emeritus); Jacquelyn R. Evans, MD (executive director); Theresa Grover, MD; Karna Murthy (board president), MD; Michael A. Padula, MD, MBI; Eugenia K. Pallotto, MD, MSCE; Anthony Piazza, MD; Kristina M. Reber, MD; and Billie Lou Short, MD, members of the CHNC, Inc. CHNC (http://www.thechnc.org) who partnered with Children’s Hospital Association, Inc (Overland Park, KS) to design, launch, and maintain (2012–2016) the CHND. The Children’s Hospital Association provided administrative and analytic support during this project. We would also like to thank Kate Conrad, Lorna Morelli, and Tina Logsdon from the Children’s Hospital Association, whose support made this project a success.

We are indebted to the following institutions that serve the infants and their families, and these institutions have participated in this collaborative.

  1. Alfred I. duPont Hospitals for Children, Wilmington, DE (Judith C. Guidash BSN, RNCNIC; Kevin Sullivan MD);

  2. All Children’s Hospital John Hopkins Medicine, St Petersburg, FL (Oscar Winners-Mendizabal MD; Victor Mckay MD; Corrie Long RN, MSN);

  3. Arkansas Children’s Hospital, Little Rock, AK (Becky Rogers MD; Allen Harrison MD, BSN; Francesca Miquel-Verges MD);

  4. Boston Children’s Hospital, Boston, MA (Denise Casey RN, CCRN, CPNP; Carolyn Gondelyman RN, BSN; Anne Hansen MD);

  5. Children’s Healthcare of Atlanta, Atlanta, GA (Sarah Keene MD; Sarah Hash BSN, RN, RNC-NIC);

  6. Children’s Hospital and Medical Center, Omaha, NE (Lynne Willett MD);

  7. Children’s Hospital Colorado, Aurora, CO (Susan Moran NNP; Sheila Kaseman MS, RNC-NIC);

  8. Children’s Hospital of Michigan, Detroit, MI (Girija Natarajan MD; Jay Ann Nelson RN);

  9. Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA (Trishelle Himmelrick MSN, CCRN; Michael Scott CNRA; Doreen Soliman, MD; Beverly Brozanski, MD);

  10. Children’s Medical Center, Dallas, TX (Becky Ennis MD; Kerry Wilder BSN, RN, MBA; James Moore MD, PhD);

  11. Children’s Mercy–Kansas City, Kansas City, MO (Darian Younger MHA, MS; Meredith Kopp BSN, RN, CNOR; Benjamin J Pieters DO);

  12. Children’s National Medical Center, Washington, DC (Lamia Soghier MD, MEd; Joyce Doering, RN);

  13. Cook Children’s Medical Center, Fort Worth, TX (Annie Chi MD; Tammy Hoff DNP, RN);

  14. Florida Hospital for Children, Orlando, FL (Kathryn Mikulencak MSN, PCNS-BC, RNCNIC; Rajan Wadhawan MD);

  15. Le Bonheur Children’s Hospital, Memphis, TN (John Ferguson MD; Bobby Bellflower DNSc, NNP-BC; Ramasubbareddy Dhanireddy MD);

  16. Nationwide Children’s Hospital, Columbus, OH (Thomas Bartman M.D., Ph.D.; Margaret Holston BSN, RN);

  17. Primary Children’s Hospital, Salt Lake City, UT (Robert DiGeronimo MD; Shrena Patel MD; Cindy Spencer RN);

  18. Rady Children’s Hospital, San Diego, CA (Brian Lane MD; Ellen Knodel RRT-NPS; Mark Speziale MD); and

  19. The Children’s Hospital of Philadelphia, Philadelphia, PA (Holly Hedrick MD; Laura Schleelein MD).

Drs Brozanski, Pallotto, and Piazza provided leadership for the design and analytics of the collaborative, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Richardson provided data analytics; Drs Chuo, Natarajan, Grover, Smith, McClead, Rao, Rintoul, and Bellflower and Ms Mingrone, Ms Guidash, and Ms Holston participated in the design and management of the collaborative; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Ms Guidash's current affiliation is Nemours/Alfted I duPont Hospital for children, Wilmington, DE

FUNDING: No external funding.

     
  • CHNC

    Children’s Hospitals Neonatal Consortium

  •  
  • CHND

    Children’s Hospitals Neonatal Database

  •  
  • CPR

    Clinical Practice Recommendations

  •  
  • IHI

    Institute for Healthcare Improvement

  •  
  • OR

    operating room

  •  
  • PDSA

    Plan-Do-Study-Act

  •  
  • QI

    quality improvement

  •  
  • SMART

    specific, measurable, attainable, relevant, time-bound

  •  
  • STEPP IN

    Safe Transitions and Euthermia in the Perioperative Period in Infants and Neonates

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Richardson was an employee of the Children’s Hospital Association throughout this project; the other authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data