Decrease in the incidence of Intraventricular hemorrhage (IVH) after the introduction of an IVH prevention bundle in the NICU

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1 Decrease in the incidence of Intraventricular hemorrhage (IVH) after the introduction of an IVH prevention bundle in the NICU Susan M Bedwell, MSN, Brianna Bright, MA and Kris C Sekar, MD. Neonatal Services, OU Medical Center, The Children's Hospital, Oklahoma City, Oklahoma, United States; and Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.

2 Susan Bedwell has documented that she has no relevant financial relationships to disclose or COIs to resolve.

3 Intraventricular Hemorrhage Severe IVH is considered a major determinant for poor neurodevelopmental outcomes.. Occurs in ~26% of all VLBW < 1250 grams. VLBW most vulnerable due to richly vascular and gelatinous structure of germinal matrix. 50% of bleeds occur in 1 st 24 hours of life.

4 Would the introduction of an evidencebased IVH prevention bundle decrease the incidence of intraventricular hemorrhage in the NICU?

5 Bundle developed from: VON NICQ2000 paper on reduction of IVH

6 Bundle developed from: VON NICQ2000 paper on reduction of IVH Evidence-based research Causes of fluctuations in blood pressure and cerebral circulation.

7 Bundle developed from: VON NICQ2000 paper on reduction of IVH Evidence-based research Causes of fluctuations in blood pressure and cerebral circulation. Effects on cerebral circulation with position changes.

8 Bundle developed from: VON NICQ2000 paper on reduction of IVH Evidence-based research Causes of fluctuations in blood pressure and cerebral circulation. Effects on cerebral circulation with position changes. Effects of infusions on cerebral circulation.

9 Bundle developed from: VON NICQ2000 paper on reduction of IVH Evidence-based research Causes of fluctuations in blood pressure and cerebral circulation. Effects on cerebral circulation with position changes. Effects of infusions on cerebral circulation.

10 Head midline X 72 hours Avoid head down position HOB at 15 Avoid rapid flushes Maintain neutral thermal regulation

11 Designed as a quality improvement project with IRB approval. Bundle introduced January 2008 with continued education and reinforcement Data collected on all infants < 32 weeks gestation born between 2007 and 2009 who survived to the first ultrasound. Head ultrasounds were completed between day of life 3-7. Grading of IVH was determined by a pediatric radiologist. Severe IVH (Grade III and IV) were included for analysis.

12 No significant difference between gestational age, gender or weight from No significant difference in # of days on ventilator or use of vasopressors. Analysis excluded infants receiving Indocin within the first 72 hours of life.

13 GA and Weights GA (in weeks) < Birth Weight <750g >1500g Overall Mortality Rate < 32 weeks gestation 24.9% 21.78% 18.3%

14 IVH Bundle Severe IVH 2007 (n=343) 2008 (n=291) 2009 (n=287) Chi-square p-value Incidence 36 (10.5%) 18 (6.19%) 10 (3.48%).0022 The incidence of severe IVH decreased from 2007 to The association between IVH and year is significant at Using the Cochran Armitage Trend Test and Lack Fit test we see a significant downward linear trend in incidence of severe IVH over time (p=.0005).

15 Percentage of IVH Incidence of Severe IVH n= n=18 4 n= n= n= n=287

16 Number of Infants with Severe IVH < Gestational Age

17 Severe IVH IVH Bundle with Indocin 2007 (n=372) 2008 (n=329) 2009 (n=343) Chi-square p-value Incidence 44 (11.83%) 23 (6.99%) 20 (5.83%).0085 The incidence of severe IVH decreased from 2007 to The association between IVH and year is significant at Using the Cochran Armitage Trend Test and Lack Fit test we see a significant downward linear trend in incidence of severe IVH over time (p=.0035).

18 Not randomized or controlled Unable to determine individual effect of interventions 85-95% compliance with protocol

19 An IVH bundle intervention may be a useful preventive strategy to reduce severe IVH and its associated morbidities. Prospective studies are needed to confirm this preliminary result.

20 Thanks to the interdisciplinary team: physicians, nursing staff and nurse practitioners of OU Medical Center, The Children s Hospital for successful implementation of the IVH bundle.

21 Questions? Decrease in the incidence of Intraventricular hemorrhage (IVH) after the introduction of an IVH prevention bundle in the NICU Susan M Bedwell, MSN, Brianna Bright, MA and Kris C Sekar, MD. Neonatal Services, OU Medical Center, The Children's Hospital, Oklahoma City, Oklahoma, United States; and Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.

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