1. Context
Beijing Chaoyang Hospital is a general hospital, there is a 20-bed neonatal intensive care unit in Department of Pediatrics, which is also the transfer center for critical newborns in eastern Beijing, China. Our neonatal follow-up clinic provides medical services for hundreds person-time of preterm infants after discharge every year.
2. Study Team
Our follow-up and QI team was established including pediatricians, otolaryngologists, dermatologists, ultrasound doctors, and pediatric nurses.
3. Study Population
Preterm infants, who were born at Beijing Chaoyang Hospital, needed to be followed up at the same hospital during March 2017- December 2017 qualified for this QI study. Infants who dead or were transferred to other hospitals before discharge were excluded.
4. Measures
In our clinic, according to the national follow-up management guidelines for preterm infants, the first follow-up for both high-risk and low-risk preterm infants is carried out within 1 month after discharge, then high-risk preterm infants should be followed up every month, and low-risk preterm infants be followed up every two months. We took all the follow-up into account as person time. One preterm infants should be followed up repeatedly at different time points, and also take into account repeatedly. The primary measure of our QI project was the follow-up rate of preterm infants every week, which was calculated as: actual number of preterm infants follow-up per week/ number of preterm infants who should be followed up this week. Mark every week follow-up rate as a data point in the control chart. After more than 12 data points, calculate the average follow-up rate, which is the baseline before QI. We set our SMART Aim as increasing follow-up rate of preterm infants from baseline to 80% within 12 months.
5. Interventions
In order to explore the reasons for breaking appointment behaviors, Pareto analysis was made through telephone inquiries or face to face investigations. (Those who have been lost for more than 3 months communicated by telephone and asked the main reasons affecting the follow-up; Families who returned to the hospital within 3 months after the loss of follow-up were asked face-to-face about the main reasons for the loss of follow-up). The top three causes of loss of follow-up were analyzed, which involved families of premature infants, doctors and follow-up platform. Key driver diagram (KDD) is subsequently developed to prioritize interventions for improvement according to the main causes of follow-up loss. Key drivers focused on three main aspects: optimizing follow-up platform; strengthening follow-up education; and improving follow-up team (Fig. 1). After discussion and preparation by the QI team, the first intervention was initiated in June 2017. Specific interventions were identified and tested with Plan Do Study Action (PDSA) cycles guided by KDD (Table 1). Weekly outcome data and processes were shared at monthly meetings.
Intervention description
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Intervention start time
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Table 1
description and timing of interventions
Establish the follow-up files and standardize the follow-up time
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June 2017
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Improve the follow-up appointment system
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July 2017
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Build a WeChat fllow-up platform to provide full-time consultation and guidance
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September 2017
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Pediatrics official account science popularization, follow-up publicity and education and other channels to improve parents' awareness of follow-up
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October 2017
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Carry out multidisciplinary clinics (Dermatology, ultrasound, otolaryngology)
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December 2017
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Increase the follow-up expert clinic to realize the "three-level" diagnosis and treatment of follow-up
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February 2018
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Set up full-time follow-up personnel and carry out a series of professional and technical training
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March 2018
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5.1 Optimizing follow-up platform
From June 2017, we established follow-up files of preterm infants and strictly implemented the time points of follow-up.
From July 2017, we improved the in-hospital follow-up appointment system and opened the follow-up registration channel for preterm infants on the Jingyitong network platform, which was a social app can be used on smart phone for registration.
During the QI program quality control meetings were hold regularly, and training of follow-up guidelines of preterm infants were conducted for all the doctors rotating in NICU and outpatient clinic.
5.2 Strengthening follow-up education
From September 2017, we strengthened the follow-up education of preterm infants in various ways.
A Carry out intrauterine consultation and follow-up education for pregnant women.
B Strengthen follow-up education in the transition ward before discharge.
C Establish a WeChat group for parents of preterm infants, whose babies needing to be followed up, to carry out medical education and follow-up reminder.
From October 2017, follow-up clinic regularly released concerned medical knowledge among parents through WeChat official account.
5.3 Improving follow-up clinic service ability
From December 2017, a multidisciplinary follow-up team including neonatologist, Otolaryngologist, Ophthalmologist, dermatologists, Ultrasound physician, and professional nurses was established to carry out medical services for preterm infants.
Professional nurses were arranged in clinics to making appointment and reminding the follow-up of preterm infants.
From February 2018, a "three-level" diagnosis and treatment follow-up team has been established, and full-time follow-up personnel have been fixed. A follow-up team with different seniority was established including professors and associate professors, attending doctors, and residents, and preterm infants follow-up appointments were arranged to doctors with different seniority according to their gestational age, birth body weight and complications. And also a specially assigned doctor was responsible for the follow-up of preterm infants.
From March 2018, follow-up content and technological process were standardized, and training of standardized follow-up process was conducted regularly.
6. Analysis
For the primary outcome, baseline median and control limits were calculated and displayed for the period from March 2017 to May 2017. The baseline mean was carried forward and displayed throughout the intervention period from May 2017 to May 2018. Data values were added weekly and monitored for evidence of significant change by using standard SPC rules, including the presence of (1) 1 point outside the upper or lower control limits, (2) 2 of 3 successive points in the outer third of the control limit, (3) 8 successive points above or below the center line, or (4) 6 consecutive points increasing or decreasing「10」.