O2110: A Quality Improvement Initiative to Improve the Management of Neonatal Shock via a Novel Calculator

Purpose/Objectives: Shock is a significant cause of morbidity and mortality in neonatal intensive care units (NICUs). Despite its numerous etiologies, many neonatologists preferentially use a single vasoactive/inotropic medication to treat all episodes of shock. The field of neonatal hemodynamics has advanced the idea of targeted management, but most units do not have access to a dedicated neonatal hemodynamics team to support decision making. Our objective was to improve the care of neonates with shock by developing a novel calculator designed to assist in diagnostic and treatment decisions in units without specialized hemodynamics support.

Design/Methods: Our Level IV NICU began a broad quality improvement (QI) initiative to improve shock outcomes in 2021 through targeted hemodynamic management. With a broad interdisciplinary team of neonatologists, neonatal advanced practice providers, cardiologists, pharmacists, and cardiac critical care physicians, we developed a key driver diagram summarizing factors associated with improved neonatal shock outcomes. After literature review, our team created a branched algorithm to support the targeted management of shock without a dedicated hemodynamics team, launching in September 2022. The algorithm was integrated into an online clinical calculator where providers input patient-specific variables and receive recommendations for workup, differential diagnosis, and management. Targeted echocardiography, when indicated, was provided by trained echocardiographers or cardiology fellows. Cycles 1-3 focused on improving algorithm usability, updating the algorithm, and provider education on using the calculator. Cycle 4 (ongoing) includes enhanced guidance for cardiopulmonary resuscitation situations and a rapid order set. Outcome measures included mortality and duration of vasoactive medication use. Process measures assessed utilization of recommendations, while balancing measures considered length of stay. The study was analyzed using statistical process control charts supplemented with descriptive statistics, the Mann-Whitney U test for continuous variables, and the chi-square test for categorical variables.

Results: Figure 1 shows mortality rates during the QI effort from 2022-2024, with baseline data from 2019-2021. A shift occurs corresponding to the development of our hemodynamics interest group with decreased mortality continuing through our project cycles. Table 1 compares the demographics and outcomes between two patient groups based on adherence to the algorithm’s recommendations. These recommendations were followed in 69% of 70 total cases. Groups were similar except adherence to the calculator’s guidance was higher in those with older gestational age at birth. Mortality did not achieve statistical significance but trended towards this with an appreciable difference noted. This will be monitored as more data is gathered.

Conclusion/Discussion: In the absence of a dedicated neonatal hemodynamics team, a complex algorithm, presented via an easy-to-use calculator, may be an effective method of employing targeted management for neonatal shock with the potential to reduce mortality. Further work will focus on improved utilization of the calculator as well as a more detailed analysis comparing baseline illness severity.