137 - Standardizing Serial Sarnat Exams in the NICU Within the First Six Hours of Life

Publication Number: 3131.137

Monica Madrid Ornelas, University of Texas Southwestern Medical School, Forney, TX, United States; Tetyana H. Nesterenko, University of Texas Southwestern, Dallas, TX, United States; Pollieanna Sepúlveda, UT Southwestern Medical Center, Dallas, TX, United States; Nancy Ornelas, Parkland Health, Dallas, TX, United States; Srinivas Kota, University of Texas Southwestern Medical School, Dallas, TX, United States; Lina Chalak, Childrens Health Dallas UT Southwestern, DALLAS, TX, United States

Background: Therapeutic hypothermia (TH) is most effective when initiated within six hours of life (HOL) in newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). The Modified Sarnat exam (SE) assesses encephalopathy severity and predicts neurodevelopmental outcomes. Because HIE evolves, a single early exam may not capture progression. At Parkland Health's NeuroNICU, only 37% of eligible newborns who initially had no or mild HIE received a repeat SE within six HOL, potentially delaying TH initiation.

Objective: We aimed to increase the percentage of eligible newborns receiving a second SE within six HOL from 37% to >64% by August 2026, >75% by August 2027, >85% by August 2028, and >90% by August 2029.

Design/Methods: We included inborn newborns ≥36 weeks' gestation admitted to a level III NICU who had an initial SE but were not eligible for TH based on the initial exam. A multidisciplinary team reviewed baseline data, conducted a root-cause analysis (Fig 1), and identified key drivers (Fig 2) to inform interventions. Data were collected monthly through electronic medical record (EMR) audits and analyzed using descriptive statistics and statistical process control charts. The primary outcome was the percentage of eligible newborns receiving two SEs within six HOL. Process measures included timing of the initial exam, mean interval between exams, and documentation completeness. Balancing measures included adverse events, delayed TH initiation, and NICU admission for seizures among newborns with initially normal or mild findings. Interventions implemented in September 2025 included: (1) a revised guideline standardizing the initial SE at 60-120 minutes of life; (2) EMR optimization adding a mandatory field to specify initial versus repeat exam and auto-generating a plan to reassess within six HOL; and (3) targeted NICU team education.

Results: Baseline data (N=49) demonstrated that 37% of eligible newborns received a second SE within six HOL (Fig 3). The mean interval between exams was 160 minutes (range: 6-641). Seven newborns later developed seizures, and six (12%) underwent delayed TH. Following the first PDSA cycle in September 2025, preliminary October data showed improvement, with 75% (3/4) of eligible newborns receiving a repeat exam within six HOL. Ongoing analysis assesses sustainability and variation.

Conclusion(s): This QI initiative supports earlier identification of newborns who may benefit from TH, improving neuroprotective care and aligning with evidence-based neonatal neurocritical practices. We anticipate significant improvement in timely SEs and detection of newborns eligible for TH.

Figure 1: Cause-effect Analysis


Figure 2: Key Driver Diagram
Interventions implemented on date in parenthesis.

Figure 3: Percentage of eligible newborns who received two Sarnat exams within six hours of life.