781 - Optimizing Risk-Adjusted Mortality Outcomes in a Level IV NICU Using Quality Improvement Strategies

Publication Number: 1757.781

Allison Peluso, Cleveland Clinic Children's, Cleveland, OH, United States; Michelle L.. Behar, Cleveland Clinic Children's, Cleveland, OH, United States; NATALIE K. YEANEY, Cleveland Clinic Children's, Chagrin Falls, OH, United States; Julie Cernanec, Cleveland Clinic Children's, Cleveland, OH, United States; Ceyda Acun, Cleveland Clinic Children's Hospital, Cleveland, OH, United States; Mohamed A. Mohamed, Cleveland, Cleveland, OH, United States; HANY ALY, Cleveland Clinic Children's Hospital, Cleveland, OH, United States; Firas Saker, Cleveland Clinic Children's, Cleveland, OH, United States

Background: Prematurity, birth complications, and infections are leading causes of neonatal death according to NICHD and WHO statistics. There is limited data regarding neonatal and infant mortalities in tertiary and quaternary centers (Level IV NICUs). A quality improvement (QI) project at Cleveland Clinic (CC) aimed to optimize survival outcomes compared to similar centers in the United States. The Vizient Mortality Model can be used for benchmarking. This model provides risk-adjusted analyses accounting for patient-specific factors such as comorbidities, congenital anomalies, and severity of illness.
Context:
The CC Main Campus NICU supports the Fetal Care Center with 214 high acuity referrals per year and regional NICUs with over 10,000 deliveries. This unit cares for infants with surgical problems and prenatally diagnosed complex congenital anomalies, including those requiring ECMO and early surgical intervention. Causes of mortality include severe anomalies, chromosomal anomalies, and prematurity complications.

Objective: Problem statement:
A baseline analysis in 2023 revealed an observed-to-expected (O:E) mortality ratio of 1.6 exceeding the 1.0 benchmark.
SMART

Aim:
Our SMART aim was to decrease our O:E from 1.6 to 0.85 within 36 months from Jan 2023 to Dec 2026.

Design/Methods: Using the A3 QI framework, two main issues were identified:
1. Gaps in documentation for conditions present on admission.
2. Under-recognition of factors contributing to cardiorespiratory failure.
All mortalities were reviewed by a multidisciplinary team, and O:E ratios assessed via Vizient analytics.
PDSA-1: Formed an Infant Mortality Team (neonatologists, quality officers, coders) and provided education on Vizient risk models.
PDSA-2: Implemented sepsis prevention groups to review sepsis-related deaths.
PDSA-3: Conducted staff education on documentation for critically ill neonates.

Results: Across the past four quarters, there is an observed downward trend in O:E mortality beginning in Q1 2024, demonstrating intervention effectiveness and sustained potential improvement (Figure 1).

Conclusion(s): Ongoing efforts aim to maintain gains by focusing on sepsis-related mortality prevention and expanding interventions to other NICUs. Future steps include ensuring timely DNR updates and exploring hospice availability to optimize end-of-life care.

Figure 1. NICU Mortality Run Chart O:E
U-Chart for 2 years of O:E mortality ratios grouped by quarter.