755 - Tennessee’s Tiniest Babies: Reducing Severe Intraventricular Hemorrhage in Very Preterm Infants

Publication Number: 1731.755

Marcelo Rains, Erlanger, Ooltewah, TN, United States; Parul Zaveri, Le Bonheur Children's Hospital, Memphis, TN, United States; Patricia A. Scott, Tennessee Initiative for Perinatal Quality Care, Mt. Juliet, TN, United States; Alicia Mastronardi, Tennessee Initiative for Perinatal Quality Care, Knoxville, TN, United States; brenda F. Barker, TIPQC, Brentwood, TN, United States; Scott Guthrie, Children's Hospital at Erlanger, Chattanooga, TN, United States

Background: The Tennessee Initiative for Perinatal Quality Care (TIPQC) launched Tennessee's Tiniest Babies (TTB) to reduce infant mortality through four care bundles targeting severe intraventricular hemorrhage (sIVH, Grade 3/4), chronic lung disease (CLD), necrotizing enterocolitis (NEC), and hospital-acquired infections (HAI) in Level 3 and 4 neonatal intensive care units (NICUs). Per Vermont Oxford Network data, sIVH affects 7.5-11% of infants (≤29.6 weeks gestational age [GA]), with a pre-project baseline of 9.0% (2019-2021) in participating Tennessee NICUs.

Objective: Reduce sIVH incidence by 25% (from 2019-2021 baseline) in ≤29.6-week GA infants by June 2024 in Tennessee's Level 3 and 4 NICUs, with a secondary aim to reduce mortality by 25% by TTB project completion.

Design/Methods: A toolkit of Potentially Better Practices (PBPs) was developed (Figure 1), including antenatal steroids (ANS), magnesium sulfate, delayed cord clamping (DCC ≥60s), thermoregulation, indomethacin prophylaxis, CPR simulation training, unit-specific guidelines, and avoidance of saline boluses, vasopressors, and sodium bicarbonate in the first 72 hours. Following IRB approval, Phase 1 (2023-2024) involved monthly huddles and quarterly learning sessions across participating NICUs. Data were collected via REDCap, tracking process measures (antenatal steroids, delayed cord clamping, saline bolus/vasopressor avoidance) and balancing measures (5-minute APGAR scores, admission temperature). Phase 2 (2024-present) focused on sustainment while integrating additional TTB bundles.

Results: 11 of 12 eligible NICUs implemented PBPs, impacting 1,123 ≤29.6-week GA infants. Phase 1 achieved 90.9% compliance with structure measures. Twelve monthly huddles supported implementation. Post-intervention, sIVH incidence stabilized at 10.2% (Table 1), falling short of the 25% reduction goal. Resuscitation of periviable ( < 24 weeks) infants increased (10.0% to 15.2%), with 34.4% sIVH in this subgroup (Figure 2). Outborn infants (10.9%) had higher sIVH rates (19.7% vs. 9.1% inborn). ANS use rose from 86.0% to 89.1%; DCC averaged 48.9%; >1 saline bolus within 72 hours occurred in 20.9%. Median 5-minute APGAR (7.0) and admission temperature (36.5°C-37.5°C) remained stable, indicating no adverse effects

Conclusion(s): 11 Tennessee NICUs successfully adopted the sIVH bundle through TIPQC's statewide collaboration. Increased resuscitation of periviable infants limited sIVH reduction. TTB continues to advance neonatal outcomes, with CLD in sustainment, NEC underway, and HAI in development.

Figure 1. Tennessee's Tiniest Babies Toolkit: Potentially Better Practices to Prevent Severe IVH
Toolkit summarizing evidence-based interventions to reduce severe IVH in extremely preterm infants.

Figure 2. Increased Resuscitation of Periviable Infants ( <24 Weeks) and Associated Severe IVH Rates
Resuscitation of infants <24 weeks increased from 10.0% to 15.2%, with 34.4% of this subgroup developing severe IVH.

Table 1. Severe IVH Incidence After Toolkit Implementation
Post-intervention, the incidence of severe IVH stabilized at 10.2% among extremely preterm infants.