CHOC’s Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants

CHOC Children’s clinicians have determined that a dedicated Small Baby Unit (SBU) improves quality and outcomes in extremely low birth weight (ELBW) infants (babies born at 28 weeks gestation or less and weighing less than 1,000 grams), according to results of an article they published in Pediatrics[i].

“In recent years, the survival rates for ELBW infants have improved with the latest advances in neonatal intensive care, but many are still released from the hospital with significant challenges, including neurodevelopmental delays and/or chronic medical problems,” said Mindy Morris, DNP, the SBU program coordinator and co-author. “Our goal was to improve these outcomes by utilizing a dedicated team with expertise in the care of this population.”

The objective of the CHOC neonatology team was to cohort ELBW infants in a single location physically separated from the main Neonatal Intensive Care Unit (NICU), and to recognize that progressive changes in culture were essential for successfully shifting the practice model. This space became the 12-bed SBU, which consisted of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional NICU, this smaller unit allows for a darker, quieter environment that encourages developmentally supportive care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely. Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences.

Outcomes from the two years before and four years after opening the SBU in March 2010:

  • Reduction in chronic lung disease from 47.5% to 35.4%.
  • Rate of hospital-acquired infection decreased from 39.3% to 19.4%.
  • Infants being discharged with growth restriction (combined weight and head circumference, < 10th percentile) decreased from 62.3% to 37.3%.
  • Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22.

The research found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location. Additionally, there was a reduction in illness and complications among infants after leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes.

[i] Morris M., et al., Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants, Pediatrics (2015),

IT Update from the Chief Medical Information Officer: Dr. Bill Feaster

What’s New With IT These Days?

There are several IT projects underway, with perhaps the most anticipated one being the switch from Groupwise to Outlook for emails, calendaring and other functions. We are currently implementing Microsoft Office 365, the web-based version of Office, and we should have everyone converted over to Outlook by the end of January 2016.

Bill Feaster, MD, MBA, CHOC Children's Chief Medical Information Officer
Bill Feaster, MD, MBA, CHOC Children’s Chief Medical Information Officer

We’re also putting a mobile device tool in place to allow people to access the enterprise network on their phones and tablets. That needs to be completed before we roll out, beginning in spring 2016, the iPad version of Powerchart called Powerchart Touch. The combination of network access and email accounts on Outlook should dramatically improve provider access to and use of our email accounts.

The promised move to badge authentication into Cerner is also starting soon, but had to wait until we got rid of Groupwise (network incompatibilities). This is another one of those nasty interdependencies, but this project will get underway in the spring and carry over into the next fiscal year.

Is anything happening with CUBS?

The last major specialty to move to electronic documentation and applications is oncology. Work to implement Cerner’s oncology product will begin in May, but take at least a year to complete. Most of our development work outside of oncology will be focused on increasing the usability of CUBS, with the goal of improving provider education on using the system, reducing the number of clicks to do things, and creating specialty-specific views, when available, to better present needed information to the provider.

ICD-10 seemed to go better than anticipated. The world didn’t end after all! It was a very smooth transition to the new coding system. But that took over three years of hard work to complete, several millions of dollars, some very skilled people on the project, and some very savvy providers and coders using the system. Early information is that the bills not only went out on time, but are actually getting paid! We’re still having a few issues with Diagnosis Assistant and a bit of confusion over diagnoses that can’t be fully specified, but fixes and education are in progress.

I’ve heard a lot about population health and the pediatric system of care. How is that going?

We’ve implemented a new Cerner solution called the Healthe Intent platform. It’s a “big data” system that takes in data from multiple sources, including CUBS, and programs running on that data implement evidence-based disease registries for chronic diseases, report on compliance with the measures in those registries, and support our care managers helping patients and parents to navigate the healthcare system. We are piloting the registries in our Garden Grove clinic beginning Nov. 2, and will be rolling the registries out to the rest of the organization soon. We are helping Cerner develop the care management piece of the platform, and it should be ready in the second quarter of 2016.

How Kids Can Heal Doctors | Dr. Anthony Chang | TEDxChapmanU Video

Anthony Chang, MD, MBA, MPH, pediatric cardiologist and CHOC Children’s chief intelligence and innovation officer, was invited to speak at the TEDxChapmanU event, which welcomed “extraordinary game-changers, challengers and thought-leaders to the stage at historic Memorial Hall at Chapman University.” His talk, “How Kids Can Heal Doctors,” addresses the doctor-patient relationship. Dr. Chang believes the training many physicians received in a paternalistic era of medicine coupled with the empowerment of patients has created greater distance between the two groups — a distance he wants to help bridge.

During his candid talk, Dr. Chang shares three patient stories that have impacted his own career path and outlook on medicine. He encourages colleagues to step out of their comfort zones, and to think innovatively on behalf of their patients. Big data and artificial intelligence are helping physicians be even smarter about medicine, creating excitement in the field for doctors and patients, alike. The medical profession is a still a very special one, something Dr. Chang’s patients remind him every day.

To hear more from Dr. Chang and other innovative leaders, please visit PEDS 2040.

CHOC Surgical NICU Reduces Post-Op Hypothermia in Infants

Consistent, standardized efforts across several disciplines helped CHOC Children’s reduce rates of post-operative hypothermia in neonates by nearly 88 percent, results of a quality improvement project show.

Staff decreased the number of babies who returned to the Surgical Neonatal Intensive Care Unit with body temperatures below 36 degrees Celsius from 10.7 percent to 1.3 percent following surgeries between September 2014 and August 2015.

Due to high body surface area, infants undergoing surgery are at risk for hypothermia, especially premature infants with decreased subcutaneous and brown fat. Hypothermia-induced vasoconstriction can lead to impaired wound healing, surgical site infections, impaired coagulation and decreased drug metabolisms, which can collectively increase perioperative morbidity, said Dr. Irfan Ahmad, co-director of the unit.

Though CHOC’s baseline figure was well below the national average rate of 15.6 percent, reducing post-operative hypothermia rates wasmock-surgery-1 identified as an area for quality improvement for the Surgical NICU and staff set out to reduce rates by half, Dr. Ahmad said.

Involving a cross-disciplinary team including nurses, neonatologists, surgeons and anesthesiologists, the project tracked 76 patients. Because infants can be at risk for hypothermia before surgery, intra-operatively and post-operatively, their temperatures were tracked during each operative stage. Staff were then able to identify problem areas and make improvements over each quarter.

Dr. Ahmad attributed the success to consistently implementing measures such as ensuring patients wore hats and blankets while headed to the operating room; pre-warming transport isolettes before placing babies inside; and using intra-operative heating devices during procedures.

Dr. Ahmad presented this data earlier this month to a quality congress held by the Vermont Oxford Network, a nonprofit, voluntary collaboration of health care professionals dedicated to the quality and safety of medical care for newborns and their families.

CHOC established its Surgical NICU in October 2013, and remains one of a handful of hospitals nationwide to cohort infants needing and recovering from surgery in a dedicated space.

Surgical NICU patients receive care from a multidisciplimock-surgery-4nary team that includes neonatologists, surgeons and many other clinicians. The surgical NICU team cares for patients jointly, discussing the cases as a group and forming a treatment plan that often calls for the expertise of other specialties.

Patients and families are a key component of the surgical NICU care team, collaborating and partnering with clinicians on every stage of the patient’s care.

The Surgical NICU rounds out CHOC’s expansive suite of services for neonates, including a main NICU; the Small Baby Unit, where infants with extremely low birth weights receive coordinated care; the Neurocritical NICU, where babies with neurological problems are cohorted; and the Cardiac NICU, which provides comprehensive care for neonates with congenital heart defects.

Learn more about CHOC’s neonatal services.

CHOC Children’s Grand Rounds Video – How we can end hunger in Orange County: Waste Not OC – Dr. Eric Handler

In this CHOC Children’s grand rounds video, Dr. Eric Handler, Orange County public health officer, highlights a unique public-private partnership focused on eliminating hunger and reducing food waste.

The Waste Not OC Coalition uses a three-pronged approach: educate the community about food donations; identify “food insecure” individuals; and connect those individuals to sources of food.  The coalition facilitates the donation of wholesome surplus food from various facilities, including restaurants and hospitals, to local pantries that serve individuals in need.

Since the coalition was formed in 2012, it has increased the visibility of food pantries, raised awareness among business owners of the need for food donations, and empowered clinicians to refer patients to food sources.

View previous grand rounds videos.