Background: Hypothermia is still a common problem and is associated with increased mortality and morbidity in preterm infants, especially in China. The objective of this study was to evaluate the efficacy of a targeted quality improvement (QI) project of hypothermia preventive measures in very low-birth weight (VLBW) infants in 3 tertiary neonatal intensive care unit (NICU) in China.Methods: Based on the literature, our preliminary findings and the needs of each unit, our team decided to focus efforts on equipment (transport incubator, pre-warmed hats and polyethylene wrap), team training and education, as well as temperature documentation and workflow. The primary outcome measure was the incidence of hypothermia, defined as temperature (rectal temperature) below 36.5ºC on admission to the NICU. This quality improvement (QI) initiative used the rapid cycle Plan - Do - Study - Act (PDSA) approach. The outcomes of pre–quality improvement (pre-QI) group (January 1, 2018– December 31, 2018) were compared with post-QI group (January 1, 2019–December 31, 2019). The study enrolled preterm infants born at less than 32 weeks’ gestation with very low birth weight less than 1500 g born at 3 academic, tertiary-care hospitals including Shandong Provincial Hospital, The First Affiliated Hospital of Shandong First Medical University, LiaoCheng People’s Hospital Affiliated to Shandong First Medical University between January 2018 and December 2019.Results: A total of 636 VLBW infants were included in this analysis, of which 235 infants (36.9%) were included in the pre-QI group and 295 infants (46.4%) in the post-QI group. The incidence of hypothermia decreased significantly from 92.3% to 62% (P < 0.001), and the mean body temperature on admission to NICU increased significantly from 35.5˚C to 36˚C (P < 0.001). There were one cases (0.3%) of neonatal hyperthermia. Infants in the post-QI group had lower rates of mortality (16.1% vs 8.8%, P = 0.01). Conclusions: Targeted interventions can dramatically reduce admission hypothermia and improve the outcome of VLBW infants in China.

Background: Admission hypothermia (AH, <36.5℃) remains a major challenge for global neonate survival, especially in China. Due to high incidence of reginal AH, we developed a prospective multicenter quality improvement (QI) initiative to reduce regional AH and evaluate the impact on outcome among VLBW neonates.Methods: The study used sequential Plan - Do - Study - Act (PDSA) approach. Clinical data were collected prospectively with 5 NICUs from Sino-Northern Neonatal Network (SNN) in China. Bundle come into practice since January 1, 2019. The clinical data in pre-QI phase (January 1, 2018– December 31, 2018) were compared with post-QI phase (January 1, 2019–December 31, 2020). Clinical characteristics and outcomes data were analysed.Results: A total of 750 in-born VLBW infants were enrolled in the study, 270 in pre-QI period and 480 in post- QI period, respectively. There had no significant differences in clinical characteristics in two phases. Compared with pre-QI period, the percentage of AH decreased in the QI period (95.9 %vs 71.3%, P < 0.01). Admission mod-severe hypothermia (AMSH) was improved significantly, reduced by 38.5% after QI (68.5 %vs 30%, P < 0.01). Average admission temperature improved after QI [36.0 ˚C（35.8˚C，36.5˚C）vs 35.5 ˚C（35.2 ˚C，36.0 ˚C）, P < 0.01 ]. No significant increase in AH rate and thermal burns (0.4%VS 0%). Risks of mortality and late-onset neonatal sepsis (LOS) were significantly lower in post-QI period as compared to pre-QI period (aRR 0.19, 95% CI 0.09–0.39; aRR 0.55, 95% CI 0.41–0.80) whether adjusting for birth weight (BW), gestational age (GA)，small for gestational age (SGA), Apgar score at 5 min < 7.Conclusion：Implementation of multicenter thermoregulatory QI help in significant reduction of AH and AMSH of VLBW neonates within a certain area, which in turn can help to improve reginal neonatal outcomes. We gained a lot from QI, learned and explored a suitable method to continuous QI, this may provide reference for similar developing countries.