Reducing Osteopenia of Prematurity-related Fractures in a Level IV NICU: A Quality Improvement Initiative

Abstract

Background: Osteopenia of prematurity (OOP) is often a silent disease in the neonatal intensive care unit (NICU). Despite its association with increased neonatal morbidity, such as fractures, wide variation exists in screening, diagnostic, and management practices. We sought to decrease the rate of OOP-related fractures in our level IV NICU by 20% within 1 year. Methods: A multidisciplinary quality improvement team identified inconsistent screening, diagnosis, and management of OOP, as well as handling of at-risk patients, as primary drivers for OOP-related fractures. Using the model for improvement, we implemented sequential interventions, including screening, diagnosis, and a management algorithm as a “handle-with-care” bundle in infants at risk for fractures. Results: 194 at-risk infants were included, 59 of whom had OOP. There was special cause variation in OOP-related fractures, with a reduction from 0.43 per 1000 patient days to 0.06 per 1000 patient days with our interventions. There was also an improvement in days between fractures from 62 to 337 days. We achieved these improvements despite a similar prevalence of OOP throughout the initiative. We showed special cause variation with increased patients between missed OOP documentation and improved collection of OOP screening laboratories at 4 weeks of life without increased blood testing. Conclusion: A multidisciplinary team approach with standardized OOP screening, diagnosis, and management guidelines, including a handle-with-care bundle, reduces OOP-related fractures in a level IV NICU.

A Quality Improvement Project to Decrease Fractures Secondary to Metabolic Bone Disease of Prematurity

“…Although guidelines and recommendations for optimizing bone health are present in the literature, very few other QI projects discussing the prevention of fractures due to OOP have been published. 12 , 13 This article adds significantly to the clinical translation of those guidelines to the bedside. Additionally, many screening protocols rely on alkaline phosphatase alone.…”

“…The team used similar interventions described in the articles by Krithika et al and Cromwell et al 12 , 13 It was standard in the unit before the initiative to fortify feeds with human milk fortifier at 100 mL/kg/day and to initiate calcium immediately in TPN; however, during the initiative, we added phosphorus to TPN on day of life one as well. Our QI initiative also added monitoring of mineral intakes and Vitamin D and assisting the clinical team in interpreting laboratory results and trends.…”