Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting Developing a Tiny Baby Program, It's The Little Things. Joining me is Dr. Colm Travers. He's a neonatologist at UAB Medicine. Dr. Travers, thank you so much for joining us today. I'd like you to start by telling us about what a Tiny Baby Program really is. Tell us about your program at UAB, why you saw the need. How did this even come about?

Dr. Colm Travers: A pleasure to be here, Melanie. Thank you for the question. So, we started our Golden Week Program for tiny babies back in 2015. We have about 150 extremely preterm infants per year, and about 40 of those infants we would classify as tiny infants. We realized that we needed to have a dedicated service with dedicated nurses who could form a team to take care of these babies, because they have such special needs. We developed guidelines that change over time. We track all of our major outcomes and small interventions and processes, and we're continuing to learn and develop as we go. Even now, we're still now learning and developing and trying to improve.

The reason why we developed this program was we felt that were multiple evidence-based, potentially better practices that could be bundled to reduce adverse outcomes. And there was a lack of standardized guidelines that could contribute to variability in outcomes in these small babies. We know that education alone has a limited effect on adherence to evidence-based practices. And whilst standardized communication tools and checklists can be helpful to improve communication and compliance and reduce variability, we felt that the electronic medical records could provide a way to standardize treatments using order sets to reduce variability and improve adherence.

So when we started, our goal was to reduce mortality and severe intracranial hemorrhage in the first week after birth in our inborn extremely preterm infants by 20%. And to do this, we developed our Golden Week Program guidelines, using a multidisciplinary core committee of nurses, respiratory therapists and physicians, as well as consulting our colleagues in obstetrics, radiology, pharmacy, and health informatics. So, we developed a number of practices that kind of included our prenatal care, our delivery room care, admissions, how we cared for the babies once they were admitted, how we handed over the patients between shifts. And also, how we focused on the babies during our rounds. So, that started back in April 2015 with a soft implementation phase over a year as we developed these processes.

And then in 2016, we kind of had a more like hard implementation period where we launched all of our order sets on our Golden Week service and nursing teams. And what we found was that we did reduce our rates of death and severe intracranial hemorrhage in the first seven days after birth in these smallest babies. We had about 820 babies born over that study period, with an average gestation age of 25 weeks and around 750 grams. And we were able to reduce the rate of severe intracranial hemorrhage or death from about a mean of 27% down to a mean of 15% within a couple of years of starting the program.

Melanie Cole, MS: Wow, that is incredible and really important. So, Dr. Travers, speak a little bit for providers that are looking to initiate a program like this. Speak about the foundations and the targeted care, starting with targeted care phases in your Golden Week Program and how this moves along. You mentioned the multidisciplinary approach, the need for many different specialties to come and be involved. So, start with the foundations and show us how it builds.

Dr. Colm Travers: I think the foundations of a program like this is that you need to find a coalition of people who are committed to improving the care of these smallest babies. We really need a coalition of committed champions. These are NICU leaders, leadership support. When you're trying to change things, you have to create that sense of urgency, and why it's important and set some goals and try to target some quick wins.

And then, as you start to get some quick wins, hopefully, you can build some momentum and encourage more people to support a program. And the best way to do that is to show using process improvement and data, that you are actually making a difference and improving outcomes in these babies.

When we set about trying to build that consensus, we tried to involve all of our team members early on in the process. So, we held lots of joint meetings between the different disciplines. We had some Kickstarter Conferences and visiting speakers who came to kind of inspire us of what was possible. We reviewed our own data. We benchmarked our data against similar facilities. And we also held a lot of meetings to manage discordance. Because when you're starting to change something, inevitably there's going to be some conversations that need to take place to manage differences between the approach, say for example, between neonatologists and obstetricians when it comes to taking care of tiny babies.

So, people also often ask us what do we think the secret sauce is for having a successful tiny baby program? And I think the secret sauce is high reliability in tiny baby care. And so, there are a number of like different attributes that people talk about when I think of high reliability and how does that apply to the neonatal intensive care unit. So, the first point would be how do we defer to expertise, because it takes a lot of humility to ask for advice and learning from people who are performing in centers that may be better than, have better outcomes than your center. I think deferring expertise also helps to achieve better buy-in by learning from higher reliability NICUs and sharing knowledge with those centers.

And the second area is preoccupation with failure. So, seeing failure as an opportunity for growth. So, every time there is an adverse outcome, it's important to learn from every baby that we take care of. So, that's focusing sometimes on what goes wrong and considering how can you improve from a system's perspective. Along those lines, avoiding oversimplification and not accepting simple answers for bad outcomes, but looking deeply into the failures, and being ready to change if you feel like there's something in the literature or something you can learn from these centers that are performing at a high level that you could bring to your own practice.

Being sensitive to operations as a physician, as an neonatologist or as a leader in your neonatal intensive care unit is really important. So for example, walking the unit every day to look for issues and identify issues, but also collecting up-to-date data on processes and outcomes rather than waiting to look back at last year. You really want to keep up-to-date with how is your unit doing in terms of outcomes on at least a monthly basis.

And then, finally, being committed to resilience. So, we know that humans are fallible. And there's a high-risk of mindlessness in a place like the intensive care unit. And so, we need to also remember why do things go well. That's often because we're responding to what the babies are doing and identifying when babies are maybe getting sicker faster. And so, we can use our entire team to create better systems to identify and respond when babies are maybe getting sick or deteriorating or preventing those things from happening. We can improve our standardization of evidence-based potentially better practices. And as I mentioned, using those checklists and the electronic health record for good.

Melanie Cole, MS: So, tell us a little bit about some of the outcomes. Again, you briefly mentioned that. Tell us what you see happening and how have been the outcomes since you've gotten this program going.

Dr. Colm Travers: So, yeah, since we started the Golden Week Program, we were able to decrease our mortality and decrease our rate of severe intracranial hemorrhage, which is a type of severe brain bleed that preterm babies can have. And we actually, at one point, had two Guinness World Records for one for the youngest survivor of prematurity.

And we also hold the Guinness World Record for the youngest surviving quadruplets of prematurity at the moment. And so, we've thankfully been successful in our approach of including the whole team and building our coalition and enacting change. But I think it takes everybody understanding why we need to change and how we can change to improve outcomes.

Melanie Cole, MS: So important. What great work that you're doing. If you're speaking to other providers about what you think is important when they are looking to start one of these programs, do you have some recommendations for developing that kind of programs? And any unique considerations for tiny baby care that you're doing at the Golden Week program?

Dr. Colm Travers: Yeah. So in Alabama we have a really high preterm birth rate, it's about three times higher than some parts of the United States. And with that, we feel like we have a responsibility to provide really excellent care for all these small babies. And over time, even though we have a high infant mortality rate in Alabama, our infant mortality rate for the small babies is among the best in the nation.

So, extreme preterm infants account for about 50% of infant deaths in the United States and tiny babies, which we can define as babies from 21 to 23 weeks account for about 25% of all infant deaths. So when we want to target improving the infant mortality rate, this is a really important group of babies where we can actually improve outcomes ideally by preventing them being delivered in the first place. But that's complicated. But if once they enter our neonatal care, we can really improve their survival. And we know this because there's such large variation in survival with some centers having up to 70% survival in these tiny babies and other centers having almost no survivors in tiny babies.

So as more centers realize that there's a lot of room for improvement, I think more and more centers are becoming interested in providing proactive care to these babies. There are really important differences by gestational age in the neonatal intensive care unit. So these differences in tiny babies impact the clinical management. And so, this led to the development of these tiny baby programs such as our Golden Week Program within NICUs across the world.

And so, now, there's huge interest in replicating the care at these high-performing centers. And what's interesting is that these centers of excellence sometimes have really different approaches to how they do some of the care, but yet they have similar outcomes. And we feel that the reason for this is that they share common fundamentals, they have lots of experience, they have high levels of reliability in the care that they provide, and they also have a very proactive culture in how they take care of these babies.

Melanie Cole, MS: What a great program. Thank you so much, Dr. Travers, for joining us and telling us all about the Golden Week Program at uabmedicine.org/physician. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.