​Optimising Thermal Care for Every Birth – a Six-Sigma Process Improvement Journey

Project Lead and team members: Dr Priyantha Edison, Dr Srabani Bharadwaj, Dr Rebekah Heng, SN Ruby, NC Audrey Seet, NC Lim Sai Hong, NC Voo Pui San, SN Jackie, Dr Selina Ho
Acknowledgement:
Facilities Dept., Obstetricians, Anesthetists, Labour Ward, Operating Theatre and Neonatal nurses

Thermoregulation is an essential aspect of neonatal transition at birth and the admission temperature of newborn is a strong predictor of mortality and morbidity across all gestations. Keeping the newborn warm at birth, during resuscitation and stabilization is a key component of neonatal resuscitation guidelines. An audit conducted in 2017 reported the incidence of admission hypothermia, defined as the first recorded axillary temperature <36.5⁰C in the unit as 59.1% among all newborns & 100% among very low birthweight (VLBW, <1500g) infants and their median admission temperature (AT) was 35.0⁰C (IQR: 34.7 – 35.0⁰C).

The quality improvement project aimed to reduce admission hypothermia by 50% and moderate hypothermia (< 36.0⁰C) by 75% from the baseline prevalence within 9 months.

The multi-disciplinary team of perinatal care providers used DMAIC methodology to analyze the key drivers of hypothermia and identify evidence based preventive measures to optimise the thermal care workflow. Process map, stakeholder survey and Gemba walks were useful to understand the existent workflow and staff awareness of hypothermia. 
Identified interventions were prioritized based on an effort-impact matrix and implemented in several PDSA cycles between Feb 2018 and May 2019. They were integrated into a thermal care bundle (TCB) - principal components of the bundle include optimising thermal supplies, increasing labour-ward and operating-theatres' ambient temperature to 22.0°C & 25.0°C respectively, mandate recording newborn' s temperature at the delivery room and implementing use of exothermic mattress in addition to polythene bag for VLBW infants. A written policy of the standardized thermal care workflow with algorithms relevant to the birth setting (LW vs OT) and admitting unit (NICU/High Dependency Unit/Nursery) was adopted as SOP- Standard Operating Procedure for the unit.

With the implementation of above methods, Incidence of admission hypothermia decreased by 55% (59% to 26%) and the clinically significant moderate hypothermia by 75% (31% to 7.5%) over 15 months. The mean AT increased from 36.1⁰C to 36.5⁰C (p<0.001).
Exothermic mattress was approved for use among the VLBW infants by the Health Science Authority for the first time in Singapore. Together with the other measures within the TCB, this resulted in 83% reduction in admission hypothermia (67% to 11 %) and 78 % reduction in moderate hypothermia (50% to 11%) among the VLBW infants. There was a significant improvement in mean AT with a mean difference of 0.88°C (95% CI 0.38 – 1.38, p=0.002).

To sustain the change, moderate hypothermia on admission was adopted as a department key performance indicator (KPI). The KPI target of 11% in 2019 shifted to 4.5% in 2020 with the consistent reduction in hypothermia rates. The process sigma has improved from 1.4 to 2.46 for all newborn infants & from 1.05 to 2.93 for the VLBW cohort. (2018 vs 2020)

Delivery room measures are key to optimise thermal care for newborn infants. A standardized TCB, tailored to the birthing facility is necessary to optimise the process and thereby reduce adverse outcomes. Six-sigma methodology creates a strong culture for continuous improvement among the healthcare staff that leads to enhanced healthcare delivery and patient safety.