In neonatal intensive care using clinical decision support, the focus of this career development proposal is to improve application of evidence-based practices for prevention and early recognition of necrotizing enterocolitis (NEC) among premature infants. NEC is a catastrophic complication threatening the life of fragile premature infants, yet adoption of prevention and early recognition practices (e.g. preferential use of human milk; adoption of standardized feeding protocols; transfusion and antibiotics management) differ widely as do NEC rates. Parents play a key role in NEC prevention (e.g. providing mother's own milk), but heretofore, have been insufficiently engaged as partners. Accounting for 20% of US NICU costs, NEC develops late in the hospital postnatal course and can strike suddenly but until now, no tools to guide early NEC recognition were available. To address this need, a NEC risk decision rule, called GutCheckNEC was derived and validated by our team to accurately discriminate NEC. Integration of prevention practices into clinical workflow using clinical decision support (CDS) has been shown to improve adherence to recommended care across settings. Yet, both the use and evaluation of CDS in NICUs are sparse, and we know of no studies related to CDS support for prevention of NEC. Informed by the Translating Research Into Practice (TRIP) framework for implementation science, in two NICUs using an interrupted time series design, we will integrate NEC-Zero into CDS to fit clinician workflow, optimize usability, and test effects on NEC disease, neonate nutrition and parental satisfaction. The central hypothesis is that adherence to guideline-recommended NEC prevention and early recognition practices (called NEC-Zero and evaluated using an adherence score) will improve when delivered using CDS and NEC disease will decline. First, clinician workflow will be described using workflow maps constructed from interviews with local clinicians and the NEC-Zero integrated into CDS in the form of standard order sets, alerts, reminders and trend data (Aim 1). Then, using a simulated NEC scenario and iterative evaluation, NEC-Zero usability will be optimized (Aim 2). Finally, with an interrupted time series analysis from indicators in the 1 year prior to and 1 year after NEC-Zero implementation, we will compare the trend for NEC disease, neonate nutrition, and parent satisfaction outcomes; then describe the relationship between post-NEC-Zero clinician CDS outcomes (adherence scores, use response rates, satisfaction, perception of unintended consequences of CDS) and NEC disease outcomes (Aim 3). Formal training in usable clinical decision support under the mentorship of Daniel Malone, PhD, RPh & co-mentor Robert Greenes, MD, PhD will complement training in theories and methodologies of Implementation Science mentored by Drs. Marita Titler and Melanie Bell. Over time we will be able to apply the automation and testing of CDS for multi-faceted interventions to other clinical challenges in NICUs to achieve the goal for this program of research, which is to reduce morbidity and mortality from neonatal complications and limit costs.
In this study, a multi-faceted intervention for prevention and early recognition of necrotizing enterocolitis called 'NEC-Zero' will be implemented using clinical decision support and guided by a change framework from implementation science. Aimed at closing the gap between recommended care and existing practice, if effective, this intervention will reduce the burden of necrotizing enterocolitis in premature infants to save lives and costs.
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