Reducing Time to Initiation of Therapeutic Hypothermia in Inborn Infants with Hypoxic-ischemic Encephalopathy.

Introduction: Earlier therapeutic hypothermia (TH) is associated with improved neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy (HIE). We aimed to increase the percentage of inborn infants with TH initiation before 3 hours from 25% to 75% within 12 months. Methods: This project took place at 2 academically affiliated Level III NICUs. We included infants inborn with moderate or severe HIE who met standard criteria for TH. The team developed a driver diagram and process map, which informed interventions. We compared data using descriptive statistics and Statistical Process Control charts. Results: Of the 70 included infants, 13 were in the baseline period, and 57 were in the implementation and sustainment period. There was a special cause variation that increased the centerline from 25% to 72%. The most common cause of initiation of TH after 3 hours of life was progression from mild to moderate HIE (39%). When infants with progression of encephalopathy were excluded, the central line further increased to 79%. In this refined cohort, the mean percentage of infants with TH initiated before 3 hours was 31%, 76%, and 80% in the baseline, implementation, and sustainment periods, respectively. Conclusions: Quality improvement methodology can reduce the time to TH initiation in inborn infants, which is associated with improved neurodevelopmental outcomes. A common reason for delayed TH initiation is progression from mild to moderate encephalopathy.