Improving completion of the red reflex examination at neonatal intensive care unit discharge: a practice improvement initiative and multisite planned experiment.

backgroundCompleting the red reflex examination (RRE) of the eyes to screen for ophthalmologic abnormalities is an essential component of the newborn physical examination. An abnormal RRE should prompt consultation with an ophthalmologist to perform a formal ocular examination. LOCAL PROBLEM: Chart review at a level IV neonatal intensive care unit (NICU 1) noted a low rate of documentation that the RRE was completed prior to discharge for eligible patients and suboptimal rates at three other NICUs of varying acuities and operational structures (NICUs 2, 3, 4). This prompted the initiation of a quality improvement initiative to improve RRE completion before discharge. METHODS AND

interventionsA driver diagram was generated to guide testing and implementation of interventions including ophthalmoscope placement, clinician education and electronic health record (EHR) reminders over eight plan-do-study-act cycles at NICU 1. Using the knowledge gained from NICU 1, two impactful tests of change were utilised to perform a 2

resultsThis initiative led to sustained improvement in completion of the RRE from baseline 66.8% (13-month period) to 100% (22-month intervention period with special cause noted) at NICU 1 with two abnormal RREs detected. The PE using established factors from NICU 1 at NICUs 2, 3 and 4 demonstrated that the combination of ophthalmoscope placement optimisation plus EHR RRE trigger led to 100% RRE compliance at all sites.

conclusionThis initiative led to a sustained improvement in RRE completion at NICU 1. PE at three other NICUs of varying types and staffing structures identified a synergistic set of change factors, which may yield the greatest improvement across the spectrum of NICUs.