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Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management. J Perinat Med 2021 Mar 26;49(3):389-395



Pubmed ID




Scopus ID

2-s2.0-85096149732   1 Citation


OBJECTIVES: Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines.

METHODS: A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied.

RESULTS: We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score.

CONCLUSIONS: Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.

Author List

Carlton K, Cabacungan E, Adams SJ, Cohen SS


Samuel J. Adams MD Assistant Professor in the Neurology department at Medical College of Wisconsin
Erwin Cabacungan MD Associate Professor in the Pediatrics department at Medical College of Wisconsin
Susan Cohen MD Associate Professor in the Pediatrics department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Eligibility Determination
Hypothermia, Induced
Hypoxia-Ischemia, Brain
Infant, Newborn
Infant, Newborn, Diseases
Intensive Care Units, Neonatal
Practice Guidelines as Topic
Quality Improvement
Retrospective Studies
United States