Implementing a CPG Screening for Term Neonates for Congenital Heart Disease When Discharged with Supplemental Oxygen: An Evidence-based Quality Improvement Project

Congenital heart defects (CHD) are the leading cause of infant morbidity and mortality from a birth defect. Early detection of critical congenital heart defects (CCHD) has improved with the institution of mandatory pulse oximetry screening due to the screening's moderate sensitivity, high specificity, and cost-effective approach. However, screening infants that require supplemental oxygen at discharge has inconsistent results, leading to inconsistencies in practice due to variability in evidence and the lack of best practice guidelines for the Neonatal Intensive Care Unit (NICU) population. Local Problem: In multi-center NICUs within the Intermountain West, CCHD continues to have missed cases due to a lack of evidence to support modification and a lack of best practices for screening infants  35 weeks gestation before discharging them home on supplemental oxygen. Methods: This needs assessment began with creating a stakeholder team to guide the usability and feasibility of CCHD screening modification in the NICU. A literature review was conducted to review best practice. A survey was distributed to physicians to assess barriers, current practices, and willingness for change. External benchmarking was done to create a comparison chart to review different practices. Patient data was obtained with a retrospective chart review from January 2021 to March 2023 to look at missed diagnoses and consider improvements in the future. A cost analysis was considered to compare pulse oximetry screening to echocardiograms. Interventions: Discussion groups were conducted with the team of stakeholders to make modifications throughout the project period. Internal and external data was collected for a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis through an internal survey, benchmarking with other centers, and identifying associated costs of screening options. An executive summary was created and included a Situation-Background-Assessment- Recommendation. Results: The survey indicated a variation in practices in the NICU, and practitioners supported the development of a modified tool for screening infants with an echocardiogram before discharging them on supplemental oxygen. Similarly, benchmarking demonstrated a lack of consistency in practice across practice settings. The retrospective chart review highlighted that 33.7% (n = 1061) of infants were discharged on nasal cannula, and over half (n = 581, 54.8%) received an echocardiogram before discharge. Of the 22 patients on supplemental oxygen discharged or transferred to a higher level of care, 19 (86.3%) were referred to cardiology due to the detection of a heart defect, all found with an echocardiogram. Only 2 (9%) of the infants discharged on nasal cannula were readmitted for CCHD after being discharged home. Conclusion: This needs assessment provided a greater understanding of the need to modify the clinical practice guideline (CPG) for screening infants that are  35 weeks gestation and remain on supplemental oxygen at discharge, creating consistency in practice. While echocardiograms are significantly more expensive than pulse oximetry screening, they may be warranted for infants discharged on supplemental oxygen for an unknown etiology. More research is necessary to guide practice in these facilities and throughout all NICUs.

1 Screening Newborns on Supplemental Oxygen for Congenital Heart Defects: A Needs Assessment Zoe N. Cohn, Con Yee Ling, Whitnee J. Hogan, Kim M. Friddle, Kelly J. Mansfield College of Nursing: The University of Utah NURS 7702: DNP Scholarly Project II Spring 2024 2 Abstract Background: Congenital heart defects (CHD) are the leading cause of infant morbidity and mortality from a birth defect. Early detection of critical congenital heart defects (CCHD) has improved with the institution of mandatory pulse oximetry screening due to the screening's moderate sensitivity, high specificity, and cost-effective approach. However, screening infants that require supplemental oxygen at discharge has inconsistent results, leading to inconsistencies in practice due to variability in evidence and the lack of best practice guidelines for the Neonatal Intensive Care Unit (NICU) population. Local Problem: In multi-center NICUs within the Intermountain West, CCHD continues to have missed cases due to a lack of evidence to support modification and a lack of best practices for screening infants  35 weeks gestation before discharging them home on supplemental oxygen. Methods: This needs assessment began with creating a stakeholder team to guide the usability and feasibility of CCHD screening modification in the NICU. A literature review was conducted to review best practice. A survey was distributed to physicians to assess barriers, current practices, and willingness for change. External benchmarking was done to create a comparison chart to review different practices. Patient data was obtained with a retrospective chart review from January 2021 to March 2023 to look at missed diagnoses and consider improvements in the future. A cost analysis was considered to compare pulse oximetry screening to echocardiograms. Interventions: Discussion groups were conducted with the team of stakeholders to make modifications throughout the project period. Internal and external data was collected for a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis through an internal survey, benchmarking with other centers, and identifying associated costs of screening options. An 3 executive summary was created and included a Situation-Background-AssessmentRecommendation. Results: The survey indicated a variation in practices in the NICU, and practitioners supported the development of a modified tool for screening infants with an echocardiogram before discharging them on supplemental oxygen. Similarly, benchmarking demonstrated a lack of consistency in practice across practice settings. The retrospective chart review highlighted that 33.7% (n = 1061) of infants were discharged on nasal cannula, and over half (n = 581, 54.8%) received an echocardiogram before discharge. Of the 22 patients on supplemental oxygen discharged or transferred to a higher level of care, 19 (86.3%) were referred to cardiology due to the detection of a heart defect, all found with an echocardiogram. Only 2 (9%) of the infants discharged on nasal cannula were readmitted for CCHD after being discharged home. Conclusion: This needs assessment provided a greater understanding of the need to modify the clinical practice guideline (CPG) for screening infants that are  35 weeks gestation and remain on supplemental oxygen at discharge, creating consistency in practice. While echocardiograms are significantly more expensive than pulse oximetry screening, they may be warranted for infants discharged on supplemental oxygen for an unknown etiology. More research is necessary to guide practice in these facilities and throughout all NICUs. Keywords: Critical congenital heart defects, screening, echocardiogram, pulse oximetry, neonatal intensive care unit 4 Screening Newborns on Supplemental Oxygen for Congenital Heart Disease: A Needs Assessment Problem Description Congenital heart defects (CHD) are the leading cause of infant death and illness from a birth defect, affecting approximately 8 per 1,000 births, with 25% of those categorized as critical congenital heart defects (CCHD) (Ailes et al., 2015). CCHDs are defined as defects requiring heart surgery or interventional catheterization within the infancy period for survival (Fernandes et al., 2017). The use of prenatal sonograms has improved the diagnosis of CHD. However, the sensitivity is highly variable due to the sonographer's expertise, the infant's position, the infant's gestational age, and the cardiac defect itself (Harold, 2014). Due to these variables, CHDs and CCHDs may not be detected prenatally (Harold, 2014). In 2011, the United States Secretary of Health and Human Services added CCHD screening tool by pulse oximetry to the US Recommended Uniform Screening Panel (RUSP) (Oster et al., 2016). Within four years, 46 states adopted the newborn screening program (Oster et al., 2016). The initial program prioritized five goals: 1) identifying target lesions for the screening tool, 2) optimizing the screening algorithm, 3) determining state-level challenges of implementation, 4) performing screening with the proper equipment, and 5) implementing screening in special settings such as in the Neonatal Intensive Care Unit (NICU), out-of-hospital deliveries, and high-altitude areas (Oster et al., 2016). The CCHD screen is now legally required in 50 states and the District of Columbia (Schwartz et al., 2022); it has been required in Utah since 2014 (Utah Department of Health and Human Services, N. D.). The CCHD screening tool effectively detects CCHD; however, despite this tool, it is estimated that the CCHD screening tool fails to detect 900 cases annually in the United States 5 (Lai et al., 2021). CCHD screening uses hypoxemia as an indirect indicator of heart defects, utilizing pulse oximetry to test pre- and post-ductal oxygen saturations (Harold, 2014; Ailes et al., 2015). Specifically, the CCHD screening tool is instrumental in detecting hypoplastic left heart syndrome (HLHS), pulmonary atresia, Tetralogy of Fallot, total anomalous pulmonary venous return (TAPVR), transposition of the great arteries, tricuspid atresia, and truncus arteriosus (Harold, 2014). Current recommendations include performing the CCHD screening within 24 to 48 hours of life and without supplemental oxygen. A screening is positive for CCHD if the infant’s oxygen saturation is <90% or the oxygen saturation is <95%, with a difference of 3% between the pre- and post-ductal saturation (American Academy of Pediatrics, 2023). A positive screen indicates the need for an echocardiogram as the gold standard diagnostic test for CHD (Harold, 2014). Although the implementation of CCHD screening has improved the detection of heart defects, some aspects of the screening are not applicable in every setting, causing centers and providers to improvise adaptations. However, the AAP states that modifications to the algorithm need to be further studied before implementing changes (AAP, 2023). The current AAP algorithm implemented throughout this healthcare organization in the Intermountain West was developed and studied at sea level for "healthy, full-term newborns, greater than 24 hours old, and in-room air" (AAP, 2023). Infants in the NICU or at altitude may have important differences from this population. Delayed or late detection of CCHDs can increase morbidity and mortality rates, and up to 75% of infants diagnosed with CHD are at risk for developmental delays due to poor perfusion, acid-base abnormalities, decreased oxygen to the brain, and failure to thrive (Sheta et al., 2023; Van Naarden Braun et al., 2017). Due to the high survival rates of CHD for pediatric patients, 6 there is an increased risk for development and behavioral impairments (Kasparian et al., 2019; Sheta et al., 2023). Although previously lacking studies, infants at moderate to high altitudes have demonstrated wider ranges and lower average oxygen saturations, creating a complication for the interpretation of pulse oximetry screening (Kim et al., 2018). Screening infants at altitude with the standard AAP algorithm has led to higher false positive rates and increased the number of echocardiograms (Sneeringer et al., 2022). To accommodate for elevation changes, some facilities at altitude modified the algorithm to ensure accurate identification of CCHD and attempt to lower the false-positives rates and repeat screenings (Bravo-Jaimes et al., 2024; Oster et al., 2016; Sneeringer et al., 2022). Infants in the NICU have significant differences from the population for which the AAP screening was developed. Currently, the AAP recommends optimal screening intervals within 24 to 48 hours of life, which is often not possible in the NICU setting due to the complexity of the diagnoses (AAP, 2023). In addition, common problems for infants admitted to the NICU include prematurity, lung disease, sepsis, and other conditions that predispose NICU newborns to hypoxemia and increased need for respiratory support such as supplemental oxygen (Schwartz et al., 2022). To adjust for these differences in the NICU population, some NICUs deviate from the standard recommendations for test timing and supplemental oxygen use (Gong et al., 2017; Oster et al., 2016; Fernandes et al., 2017). The State Department of Health recommends modifying the standard AAP guideline for NICU infants on supplemental oxygen. Their recommendations include delaying the CCHD screening until they can wean from supplemental oxygen; however, no specific guidance or practice modification is available for infants who cannot wean from supplemental oxygen before 7 discharge (Fernandes et al., 2017; Oster et al., 2016). Due to the inconsistency surrounding CCHD screening for newborns discharged home with supplemental oxygen, there is a potential for over-screening with echocardiograms. Additionally, the AAP provided an updated statement in July 2023 stating that infants discharged with supplemental oxygen who have not had an echocardiogram as part of their care should follow the CCHD screening protocol once the infant can wean off supplemental oxygen. Due to the inconsistency surrounding CCHD screening for newborns discharged home with supplemental oxygen, there is a potential for over-screening with echocardiograms. Developing a new screening tool may help reduce the number of echocardiograms required before discharge, leading to higher quality care, decreased spending, and unnecessary transfers. Available Knowledge Recent research has validated the current AAP recommendations and screening results. The sensitivity of the CCHD varies widely depending on the type of CCHD lesion (Klausner, 2018). Although the CCHD screening has increased the detection of CCHDs, there are still missed diagnoses. Despite the mandated CCHD screening, the sensitivity to diagnose aortic arch anomalies from the CCHD screen is low (AAP, 2023; Fernandes et al., 2017). Examples include HLHS, which is more commonly diagnosed prenatally when compared to TAPVR (Ailes et al., 2015). Additionally, coarctation of the aorta (CoA) is only detected in less than 60% by CCHD screening, and interrupted aortic arch (IAA) does not have a known detection rate by CCHD screening (Manja et al., 2015). CoA and IAA are often undiagnosed until >3 days after delivery (Ailes et al., 2015). The issue with a delayed diagnosis of CCHD has been shown to lead to poorer preoperative conditions with worse cardiopulmonary and neurological outcomes postoperatively (AAP, 2023). 8 Because the CCHD screen indirectly detects CCHD by assessing for hypoxemia, it has a high potential for false positives. There are a number of non-cardiac pathologies that can generate hypoxemia, including sepsis, other infections, persistent pulmonary hypertension, pulmonary disease, transient tachypnea of the newborn, hypothermia, and hemoglobinopathies account for up to 79% of “positive” CCHD screens (Oster et al., 2016). Schwartz et al. (2022) stated that there is no national best practice for screening NICU babies, although delaying screening until after the newborn is weaned from oxygen is appropriate. In practice settings, some NICUs have modified their protocols to obtain an echocardiogram if the infant cannot wean from or is discharged home with supplemental oxygen (Lakshminrusimha et al., 2014). In contrast, others only use the AAP protocol to delay screening for CCHD until the infant can wean from supplemental oxygen without a guideline of how to screen if they are unable to wean from supplemental oxygen before discharge, such as this healthcare system (AAP, 2023; Fernandes et al., 2017). There are additional NICUs that do not use the CCHD screening tool due to the continuous pulse oximetry monitoring and the assumption that there will be detection in the routine monitoring (Van Naarden Braun et al., 2017). Supplemental oxygen can make interpretation of the results challenging or considerably indeterminant, leading to variation throughout multiple practice settings. The AAP recommends CCHD screening after being weaned from oxygen or, if unable to be weaned from oxygen before discharge, obtaining an echocardiogram. In addition, the APP recommends following practicesetting policies and procedures (American Academy of Pediatrics, 2023; Gong et al., 2017; Oster et al., 2016). However, an official guideline by the AAP has yet to be released for screening infants discharged home with supplemental oxygen in the NICU setting, allowing facilities to 9 create their own guidelines (Gong et al., 2017; Oster et al., 2016). The protocol in Wisconsin was modified to delay CCHD screening until the newborn was off supplemental oxygen for 24 hours or once the newborn was weaned to a supplementation level for home oxygen prescription (Gong et al., 2017). Texas follows the AAP guidance to perform the CCHD screen once the infant has been weaned from supplemental oxygen if they have not already had an echocardiogram before discharge (Gong et al., 2017). Due to the limitations in the application of the AAP CCHD screening protocol to NICU patients and patients discharged on oxygen and a paucity of available evidence/official opinion regarding the management of these exceptions, there is a need to determine the best practice to inform the practice settings guidelines. Rationale This project utilizes a needs assessment approach and gap analysis to examine an organization’s need for change systematically. The goal of performing a needs assessment was to obtain sufficient information to recommend a practice change within a specific population based on evidence. The Johns Hopkins Evidence-Based Practice Model (JHEBP) (Dang et al., 2022) guided the project. The JHEBP addresses variations of best-practice guidelines and evidence-based practice by using a three-phase model known as the PET process. The PET process includes a practice question, evidence, and translation. The practice question is built on a population, intervention, comparison, and outcome (PICO) question used to guide the practice change. The next phase includes obtaining evidence via a literature review and from internal and external sources to drive the practice change. The final step is translating the synthesized literature into the recommendations for practice (Dang et al., 2022). 10 The JHEBP model also addresses sustainability by linking evidence to best practices. Additionally, the plan-do-study-act (PDSA) cycle was used every two weeks to review the findings and strategize further methods to facilitate the needs assessment rapidly with the continuous cycle. Specific Aims This DNP Scholarly Project aimed to conduct a needs assessment to identify the need to modify the current clinical practice guideline (CPG) for congenital heart defect screening for neonates receiving supplemental oxygen before discharge home from the NICU. The specific aims of this project were to 1) assess the usability, feasibility, and satisfaction of the current CCHD screening processes for term newborns discharged home with supplemental oxygen, 2) identify barriers or facilitators associated with the use of echocardiograms for NICU patients on supplemental oxygen at the time of discharge, 3) develop recommendations based on internal and external data, 4) develop a strategic plan for CCHD screenings for neonates on supplemental oxygen. Methods Context This DNP project was conducted within a large healthcare system located in the Intermountain West region of the United States. The project reviewed eleven NICUs in the state. The participants included neonatologists, fellows, nurse practitioners, and physician assistants who work within an urban region. The participants comprise approximately thirty neonatologists and neonatal fellows, eighty neonatal nurse practitioners, and neonatal physician assistants. This DNP project is inclusive of all newborns admitted to the NICU. This project reviewed retrospective data to identify previously missed diagnoses and aimed to make a change to improve the process in the future. 11 Social determinants of health may have an impact on the newborn population due to the lack of resources available for diagnostic procedures. Pediatric echocardiograms are more logistically troublesome among rural populations. They may require transfer to a higher level of care to perform an echocardiogram, leading to more spending and separation from families and support systems (Adappa et al., 2023; Parker et al., 2021). Intervention(s) The first step of the needs assessment was to create a stakeholder team within the healthcare system. A team was formed, and five members were recruited (a NICU medical director, a pediatric cardiologist and pulmonologist, and two nurse practitioners). The goal of creating this team was to establish the objectives of the needs assessment and create a practice question to guide the usability and feasibility of modifying the CCHD screening process in the NICU. The next step was to gather evidence surrounding the current cardiac screening process. First, a literature search was conducted to review the current practices associated with CCHD screening. External sites were identified as potential benchmarks for CCHD screening. These sites consisted of other children’s hospitals and delivery hospitals with Level III to IV NICUs that also care for cardiac patients. Data collection included administering a survey to all participants to understand their current practice, perceptions, and attitudes about a practice change. The survey was the basis for a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis identifying the facilitators, barriers, and gaps/variations. The survey was created using the Research Electronic Database Capture (REDCap) tool (Harris et al., 2009). It was distributed to the participants via 12 email, and their responses were all voluntary. Stakeholder meetings were conducted monthly to discuss progress and continuation of the project goals. We obtained retrospective data from the electronic health record (EHR) from January 2021 to March 2023 with the assistance of a Clinical Specialist. The inclusion criteria for the chart review began with all infants discharged from the NICUs within this healthcare system, regardless of their oxygen therapy at discharge. Once this was developed, we modified inclusion several times to ensure the appropriate data was collected to answer the question driving the project. First, we identified the infants admitted to a pediatric Cardiac Intensive Care Unit (CICU) regardless of gestation age. The initial data did not differentiate the infants discharged to home before readmission vs. those transferred directly due to an identified diagnosis inpatient. It also did not determine oxygen therapy before discharge. Therefore, we adapted our initial search to identify the infants readmitted to the CICU  37 weeks gestation AND receiving supplemental oxygen via nasal cannula. We excluded infants on high-flow nasal cannula, trach nose, or a ventilator for the project. Next, we reestablished the inclusion criteria, and more direct data was obtained from the Clinical Specialist to include infants discharged from all NICUs from Level II to Level IV within the healthcare system and then readmitted to a pediatric CICU. Then, we changed the parameters to include any infant discharged home before readmission to the CICU. Lastly, we expanded the inclusion criteria to include infants born at  35 weeks gestation AND nasal cannula at the time of initial discharge from the NICU to include the late preterm and term infants. See Appendix A. We gathered data from three other facilities to understand their current process surrounding CCHD screening. These included one Level III NICU in the Mountain West region 13 and one Level IV NICU in the northeast of the United States to allow for a range of comparisons and similarities within the observed practice setting. The third site came from a published NICU in Buffalo, New York (Lakshminrusimha et al., 2014). To further understand the cost associated with CCHD screening and echocardiograms, the project lead obtained actual echocardiogram cost data from Intermountain Health cost estimates (Intermountain Healthcare, n.d.). The average cost of a pulse oximetry screening was obtained online from the Centers for Disease Control and Prevention (CDC, 2022). Information and recommendations were compiled into a strategic plan and executive summary and distributed to the stakeholders. The reported data included feasibility and usability and recommended next steps for the project. See Appendix B. Study of the Intervention(s) The survey for this project was designed to understand the need for standardization of CCHD screening in neonates and current practices. The project lead created a survey, which was reviewed, discussed, and approved by the project team. Data was collected using the REDCap tool hosted at the University of Utah (Harris et al., 2009). The surveys were distributed by email to the participants, and responses were all anonymous. The data was imported from REDCap to the Statistical Package for Social Sciences (SPSS) for software analysis. The retrospective data included charts of the infants discharged home post-hospital delivery from the well-baby nursery or a NICU within this healthcare system and transfers from other hospitals in the Intermountain West from January 2021 to March 2023. The project lead analyzed the raw retrospective data, and the infants that met inclusion were highlighted and further discussed with the medical director. Meetings were conducted on December 7, 2023, December 14, 2023, and January 8, 2024. The medical director and stakeholder team endorsed 14 the data being reviewed and all changes to the inclusion criteria. The data was also imported into SPSS for software analysis. Measures The survey distributed consisted of seven questions, displayed in Appendix C. The first two questions established demographic data: years of experience and role. The following three questions used a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree,” to determine the current understanding of practice and the need for standardization. The last two questions examined individual practice approaches to determine if an echocardiogram was ordered for any term infant discharged home with supplemental oxygen using a selection of “yes,” “no,” and “sometimes.” The final question was a free-text question about the factors influencing their decision to order an echocardiogram for a term infant discharged home with supplemental oxygen. The focused chart review components included gestational age, length of stay, race, last documented oxygen therapy, identification of a CCHD screen or echocardiogram, discharge to home or transfer to a higher level of care (such as Level IV NICU or CICU), outpatient cardiology follow-up (if any), and readmission diagnosis (if any). Analysis This DNP project collected two data sets for analysis: the survey data and the retrospective chart review. Both data sets were analyzed using IBM SPSS Statistics (Version 29) to perform the statistical analysis. Surveys Data was analyzed using multiple methods. Demographic data was summarized using descriptive statistics. We summarized participant demographics using frequency counts and 15 central tendencies. Participants were organized by role (physician, fellow, nurse practitioner, physician assistant). Years of experience were grouped into categories (less than five years, more than five years, less than ten years, more than ten years, less than 15 years, more than 15 years, less than 20 years, and greater than 20 years.). Benchmarking and cost analysis data from other hospitals were organized and compared to current standards. Short-answer responses were qualitatively analyzed. First, the coding team (ZNC and KJM) reviewed the responses. The project lead then inductively coded all the responses. The codes were then reviewed by the team and combined into overarching themes. Coding discrepancies were reviewed and resolved by team consensus. Chart Review The second data set included retrospective patient charts and utilized descriptive statistics. Data from the chart review was summarized using descriptive statistics to create tables for demographics, oxygen therapy at discharge, echocardiograms, and inpatient transfer vs. discharge home. Ethical Considerations This project was a quality improvement initiative and did not require Institutional Review Board approval deemed by the University of Utah. There were no conflicts of interest or compensation for participants’ time. Results Survey We distributed the needs assessment survey to attending physicians, fellows, and APPs, which accounts for approximately 110 individuals. See Appendix C. A total of 45 (41%) surveys were completed, the majority being from the APPs (n = 29, 64.4%). We did not receive any 16 responses from the NICU fellows, so our reported results will focus on two groups: the attending physicians and APPs. The plurality of respondents across the sample had 20 years of experience (n = 16, 35.6%). Many APP respondents had more than 20 years of experience (n = 12, 41.4%), while most attending physicians indicated they had five to 10 years of experience (n = 6, 37.5%). See Table 1. The Likert scale questions demonstrated that both groups strongly agree on the need for an echocardiogram on term infants ( 37 weeks gestation) discharged from the NICU with supplemental oxygen if they have an unknown etiology (M = 4.19, SD = 1.19). In comparison, APPs and attendings were more neutral about the need for an echocardiogram on ALL term infants ( 37 weeks gestation) discharged with supplemental oxygen (M = 3.05, SD = 1.21). However, when looking at the attendings compared to the APP group, the APPs were more neutral in agreeing to obtain an echocardiogram on ALL term infants (M = 3.41, SD = 1.19). In contrast, the attending group tended to slightly disagree (M = 2.44, SD = 1.03). Additionally, the APP group was more likely to strongly agree with obtaining an echocardiogram for infants requiring supplemental oxygen for an unknown etiology before discharge (M = 4.5, SD = 0.95). The attending group responses were lower (M = 3.69, SD = 1.40). Both groups indicated that modifying the clinical practice guideline would benefit practice in the NICU (M = 4.39, SD = 0.92). Attending physicians and APPs indicated differences in their current practice for ordering an echocardiogram for a term infant discharged home on supplemental oxygen, with more than 50% of respondents saying sometimes (n = 24, 53.3%). The attendings more frequently said in their practice that they sometimes get an echocardiogram on a term infant (n = 13, 81.25%), 17 while the APP group responded more frequently said in their practice that they often get an echocardiogram on term infants (n = 18, 62.1%). See Table 2. We identified four themes linked to the influence on the decision to obtain an echocardiogram on a term infant discharged home on supplemental oxygen: preferences, clinical findings, oxygen requirements, and etiology. See Table 3. First, respondents indicated practice preferences that dictated their choices. Some described requiring an echocardiogram if oxygen is required at discharge as their standard practice. APPs indicated that they often defaulted to the attending physician's preference. Respondents also indicated that clinical findings dictated their clinical decision to obtain an echocardiogram before discharging the infant on supplemental oxygen. One attending respondent with more than 20 years of experience noted that they evaluated the presence and characteristics of a murmur and vital signs, including blood pressure and heart rate, to decide if an echocardiogram was warranted. In addition, the amount of supplemental oxygen was a factor in their decision to obtain an echocardiogram before discharging an infant on supplemental oxygen. The amount of oxygen that triggered the need for an echocardiogram varied by respondent, with some obtaining an echo with any oxygen use and others requiring a flow greater than 0.06 LPM. The final theme was etiology. Participants noted they would not obtain an echocardiogram if the patient had a diagnosis explaining the oxygen use. If there were no known etiology, they would order an echocardiogram before discharge to ensure a cardiac defect was not present, causing the need for supplemental oxygen. See Table 3. This survey did contain missing data within the Likert-based questions. Four of the 45 surveys contained missing data. Due to the small amount of missing data, we excluded these responses from the results. Benchmarking 18 We benchmarked with three sites to compare national practices. See Appendix D. All three sites followed the AAP guidelines with some exceptions. The first site provided their CCHD screening clinical practice guideline utilized in their Level IV NICU. The background of the clinical practice guidelines identified that there are no national screening guidelines for the NICU population. The eligible patients for the CCHD screening in the NICU were limited to those that have been weaned from oxygen and are less than seven days of life and those on oxygen that meet other criteria (24 hours or greater, but less than seven days of life) should undergo CCHD screening at their prescribed oxygen per the discretion of the provider. However, ineligible infants include those prenatally diagnosed with CCHD, infants with a previous echocardiogram, and infants in the NICU on oxygen during the screening period or greater than seven days of life at the time of discharge. The second site included the process for performing the screen within their Level III NICU. The exclusion at this hospital included infants under 24 hours old, on oxygen, or having had a documented echocardiogram. This hospital requires a form to be submitted for incomplete CCHD screening for infants meeting the exclusion criteria. However, further steps were unidentified. The third site implemented a modified guideline recommending that newborns unable to wean from oxygen for 24 hours before screening must undergo an echocardiogram if they have not had one previously (Lakshminrusimha et al., 2014). Electronic Health Record We reviewed 3130 medical records. The sample was primarily white (n = 146, 46%) and Hispanic (n = 392, 5%). The average gestational age in the group was 37.76 weeks (SD = 1.67). Next, we compared the patients on room air (n = 2024) and nasal cannula (n = 1061) at 19 discharge. Within these groups, the average gestational age was 37.81 days (SD = 1.68) for the room air group and 37.65 days (SD = 1.64) for the nasal cannula group. The length of hospitalization varied between the groups. The entire population had an average hospital stay of 9.72 days (SD = 14.07), while the room air group was hospitalized for an average of 8.94 days (SD = 12.15), and the nasal cannula group for 10.08 days (SD = 10.37). See Table 4. Most infants were discharged in room air (n = 2024, 64.6%). If the patient was on supplemental oxygen at discharge, it was most often nasal cannula (n = 1061, 33.7%). See Table 5. For this sample, 65.5% (n = 2060) received an echocardiogram regardless of diagnosis. The room air group had fewer echocardiograms than the nasal cannula group (22.9%, n = 464 vs. 54.8%, n = 581). See Table 6. From the initial review of medical records, we evaluated CICU transfers or readmissions (with or without cardiology follow-up) (n = 22). See Table 4 for demographic data. Both the transfers and readmission groups had similar gestational ages (transfer/discharge M = 37.85 days, SD = 1.31 vs. readmission M = 37.4 days, SD = 1.42). The length of stay varied between the groups, with the CICU transfers or readmission group having an average stay of 20.38 days (SD = 25.82) compared to the readmission group, which had an average stay of 12.67 days (SD = 9.3). Out of the 22 infants either transferred to the CICU inpatient, home with cardiology follow-up, or readmissions, 86.3% (n = 19) had an echocardiogram, and 13.6% (n = 3) did not have one. Of the 12 (52.5%) infants that were transferred inpatient for a critical defect, 7 (31.8%) had prenatal diagnoses including inability to rule out coarctation or difficulty visualizing structures, narrow aortic arch, congenital heart block, hypoplastic tricuspid valve, and hypoplastic left heart syndrome. Of these three infants that did not have an echocardiogram, one 20 was discharged home without oxygen and without a CCHD screening, indicating a true miss for screening. See Figure 1. Because they were not on oxygen, we did not include them in the full data review. Next, we evaluated the 9 (45.4%) infants on nasal cannula at the time of discharge who were readmitted back into the CICU with a congenital heart defect. Of these, 22.2% (n = 2) did not have an echocardiogram before discharging home from the NICU. Both infants were readmitted with a defect categorized as critical, one with intracardiac TAPVR and the other with an absent pulmonary artery. The timing of readmission for these infants was on day of life (DOL) 11 and DOL 16. The remaining 7 (31.8%) patients did have an echocardiogram before being discharged from the NICU. They were referred to cardiology outpatient follow-ups with noncritical defects such as ASD, VSD, PFO, PDA, complete AV canal, bicuspid aortic valve, and mitral valve regurgitation. Along with the heart defects, 5 (71.4%) of the sample also had chromosomal abnormalities, such as Trisomy and translocation. Additionally, two (28.6%) of these patients had prenatal ultrasounds, indicating a possible coarctation of the aorta. However, on the postnatal echocardiogram, one of the results showed mild hypoplasia of the aortic valve, aortic root, transverse arch, and isthmus. However, no PDA was present, and they were discharged. This infant was readmitted on DOL 7 and required prostaglandin infusion and surgical repair. The second infant also had a postnatal echocardiogram before discharge but was readmitted at two months of age for aortic arch augmentation for findings of a hypoplastic transverse arch, hypoplastic branch pulmonary arteries, and PDA with bidirectional shunting. Cost-Analysis 21 CCHD pulse oximeter screening ranges from $5 to $14 (CDC, 2022). The cost of an echocardiogram, which includes color flow mapping and a cardiac Doppler, averages $960.92 (Intermountain Healthcare, n.d.). CCHD screening is a cost-effective approach for early detection; however, if an infant is on oxygen supplementation for an unknown etiology or has clinical findings suspicious for CCHD, an echocardiogram is warranted to determine if a CCHD is a reason for the oxygen supplementation. The cost of CCHD interventions varies with the type of defect and the necessary repair and follow-up. In 2012, the average cost for cardiac surgery was $51,302, and cardiac catheterization cost was $4,134 (Faraoni et al., 2016). Infants with late detected CCHD, defined as a diagnosis after discharge from the hospital, spent, on average, ten more days hospitalized compared with infants whose congenital heart defect was found with CCHD screening (Peterson et al., 2015). However, this does not reflect the cost of the complications of delayed diagnosis. On average, the bed cost for each additional day in the CICU is $11,295, which would increase the cost by a minimum of $112,950 for an additional ten-day stay (Intermountain Healthcare, n.d.). Discussion Summary CCHD screening remains an essential test for all infants. This needs assessment aimed to determine the need to modify the current CPG for congenital heart defect screening for neonates receiving supplemental oxygen before discharge home from the NICU. The findings suggest that physicians have different practices regarding which infants require an echocardiogram before discharge, which, in turn, has created a variation of practice in the observed practice setting. Some of the barriers or facilitators identified included the physician preference, the clinical presentation of the infants, the oxygen requirement, and the etiology of the oxygen supplementation. The benchmarking data demonstrated a variation in practice 22 throughout multiple NICUs, making it challenging to create a recommendation in line with practices of other similar facilities, and highlighted a need for more information about appropriate screening criteria and processes for infants on supplemental oxygen. Additionally, the retrospective chart review had multiple components that, while helpful to determining the infants readmitted for CCHD, did not provide adequate information regarding the criteria that would determine how to evaluate patients for a CCHD while on oxygen. Due to these barriers, continued research and review may be necessary to allow for recommendations for screening this defined population. While this assessment did not define the next steps for CCHD screening, we did find that the detection of non-critical defects was increased due to the increased number of echocardiograms. Of the 22 patients on supplemental oxygen who received an echocardiogram, 7 (31.8%) were referred to cardiology for outpatient follow-up, and 12 (54.5%) were transferred to the CICU to receive care for critical defects. Early detection of non-critical CHD enabled infants to receive early intervention by cardiology, which may improve their long-term outcomes and indicate continued use of echocardiograms to detect non-critical defects in patients on supplemental oxygen. Pulse oximetry does not always detect a CCHD due to the nature of the defect. Most commonly, the undetected defects include ones that do not cause hypoxemia or low pulse oximetry saturation, such as defects that cause systemic blood flow obstruction, including Coarctation of the Aorta (CoA). While the use of echocardiograms is one method that could improve the detection of critical defects, other options are being explored that could improve the early detection of CCHDs. Currently, Lai et al. (2021) is investigating the interpretable machine learning (ML) model and the SpO2 test to improve the sensitivity and detection of CCHDs. The 23 results suggest that the ML model used concurrently with the SpO2 test identified more cases than the standard pulse oximetry screening alone. The dual test increased the sensitivity of CCHD detection by 10% (Lai et al., 2021). This model could prove to be a cost-effective screening that could be used in place of echocardiograms and a standard of care. At this point, continuing to explore options for accurate screening of CCHD in special populations should be a focus of continued research. Interpretation The survey results indicate that the current CPG in the NICU needs to be modified to determine which infants need an echocardiogram before discharging on supplemental oxygen. Additionally, we noted practice variation between the attending physicians and APPs, and consistency in the practice needs to be established within this practice setting. In our setting, we found clinicians defaulted to their own clinical judgment due to a lack of consistent guidelines. It is unclear if underlying conditions and assessment data are considered in clinical decisionmaking. This could be similar to other centers, yet no evidence details current deviations from practice at different centers. Therefore, further research is necessary to understand current practices in this area. Our investigation found that there is no universal guideline for screening for CCHD in the NICU. There continue to be modifications in the practice setting based on individual states and NICUs. However, due to the need for more consistency and evidence-based decisionmaking, utilizing other facility guidelines may not be beneficial to implement into practice. While the AAP continues to update and modify the guidelines, they have not adapted their recommendations to account for the use of supplemental oxygen in this population. Without 24 more research and guidance from a national organization, individual states, and hospitals continue to alter the guidelines to meet current needs. Other factors that may have caused a difference in practice include infants that live in moderate to high altitudes and the physiological challenges that occur, including a lower partial pressure of oxygen at higher altitudes, higher hemoglobin levels, a hypoxic ventilator response, large lung volumes accompanied by more narrow alveoli to arterial gradients of oxygen, a decreased pulmonary vasoconstriction response, and increased pulmonary artery pressures (Bravo-Jamies et al., 2024). Due to the described factors, adjusting an algorithm to account for populations at higher altitudes may be necessary. In addition, differences in altitude may further complicate this issue, requiring regionally based guidelines due to geographic differences rather than implementation of a national standard. The electronic health record data demonstrates increased echocardiograms for infants on supplemental oxygen compared to their room air counterparts. The increased number of infants who received an echocardiogram may have led to increased identification of critical as well as non-critical CHDs in multiple patients that led to direct inpatient transfer to the CICU or cardiac outpatient follow-up. The cost of echocardiograms is significantly more expensive than CCHD pulse oximetry screening. However, using echocardiograms to rule out CCHD may be warranted if an unknown etiology exists. While the cost is higher initially if warranted based on factors such as physical assessment and supplemental oxygen of an unknown etiology, an early echocardiogram and intervention could improve long-term outcomes by preventing complications such as cardiogenic shock (Siefkes et al., 2020). 25 Limitations This needs assessment had limitations. First, the lack of research on CCHD screening for the NICU population and supplementary oxygen impeded our ability to create an evidence-based practice guideline. Next, due to the data available, we changed our inclusion criteria to  35 weeks gestation after distributing the survey to participants. The survey questions were specific to term infants  37 weeks gestation. Participants' survey responses may have differed from those of a younger population. The data review and analysis for this project was limited. Future projects should focus on other factors surrounding clinical decision-making, such as patient assessment, the timing of the CCHD screening, and the reason for the use of supplemental oxygen to determine when an echocardiogram is indicated. Additionally, an altitude adjustment guideline has continued to result in high false positive rates and more studies are needed for higher altitude NICUs before considering their use (Bravo-Jamies et al., 2024). However, again, it creates differences within practice settings. Further review with more studies will be necessary to meet the needs of this vulnerable population. Conclusions CCHD screening in the NICU is beneficial for early diagnosis and treatment. Our findings suggest a need for standardization, yet there continues to be a variation in practice, and there are multiple modifications in different practice settings. In general, more research is necessary to recommend a practice change to understand the factors that could indicate the need for an echocardiogram. Although we cannot recommend a CPG, we recommend continued investigation into the factors that indicate a need for an echocardiogram as a diagnostic tool for infants receiving 26 supplemental oxygen. Our results show that echocardiograms could help diagnose noncritical defects in the neonatal population. However, there is a need for more research on the parameters that should be followed to prevent costly and unnecessary testing. There may be modifications within other NICUs that can be implemented to adjust for the population, but more studies or consistency in a facility should be established to ensure consistency. 27 Acknowledgments I want to thank my project chair, Kelly Mansfield, PhD, RN, my content experts, Con Yee Ling, MD, and Whitnee Hogan, MD, and my project sponsor and Specialty Track Director, Kim Fiddle, PhD, NNP-BC, APRN, for all their expertise, guidance, and continual support throughout this DNP project. I would also like to thank Ashlee Ruoti, DNP, NNP-BC, APRN, for her time and support. 28 References Adappa, R., & Barr, S. (2023). Social determinants of health and the neonate in the neonatal intensive care. Paediatrics and Child Health, 33(6), 154– 157. https://doi.org/10.1016/j.paed.2023.03.002 Ailes, E. C., Gilboa, S. M., Honein, M. A., & Oster, M. E. (2015). Estimated Number of Infants Detected and Missed by Critical Congenital Heart Defect Screening. Pediatrics, 135(6), 1000–1008. https://doi.org/10.1542/peds.2014-3662 American Academy of Pediatrics (2023). Newborn screening for critical congenital heart defect (CCHD). American Academy of Pediatrics. https://www.aap.org/en/patientcare/congenital-heart-defects/newborn-screening-for-critical-congenital-heart-defectcchd/ CDC (2022). Screening for critical congenital heart defects. Centers for Disease Control and Prevention. https://www-cdcgov.ezproxy.lib.utah.edu/ncbddd/heartdefects/screening.html#:~:text=4,Costs,for%20each%20newborn%20baby%20screened. Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International Faraoni, D., Nasr, V. G., & DiNardo, J. A. (2016). Overall Hospital Cost Estimates in Children with Congenital Heart Disease: Analysis of the 2012 Kid’s Inpatient Database. Pediatric Cardiology, 37(1), 37–43. https://doi.org/10.1007/s00246-015-1235-0 Fernandes, N., Short, B., Manja, V., & Lakshminrusimha, S. (2017). Critical Congenital Heart Disease Screening in NICU: Need for Revision and Standardization. American Journal of Perinatology, 34(14), 1470–1476. https://doi.org/10.1055/s-0037-1603654 29 Gong, A., Guillory, C., Creel, L., Livingston, J. E., McKee-Garrett, T. M., & Fortunov, R. (2017). A Multicenter Initiative for Critical Congenital Heart Disease Newborn Screening in Texas Neonatal Intensive Care Units. American Journal of Perinatology, 34(09), 839–844. https://doi.org/10.1055/s-0037-1599053 Harold, J. G. (2014). Screening for Critical Congenital Heart Disease in Newborns. Circulation, 130(9), e79–e81. https://doi.org/10.1161/CIRCULATIONAHA.113.008522 Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010 IBM Corp. (2023). IBM SPSS Statistics for Mac (Version 29.0) [Computer software]. IBM Corp. Intermountain Healthcare. (n.d). Intermountain Primary Children’s Hospital - Hospital Prices. Retrieved March 15, 2024, from https://intermountainhealthcare.org/primarychildrens/about/standard-charges Kasparian, N. A., Kan, J. M., Sood, E., Wray, J., Pincus, H. A., & Newburger, J. W. (2019). Mental health care for parents of babies with congenital heart disease during intensive care unit admission: Systematic review and statement of best practice. Early Human Development, 139, 104837. https://doi.org/10.1016/j.earlhumdev.2019.104837 Kim, J. S., Ariefdjohan, M. W., Sontag, M. K., & Rausch, C. M. (2018). Pulse Oximetry Values 30 in Newborns with Critical Congenital Heart Disease upon ICU Admission at Altitude. International Journal of Neonatal Screening, 4(4), 30. https://doi.org/10.3390/ijns4040030 Klausner, R. E. (2018). Evaluation Of Pulse Oximetry As A Screen For Critical Congenital Heart Disease In Newborns. Yale Medicine Thesis Digital Library. https://elischolar.library.yale.edu/ymtdl/3417/ Lai, Z., Vadlaputi, P., Tancredi, D. J., Garg, M., Koppel, R. I., Goodman, M., Hogan, W., Cresalia, N., Juergensen, S., Manalo, E., Lakshminrusimha, S., Chuah, C.-N., & Siefkes, H. (2021). Enhanced Critical Congenital Cardiac Disease Screening by Combining Interpretable Machine Learning Algorithms. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference, 2021, 1403– 1406. https://doi.org/10.1109/EMBC46164.2021.9630111 Lakshminrusimha, S., Sambalingam, D., & Carrion, V. (2014). Universal pulse oximetry screen for critical congenital heart disease in the NICU. Journal of Perinatology, 34(5), Article 5. https://doi.org/10.1038/jp.2013.145 Manja, V., Mathew, B., Carrion, V., & Lakshminrusimha, S. (2015). Critical congenital heart Disease screening by pulse oximetry in a neonatal intensive care unit. Journal of Perinatology: Official Journal of the California Perinatal Association, 35(1), 67– 71. https://doi.org/10.1038/jp.2014.135 Oster, M. E., Aucott, S. W., Glidewell, J., Hackell, J., Kochilas, L., Martin, G. R., Phillippi, J., 31 Pinto, N. M., Saarinen, A., Sontag, M., & Kemper, A. R. (2016). Lessons Learned From Newborn Screening for Critical Congenital Heart Defects. Pediatrics, 137(5), e20154573. https://doi.org/10.1542/peds.2015-4573 Parker, M. G., Garg, A., Brochier, A., Rhein, L. M., Forbes, E. S., Klawetter, S., & Drainoni, M.L. (2021). Approaches to addressing social determinants of health in the NICU: A mixed methods study. Journal of Perinatology: Official Journal of the California Perinatal Association, 41(8), 1983–1991. https://doi.org/10.1038/s41372-020-00867-w Peterson, C., Grosse, S. D., Oster, M. E., Olney, R. S., & Cassell, C. H. (2013). CostEffectiveness of Routine Screening for Critical Congenital Heart Disease in US Newborns. Pediatrics, 132(3), e595–e603. https://doi.org/10.1542/peds.2013-0332 Schwartz, B. N., Hom, L. A., Revenis, M. E., & Martin, G. R. (2022). Rethinking Pulse Oximetry Screening in the Level-IV Neonatal Intensive Care Unit. American Journal of Perinatology, S49–S51. https://doi.org/10.1055/s-0042-1757350 Siefkes, H., Kair, L., Tancredi, D. J., Vasquez, B., Garcia, L., Bedford-Mu, C., & Lakshminrusimha, S. (2020). Oxygen Saturation and Perfusion Index-Based Enhanced Critical Congenital Heart Disease Screening. American Journal of Perinatology, 37(2), 158–165. https://doi.org/10.1055/s-0039-1685445 Sneeringer, M. R., Vadlaputi, P., Lakshminrusimha, S., & Siefkes, H. (2022). Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives. Journal of Perinatology: Official Journal of the California Perinatal Association, 42(9), 1176–1182. https://doi.org/10.1038/s41372022-01491-6 Utah Department of Health and Human Services. (N.D.). Critical congenital heart disease 32 screening: Office of children with special health care needs. https://familyhealth.utah.gov/cshcn/cchd/#:~:text=Utah%20CCHD%20Screening&text= To%20prevent%20serious%20morbidity%20and,became%20effective%20October%201 %2C%202014. Van Naarden Braun, K., Grazel, R., Koppel, R., Lakshminrusimha, S., Lohr, J., Kumar, P., Govindaswami, B., Giuliano, M., Cohen, M., Spillane, N., Jegatheesan, P., McClure, D., Hassinger, D., Fofah, O., Chandra, S., Allen, D., Axelrod, R., Blau, J., Hudome, S., … Garg, L. F. (2017). Evaluation of critical congenital heart defects screening using pulse oximetry in the neonatal intensive care unit. Journal of Perinatology: Official Journal of the California Perinatal Association, 37(10), 1117– 1123. https://doi.org/10.1038/jp.2017.105 33 Tables and Figures Table 1 Survey Demographics Role Years of Experience Less than 5 years Between 5-10 years Between 10-15 years Between 15-20 years More than 20 years All n (%) 45 Attending n (%) 16 (35.6) APP n (%) 29 (64.4) 4 (8.9) 12 (26.6) 9 (20.0) 4 (8.8) 16 (35.6) 1 (2.2) 6 (13.3) 3 (6.7) 2 (4.4) 4 (8.9) 3 (6.7) 6 (13.3) 6 (13.3) 2 (4.4) 12 (26.7) 34 Table 2 Survey Likert Responses All M (SD) 3.05 (1.21) Attending M (SD) 2.44 (1.03) APP M (SD) 3.41 (1.19) An echocardiogram should be done for ALL term infants discharged with supplemental oxygen due to an unknown etiology 4.19 (1.19) 3.69 (1.40) 4.5 (0.95) Modifying the current CPG to determine which infants need an echocardiogram before discharging on supplemental oxygen would be a beneficial practice in the NICU. 4.39 (0.92) 4.06 (1.24) 4.57 (0.63) N (%) n (%) n (%) 20 (44.4) 1 (2.2) 24 (53.3) 2 (12.5) 1 (6.25) 13 (81.25) 18 (62.1) 0 (0) 11 (37.9) An echocardiogram should be done for ALL term infants discharged with supplemental oxygen. Do you order an echocardiogram for a term infant discharged home on supplemental oxygen? Yes No Sometimes 35 Table 3 Factors that Influence the Decision to Obtain an Echocardiogram when Discharged on Oxygen Code Preference Definition Described their own practice preferences. Clinical Findings Described symptoms or presentation that influence a decision. Describes the amount of oxygen that influences a decision. Describes the reason for the supplemental oxygen use. Oxygen Requirement Etiology Examples 1. “If a term infant has not had a previous Echo, then requiring NC O2 at discharge is considered a failed CCHD screen, and he/she needs an Echo.” 2. “Attending physician preference.” 1. “Everything! Murmur, no murmur. Characteristic of said murmur if present. Vitals (in particular) systolic and diastolic blood pressures. Heart rate.” 1. “Depends on the amount of oxygen required.” 2. “Oxygen requirement greater than 0.06.” 1. “An echo should be considered prior to d/c if the supplemental O2 need has unknown etiology.” 2. “Clear respiratory diagnosis that accounts for oxygen need such as a healing pneumothorax, I don't think they need one. If there is an unknown etiology, I order an ECHO.” 36 Table 4 Infant demographics Variable Readmission n (%) Inpatient CICU Transfer or Home on NC n (%) 2024 (64.7) 1061 (33.9) 22 (0.7) 9 (0.2) M (SD) M (SD) M (SD) M (SD) M (SD) Gestational Age (Weeks) Length of Stay (Days) Race 37.76 (1.67) 37.81 (1.68) 37.65 (1.64) 37.85 (1.31) 37.4 (1.42) 9.72 (14.07) 8.94 (12.15) 10.08 (10.37) 20.38 (25.82) 12.67 (9.3) n (%) n (%) n (%) n (%) n (%) Asian 26 (0.8) 18 (0.9) 8 (0.8) -- -- Black 30 (1) 26 (1.3) 4 (0.4) -- -- Hispanic 392 12.5) 268 (13.2) 114 (10.7) 3 (13.6) 2 (22.2) Native American 22 (0.7) 15 (0.7) 6 (0.6) -- -- Pacific Islander 45 (1.4) 32 (1.6) 12 (1.1) 1 (4.5) -- White 1461 (46.5) 959 (47.4) 474 (44.7) 16 (72.7) 6 (66.7) Other/No Data 1169 (37.2) 706 (34.9) 443 (41.8) 2 (9.1) 1 (11.1) Sample Size All* Room Air Nasal Cannula N (%) n (%) 3130 * Includes all oxygen therapy types at discharge. n (%) 37 Table 5 Oxygen Therapy at Discharge Oxygen Therapy High-Flow NC NC Room air Trach nose Ventilator n (%) 6 (0.2) 1061 (33.9) 2024 (64.7) 7 (0.2) 32 (1) 38 Table 6 Echocardiograms Echocardiogram All* Room Air Nasal Cannula n (%) n (%) n (%) CICU Readmission** Transfer or Home on NC n (%) n (%) No 1085 (34.6) 1560 (77.1) 480 (45.2) 3 (13.6) 2 (22.2) Yes 2060 (65.5) 464 (22.9) 581 (54.8) 19 (86.3) 7 (77.8) * Includes all oxygen therapy types at discharge. **On nasal cannula at time of discharge. 39 Figure 1 Critical Defect Transfer vs. Home with Cardiology Follow-Up vs. Home Critical Defect Transfer vs. Home with Cardiology Follow-Up vs. Home N=22 14 12 10 8 6 4 2 0 Critical Defect Inpatient Transfer Non-Critical Defects Home With Cardiology Outpatient Follow-Up Home* *One out of the three infants was discharged home without oxygen supplementation. 40 Appendix A Evolution of Inclusion Criteria for Chart Review 41 Appendix B Executive Summary Executive Summary Screening Newborns on Supplemental Oxygen for Congenital Heart Disease: A Needs Assessment Situation: The newborn intensive care unit (NICU) cares for a unique population of vulnerable infants. The CCHD (critical congenital heart defects) screening tool was mandated into law and has significantly increased the detection of CCHD. However, the population that the CCHD screening tool from the American Academy of Pediatrics (AAP) was studied for infants in the well-baby nursery, at sea level, in room air, and between 24-48 hours of age for optimal screening. Due to these parameters, the NICU is often unable to screen these infants due to their acuity in the ICU setting, potential altitude differences, supplemental oxygen use, instability, and optimal time for screening. Background: Congenital heart defects (CHD) are the leading cause of infant death and illness from a birth defect. CCHDs are defined as defects requiring heart surgery or interventional catheterization within the infancy period for survival. Delayed or late detection of CCHDs can increase morbidity and mortality rates, and up to 75% of infants diagnosed with CHD are at risk for developmental delays due to poor perfusion, acid-base abnormalities, decreased oxygen to the brain, and failure to thrive. Assessment: The Needs Assessment was conducted in multi-center NICUs throughout Intermountain Health (IH). 1. SWOT Analysis to determine strengths, weaknesses, opportunities, and threats through the distribution of a survey (N = 45) to assess the current practices and the need for modification in the NICU. 2. Retrospective chart review consisted of a review of infants discharged from multi-center NICUs at IH (N = 3130) between January 2021 and March 2023. 3. Review current policy, procedure, and benchmarking to identify internal and external practices. 4. Cost analysis to compare the procedures for CCHD screening. Financials: The cost of the CCHD screen, using a pulse oximeter, ranges from $5 to $14, and the cost of an echocardiogram, which includes color flow mapping and a cardiac Doppler, averages $960.92. Pulse oximetry CCHD screening is a cost-effective approach for early detection; however, if an infant is on oxygen supplementation for an unknown etiology or has clinical findings, an echocardiogram is warranted to determine if a CCHD is a reason for the oxygen supplementation. However, more research is needed on the parameters to prevent costly and unnecessary testing. Results: The survey indicated a variation in practices in the NICU, and practitioners supported the development of a modified tool for screening infants with an echocardiogram before discharging them on supplemental oxygen. Similarly, benchmarking demonstrated a need for more consistency in practice across practice settings. The retrospective chart review highlighted that 33.7% (n=1061) of infants were discharged on nasal cannula, and over half (n=581, 54.8%) received an echocardiogram before discharge. Of the 22 patients on supplemental oxygen discharged or transferred to a higher level of care, 19 (86.3%) were referred to cardiology due to the detection of a heart defect, most found with an echocardiogram. While only 2 (9%) of the infants discharged on nasal cannula were readmitted for CCHD after being discharged home. Recommendation: Findings suggest the need for standardization due to continued variations in practice internally within the practice setting as well as externally in different NICUs. However, a clinical practice guideline could not be created due to the variations and inconclusion of evidence-based practice and research. However, it is recommended that the investigation into factors that indicate the need for an echocardiogram for infants receiving supplemental oxygen be continued. It is strongly recommended that the current practice be modified to obtain an echocardiogram for an unknown etiology of supplemental oxygen until a recommended evidence-based guideline can be utilized in the NICU. 42 Appendix C Survey Demographics 1. How long have you worked in the NICU? 1. Less than 5 years 2. More than 5 years, less than 10 years 3. More than 10 years, less than 15 years 4. More than 15 years, less than 20 years 5. More than 20 years 2. What is your position? 1. Attending 2. Fellow 3. NNP 4. PA Likert Scale 3. An echocardiogram should be done for all term infants ( 37 weeks’ gestation) that are discharged from the NICU with supplemental oxygen. 1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree 4. An echocardiogram should be done for all term infants ( 37 weeks’ gestation) that are discharged from the NICU with supplemental oxygen due to an unknown etiology. 1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree 5. Modifying the current clinical practice guideline to determine which infants need an echocardiogram prior to discharging on supplemental oxygen would be beneficial for practice in the NICU. 1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree Other Questions 6. In your practice, do you currently order an echocardiogram for a term infant discharging home with supplemental oxygen? 1. Yes 2. No 3. Sometimes 43 7. What factors influence your decision to obtain an echocardiogram on a term infant being discharged home with supplemental oxygen? 44 Appendix D Benchmarking CCHD screening CPG Site 1 Inclusion criteria: - Weaned from oxygen and less than seven days of life OR On oxygen and meet other criteria, including 24 hours or greater, but less than seven days of life may undergo CCHD screening at prescribed oxygen per provider discretion Exclusion criteria: - Prenatal CCHD diagnosis - Previous echocardiogram - Infants on oxygen during the screening period - Infants greater than seven days of life at the time of discharge Screening process in the NICU Site 2 Exclusion criteria: - Infants less than 24 hours old - Infants on oxygen - Previous echocardiogram For those that meet exclusion criteria: - A form must be filled out and documented - No further steps for screening are outlined Clinical flowchart Site 3 Inclusion criteria: - All infants who are unable to wean from oxygen for 24 hours must undergo an echocardiogram if not done previously