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.