Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit

Necrotizing enterocolitis (NEC) is a serious, life-threatening complication of fragile premature infants, yet adoption of prevention and early recognition practices--such as use of human milk, adoption of standardized feeding protocols, and transfusion and antibiotics management--differs widely. Thus, there is the need to improve the application of evidence-based practices for prevention and early recognition of NEC among premature infants. To address this need, the research team previously developed and evaluated a risk decision rule to accurately recognize NEC. This followup study integrated clinical decision support (CDS) into providers’ workflow in neonatal intensive care units (NICUs) with the goal to deliver evidence-based guidelines for early recognition and prevention of NEC with an intervention called “NEC-Zero.”

The specific aims of the research study were as follows:

• Describe clinician workflow derived through workflow clinical maps constructed from interviews with local clinicians, and then integrate NEC-Zero into CDS in the form of standard orders, sets, alerts, reminders, and trend data. 
• Optimize NEC-Zero data usability using a simulated NEC scenario and iterative evaluation. 
• Compare NEC disease, neonate nutrition, and parent satisfaction pre- and post-intervention, and describe the relationship between post-NEC-Zero clinician CDS outcomes and NEC disease outcomes (not completed). 

Researchers undertook three steps to design and operationalize NEC-Zero. First, the formalization of evidence with the NEC-Zero expert team was completed through online collaboration to complete a scoping review, assign GRADE criteria, and propose implementation strategies. Second, workflow mapping of clinician interactions with the electronic health record to fit CDS was completed in two NICUs with clinician participants. Third, an adherence score for NEC-Zero was validated separately and then incorporated into the CDS.

The NEC-Zero tools were designed to support team-based and widespread adoption of NEC prevention in ways that engage families and make best practices repeatable. NEC-Zero has provided synthesized and vetted evidence reviews and tools for clinical use to close the gap between recommended and actual care. Nearly 8,000 downloads from the NEC-Zero site demonstrate that the tools are being accessed and used. Next steps will continue to refine and implement the NEC-Zero CDS and investigate its impact on clinical care processes and neonatal outcomes.