By Caroline Porter, RN, BSN; The University of Arizona College of Nursing

When it comes to caring for fragile infants, many aspects need to be considered to help them thrive. Necrotizing enterocolitis (NEC) is a devastating disease that can quickly change the fate of a medically fragile infant. Fortunately, there are tools to help clinicians identify NEC risk and consistently deliver prevention practices, including the Avoiding NEC Checklist developed as part of the NEC-Zero Project at the University of Arizona College of Nursing.

Led by Dr. Sheila Gephart, who serves on the NEC Society’s Scientific Advisory Council, the NEC-Zero Project involves a group of healthcare professionals, researchers and parent advocates whose aim is to support clinicians to help prevent NEC. When searching for the most effective ways to prevent NEC, Dr. Gephart identified a core of potentially better evidence-based practices. Because NEC is a complex, multifactorial disease, the NEC-Zero bundle is an evidence-based intervention that emphasizes:

• Early use of mother’s milk and colostrum for oral care
• Preferential use of human milk
• Unit-adopted feeding guidelines to guide feeding decisions
• Minimizing the unnecessary use of antibiotics early in life
• Avoiding antacids
• Adopting a structured score for recognizing NEC risk, like the one Dr. Gephart developed called GutCheck^NEC.

Dr. Vartanian reporting to the NEC Symposium about the NEC Prevention Checklist

After publishing their findings, the NEC-Zero team recognized the need to make consistent and simple the delivery of prevention strategies. With help from the NEC Society and Dr. Rebecca Vartanian, Neonatologist and Assistant Professor at the University of Michigan, a customizable checklist was created outlining the specifics of NEC detection and prevention. This checklist provides clinicians with a framework to help support consistency for adhering to clinical recommendations. The various components of the checklist help to promote teamwork and communication between the care team, while easily displaying the critical steps needed. In April 2017, the checklist was presented to a group of clinicians and NEC researchers at North America’s first NEC Symposium, made possible through a partnership between the NEC Society and UC Davis Division of Neonatology, with support from the Patient-Centered Outcomes Research Institute (PCORI).

Discussion during the NEC Symposium about NEC Prevention Checklists

The Avoiding NEC Checklist was designed to be inclusive of everyone involved in the care of medically fragile infants. To effectively implement these NEC prevention strategies, multidisciplinary care teams must work together. The first part of the checklist is center-specific, while the second is geared toward bedside protocols. It is fully customizable to an individual NICU’s protocols and was modeled after the Surgical Safety Checklist. While the checklist is intended for use by medical professionals, it integrates the essential need for parental involvement in an infant’s care by empowering parents with information about NEC. The Avoiding NEC Checklist recognizes parents as a critical part of the care team and helps to ensure their voices are heard. At different stages in completing the checklist, parents are encouraged to participate in rounds. One reason the checklist prioritizes parent involvement is because they found that parents are not typically told about NEC until it is too late.

Caroline Porter presenting her poster at the University of Arizona about the NEC-Zero Project

Dr. Gephart and the NEC-Zero Project hope that this checklist will soon be incorporated into NICUs everywhere. In spring 2018 they conducted a series of webinars sponsored by the Pacific Southwest Region of the National Network of Libraries of Medicine to share the NEC-Zero toolkit, including the checklist, with NICUs and parent advocacy groups. The tools (risk score, structured communication tool, checklist, parent brochures, website resources, technology-based clinical decision support tools) were developed to make NEC prevention simpler, more integrated, and widely accessible. Through increased teamwork, potentially better practice adherence, and parent involvement we can work to prevent NEC.

About the Author: Caroline Porter, RN, BSN worked on the NEC-Zero project as an undergraduate nursing student. Communication about the checklist can be sent to Dr. Sheila Gephart: gepharts@email.arizona.edu.

Acknowledgements: Dr. Sheila Gephart, Mr. Francesco Nunez, and Ms. Christina Wyles reviewed and contributed to this blog post. Dr. Rebecca Vartanian, Erin Umberger and Jennifer Canvasser supported the presentation of the checklist at the NEC Symposium in Davis, California in April 2017. We thank the generous support of the Robert Wood Johnson Foundation Nurse Faculty Scholars Program (72114), the Agency for Healthcare Research and Quality (K08HS022908), and the Pacific Southwest Region of the National Network of Libraries of Medicine for supporting this work. These views do not necessarily represent those of any of the funding agencies.