title: Assessment of the severity of visible blood in the stool using a cluster of neonatal cases -a quality improvement study.
abstract: BACKGROUND
  Non-availability of an established validated tool to assess and monitor the severity of visible blood in a stool (VBS) specimen over time, prevents effective decision making about discontinuation of contact precautions and hospital discharge.
  
  
  OBJECTIVE
  To determine the impact of implementing a VBS investigation, parent apprisal template and Visible Blood in the Stool -Assessment Tool (VBS-AT) on standardized reporting and the evaluation of clinical improvement.
  
  
  METHODS
  A prospective quality improvement cohort study was conducted in a tertiary, neonatal unit. All infants with isolated VBS without clinical signs, radiological pneumatosis and abnormal laboratory results were included. The template and VBS-AT instrument were implemented at the bedside. Criteria for discontinuation of contact precautions and readiness for discharge home were defined apriori.
  
  
  RESULTS
  Eight infants developed VBS during the cluster lasting ten days. Seventy-four (78%) of the 98 episodes were graded by the VBS-AT. Five of the six infants had a maximum VBS grade of 3. The duration of VBS and contact precautions ranged from 4-38 days. All six infants with a VBS grade ≤2 for 4 consecutive days did not deteriorate beyond grade ≥3 or develop gastrointestinal complications during the ten week period following the end of the cluster. Consistent objective reporting of the severity of VBS and consistent evaluation of infants' progress over time contained the cluster effectively and facilitated discharge of stable infants.
  
  
  CONCLUSIONS
  Implementation of a tool to standardize, investigate and objectively monitor the severity of VBS is feasible and improves effectiveness of care at no extra cost.
authors.affiliation: Division of Neonatology, Department of Pediatrics, McMaster University and Children's Hospital, ON, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Department of Pediatric Medicine, Neonatology, Houston, TX, USA.
authors.forename: G S
authors.initials: GS
authors.lastname: Suresh
authors.affiliation: Division of Neonatology, Department of Pediatrics, McMaster University and Children's Hospital, ON, Canada.
authors.forename: B
authors.initials: B
authors.lastname: Paes
authors.affiliation: Division of Neonatology, Department of Pediatrics, McMaster University and Children's Hospital, ON, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Shivananda
mesh_terms: D016000:Cluster Analysis; D003661:Decision Support Techniques; D004282:Documentation; D005243:Feces; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D008297:Male; D010351:Patient Discharge; D010356:Patient Isolation; D011446:Prospective Studies; D058996:Quality Improvement; D012007:Rectum; D012720:Severity of Illness Index
keywords: Visible blood; neonates; quality improvement; stool