Increasing the follow-up rate of preterm infants after discharge: a quality improvement project in a Chinese neonatal clinic

Increasing the follow-up rate of preterm infants after discharge: a quality improvement project in a Chinese neonatal clinic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Increasing the follow-up rate of preterm infants after discharge: a quality improvement project in a Chinese neonatal clinic Hesheng Chang, Xuanguang Qin, Xue Yang, Ying Wen, Xiaoyan Fu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2341722/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Adopting the methodology of quality improvement (QI) to explore the multiple interventions to increasing the follow-up rate of preterm infants and evaluate the effect of these QI interventions. Methods The quality improvement method based on statistical process control was used in this project. The baseline was measured per week from March to May 2017 according to the follow-up rate of preterm infants before the interventions, further, the specific aim of improvement was determined. The Pareto analysis of follow-up failure and the key driving diagram was constructed. The intervention measures were synchronized to monitor the change of weekly follow-up rate through the control chart until the QI goal was achieved. Results The baseline of follow-up rate was 57.92%, and the aim of the QI project was to increase the follow-up rate to 80% within 12 months. Major interventions included optimizing follow-up platform, strengthening family follow-up education and improving follow-up clinic service ability. The control chart showed that the follow-up rate increased to 74.09% in July 2017 and to 83.09% in December 2017 with a series of interventions and achieved the aim of QI. This improvement had been sustained for 6 months. Conclusion Our QI project increased the follow-up rate of preterm infants significantly. Interventions according to analysis of follow-up failure, such as strengthening family follow-up education and improving follow-up clinic service ability, could improve follow-up of preterm infants. preterm infants1 follow-up2 quality improvement3 patient discharge4 statistical process control5 Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The medical care of preterm infants is a long-term and continuous process, especially focusing on those who need to continue treatment, observe the curative effect, or monitor the sequelae 「 1 」 . Follow-up of preterm infants means that preterm infants return to the clinic regularly for examination, evaluation and treatment after discharge. Many studies had proven that the follow-up of preterm infants could reduce the cognitive and motor adverse outcomes in infancy, promote the physical growth and neurodevelopment after discharge 「 2 – 4 」 , and ensure the prognosis of high-risk groups of retinopathy of prematurity 「 5 」 . Therefore, all preterm infants need regular follow-up. Unfortunately, Neonatal follow-up clinics all over the world are facing the challenge of high proportion of lost visits in the group of preterm infants after discharge. A survey in Australia showed that the follow-up rate of preterm infants was only 50%, and many families of preterm infants cannot be contacted after discharge 「 6 」 . There is a 62% loss of follow-up over 2 years in a level IV neonatal intensive care unit in the United States, social disparities negatively impacted clinic attendance of neonates born at 26–32 weeks gestation 「 7 」 . The situation is similar in China, a study by Peking University showed that only 23.8% of families of preterm infants had good follow-up compliance 「 8 」 . Increasing the follow-up rate of preterm infants involves many links such as society, hospitals and families, which is difficult to improve 「 7 」 . Using one single improvement measure in a certain link may have limited effect on the follow-up rate of preterm infants. Our quality improvement (QI) project applied the method recommended by the American Academy of Pediatrics 「 9 」 , which was to verify whether the follow-up rate had been significantly increased after a series of improvement interventions conducted. Our overall objective of this project was to strengthen the standardized management of follow-up of preterm infants. Our specific objective was to increase the follow-up rate of preterm infants in our clinic. Methods 1. Context Beijing Chaoyang Hospital is a general hospital, there is a 20-bed neonatal intensive care unit in Department of Pediatrics, which is also the transfer center for critical newborns in eastern Beijing, China. Our neonatal follow-up clinic provides medical services for hundreds person-time of preterm infants after discharge every year. 2. Study Team Our follow-up and QI team was established including pediatricians, otolaryngologists, dermatologists, ultrasound doctors, and pediatric nurses. 3. Study Population Preterm infants, who were born at Beijing Chaoyang Hospital, needed to be followed up at the same hospital during March 2017- December 2017 qualified for this QI study. Infants who dead or were transferred to other hospitals before discharge were excluded. 4. Measures In our clinic, according to the national follow-up management guidelines for preterm infants, the first follow-up for both high-risk and low-risk preterm infants is carried out within 1 month after discharge, then high-risk preterm infants should be followed up every month, and low-risk preterm infants be followed up every two months. We took all the follow-up into account as person time. One preterm infants should be followed up repeatedly at different time points, and also take into account repeatedly. The primary measure of our QI project was the follow-up rate of preterm infants every week, which was calculated as: actual number of preterm infants follow-up per week/ number of preterm infants who should be followed up this week. Mark every week follow-up rate as a data point in the control chart. After more than 12 data points, calculate the average follow-up rate, which is the baseline before QI. We set our SMART Aim as increasing follow-up rate of preterm infants from baseline to 80% within 12 months. 5. Interventions In order to explore the reasons for breaking appointment behaviors, Pareto analysis was made through telephone inquiries or face to face investigations. (Those who have been lost for more than 3 months communicated by telephone and asked the main reasons affecting the follow-up; Families who returned to the hospital within 3 months after the loss of follow-up were asked face-to-face about the main reasons for the loss of follow-up). The top three causes of loss of follow-up were analyzed, which involved families of premature infants, doctors and follow-up platform. Key driver diagram (KDD) is subsequently developed to prioritize interventions for improvement according to the main causes of follow-up loss. Key drivers focused on three main aspects: optimizing follow-up platform; strengthening follow-up education; and improving follow-up team (Fig. 1). After discussion and preparation by the QI team, the first intervention was initiated in June 2017. Specific interventions were identified and tested with Plan Do Study Action (PDSA) cycles guided by KDD (Table 1 ). Weekly outcome data and processes were shared at monthly meetings. Intervention description Intervention start time Table 1 description and timing of interventions Establish the follow-up files and standardize the follow-up time June 2017 Improve the follow-up appointment system July 2017 Build a WeChat fllow-up platform to provide full-time consultation and guidance September 2017 Pediatrics official account science popularization, follow-up publicity and education and other channels to improve parents' awareness of follow-up October 2017 Carry out multidisciplinary clinics (Dermatology, ultrasound, otolaryngology) December 2017 Increase the follow-up expert clinic to realize the "three-level" diagnosis and treatment of follow-up February 2018 Set up full-time follow-up personnel and carry out a series of professional and technical training March 2018 5.1 Optimizing follow-up platform From June 2017, we established follow-up files of preterm infants and strictly implemented the time points of follow-up. From July 2017, we improved the in-hospital follow-up appointment system and opened the follow-up registration channel for preterm infants on the Jingyitong network platform, which was a social app can be used on smart phone for registration. During the QI program quality control meetings were hold regularly, and training of follow-up guidelines of preterm infants were conducted for all the doctors rotating in NICU and outpatient clinic. 5.2 Strengthening follow-up education From September 2017, we strengthened the follow-up education of preterm infants in various ways. A Carry out intrauterine consultation and follow-up education for pregnant women. B Strengthen follow-up education in the transition ward before discharge. C Establish a WeChat group for parents of preterm infants, whose babies needing to be followed up, to carry out medical education and follow-up reminder. From October 2017, follow-up clinic regularly released concerned medical knowledge among parents through WeChat official account. 5.3 Improving follow-up clinic service ability From December 2017, a multidisciplinary follow-up team including neonatologist, Otolaryngologist, Ophthalmologist, dermatologists, Ultrasound physician, and professional nurses was established to carry out medical services for preterm infants. Professional nurses were arranged in clinics to making appointment and reminding the follow-up of preterm infants. From February 2018, a "three-level" diagnosis and treatment follow-up team has been established, and full-time follow-up personnel have been fixed. A follow-up team with different seniority was established including professors and associate professors, attending doctors, and residents, and preterm infants follow-up appointments were arranged to doctors with different seniority according to their gestational age, birth body weight and complications. And also a specially assigned doctor was responsible for the follow-up of preterm infants. From March 2018, follow-up content and technological process were standardized, and training of standardized follow-up process was conducted regularly. 6. Analysis For the primary outcome, baseline median and control limits were calculated and displayed for the period from March 2017 to May 2017. The baseline mean was carried forward and displayed throughout the intervention period from May 2017 to May 2018. Data values were added weekly and monitored for evidence of significant change by using standard SPC rules, including the presence of (1) 1 point outside the upper or lower control limits, (2) 2 of 3 successive points in the outer third of the control limit, (3) 8 successive points above or below the center line, or (4) 6 consecutive points increasing or decreasing 「 10 」 . Results 1. Baseline data From March 5, 2017 to May 28, 2017, follow-up rate of preterm infants was calculate every week, and 13 data points were recorded, the average follow-up rate was 57.92% (Fig. 2 ). 2. Pareto of failures analysis The Pareto chart contained survey data from 92 families of preterm infants: These statistics showed that 77.1% of lost visits was caused by the three reasons: A. defective follow-up management and non-standard setting of follow-up time points; B. inadequate follow-up education and poor communication; C. medical services of follow-up clinic could not meet the needs of families of preterm infants (Fig. 3). While implementation of interventions, the P control chart was used to monitor the weekly follow-up rate. Since the 17th data point, which was after June 25, 2017, the follow-up rate of preterm infants was higher than the baseline, and there were more than 8 data points continuously higher than the baseline, which showed statistical significance. The follow-up rate increased significantly from the baseline level to the new mean value of 74.09% and remained stable. Since the 39th data point, that was November 26, 2017, the follow-up rate had been higher than 74.09% for 8 consecutive data points, indicating that the follow-up rate had further increased to 83.09%, which showed statistical significance. It is suggested that a series of interventions in this study had achieved the QI goal of more than 80% follow-up rate within 12 months. (Fig. 4 ) Discussion Undoubtedly, follow-up of preterm infants is necessary and important, which can be continuous therapy after discharge, help monitor the growth and development of preterm infants, and detecting diseases and sequelae early, but conducting the follow-up maybe difficult and facing different challenge. Generally the three links affecting follow-up of preterm infants are doctors conducting the follow-up, follow-up appointment and arrangement, and compliance of parents of preterm infants. So the key interventions of our QI project are improving follow-up clinic service ability, optimizing follow-up platform, and strengthening follow-up education. The construction of follow-up platform is the primary condition to ensure the follow-up rate. Both the management of files and the implementation of standardized plan are necessary. All preterm infants from discharge to 36 months old were included in the follow-up system. According to gestational age, birth weight and complications of preterm infants, they were assigned as low-risk and high-risk groups, we established personal follow-up files and formulated standardized and individualized follow-up plans at the first follow-up visit of preterm infants. By improving the in-hospital and online follow-up appointment system, parents of preterm infants know when they should take their babies for follow-up and how they could make the appointment for follow-up, and the continuity of follow-up is fully guaranteed. Strengthening the capacity-building of follow-up team is the technical support. Preterm infants face many problems after discharge, such as nutritional guidance, neurodevelopmental evaluation, disease rehabilitation, and even family factors. Pediatricians, together with ultrasound doctors, dermatologists, otolaryngologists and professional nurses, carry out joint clinics for premature infants and implement graded treatment, to realize professional complementarity and improve the follow-up efficiency. On this basis, technical training is provided to full-time follow-up doctors to improve their medical services. Good experiences of follow-up, which giving parents guide for feeding, growth monitoring, diseases detecting, et al, will increase the willingness of parents of preterm infants to follow up. Carrying out follow-up education is an important way to improve follow-up compliance. The education runs through the whole period from pregnancy, hospitalization, before discharge and after discharge. First, pregnant women are prepared for possible premature delivery and follow-up after discharge through intrauterine consultation and pregnant women's school, which plays a key role in building follow-up trust. Second, parents of preterm infants in the transition ward before discharge were educated about the detailed follow-up plan. Third, to facilitate communication between doctors and patients outside the hospital, our follow-up clinic provides consultation and guidance through the WeChat platform, as well as education and reminders. Finally, by using the pediatric official account to set up a column and release follow-up propaganda and education articles, parents can obtain nursing knowledge of preterm infants and improve their follow-up awareness. In recent years, QI method has been widely used in medical institutions around the world to solve clinical practice problems 「 11 – 14 」 . By formulating quantifiable specific objectives, the interventions can be gradually implemented on the basis of the operation of the system, and the change of data can be displayed by control chart to evaluate the effect until the QI goal is achieved. This QI project increased the follow-up rate of preterm infants after discharge effectively, indicated we can implement different improving interventions according different problems at different links to achieve the same SMART aim. This project is a single center study, affected by the actual environment and other factors, the QI measures and interventions have certain limitations. But it can be a reminder we always can do better than what we are doing now. Some of our interventions maybe not suitable for other hospitals, but can be a reference. In the future, it is expected that best practices from multiple centers will improve the follow-up management quality of preterm infants. Declarations Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest . Author Contributions Hesheng Chang involved in the project design, data collection, data analysis and drafting this manuscript. Xuanguang Qin involved in optimizing follow-up platform. Xue Yang involved in strengthening follow-up education. Ying Wen involved clinical support. Xiaoyan Fu and Shuxia Huang assisted with improving follow-up clinic service ability. Zhenghong Li involved in the project design, assisted with data analysis and revision of the manuscript. Funding Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences(2019XK320026). Acknowledgments None. References Shin SH, Sohn JA, Kim EK, et al. Factors associated with the follow-up of high risk infants discharged from a neonatal intensive care unit [published online ahead of print, 2022 Mar 28]. Pediatr Neonatol. 2022;S1875-9572(22)00054-7. doi:10.1016/j.pedneo.2022.02.004 Peralta-Carcelen M, Carlo WA, Pappas A, et al. Behavioral Problems and Socioemotional Competence at 18 to 22 Months of Extremely Premature Children. Pediatrics. 2017;139(6):e20161043. doi:10.1542/peds.2016-1043 Cheong JLY, Wark JD, Cheung MM, et al. Impact of extreme prematurity or extreme low birth weight on young adult health and well-being: the Victorian Infant Collaborative Study (VICS) 1991-1992 Longitudinal Cohort study protocol. BMJ Open. 2019;9(5):e030345. Published 2019 May 9. doi:10.1136/bmjopen-2019-030345 Christmann V, van der Putten ME, Rodwell L, et al. Effect of early nutritional intake on long-term growth and bone mineralization of former very low birth weight infants. Bone. 2018;108:89-97. doi:10.1016/j.bone.2017.12.022 Ahn YJ, Hong KE, Yum HR, et al. Characteristic clinical features associated with aggressive posterior retinopathy of prematurity. Eye (Lond). 2017;31(6):924-930. doi:10.1038/eye.2017.18 L Orton J, McGinley JL, Fox LM, et al. Challenges of neurodevelopmental follow-up for extremely preterm infants at two years. Early Hum Dev. 2015 Dec;91(12):689-94. doi: 10.1016/j.earlhumdev.2015.09.012. Epub 2015 Oct 27. PMID: 26513630 Swearingen C, Simpson P, Cabacungan E, et al. Social disparities negatively impact neonatal follow-up clinic attendance of premature infants discharged from the neonatal intensive care unit. J Perinatol. 2020 May;40(5):790-797. doi: 10.1038/s41372-020-0659-4. Epub 2020 Mar 23. PMID: 32203182 Wang X, Zhou M, Zhang X, et al. Influencing factors of follow-up and early comprehensive intervention compliance among post-discharge premature infants. Chin J Publ Heal, 2019, 35(6): 712-715. doi: 10.11847/zgggws1119992 McInerny TK, Sachdeva RC. The American Academy of pediatrics and quality improvement. Acad Pediatr. 2013;13(6 Suppl):S7-S8. doi:10.1016/j.acap.2013.01.006 Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003 Dec;12(6):458-64. doi: 10.1136/qhc.12.6.458. PMID: 14645763; PMCID: PMC1758030. Ellsbury DL, Ursprung R. A primer on quality improvement methodology in neonatology. Clin Perinatol. 2010 Mar;37(1):87-99. doi: 10.1016/j.clp.2010.01.005. PMID: 20363449 Tveit JV, Saastad E, Stray-Pedersen B, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth. 2009 Jul 22;9:32. doi: 10.1186/1471-2393-9-32. Erratum in: BMC Pregnancy Childbirth. 2010;10:49. PMID: 19624847; PMCID: PMC2734741 Oshiro BT, Henry E, Wilson J, et al. Women and Newborn Clinical Integration Program. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009 Apr;113(4):804-811. doi: 10.1097/AOG.0b013e31819b5c8c. PMID: 19305323 Donovan EF, Lannon C, Bailit J, et al. Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation. Am J Obstet Gynecol. 2010 Mar;202(3):243.e1-8. doi: 10.1016/j.ajog.2010.01.044. Erratum in: Am J Obstet Gynecol. 2010 Jun;202(6):603. PMID: 20207241 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2341722","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":157471217,"identity":"0bb5b8d3-5a64-4252-9bd2-88ccdf10b726","order_by":0,"name":"Hesheng Chang","email":"","orcid":"","institution":"Department of Pediatrics, Beijing Chaoyang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hesheng","middleName":"","lastName":"Chang","suffix":""},{"id":157471220,"identity":"f17eb939-486d-4264-99a5-8f2fb1e0c97a","order_by":1,"name":"Xuanguang Qin","email":"","orcid":"","institution":"Department 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2","display":"","copyAsset":false,"role":"figure","size":98107,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBaseline data of follow-up rate of preterm infants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-2341722/v1/a748fedb221172cd1a616153.png"},{"id":30017519,"identity":"8ddff33b-cd4d-4ed6-bbd1-a665ec64303f","added_by":"auto","created_at":"2022-12-07 15:55:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115888,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePareto chart for loss of follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. defective follow-up management and non-standard setting of follow-up time points\u003c/p\u003e\n\u003cp\u003eB. inadequate follow-up education and poor communication\u003c/p\u003e\n\u003cp\u003eC. medical services of follow-up clinic could not meet the needs of families of preterm infants\u003c/p\u003e\n\u003cp\u003eD. worry about distance and nosocomial infection, refuse to come to the hospital\u003c/p\u003e\n\u003cp\u003eE. the number of follow-up clinic registration is insufficient, and the appointment registration channel is unclear\u003c/p\u003e\n\u003cp\u003eF. other reasons (delayed for some reason, transfer to community follow-up, etc.)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-2341722/v1/e1e65ad48a241440729c8c7e.png"},{"id":30018503,"identity":"fbdb70cc-b3a2-4af6-8198-44ba4e5ea32a","added_by":"auto","created_at":"2022-12-07 16:03:32","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":225674,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ethe P control chart of follow-up rate of preterm 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observe the curative effect, or monitor the sequelae\u003csup\u003e「\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e」\u003c/sup\u003e. Follow-up of preterm infants means that preterm infants return to the clinic regularly for examination, evaluation and treatment after discharge. Many studies had proven that the follow-up of preterm infants could reduce the cognitive and motor adverse outcomes in infancy, promote the physical growth and neurodevelopment after discharge\u003csup\u003e「\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e」\u003c/sup\u003e, and ensure the prognosis of high-risk groups of retinopathy of prematurity\u003csup\u003e「\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e」\u003c/sup\u003e. Therefore, all preterm infants need regular follow-up.\u003c/p\u003e \u003cp\u003eUnfortunately, Neonatal follow-up clinics all over the world are facing the challenge of high proportion of lost visits in the group of preterm infants after discharge. A survey in Australia showed that the follow-up rate of preterm infants was only 50%, and many families of preterm infants cannot be contacted after discharge\u003csup\u003e「\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e」\u003c/sup\u003e. There is a 62% loss of follow-up over 2 years in a level IV neonatal intensive care unit in the United States, social disparities negatively impacted clinic attendance of neonates born at 26\u0026ndash;32 weeks gestation\u003csup\u003e「\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e」\u003c/sup\u003e. The situation is similar in China, a study by Peking University showed that only 23.8% of families of preterm infants had good follow-up compliance\u003csup\u003e「\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e」\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIncreasing the follow-up rate of preterm infants involves many links such as society, hospitals and families, which is difficult to improve\u003csup\u003e「\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e」\u003c/sup\u003e. Using one single improvement measure in a certain link may have limited effect on the follow-up rate of preterm infants. Our quality improvement (QI) project applied the method recommended by the American Academy of Pediatrics\u003csup\u003e「\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e」\u003c/sup\u003e, which was to verify whether the follow-up rate had been significantly increased after a series of improvement interventions conducted. Our overall objective of this project was to strengthen the standardized management of follow-up of preterm infants. Our specific objective was to increase the follow-up rate of preterm infants in our clinic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e1. Context\u003c/p\u003e\n\u003cp\u003eBeijing Chaoyang Hospital is a general hospital, there is a 20-bed neonatal intensive care unit in Department of Pediatrics, which is also the transfer center for critical newborns in eastern Beijing, China. Our neonatal follow-up clinic provides medical services for hundreds person-time of preterm infants after discharge every year.\u003c/p\u003e\n\u003cp\u003e2. Study Team\u003c/p\u003e\n\u003cp\u003eOur follow-up and QI team was established including pediatricians, otolaryngologists, dermatologists, ultrasound doctors, and pediatric nurses.\u003c/p\u003e\n\u003cp\u003e3. Study Population\u003c/p\u003e\n\u003cp\u003ePreterm infants, who were born at Beijing Chaoyang Hospital, needed to be followed up at the same hospital during March 2017- December 2017 qualified for this QI study. Infants who dead or were transferred to other hospitals before discharge were excluded.\u003c/p\u003e\n\u003cp\u003e4. Measures\u003c/p\u003e\n\u003cp\u003eIn our clinic, according to the national follow-up management guidelines for preterm infants, the first follow-up for both high-risk and low-risk preterm infants is carried out within 1 month after discharge, then high-risk preterm infants should be followed up every month, and low-risk preterm infants be followed up every two months. We took all the follow-up into account as person time. One preterm infants should be followed up repeatedly at different time points, and also take into account repeatedly. The primary measure of our QI project was the follow-up rate of preterm infants every week, which was calculated as: actual number of preterm infants follow-up per week/ number of preterm infants who should be followed up this week. Mark every week follow-up rate as a data point in the control chart. After more than 12 data points, calculate the average follow-up rate, which is the baseline before QI. We set our SMART Aim as increasing follow-up rate of preterm infants from baseline to 80% within 12 months.\u003c/p\u003e\n\u003cp\u003e5. Interventions\u003c/p\u003e\n\u003cp\u003eIn order to explore the reasons for breaking appointment behaviors, Pareto analysis was made through telephone inquiries or face to face investigations. (Those who have been lost for more than 3 months communicated by telephone and asked the main reasons affecting the follow-up; Families who returned to the hospital within 3 months after the loss of follow-up were asked face-to-face about the main reasons for the loss of follow-up). The top three causes of loss of follow-up were analyzed, which involved families of premature infants, doctors and follow-up platform. Key driver diagram (KDD) is subsequently developed to prioritize interventions for improvement according to the main causes of follow-up loss. Key drivers focused on three main aspects: optimizing follow-up platform; strengthening follow-up education; and improving follow-up team (Fig. 1). After discussion and preparation by the QI team, the first intervention was initiated in June 2017. Specific interventions were identified and tested with Plan Do Study Action (PDSA) cycles guided by KDD (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Weekly outcome data and processes were shared at monthly meetings.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention description\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention start time\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003edescription and timing of interventions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstablish the follow-up files and standardize the follow-up time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJune 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImprove the follow-up appointment system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJuly 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBuild a WeChat fllow-up platform to provide full-time consultation and guidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeptember 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatrics official account science popularization, follow-up publicity and education and other channels to improve parents\u0026apos; awareness of follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOctober 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCarry out multidisciplinary clinics (Dermatology, ultrasound, otolaryngology)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecember 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease the follow-up expert clinic to realize the \u0026quot;three-level\u0026quot; diagnosis and treatment of follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFebruary 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSet up full-time follow-up personnel and carry out a series of professional and technical training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarch 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e5.1 Optimizing follow-up platform\u003c/p\u003e\n\u003cp\u003eFrom June 2017, we established follow-up files of preterm infants and strictly implemented the time points of follow-up.\u003c/p\u003e\n\u003cp\u003eFrom July 2017, we improved the in-hospital follow-up appointment system and opened the follow-up registration channel for preterm infants on the Jingyitong network platform, which was a social app can be used on smart phone for registration.\u003c/p\u003e\n\u003cp\u003eDuring the QI program quality control meetings were hold regularly, and training of follow-up guidelines of preterm infants were conducted for all the doctors rotating in NICU and outpatient clinic.\u003c/p\u003e\n\u003cp\u003e5.2 Strengthening follow-up education\u003c/p\u003e\n\u003cp\u003eFrom September 2017, we strengthened the follow-up education of preterm infants in various ways.\u003c/p\u003e\n\u003cp\u003eA Carry out intrauterine consultation and follow-up education for pregnant women.\u003c/p\u003e\n\u003cp\u003eB Strengthen follow-up education in the transition ward before discharge.\u003c/p\u003e\n\u003cp\u003eC Establish a WeChat group for parents of preterm infants, whose babies needing to be followed up, to carry out medical education and follow-up reminder.\u003c/p\u003e\n\u003cp\u003eFrom October 2017, follow-up clinic regularly released concerned medical knowledge among parents through WeChat official account.\u003c/p\u003e\n\u003cp\u003e5.3 Improving follow-up clinic service ability\u003c/p\u003e\n\u003cp\u003eFrom December 2017, a multidisciplinary follow-up team including neonatologist, Otolaryngologist, Ophthalmologist, dermatologists, Ultrasound physician, and professional nurses was established to carry out medical services for preterm infants.\u003c/p\u003e\n\u003cp\u003eProfessional nurses were arranged in clinics to making appointment and reminding the follow-up of preterm infants.\u003c/p\u003e\n\u003cp\u003eFrom February 2018, a \u0026quot;three-level\u0026quot; diagnosis and treatment follow-up team has been established, and full-time follow-up personnel have been fixed. A follow-up team with different seniority was established including professors and associate professors, attending doctors, and residents, and preterm infants follow-up appointments were arranged to doctors with different seniority according to their gestational age, birth body weight and complications. And also a specially assigned doctor was responsible for the follow-up of preterm infants.\u003c/p\u003e\n\u003cp\u003eFrom March 2018, follow-up content and technological process were standardized, and training of standardized follow-up process was conducted regularly.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e6. Analysis\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eFor the primary outcome, baseline median and control limits were calculated and displayed for the period from March 2017 to May 2017. The baseline mean was carried forward and displayed throughout the intervention period from May 2017 to May 2018. Data values were added weekly and monitored for evidence of significant change by using standard SPC rules, including the presence of (1) 1 point outside the upper or lower control limits, (2) 2 of 3 successive points in the outer third of the control limit, (3) 8 successive points above or below the center line, or (4) 6 consecutive points increasing or decreasing\u003csup\u003e「\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e」\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1. Baseline data\u003c/p\u003e\n\u003cp\u003eFrom March 5, 2017 to May 28, 2017, follow-up rate of preterm infants was calculate every week, and 13 data points were recorded, the average follow-up rate was 57.92% (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"text-align: inherit;\"\u003e2. Pareto of failures analysis\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThe Pareto chart contained survey data from 92 families of preterm infants: These statistics showed that 77.1% of lost visits was caused by the three reasons: A. defective follow-up management and non-standard setting of follow-up time points; B. inadequate follow-up education and poor communication; C. medical services of follow-up clinic could not meet the needs of families of preterm infants (Fig. 3).\u003c/p\u003e\n\u003cp\u003eWhile implementation of interventions, the P control chart was used to monitor the weekly follow-up rate. Since the 17th data point, which was after June 25, 2017, the follow-up rate of preterm infants was higher than the baseline, and there were more than 8 data points continuously higher than the baseline, which showed statistical significance. The follow-up rate increased significantly from the baseline level to the new mean value of 74.09% and remained stable. Since the 39th data point, that was November 26, 2017, the follow-up rate had been higher than 74.09% for 8 consecutive data points, indicating that the follow-up rate had further increased to 83.09%, which showed statistical significance. It is suggested that a series of interventions in this study had achieved the QI goal of more than 80% follow-up rate within 12 months. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUndoubtedly, follow-up of preterm infants is necessary and important, which can be continuous therapy after discharge, help monitor the growth and development of preterm infants, and detecting diseases and sequelae early, but conducting the follow-up maybe difficult and facing different challenge. Generally the three links affecting follow-up of preterm infants are doctors conducting the follow-up, follow-up appointment and arrangement, and compliance of parents of preterm infants. So the key interventions of our QI project are improving follow-up clinic service ability, optimizing follow-up platform, and strengthening follow-up education.\u003c/p\u003e \u003cp\u003eThe construction of follow-up platform is the primary condition to ensure the follow-up rate. Both the management of files and the implementation of standardized plan are necessary. All preterm infants from discharge to 36 months old were included in the follow-up system. According to gestational age, birth weight and complications of preterm infants, they were assigned as low-risk and high-risk groups, we established personal follow-up files and formulated standardized and individualized follow-up plans at the first follow-up visit of preterm infants. By improving the in-hospital and online follow-up appointment system, parents of preterm infants know when they should take their babies for follow-up and how they could make the appointment for follow-up, and the continuity of follow-up is fully guaranteed.\u003c/p\u003e \u003cp\u003eStrengthening the capacity-building of follow-up team is the technical support. Preterm infants face many problems after discharge, such as nutritional guidance, neurodevelopmental evaluation, disease rehabilitation, and even family factors. Pediatricians, together with ultrasound doctors, dermatologists, otolaryngologists and professional nurses, carry out joint clinics for premature infants and implement graded treatment, to realize professional complementarity and improve the follow-up efficiency. On this basis, technical training is provided to full-time follow-up doctors to improve their medical services. Good experiences of follow-up, which giving parents guide for feeding, growth monitoring, diseases detecting, et al, will increase the willingness of parents of preterm infants to follow up.\u003c/p\u003e \u003cp\u003eCarrying out follow-up education is an important way to improve follow-up compliance. The education runs through the whole period from pregnancy, hospitalization, before discharge and after discharge. First, pregnant women are prepared for possible premature delivery and follow-up after discharge through intrauterine consultation and pregnant women's school, which plays a key role in building follow-up trust. Second, parents of preterm infants in the transition ward before discharge were educated about the detailed follow-up plan. Third, to facilitate communication between doctors and patients outside the hospital, our follow-up clinic provides consultation and guidance through the WeChat platform, as well as education and reminders. Finally, by using the pediatric official account to set up a column and release follow-up propaganda and education articles, parents can obtain nursing knowledge of preterm infants and improve their follow-up awareness.\u003c/p\u003e \u003cp\u003eIn recent years, QI method has been widely used in medical institutions around the world to solve clinical practice problems\u003csup\u003e「\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e」\u003c/sup\u003e. By formulating quantifiable specific objectives, the interventions can be gradually implemented on the basis of the operation of the system, and the change of data can be displayed by control chart to evaluate the effect until the QI goal is achieved. This QI project increased the follow-up rate of preterm infants after discharge effectively, indicated we can implement different improving interventions according different problems at different links to achieve the same SMART aim.\u003c/p\u003e \u003cp\u003eThis project is a single center study, affected by the actual environment and other factors, the QI measures and interventions have certain limitations. But it can be a reminder we always can do better than what we are doing now. Some of our interventions maybe not suitable for other hospitals, but can be a reference. In the future, it is expected that best practices from multiple centers will improve the follow-up management quality of preterm infants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of Interest\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eHesheng Chang involved in the project design, data collection, data analysis and drafting this manuscript. Xuanguang Qin involved in optimizing follow-up platform. Xue Yang involved in strengthening follow-up education. Ying Wen involved clinical support. Xiaoyan Fu and Shuxia Huang assisted with improving follow-up clinic service ability. Zhenghong Li involved in the project design, assisted with data analysis and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNon-profit Central Research Institute Fund of Chinese Academy of Medical Sciences(2019XK320026).\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eNone. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShin SH, Sohn JA, Kim EK, et al. Factors associated with the follow-up of high risk infants discharged from a neonatal intensive care unit [published online ahead of print, 2022 Mar 28]. Pediatr Neonatol. 2022;S1875-9572(22)00054-7. doi:10.1016/j.pedneo.2022.02.004\u003c/li\u003e\n\u003cli\u003ePeralta-Carcelen M, Carlo WA, Pappas A, et al. Behavioral Problems and Socioemotional Competence at 18 to 22 Months of Extremely Premature Children. Pediatrics. 2017;139(6):e20161043. doi:10.1542/peds.2016-1043\u003c/li\u003e\n\u003cli\u003eCheong JLY, Wark JD, Cheung MM, et al. Impact of extreme prematurity or extreme low birth weight on young adult health and well-being: the Victorian Infant Collaborative Study (VICS) 1991-1992 Longitudinal Cohort study protocol. BMJ Open. 2019;9(5):e030345. Published 2019 May 9. doi:10.1136/bmjopen-2019-030345\u003c/li\u003e\n\u003cli\u003eChristmann V, van der Putten ME, Rodwell L, et al. Effect of early nutritional intake on long-term growth and bone mineralization of former very low birth weight infants. Bone. 2018;108:89-97. doi:10.1016/j.bone.2017.12.022\u003c/li\u003e\n\u003cli\u003eAhn YJ, Hong KE, Yum HR, et al. Characteristic clinical features associated with aggressive posterior retinopathy of prematurity. Eye (Lond). 2017;31(6):924-930. doi:10.1038/eye.2017.18\u003c/li\u003e\n\u003cli\u003eL Orton J, McGinley JL, Fox LM, et al. Challenges of neurodevelopmental follow-up for extremely preterm infants at two years. Early Hum Dev. 2015 Dec;91(12):689-94. doi: 10.1016/j.earlhumdev.2015.09.012. Epub 2015 Oct 27. PMID: 26513630\u003c/li\u003e\n\u003cli\u003eSwearingen C, Simpson P, Cabacungan E, et al. Social disparities negatively impact neonatal follow-up clinic attendance of premature infants discharged from the neonatal intensive care unit. J Perinatol. 2020 May;40(5):790-797. doi: 10.1038/s41372-020-0659-4. Epub 2020 Mar 23. PMID: 32203182\u003c/li\u003e\n\u003cli\u003eWang X, Zhou M, Zhang X, et al. Influencing factors of follow-up and early comprehensive intervention compliance among post-discharge premature infants. Chin J Publ Heal, 2019, 35(6): 712-715. doi: 10.11847/zgggws1119992\u003c/li\u003e\n\u003cli\u003eMcInerny TK, Sachdeva RC. The American Academy of pediatrics and quality improvement. Acad Pediatr. 2013;13(6 Suppl):S7-S8. doi:10.1016/j.acap.2013.01.006\u003c/li\u003e\n\u003cli\u003eBenneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003 Dec;12(6):458-64. doi: 10.1136/qhc.12.6.458. PMID: 14645763; PMCID: PMC1758030.\u003c/li\u003e\n\u003cli\u003eEllsbury DL, Ursprung R. A primer on quality improvement methodology in neonatology. Clin Perinatol. 2010 Mar;37(1):87-99. doi: 10.1016/j.clp.2010.01.005. PMID: 20363449\u003c/li\u003e\n\u003cli\u003eTveit JV, Saastad E, Stray-Pedersen B, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth. 2009 Jul 22;9:32. doi: 10.1186/1471-2393-9-32. Erratum in: BMC Pregnancy Childbirth. 2010;10:49. PMID: 19624847; PMCID: PMC2734741\u003c/li\u003e\n\u003cli\u003eOshiro BT, Henry E, Wilson J, et al. Women and Newborn Clinical Integration Program. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009 Apr;113(4):804-811. doi: 10.1097/AOG.0b013e31819b5c8c. PMID: 19305323\u003c/li\u003e\n\u003cli\u003eDonovan EF, Lannon C, Bailit J, et al. Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks\u0026apos; gestation. Am J Obstet Gynecol. 2010 Mar;202(3):243.e1-8. doi: 10.1016/j.ajog.2010.01.044. Erratum in: Am J Obstet Gynecol. 2010 Jun;202(6):603. PMID: 20207241\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"preterm infants1, follow-up2, quality improvement3, patient discharge4, statistical process control5","lastPublishedDoi":"10.21203/rs.3.rs-2341722/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2341722/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eAdopting the methodology of quality improvement (QI) to explore the multiple interventions to increasing the follow-up rate of preterm infants and evaluate the effect of these QI interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe quality improvement method based on statistical process control was used in this project. The baseline was measured per week from March to May 2017 according to the follow-up rate of preterm infants before the interventions, further, the specific aim of improvement was determined. The Pareto analysis of follow-up failure and the key driving diagram was constructed. The intervention measures were synchronized to monitor the change of weekly follow-up rate through the control chart until the QI goal was achieved.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe baseline of follow-up rate was 57.92%, and the aim of the QI project was to increase the follow-up rate to 80% within 12 months. Major interventions included optimizing follow-up platform, strengthening family follow-up education and improving follow-up clinic service ability. The control chart showed that the follow-up rate increased to 74.09% in July 2017 and to 83.09% in December 2017 with a series of interventions and achieved the aim of QI. This improvement had been sustained for 6 months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur QI project increased the follow-up rate of preterm infants significantly. Interventions according to analysis of follow-up failure, such as strengthening family follow-up education and improving follow-up clinic service ability, could improve follow-up of preterm infants.\u003c/p\u003e","manuscriptTitle":"Increasing the follow-up rate of preterm infants after discharge: a quality improvement project in a Chinese neonatal clinic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-07 15:55:27","doi":"10.21203/rs.3.rs-2341722/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94c19214-4b18-4b70-95f0-7d61fd23a747","owner":[],"postedDate":"December 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-01-04T15:44:25+00:00","versionOfRecord":[],"versionCreatedAt":"2022-12-07 15:55:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2341722","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2341722","identity":"rs-2341722","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}