A Quality Improvement Study to Improve the Utilization of Occupational Therapy and Physiotherapy Services in a Level 4 Neonatal Intensive Care Unit and Neurodevelopmental Follow-Up Clinics : CHRISMED Journal of Health and Research

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A Quality Improvement Study to Improve the Utilization of Occupational Therapy and Physiotherapy Services in a Level 4 Neonatal Intensive Care Unit and Neurodevelopmental Follow-Up Clinics

Jindal, Pranay; Shah, Irfana Ajab; Mathew, Jisha Elizabeth; Kannappillil, Shihab; Sibayan, Ma Lorena Igna; Ragesh, Parvathy; Girish, Sashtha; Cabanillas, Irian Jade; Villa, Ana Princess; Rens, Matheus Franciscus Petrus Van; Alturk, Mohamed Rami; Mahmah, Mohamad Adnan; AlQuabaisi, Mai; AlMudehka, Noora Rashid1; Hussein, Alaa Al Sheikh1

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CHRISMED Journal of Health and Research 10(1):p 86-98, Jan–Mar 2023. | DOI: 10.4103/cjhr.cjhr_87_22
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Neonates admitted to the neonatal intensive care unit (NICU) are at risk of neuromotor and behavioral impairments, and therapy services can optimize their neurodevelopment. Physiotherapy (PT) and Occupational therapy (OT) services are available in the NICU of Women’s Wellness and Research Center, and as per the guidelines, physicians should refer the neonates for appropriate services. Baseline analysis of 1-month data revealed that 25%, 36%, 62%, and 10% of eligible neonates were not referred to (1) inpatient OT, (2) inpatient PT, (3) baby therapy, and (4) neonatal neurodevelopmental clinic, respectively. The study’s objective is to increase the number of babies being referred, by reducing the number of eligible neonates not being referred to 4 available therapy services to 50% of the baseline data after 1 month of implementation.


A Plan-Do-Study-Act cycle guided the interventions. The 1st phase identified stakeholders’ challenges for not referring the babies to appropriate services. Based on their feedback, the referral criteria were revised. The 2nd phase involved implementing the revised criteria. Steps included (a) stakeholders’ education on the revised criteria and making it available all the time, (b) daily triage and huddle to inform stakeholders of the needed referrals, and (c) establishing communication pathways.


Exceeding the targets, all eligible and 75% of the eligible neonates for neonatal neurodevelopmental and baby therapy clinics, respectively, were referred. For inpatient OT and PT services, 22% (targeted 12.5%) and 20% (targeted 18%) of the eligible neonates were missed.


Within 1 month, we decreased the number of nonreferrals to all 4 therapy services. Inpatient PT and OT referrals need more focus.


Preterm babies typically need neonatal intensive care unit (NICU) care for extended periods and are at risk for a range of neurodevelopmental, sensory, and musculoskeletal impairments due to prematurity and other significant associated medical conditions.[1–3] Preterm infants are at great risk for significant short- and long-term neurodevelopmental impairments, as their brains go through a critical period of development and maturation between 24 and 40 weeks of gestation, which occurs mainly during their NICU admission.[4] Recent studies indicate that extreme, early, and late preterm infants have high mortality and morbidity compared to term infants.[5,6] In recent years, though the rates of severe cerebral palsy (CP) have decreased, mild CP and developmental coordination disorders have increased in preterm infants.[7,8] The stressful sensory environment and exposures in the NICU are prone to alter the developmental trajectories and neurobehavior of preterm neonates.[9,10] Importantly, higher quality of developmental care promotes better neurobehavioral stability.[11]

Neonates born extremely preterm show cognitive problems, executive dysfunction, depression, and anxiety, which has adverse implications on academic achievement and socioemotional well-being.[12–14] They also report having a poor health-related quality of life into adulthood.[15] Infants born very preterm and with very low birth weight are also at higher risk of neurodevelopmental disability, face challenges in behavior and socioemotional development, and have cognitive and motor delays.[8,16,17] Neonates born moderate and late preterm who constitute a significant number of preterm births are also at risk of developmental disability, school failure, speech, cognitive and developmental delay, and social and behavior problems.[17–19]

Even into adolescence and adult life, babies born preterm and with low birth weight are at a higher risk of disability, social and behavior problems, mental health and poor academic performance, and other chronic conditions in adults and adolescents.[20–22] There is a stronger association between decreasing gestational age and greater challenges in educational levels, employment, and income levels in adulthood.[23,24]

These challenges faced by preterm infants in early childhood, adolescence, and throughout adulthood warrant early screening programs and preventive strategies to be introduced early. There are many challenges faced by a preterm neonate, and a multidisciplinary team comprising neonatal therapists (physiotherapists [PT] and occupational therapists [OT]) is recommended to optimize the neurodevelopmental outcomes and mitigate the adverse effects of the NICU stay, and also during the neurodevelopmental follow-ups post-NICU discharge.[25–27] Neonatal therapy is an art and science of integrating the typical development of the infant and family into the environment of the NICU.[28]

Women’s Wellness and Research Center (WWRC) has a level 4 NICU and a nursery, where physiotherapy (PT) and occupational therapy (OT) services are available to the neonates. There are referral criteria [Appendix 1] as per which physicians should refer the eligible neonates for inpatient PT and OT consultations and to separate two neurodevelopmental follow-up clinics (baby therapy clinic and neonatal neurodevelopmental clinic) divided based on the gestational ages and severity of conditions. Despite having referral criteria, many neonates are not referred to PT and OT consultations and to neurodevelopmental follow-up clinics. Baseline analysis of 1-month data (318 babies) reveals that 25%, 36%, 62%, and 10% of eligible neonates were not referred to (1) inpatient OT, (2) inpatient PT, (3) baby therapy, and (4) neonatal neurodevelopmental clinic, respectively [Table 1].

Appendix 1:
Old physiotherapy and occupational therapy referral criteria
Table 1:
Baseline and postimplementation data of number of eligible babies not referred to the given services

Not referring the babies to the needed PT and OT services leads to manpower underutilization, delay in diagnosis and intervention in the NICU, lack of neurodevelopmental follow-up appointments, and potentially impaired patient outcomes.

In the NICU of WWRC, using developmental care principles,[29] for the referred neonates, Physiotherapists and Occupational therapists help to/in: 1) prevent osteopenia of prematurity by providing range of motion exercises. Apart from nutritional supplementation, evidence suggests that 4-8 weeks of brief, passive range of motion with gentle joint compression administered 5–15 minutes daily for infants between 26-35 weeks of gestational age improves the bone area, bone mineral content, and bone mineral density,[30–32] 2) facilitate weight gain, better neurodevelopment, decreased infection rate and length of hospital stay in an infant by massage,[33–35] 3) engage parents with their baby using Newborn Behavioral Observation (NBO) which is an evidence-based relationship-building tool.[36–39] Parent engagement in the NICU helps to decrease emotional and behavioral problems in a child’s later life, promotes weight gain and decreases infection, helps in mother-child bonding and increased parental confidence, increases breast milk supply and weight gain, promotes better tone and neurodevelopment, decreases pain, hypoglycemia hypothermia, and readmissions,[40–44] 4) improve alertness in medically stable preterm infants from 33 weeks onwards, which further enhances sucking organization, tonal maturation, feeding progression and facilitates early discharge by using Auditory, Tactile, Visual and Vestibular (ATVV) stimulation,[45–48] 5) assist musculoskeletal maturation process and prevent musculoskeletal complications by providing appropriate positioning and discharge teachings,[3] 6) successfully and safely feed the baby orally by enhancing oromotor skills using oral stimulation program, pacing, and non-nutritive sucking, and reading feeding readiness cues.[49–51] Incorporating these techniques ensures gradual feeding progression for neonates, easy transition to oral feeds, shortens hospital stay and the duration of parenteral nutrition in the NICU,[50,52,53] 7) early detection of cerebral palsy using Prechtl’s assessment of general movements, and initiate early intervention if needed (by mimicking the normal pattern of movements),[54,55] 8) providing developmentally appropriate and supportive positioning which enhances sleep, promotes early midline, decreases fuzziness and motor asymmetry.[56–58]

In addition, for neonates referred to therapy services, PT and OT educate and inform parents on the range of functional exercises and techniques to achieve independent safe oral feeding, massage, swaddling, positioning, plagiocephaly prevention, and tummy time for their babies upon discharge. These efforts help foster family-centered care, which benefits parents and their babies in the NICU.[59] Recent research indicates that intervention provided to the babies in the NICU via therapists and parents improved motor, cognitive, and developmental outcomes.[26]

Currently, there is no standard practice for follow-up of preterm neonates and practices vary among countries and centers.[60] However, standardized, early assessment and intervention and longer, comprehensive follow-ups by a multidisciplinary allied health-care team are recommended to improve neurodevelopmental outcomes.[25,27,61,62] Most studies follow up preterm neonates till 3 years of age with the focus to identify neurodevelopmental impairment in the early years of life. These early assessments do not always correlate with long-term outcomes and may not correctly estimate functional concerns in later life.[62] Thus, standardized, longer, and comprehensive follow-ups are recommended, given the complexity of premature birth.[5,62]

Upon discharge, in the WWRC, according to a set of criteria [Appendix 1], physicians need to refer preterm babies to two distinct neurodevelopmental follow-up clinics with separate criteria (neonatal neurodevelopmental clinic and baby therapy clinic). In these clinics, PT and OT assess these babies at different time points and early intervention services are provided if needed. Early developmental interventions postdischarge prevent motor and cognitive impairment in preterm babies.[61]

This quality improvement study aims to ensure that all babies who fit within the referral criteria are referred to PT and OT inpatient services and to neurodevelopmental follow-up clinics at appropriate times. We aim to reduce the number of babies not referred to inpatient OT and PT services in the NICU and to two neurodevelopmental clinics (neonatal neurodevelopmental clinic and baby therapy clinic) to 50% of the baseline data within 1 month. Literature suggests that educational, technological, and communication strategies help in achieving QI goals, and we aim to implement a combination of similar strategies in this project.[63–68]



This quality improvement study was conducted in the level 4 NICU of WWRC, which is a hospital under Hamad Medical Corporation, Qatar. With 112 NICU beds, it is one of the largest NICUs in the world and approximately 2000 babies are admitted yearly. This was a prospective, pre–post intervention study to improve and optimize the referral rates to PT and OT services in NICU and to neurodevelopmental clinics upon discharge. One-month data (January–February 2020) were analyzed to get the baseline values. A data extraction sheet was designed and pilot tested to extract baseline and postintervention data from patients’ electronic records. The study was approved by the NICU quality improvement team and WWRC administration. The paper follows SQUIRE2 guidelines.[69]


The Institute for Healthcare Improvement Collaborative Quality Improvement Model was used to guide the program.[70] A team meeting was conducted with all the therapists in the NICU and their lead physician to identify the bottlenecks and to find ways for improving the referrals to PT and OT services within the NICU and to neurodevelopmental clinics. Three sequential steps for improvements were identified:

  1. Enquire with stakeholders about the reasons for not referring the babies to appropriate services and address them
  2. To revise the existing referral criteria [Appendix 1], to make them clear and comprehensive
  3. Implement the revised criteria.

The study was divided into three phases:

In the first phase, a questionnaire was created to explore nurses’ and physicians’ awareness of the existing referral criteria, reasons for not referring the babies to appropriate PT and OT services within the NICU and to neurodevelopmental clinics, and suggestions to improve the referral rates (Appendix 2). All case managers, nurse educators, 46 nurses, and, 17 physicians completed the survey within one-week time.[17,46]

Appendix 2:
1st Survey Questions

Most nurses and physicians were aware of the criteria and the purpose of the follow-up clinics [Figure 1].

Figure 1:
Nurses and Physicians responses to survey questions

Nurses and physicians cited the need for reminders as the most common reason for not referring the baby to appropriate therapy services [Figure 2].

Figure 2:
Reasons for not referring the babies to appropriate services

The most common suggestions to increase the referral rates were a) to place the criteria in patient rooms and nursing stations, and , b) therapists should put the needed orders themselves with doctors co-signing it [Figure 3].

Figure 3:
Suggestions to increase the consult and referral rates to appropriate therapy services

In the 2nd phase, based on the feedback, the existing criteria [Appendix 1] were comprehensively revised to make them evidence based as per the neonatal conditions seen in the NICU of WWRC. The revised criteria were evaluated for clarity using a survey [Appendix 3]. The major revisions made were (a) to include all possible diagnoses which could affect the neurodevelopment of preterm neonates, (b) to include late preterm babies for neurodevelopmental follow-ups, (c) to set timelines for consult orders to initiate early referral and intervention, and (d) to clarify pathways for neurodevelopmental and outpatient clinics. A total of 25 nurses and physicians answered the survey and slight clarifications were made based on the feedback. The new criteria were named revised consult and referral criteria for physiotherapy and/or occupational therapy and therapy services within WWRC NICU and Transitional care Neonatal Unit (TCNU) and upon discharge [Figure 4].

Appendix 3:
2nd Survey Questions
Figure 4:
Revised consult and referral criteria for physiotherapy and/or occupational therapy and therapy services within WWRC NICU and TCNU and upon discharge. WWRC: Women’s wellness and research center, NICU: Neonatal intensive care unit, TCNU: Transitional care Neonatal Unit

Plan-Do-Study-Act (PDSA) cycles are an effective way to implement change.[71] The 3rd phase focused on implementing the revised criteria using a PDSA cycle. Initially, other than the physician, no other stakeholders were actively involved in the process of getting consults and referral orders. Furthermore, the consult and referral criteria were not accessible and visible to all the stakeholders. Incorporating the feedback from the previous surveys, all the key stakeholders were identified and were given important tasks and a process map was created [Figure 5].

Figure 5:
Process map to implement the revised consult and referral criteria

Measures and analysis

The aim of the study was to reduce the number of neonates not referred to inpatient OT and PT services and to neurodevelopmental clinics to 50% of the baseline data within 1 month. Quantitative analysis and monthly audit of the patient electronic records admitted from December 6, 2020, to January 2, 2021 (1 month), were done to see if the needed orders were given as per the revised criteria.

Within the 1st month of implementation, the focus was to get the needed consult order before discharge (as opposed to within 48 h of admission/1st week of life/hemodynamic stable as per the revised criteria). Referral orders if given after the discharge were counted as not given.


From December 6, 2020, to January 2, 2021, a total of 239 neonates were admitted to the NICU. Out of 239 neonates, 64, 55, 100, and 20 were eligible for physiotherapy consults, occupational therapy consults, referral to baby therapy, and neonatal neurodevelopmental clinic, respectively.

For referral orders, exceeding our target, no eligible neonates missed the order for the neonatal neurodevelopmental clinic, and 75% of the eligible neonates (target 50%) for the baby therapy clinic were referred appropriately. For inpatient OT and PT services, the percentage of neonates not given consult orders decreased substantially; however, we did not achieve the set target. Twenty-two percent (targeted 12.5%) and 20% (targeted 18%) of the eligible neonates missed OT and PT consult orders, respectively. A comparison of pre–post intervention results is outlined in Table 1.


Following the implementation of the revised referral criteria, for referral orders, exceeding the target, all the neonates eligible for neonatal neurodevelopmental, and 75% of the eligible neonates for baby therapy clinic were referred appropriately. For inpatient OT and PT services, the percentage of neonates missing the needed consult orders decreased substantially; however, we did not achieve the set target. Twenty-two percent (targeted 12.5%) and 20% (targeted 18%) of the eligible neonates missed OT and PT consult orders, respectively. Neonates who got timely orders benefitted from early assessment and interventions within the NICU and neurodevelopmental follow-up clinics. Research indicates that interventions provided to the babies in the NICU and early developmental interventions postdischarge improve motor, cognitive, and developmental outcomes in preterm babies.[26,61] Importantly, an increased number of consults and referrals led to adequate utilization of manpower resources and cost-efficiency in addition to boosting the therapist’s morale.

A major strength of this project was the involvement of multiple stakeholders. Research suggests active involvement of multiple stakeholders and their education is an essential element in QI that leads to success.[67,68] Involving multiple stakeholders allowed us to assign the task to a key stakeholder group and make them responsible for the needed orders. The process map helped in making stakeholders aware of their role, and within a short period, we could achieve the targets for inpatient consults and referral clinics.

Multiple factors led to not achieving the inpatient consult target. As per the process map, the therapists daily conducted the huddle at a dedicated time and informed the charge nurses and the case managers of the needed consult and referral orders, respectively. Charge nurses, primary nurses, and case managers then remind the physician to place the needed orders. Many times, due to the busy schedules of the doctors and the nurses, and due to the dynamic nature of the NICU, communication did not happen efficiently. The nurses work in rotatory shifts and use a patient handover tool to pass the needed information to the incoming colleague at the shift change. If a morning nurse could not contact the physician to get the needed order, she should endorse it to the incoming nurse to contact the physician. At times, if the nurse forgets to endorse the needed orders, the neonate missed the order. Furthermore, as NICU is a dynamic area, emergencies can emerge at any time and doctors need to attend to the emergency. In these cases, even after reminders, at times, doctors forgot to place the needed orders. Making one physician per team responsible and as a point of contact for giving the needed orders might help decrease the communication gap and will ease the burden on the nurses. In addition, reminder pop-ups based on the referral criteria can be enabled in the electronic patient record system which will prompt physicians to place the needed orders, thus closing the communication gap.

Importantly, during their shift, a nurse might have 1–3 babies to take care of. All nurses have a phone via which they can call landline numbers but calls to the mobile number are restricted. Most physicians carry mobile phones, and to call a mobile number, the nurse needs to go to the nursing station leaving her babies and have to ask a colleague or floater nurse to cover her babies while she calls the doctor. At times, due to the busy nature of the NICU and staff shortages, it is difficult to leave the babies and go to the nursing station for calling a physician. Providing nurses with phones having the facility to call mobile numbers will ease the burden on the nurses and will make the care more effective.

In the NICU, the focus is to save life and the neurodevelopment aspect in later life is not often thought of. However, the stressful sensory environment and exposures in the NICU are prone to alter the developmental trajectories and neurobehavior of preterm neonates.[9,10] Few physicians were reluctant to put the needed orders as they didn’t see the value of it. This was more prevalent with the orders for babies with Intra Uterine Growth Retardation (IUGR) and, follow-up orders for the late preterm babies post NICU discharge. Studies show that neonates born moderate and late preterm are at risk of developmental disability, school failure, speech, cognitive and developmental delay, and social and behavior problems.[17–19] Studies also highlight that neonates born with IUGR are at risk of poor neurodevelopmental and childhood cognitive outcomes.[72–75] Importantly, the early developmental intervention provided to the babies in the NICU via therapists and parents improves motor, cognitive and developmental outcomes in preterm babies.[26,61] Therapy services are not lifesaving but augment the quality of life of a neonate and parents within the NICU and in later life

Nurses were hesitant to call a few physicians to ask for the needed therapy order, as they anticipated that physicians will not like it. Nurses designed innovative ways and waited to convey something meaningful that physicians value, for e.g., blood test results, and asked for the therapy order when they conveyed the test results to the physicians. Power struggles exist in the NICU and organizational, managerial, and operational changes are needed to optimize the care of babies.[76] On weekends, therapists work on-call and were not available to do the huddle. This also led to missing some cases, mostly late preterm and babies with IUGR. On weekends, physicians placed the necessary orders for oxygen and medicines, but, were reluctant to put the needed therapy orders (citing its non-urgent and not lifesaving) and waited for the primary physician to place the order on the weekday. This further impacted late-preterm babies, and babies with IUGR as they get discharged quickly and might not be in the NICU when the primary physician comes for weekday duty. Many physicians might not see the need for therapy services for the neonates in the NICU, and thus don’t place the needed order, even after reminders. More education sessions on the implications of prematurity in the later part of life and the role of a therapist in the NICU could help physicians understand the value of therapy services in the NICU, thus making them more likely to give the needed order. More administrative controls and consistent reminders from the leadership management are needed to make physicians comply with the criteria. Additionally, if on-call therapists could do huddles on the weekends, it will further avoid missing the cases.

Although we have limited data of 1 month, we were able to involve all the stakeholders and decreased the number of nonreferrals to all 4 therapy services. In this project, we focused on getting the needed consult order before discharge and did not follow timelines as proposed in the revised criteria. In the future, to further decrease the number of nonreferrals to the needed services, and to get the needed orders within the stipulated time, a quality control team with dedicated time and staff is needed: (a) to conduct ongoing data analysis and audit, (b) to monitor the compliance of the project, and (c) to address the issues emerging from the iterative data analysis. A vested team of neonatal therapists is imperative for the long-term sustenance of this project and will help modulate the long- and short-term neurodevelopment of these babies.


Within 1 month, we decreased the number of nonreferrals to all 4 therapy services. Inpatient PT and OT referrals need more focus to achieve the target. The major reason for not referring the neonates to the therapy services was the lack of reminders, and suggestions to increase the referrals were to keep the criteria in various locations where it is available and visible. We kept the revised criteria in every baby file and also made it available to all the stakeholders. The following strategies are further needed to achieve the targets in entirety. Education of physicians and nurses on the implications of prematurity, neurodevelopmental implications of late preterm births and IUGR, and the role of a therapist in the NICU can help get the needed orders. Administrative controls such as (a) making one physician per team responsible for getting the needed orders and (b) consistent reminders from the leadership management to make physicians comply with the criteria are needed to achieve the targets. Using technology, reminder pop-ups based on the referral criteria can be enabled in the electronic patient record system which will prompt physicians to place the needed orders, thus decreasing the nonreferrals.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


We acknowledge Ms. Lizy, Fathen, Sabah (Case managers), Ms. Tiruveni, Rose, Silveria, Amor (Head nurses), Ms. Binsy (Clerk), Ms. Ava (secretary), Ms. Bindu (medical transcriptionist), and all NICU nurses for their cooperation and support.


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Neonates neonatal therapy; neurodevelopmental outcomes; neonatal intensive care unit; occupational therapy; physiotherapy; quality improvement; service utilization

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