# Improving Skin-to-Skin Care Among Stable Infants in a Level III NICU: A Quality Improvement Project Using Kotter’s Change Management Model

## TL;DR

This study improved skin-to-skin care rates for stable infants in a NICU using change management strategies, showing lasting benefits.

## Contribution

The novel application of Kotter’s model to increase SSC in non-critically ill infants in NICUs is highlighted.

## Key findings

- SSC rates increased from 63.8% to 80.5% in three PDSA cycles.
- Sustained compliance of 80.5% was maintained during a four-month follow-up.

## Abstract

Introduction

Skin-to-skin care (SSC), also known as kangaroo care, is defined as placing an infant directly prone, typically with the infant's chest against the caregiver's chest. SSC has demonstrated significant benefits for newborns, including improved thermoregulation, cardiorespiratory stability, reduced stress responses, and enhanced neurodevelopmental outcomes. While its use is widely promoted for preterm or critically ill infants, term and clinically stable infants are often overlooked in SSC initiatives despite evidence suggesting they, too, obtain substantial benefit. This is especially true in neonatal intensive care units (NICUs). Most quality improvement (QI) studies related to SSC revolve around critically ill preterm infants. Efforts to improve SSC rates tend to prioritize acutely ill infants, with less attention given to those with short-term NICU admissions and stable conditions. Therefore, non-acutely ill infants miss out on the benefits of SSC. This QI project aimed to address this disparity.

Setting

The initiative was conducted in a level III NICU located in an urban hospital in Brooklyn, New York.

Methods

Using the Plan-Do-Study-Act (PDSA) model and Kotter's Eight-Step Change Management framework, we sought to achieve a Specific, Measurable, Achievable, Relevant, Time-Bound (SMART) aim: to increase SSC to 80% of non-acutely ill infants >35 weeks gestational age, admitted to the NICU without respiratory support by hospital day 2, within one year. Key interventions included electronic medical record (EMR) updates, nurse education, parent engagement, and visual bedside cues.

Results

Between December 2023 and April 2024, 277 newborns admitted to the NICU met our study criteria. SSC rates improved from a baseline of 63.8% to 80.5% across three PDSA cycles. A four-month follow-up phase demonstrated sustained compliance (80.5%, n = 103), indicating durable change.

Conclusion

Non-acutely ill infants are underserved by the benefit of SSC due to institutional culture and resource allocation that emphasize care for high-acuity patients. This QI initiative shows that, when applied intentionally, structured change management can effectively integrate SSC into routine care for this overlooked population. Through structured change management, we included SSC into routine NICU care, achieving and sustaining our goal.