Implementation of a pilot program of Reach Out and Read® in the neonatal intensive care unit: a quality improvement initiative

Abstract

Objective:
Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU).

Study design:
We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent infants read to by their parents, and data from parental surveys.

Result:
98 infants were included (40 before, 58 after). We obtained books in the mother's language for 95% of infants, 82% eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ± 0.35 times/day). Surveyed parents enjoyed reading, noted positive effect(s), and intended to read post-discharge.

Conclusion:
We launched a well-received pilot ROR program in the NICU and reached our goal of ≥50% infants being read to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.

Full text

Journal of Perinatology (2018) 38:759–766
https://doi.org/10.1038/s41372-018-0060-8
QUALITY IMPROVEMENT ARTICLE
Implementation of a pilot program of Reach Out and Read® in the
neonatal intensive care unit: a quality improvement initiative
Bernadette M. Levesque1,2 ●Anh Tran3●Emily Levesque4●Hira Shrestha4●Ramona Silva5●Marsha Adams5●
Marilyn Valles5●Judith Burke5●Alison Corning-Clarke6●Carole Ferguson6
Received: 11 August 2017 / Revised: 15 January 2018 / Accepted: 17 January 2018 / Published online: 12 February 2018
© Nature America, Inc., part of Springer Nature 2018
Abstract
Objective: Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU).
Study design: We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase
language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent
infants read to by their parents, and data from parental surveys.
Result: 98 infants were included (40 before, 58 after). We obtained books in the mother’s language for 95% of infants, 82%
eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ±0.35 times/day). Surveyed parents enjoyed
reading, noted positive effect(s), and intended to read post-discharge.
Conclusion: We launched a well-received pilot ROR program in the NICU and reached our goal of ≥50% infants being read
to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.
Introduction
Premature infants hear plenty of noise but little language in
the neonatal intensive care unit (NICU), and they are
deprived of the full extent of in-utero language exposure
due to their shortened gestation [1]. Language exposure,
such as talking, reading, or singing, is essential for normal
speech and language development [2,3]. Surviving pre-
mature infants often have delays in receptive and expressive
language processing, lower IQ scores, and lower Bayley
Mental Developmental Index scores [4–7]. The altered
sound and language exposure experienced by preterm
infants in the NICU may put them at increased risk for the
subsequent hearing, language, and cognitive disabilities that
are so common. This quality improvement (QI) initiative
was designed to increase language exposure for
preterm infants in our NICU out of concern that they may
not be exposed to enough language to foster optimal
development.
Greater language exposure in the NICU is associated
with better neurodevelopmental outcome at 18–22 months
of age [8]. Both ambient language and audio-recordings of
maternal sounds have been shown to positively affect
neurodevelopment [8,9]. In contrast, infants cared for in
single family NICU rooms have lower Bayley III language
scores at 2 years of age compared to those cared for in the
NICU’s open bay area, likely due to relative sensory
deprivation and less language exposure [10].
Low socioeconomic status (SES) infants experience
significant disparities in language exposure during early
childhood and consequently have lower levels of vocabu-
lary growth, school readiness, and reading skills [11].
Shared book reading can help parents promote cognitive,
literacy, and reading achievement in their children [12], but
this activity is less common among non-Hispanic black,
*Bernadette M. Levesque
Bernadette.levesque@bmc.org
1Boston Medical Center, Division of Neonatology, Boston, MA,
USA
2Boston University School of Medicine, Boston, MA, USA
3Boston University School of Public Health, Boston, MA, USA
4Department of Pediatrics, Boston Medical Center, Boston, MA,
USA
5Department of Nursing, Boston Medical Center, Boston, MA,
USA
6Reach Out and Read of Massachusetts, Boston, MA, USA
Electronic supplementary material The online version of this article
(https://doi.org/10.1038/s41372-018-0060-8) contains supplementary
material, which is available to authorized users.
1234567890();,:

Hispanic, and less-educated mothers [13,14], and with non-
native English speakers [14]. Among preterm infants,
reading aloud by parents >2 times per week is associated
with higher cognitive development scores at 2 years of age,
even after adjusting for neonatal, maternal, and socio-
economic characteristics [13]. Parents who read to their
infant in the NICU are more likely to continue to read to
their infant after discharge, and they also experience less
stress [15], but this was not being done in our NICU prior to
this initiative. Introducing shared book reading to parents in
the NICU could impact a significant, modifiable factor
affecting neurodevelopmental outcome.
We identified our NICU population to be at particularly
high risk for inadequate language exposure. We serve a
diverse, low-income population for whom frequent visiting
can be a challenge. An “open bay”NICU, we were antici-
pating a move to private family rooms in January of 2017,
which could further reduce language exposure. With these
factors in mind, we opted to introduce Reach Out and Read
(ROR) in our NICU as a QI initiative.
ROR gives young children a foundation for success by
incorporating books into pediatric care and encouraging
families to read aloud together [16]. ROR was founded in
1989 by pediatricians at Boston Medical Center (then called
Boston City Hospital). Currently implemented in over 5800
primary care offices, a new book and anticipatory guidance
are given at each well child visit from 6 months to 5 years of
age. The American Academy of Pediatrics supports literacy
promotion in primary care clinics beginning in infancy [17],
but ROR had not previously been implemented in the
NICU.
We report on our experience initiating ROR in the NICU,
a pediatric population not previously targeted until our
request, to increase language exposure for our preterm
infants. In July of 2015, we launched a QI intervention
aimed to increase the percentage of infants who are read to
by their parents in the NICU from zero to ≥50% by 31
December 2015. We chose several process measures to
assess the efficiency of our program and explored potential
negative effects by way of a parent survey.
Fig. 1 Outline of aims, drivers, and change concepts, including process and balancing measures. NICU neonatal intensive care unit, ROR Reach
Out and Read
760 B. M. Levesque et al.

Patients and Methods
Context
The Boston Medical Center (BMC) NICU is a 21-bed unit
in an urban, non-profit, safety-net hospital in Boston, MA,
with ~2700 deliveries per year. BMC serves a diverse, low-
income population. At the time of this initiative, the NICU
was a 2 room, “open bay”style unit.
Interventions and Measures
There are many socioeconomic and NICU-specific barriers
to parent reading in the NICU. These barriers and our pri-
mary and secondary drivers, aims, and potential change
concepts are summarized in our driver diagram (Fig. 1). Our
primary aim was to increase the percentage of infants who
are read to by their parents in the NICU from 0 to ≥50%.
Our process measures included: percent of infants for whom
we have books in mother’s native language, average daily
visits by mother and/or father during hospitalization, and
percent of eligible infants who were enrolled in ROR. Our
balancing measures were parental feedback from an anon-
ymous survey and informal nursing feedback.
The Institute for Healthcare Improvement Model for
Improvement was used for this project [18]. The initial team
included one neonatologist, the NICU Nurse Manager, the
Boston-area ROR coordinator, and a data collector. We
added five nurse champions midway through the project.
The neonatologists, NICU nurse manager, and five nurse
champions completed the formal online ROR training that
focuses on children from 6 months to 5 years of age, and
this was the group tasked with enrolling families in ROR. In
preparation to launch our reading program, we created two
educational training PowerPoint presentations, one that was
created for the neonatologists and nurses who had already
completed the formal online ROR training. The second was
more comprehensive and was used as a “Net Learning”
presentation for the rest of the staff, whose role was to
encourage parents to read (and talk and sing) to their infants
when they visited. Books were initially obtained with a
preference for staff favorites.
All infants in the NICU at the time of the launch were
eligible to be enrolled in ROR, but only infants born
between 1 March 2015 and 31 December 2015 at
<37 weeks of gestation who remained in the NICU ≥7 days
were included in this data collection cohort.
At the time of enrollment, parents were provided with in-
person, “one-on-one”anticipatory guidance regarding the
benefits of reading to their infants, outlined in Table 1, and
were given two free books. A brief enrollment form was
completed that included notation of parents’prior experi-
ence with ROR, prior reading to their infant in the NICU,
degree of expressed interest, and the language(s) of the
books provided. At least one additional book was offered to
each patient weekly. At the time of enrollment, each family
was given a ROR calendar and a collection of stickers and
were asked to record when they read to their infants.
Calendars were collected each month and/or at discharge.
Parental presence in the NICU was tracked as routinely
recorded in the electronic medical record (EMR). The total
number of days where each parent was present in the NICU
was recorded for each infant and the percent of LOS days
where the mother, father, or both were present was calcu-
lated. Duration of visits are not recorded in the EMR, so
were not included.
Efforts were made to enhance the NICU environment in
support of reading. Children’s books were placed in the
Table 1 Information and Anticipatory Guidance for Parents
TALKING WITH PARENTS ABOUT BOOKS
Here are some suggestions for making literacy development part of
your standard anticipatory guidance.
In the NICU (Pilot Program)
Newborn babies love your voice: sing, talk, and read aloud as often
as possible.
Your baby already knows your voice, even at birth
Your baby needs to continue to hear words to help with brain and
language development
The NICU can be a noisy place, but sometimes it can be too quiet
Reading is a good way to increase the number of words your baby
hears
If you speak a language other than English, it is important for your
baby to hear your language
Reading to a premature baby is different from reading to an older
infant or child
Your baby won’t know what you are saying, so you can read
anything that interests you
Your baby may respond to hearing your voice by relaxing, or making
little noises while you talk, or maybe just fall asleep!
You might not notice anything, but don’t be discouraged, hearing
your voice is still helpful
A good time to sing, talk, and read is when your baby is awake but
quiet; it is OK to read while your baby sleeps too. Hold your baby if
you can, but if not, it is also good to read while your baby is in a crib
or through the portholes of the incubator
Sometimes your baby might not be in the mood for listening
If you notice your baby won’t settle or cries or puts out his or her
hands like saying “stop”, then it may not be a good time. Try again
another time.
Implementation of a pilot program of Reach Out and Read® in…761

waiting room for siblings, ROR posters were hung in pro-
minent NICU locations, and an ROR bulletin board was
created to post pictures and reading-related information.
Books were initially stored in the NICU with a small
selection presented to the parent(s) at enrollment. Subse-
quently, a book cart was obtained to bring a larger selection
to the bedside. At the time of discharge, parents took their
books home with them. During the last two months of the
intervention period, anonymous parental surveys were
conducted to elicit feedback on the program (survey
included in Supplementary Information). Nursing feedback
was elicited frequently during planning and implementa-
tion, but this was done informally.
Analysis
Comparisons of demographic characteristics and parental
presence were conducted using T-tests, with P<0.05 con-
sidered significant. For parental presence in the NICU over
time, enrollment in ROR, and documentation of reading in
the NICU, analysis was conducted using run charts created
using QI-Charts Version 2.0.22 Add-in for Excel, using
rules for special causes to determine statistical significance
[19].
Results
A total of 98 infants were included in the cohort, 40 were
discharged on or before 1 July 2015 when ROR was
launched, and 58 were discharged after. BMC serves a
diverse, low-income population; 70% were non-white, 96%
were insured by Medicaid, and only 53% were primarily
English speaking. There were no significant differences in
demographic characteristics between the before and after
groups (Table 2).
We obtained books in English, Spanish, Portuguese,
French, Haitian Creole, and Vietnamese; some of the non-
English books were bilingual with English. Prior to launching
ROR in the NICU, we did not have any children’s books in
the NICU and parents did not bring in books. After launching
ROR, we had books in the mother’s primary language for
95% of infants. During this time frame, we were unable to
provide books in the mother’s primary language for five
infants whose mothers spoke Albanian, Arabic, Bengali, or
Tigrinya. In these cases, we offered the family picture books
with very few English words. One mother was open about
being illiterate, and she chose similar such books.
One or both parents were present in the NICU a median of
75% of LOS days (first quartile (Q1) 56.4%, third quartile
(Q3) 87.7%), or a median of 3 of every 4 days. Mothers were
present more frequently than fathers: mothers’median 71.4%
(Q1 48.6%, Q3 85.5%) of LOS days compared to fathers’
median 32.6% (Q1 13.6%, Q3 52.0%) of LOS days. There
were no trends in rates of parental presence over time during
our study period (data not shown). The median percentage of
infants enrolled in ROR per discharge month increased sig-
nificantly over time, from a median 0% before to 81.8% after
launching ROR (Fig. 2).
A total of 46 infants were enrolled in ROR. The median
day of life at entry was 15 (Q1 7, Q3 23.5) days, and the
median post-conceptual age was 34.8 (Q1 33.1, Q3 36.3)
weeks. Enrollment forms were completed for 43 of the 46
enrolled infants (94%) of infants. The enrolled infant was
firstborn in 44%. Seventy nine percent of the parents had no
prior experience with ROR; of the 21% who had prior
experience, all expressed favorable experiences. None of the
parents had read to their infants in the NICU prior to
enrollment, but all parents expressed interest in participating.
Not every family utilized the calendar to record reading
episodes; some used it sporadically. Calendars were
obtained from 34 of the 46 infants enrolled (74%); reading
episodes were recorded on 32 calendars, indicating that of
the 46 families enrolled in ROR, 70% of them used the
calendar to record that they had read to their infant at least
once. The percentage of families who read to their infants in
the NICU by month of discharge over time is presented in
Fig. 3. These data include all families: those who were not
enrolled in ROR, those who were enrolled but did not return
calendars, and those who were enrolled and returned
calendars. The median percentage of families who read to
their infants increased from 0% before to 59% after
launching ROR in the NICU. Of the 32 families who
returned calendars recording reading episodes, parents read
to their infants an average of 0.45 ±0.35 times per day from
enrollment to discharge (or roughly once every 2–3 days),
ranging from a minimum of 0.06 times per day (once every
9–10 days) to a maximum of 1.2 times per day.
We distributed 20 parental surveys (representing nearly
all parents of eligible infants during the last 2 months of the
intervention period), 15 were completed and returned: 87%
were completed by the mother, 87% remembered why they
had been encouraged to read, and 100% had read to their
infants while in the NICU. Of those who recalled why they
were encouraged to read, 73% said it was to help the baby’s
brain develop; other comments included: “encourages great
mental health”,“helps communication”,“helps with voice
recognition”, and “makes baby feel safe to hear their parent’s
voice.”All 15 said they enjoyed reading to their infant in the
NICU, and all said one of their favorite things about reading
was that they were helping their baby develop. The other
4 survey options of favorite things were chosen at least once
each (they liked the stories, felt more relaxed and happy
themselves, liked that it was something normal to do with
their baby, or baby seemed to like it). Thirteen of 15 (87%)
of respondents noted a “least favorite”thing about reading: 6
762 B. M. Levesque et al.

(40%) did not like reading out loud in front of other people,
4 (27%) said they didn’t like that they could not visit and
read more often, 3 (20%) didn’t like that the baby did not
respond to the reading, and 2 (13%) said they wondered if it
could really help the baby. None reported that the books
were too difficult or complained about not having books in
their native language. Twelve out of 15 parents (80%) said
they noticed a change in their infants when they read to
them: 7 said they seemed more relaxed or fell asleep, 2
noted increased interaction, and 3 noted physiologic chan-
ges, including 2 with decreased oxygen requirement and 1
with decreased heart rate. Thirteen parents (87%) noted a
favorite book. Five of the 13 (38%) wrote that their favorite
book was written by Dr. Seuss. All 15 parents indicated that
they plan to continue to read to their infant after discharge.
The informal nursing feedback was similar. Most were in
favor of the program, and many advocated for their patients
to ensure they were enrolled, but one or two nurses won-
dered if it could make a difference for the baby.
Discussion
We introduced ROR in our NICU to increase language
exposure among our population of preterm, low-SES
infants. We obtained language-appropriate books for over
95% of our infants and found that parents were present
often enough to read to their infants with some frequency.
Enrollment in ROR was facilitated by the addition of bed-
side NICU nurses as ROR providers, allowing us to enroll a
median of >80% of eligible infants over time. When first
approached, all parents were interested in participating in
Table 2 Demographic Characteristicsa
Variable Total population Discharged before ROR
in NICU
Discharged after ROR in
NICU
N=98 N=40 N=58
Gestational age (weeks),
mean ±SD
32.7 ±3.0 33.2 ±2.9 32.4 ±3.1
Birth weight (grams), mean
±SD
1867 ±684 1903 ±724 1841 ±660
Maternal age (years), mean
±SD
30.0 ±5.9 28.8 ±6.4 30.8 ±5.4
Maternal race (%)
White 30.6 37.5 25.9
Black 32.7 32.5 32.8
Hispanic 32.7 25.0 37.9
Asian 4.1 5.0 3.5
Maternal language (%)
English 53.1 60.0 48.3
Spanish 26.5 22.5 29.3
Haitian Creole or French 6.1 2.5 8.6
Portuguese or Portuguese
Creole
5.1 2.5 6.9
Vietnamese 4.1 5.0 3.5
African 1.0 0.0 1.7
Arabic 2.0 2.5 1.7
Other 2.0 5.0 0.0
Insurance
Private (%) 4.1 2.5 5.2
Medicaid (%) 95.9 97.5 94.8
LOS (days), mean ±SD
(Range)
36.9 ±30.1 (7–133) 32.8 ±28.2 (8–133) 39.7 ±31.3 (7–133)
PCA at D/C (weeks), mean
±SD (Range)
37.9 ±2.1
(32.1–44.1)
37.8 ±2.0 (35.0–44.1) 38.0 ±2.1 (32.1–44.0)
D/C discharge, LOS length of stay, NICU neonatal intensive care unit, NS not significant, P. Creole Portuguese Creole, PCA post-conceptual age,
ROR Reach Out and Read
aNone of these comparisons revealed statistically significant differences
Implementation of a pilot program of Reach Out and Read® in…763

ROR, and 70% of enrolled parents used the bedside
calendar to document reading to their infant, with a wide
range of reading frequency. We reached our goal of at least
50% of infants being read to by their parent(s) during their
NICU stay. Of our surveyed parents, most recalled why
they were encouraged to read, all had read their infants in
the NICU, and all had enjoyed it. They especially liked that
they were helping their baby to develop, though several
noted not liking to read in front of other people. Most had
noticed a positive effect on their infant, and all intended to
continue to read post-discharge.
We obtained books for this intervention from a variety of
sources: ROR provided approximately half free-of-charge;
we received 200 free books at a First Book event; we
purchased books online using BMC philanthropic resour-
ces; and staff members donated new books. Non-English
books in Spanish and French were readily available on low
cost sites, as were bilingual Spanish-English books, but
other languages were more difficult to find. A greater
variety of non-English language children’s books were
found on conventional bookseller websites, but at greater
expense. Prior to this initiative, parents did not bring in
books to read to their babies, but following the launch,
several parents would bring books from home, including
children’s books, religious texts, and other reading material.
Mothers visited their infants more often than fathers. In
aggregate, parents visited often, but there was significant
variability in frequency. While we have identified many
drivers for parental visitation, further investigation would be
necessary to fully understand the patterns and factors con-
tributing to visitation by our NICU parents.
Enrollment in ROR was greatly facilitated by the addition of
nurses to the ROR provider group. This is understandable, as
NICU nurses serve as the primary source of information for
parents and do the bulk of the parent teaching. Other staff
members that might be helpful in the future include pediatric
residents, child life staff, and volunteers. Enrollment during this
initial effort included completing an enrollment form, but we
have since simplified the process to a brief conversation touching
on the points outlined in Table1. We also give each family a
book mark that encourages reading along with a first book that
provides information about reading and parenting called “I Love
You Like Sunshine”by Mariana Glusman and Marta Killner.
Our goal of having at least half of the infants read to at
least once during hospitalization was chosen due to the
variability in length of stay, timing of enrollment during
hospital stay, particularly with our initial launch, and degree
of infant illness while in the NICU. These factors would
have made the denominator for frequency so variable that
we decided that just reporting reading once would be our
goal. To compensate, we also presented data on frequency
from date of enrollment to discharge.
At the onset, we were not sure if this intervention would
be well-received, but we were pleased by the enthusiasm of
families and staff alike. While only a small portion of
parents were surveyed, our findings mirror the positive
feedback we have received directly from parents, nurses,
and other staff members. Reading can have “normalizing”
effects for some parents, who often find the NICU experi-
ence ranging from highly stressful to traumatic. We moved
to a new NICU in January 2016 that has 10 private rooms
and 12 semi-private rooms. We believe the added privacy
has alleviated some of the discomfort some parents
expressed about reading aloud in public.
We enrolled infants after they were stable enough to be
held, but several were enrolled earlier, either at the parents’
request or staff’s suggestion. Our method of tracking read-
ing using a calendar and stickers was admittedly limited.
Fig. 2 The percent of eligible infants enrolled in ROR are plotted for
10 sequential discharge months, from March to December 2015. The
median increased from zero prior to 81.8% after launching ROR in the
NICU. MDs medical doctors, NICU neonatal intensive care unit, RNs
registered nurses, ROR Reach Out and Read
764 B. M. Levesque et al.

Some families enthusiastically used the calendar, but others
did not. Some calendars were lost at the time of discharge.
We initially planned to wait until we could add a field in our
EMR to document reading, but this would have delayed our
launch significantly. While we reached our goal of 50% of
infants being read to by their parents in the NICU, we
believe this is an underestimation.
We did not inquire about parental literacy at the time of
enrollment; instead, we offered books that ranged greatly in
complexity. Most of our books were appropriate for 6-to 9-
year-old children, but we had a good selection of very
simple board books, compilations of nursery rhymes, and a
few short stories. Parents were free to choose the type of
book that they preferred; they often chose books that their
older children would also like. Some parents read other
material, including religious texts and novels, either in print
or electronic. After this project we elicited the help of an
English as a second language expert, and we have stocked
the waiting room with additional reading material that might
be of interest to our parents. Future efforts will be focused
on exploring literacy among our parent population, as this is
an important factor both in infant neurodevelopmental
outcome and in navigating the health care system.
One strength of this project was our close collaboration
with ROR. As the institution where ROR originated, we had
institutional support for ROR and the enthusiasm of the
staff, and we are now able to use our findings to help spread
reading in the NICU through a wider launch of ROR in the
NICU. ROR is the oldest, largest, and most recognizable
reading program. While this is a small pilot project, ROR
has the organization, staff, and resources already in place
that could facilitate a state-wide and nation-wide launch.
They could also incorporate the NICU into their continuum
of care from infancy to age 5 years. For ROR, this project
was useful to test the feasibility of the program, assess
responsiveness, and help in selection of books for a wider
launch. Since this project, ROR in the NICU has been
launched in two other Massachusetts NICUs and there are
plans underway for further expansion.
Strengths of this project also include the multi-
disciplinary team approach, the inclusion of “talking points”
other centers could use to facilitate adoption of reading in
other centers, and the anonymous parental feedback. Our
small sample size was a limitation. Requiring a formal
enrollment prior to provision of books allowed us to gather
useful information, but may have also limited the numbers
enrolled for this pilot effort. Other limitations included the
inability to measure the length or quality of parental visits
and the lack of follow-up post-discharge.
In summary, we have launched a first-ever program of
ROR in the NICU and have reached our primary goal of
≥50% of infants being read to by their parents while they
were in the NICU. Further research is required to determine
the short and long-term outcomes of supporting reading to
NICU patients, including the impact on family reading
behavior and neurodevelopmental outcome.
Acknowledgements
Funding This work was supported by grants from Reach Out and
Read of Massachusetts and the Cabot Family Charitable Trust, as well
as the Boston Medical Center Elaine Ullian Fund.
Compliance with ethical standards
Conflict of Interest All authors are responsible for this reported
research. Dr. Levesque currently serves as a consultant to Reach Out
and Read of Massachusetts to provide training for other neonatal
intensive care units in Massachusetts who are interested in introducing
Reach Out and Read in their units. Alison Corning-Clarke and Carole
Ferguson are both employed by Reach Out and Read of Massachu-
setts. The remaining authors declare that they have no conflict of
interest.
Fig. 3 The percent of eligible infants read to by their parent(s) in the
NICU per month are plotted for sequential discharge months
(March–December 2015). The median increased from zero prior to
59.2% after launching ROR in the NICU. MDs medical doctors, NICU
neonatal intensive care unit, RNs registered nurses
Implementation of a pilot program of Reach Out and Read® in…765

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