Impact of Quality Improvement Program on Expressed Breastmilk Usage in Very Low Birth Weight Infants

Oral Care Performed with Breast Milk in Preterm Newborns Fed by Tube: A Randomized Controlled Study

Objective: This study examined the effect of breast milk on oral care practices in neonatal intensive care units. Methods: This study involved 64 preterm infants (intervention/breast milk: 32, control/distilled water: 32) and was carried out with a prospective, parallel, randomized controlled design. The "Newborn Oral Health Assessment Tool (NOHAT)" was used to assess oral care. The Mann-Whitney U test, continuity correction test, Fisher's exact test, independent-samples T test, and Wilcoxon signed ranks test were used to analyze the data. Results: Examining the oral care performed using breast milk and distilled water with NOHAT scores, it was determined that there was a significant difference in the intervention group (p < 0.05). Conclusions: It is recommended to use breast milk for oral care.

Improving the Quality of Health Care in Special Neonatal Care Units of India: A Before and After Intervention Study

BACKGROUND

We evaluated the efficacy of training health care workers (HCWs) in point-of-care quality improvement (POCQI) and a preterm newborn health care package (PHCP), followed by remote mentoring and supportive supervision in improving health care practices, neonatal survival, and morbidities in special neonatal care units (SNCUs).

METHODS

This pre- and postintervention quality improvement study was conducted at 3 SNCUs in Madhya Pradesh, India from February 2017 to February 2019. Clinical care teams comprising doctors and nurses from the study sites were trained in POCQI and the PHCP. The teams identified, prioritized, and analyzed problems and designed quality improvement initiatives at their respective health facilities. Change ideas were tested by the local teams using sequential plan-do-study-act cycles. Facilitators maintained contact with the teams through quarterly review meetings, fortnightly videoconferencing, on-demand phone calls, and group chat service. State SNCU coordinators made follow-up visits to supplement coaching. Study research staff independently collected data on admissions, health care practices, and outcomes of neonates.

FINDINGS

A total of 156 HCWs were trained in the POCQI methodology and PHCP. Sixteen quality improvement projects were formulated and implemented. Among 13,821 enrolled neonates (birth weight 2275±635 g; gestation: 35.8±2.8 weeks), improvement was seen in reduction of use of oxygen (36.1% vs. 48.0%; adjusted odds ratio [aOR]=0.60, 95% confidence interval [CI]=0.55, 0.66), antibiotics (29.4% vs. 39.0%; aOR=0.76, 95% CI=0.68, 0.85), and dairy milk (33.8% vs. 49.4%; aOR=0.34, 95% CI=0.31 to 0.38). Enteral feeds were started within 24 hours of admission in a larger number of neonates, resulting in fewer days to reach full feeds. There was no effect on survival at discharge from the hospital (aOR=0.93; 95% CI=0.80, 1.09).

CONCLUSION

A collaborative cross-learning quality improvement approach with remote mentoring, coaching, and supportive supervision was successful in improving the quality of care at SNCUs.

Strengthening emergency care systems to improve patient care for ST-elevation myocardial infarction (STEMI) at a high-volume tertiary care centre in India

Background

ST-elevation myocardial infarction (STEMI) is a highly time-sensitive and life-threatening condition. Early recognition and timely management are challenging in a busy emergency department (ED), especially in low/middle-income countries where emergency systems are often fragmented. The aim of our quality improvement (QI) project was to increase the percentage of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with door to balloon (D2B) time of <90 min by 30% over 12 months.

Methods

As part of the first step in QI, baseline data were collected at different points in the process of care. Using process maps and fishbone analysis, delays in patient registration, ECG and communication with cardiology were identified as some bottlenecks, and change ideas were tested using plan–do–study–act cycles using point-of-care QI methodology. The majority of the change ideas focused on interventions in the ED like strengthening triage, training frontline staff, early diagnosis and quick transportation of patients.

Results

During the baseline phase, 22.22% of patients were found to have a D2B time of <90 min. We achieved an increase of 47.78% in patients receiving PCI within 90 min and hence increased to 70% at the end of the intervention phase. Data collected for 4 months after the intervention phase were found to have sustained the effort.

Conclusion

Significant improvement in the door to reperfusion time resulted from a meticulous assessment of emergency care processes by drawing process flow chart and implementation of change ideas like introduction of fast-track policy for patients with chest pain, reducing staff turnover in the triage area, formal training of staff, continuous engagement with cardiology team and by interchanging of processes which led to a reduction in time to ECG.

Availability of Breast Milk for Preterm Neonates by Gestational Age during NICU Stay

The objective of this study was to explore the availability of expressed breast milk (EBM) volume for the premature neonates born from mothers in different gestational age groups during neonatal intensive care unit (NICU) stay. All preterm infants (extreme-preterm infant [EPTI, <28 weeks], very-preterm infant [VPTI, 28–316/7 weeks], and moderate-preterm infant [MPTI, 32–336/7 weeks]) and their mothers were included in the study. Infants not receiving mother's own milk and neonates deceased or discharged against medical advice, and the mother with illness during postpartum period were excluded from the study. A predesigned tool was used to collect information on maternal characteristics, neonatal characteristics, and milk diary for preterm neonates from the NICU case records. The primary outcome variable EBM volume available on day 7 was compared across three gestational groups. Logistic regression was used to predict EBM availability. A total of 78 preterm neonates, including 10 EPTI, 37 VPTI, and 31 MPTI, had average birth weight of 962.5 ± 228.25, 1,185.1 ± 183.14, and 1,293.2 ± 182.92 g, respectively. Receipt of exclusive breast milk among EPTI, VPTI, and MPTI was 80, 94, and 83.8%, respectively. Maternal characteristics were similar except for the mode of conception (p = 0.001), mode of delivery (p = 0.04), and antenatal steroid exposure (p = 0.02) among three gestational categories. The median (Q1–Q3) volume of EBM on day 7 were 160 (136.3–202.5), 150 (140–187.5), and 160 (150–220) mL for EPTI, VPTI, and MPTI neonates, respectively, without any statistical significance. Regression analysis suggests no effect of gestational age on EBM availability. The feasibility of mother's own milk use for extremely preterm neonates is similar to higher gestational preterm neonates.

Oral Care with Mother's Own Milk in Sick and Preterm Neonates: A Quality Improvement Initiative

OBJECTIVE

Oral care with mother's own milk (OC-MOM) in sick and preterm neonates provides immune protection, improves feed tolerance and helps in earlier achievement of full enteral nutrition. This quality improvement (QI) initiative was undertaken when authors documented scanty awareness regarding neonatal oral care practices among care-givers in their neonatal unit. The project aimed to improve the proportion of OC-MOM in sick and preterm neonates from the baseline of 5.9% to 80%.

METHODS

The QI project was designed as per Point of Care Quality Improvement (POCQI) model and conducted over 6 mo (January 14, 2019 to July 12, 2019). Preterm and sick term neonates on enteral fasting or gavage feeding were included. Neonates with major congenital malformation and whose MOM was not available were excluded. An OC-MOM team was formed and baseline data were collected. Flow charts and fish-bone diagrams were used to analyse the problem and identify the key issues. Mouth assessment tool (MAT) was customized and adapted as one of the outcome measures. An OC-MOM protocol was designed and implemented as a part of routine neonatal care.

RESULTS

Four Plan-Do-Study-Act (PDSA) cycles were conducted to achieve the target. After successful implementation of OC-MOM protocol, proportion of neonates receiving OC-MOM increased to 83.3% from a baseline of 5.9% and proportion of neonates having MAT score "0" improved to 94.4% from a baseline of 24.4%.

CONCLUSIONS

This QI initiative using POCQI model resulted in a significant and sustained improvement in the proportion of neonatal oral care with MOM using locally available resources.

Quality Improvement to Increase Breastfeeding in Preterm Infants: Systematic Review and Meta-Analysis

Background and Objective: Due to its numerous health benefits, breast milk (BM) is recommended for preterm infants. Despite such recommendations, the rates of breastfeeding in preterm infants are lower than that in term infants. Quality improvement (QI) bundles increase breastfeeding in preterm infants, but their replication in neonatal intensive care units has had inconsistent outcomes. Methods: We used the Population or Problem, Intervention, Comparison, and Outcomes (PICO) framework to develop our search strategy, and searched MEDLINE, Embase, and the Cochrane Library from inception through January 15, 2021. Studies describing any active QI intervention to increase BM use in preterm infants were included. The primary outcome measure was the rate of any breastfeeding or exclusive mother's own milk (MOM) at discharge or during hospitalization. Results: Sixteen studies were eligible for inclusion and showed an acceptable risk of bias, and included 1 interrupted time series, study 3 controlled before-and-after studies, and 12 uncontrolled before-and-after studies; of these, 3 studies were excluded due to insufficient dichotomous data, 13 were included in the meta-analysis. In the meta-analysis, the rate of any breastfeeding was significantly improved at discharge and during hospitalization after QI [risk ratio (RR) = 1.23, 95% confidence interval (CI): 1.14-1.32, P < 0.00001 and RR = 1.89, 95% CI: 1.09-3.29, P = 0.02, respectively]. The rate of exclusive MOM after QI was also significantly increased at discharge (RR = 1.51, 95% CI: 1.04-2.18, P = 0.03), but not during hospitalization (RR = 1.53, 95% CI: 0.78-2.98, P = 0.22). However, after sensitivity analysis, the comprehensive results still suggested that QI could significantly improve the rate of exclusive MOM during hospitalization (RR = 1.21, 95% CI: 1.08-1.35, P = 0.001). Funnel plots and Egger's test indicated publication bias in the rate of any BF at discharge. We corrected publication bias by trim and fill analysis, and corrected RR to 1.272, 95% CI: (1.175, 1.369), which was consistent with the results of the initial model. Conclusions: A QI bundle appears to be effective for promoting BM use in preterm infants at discharge or during hospitalization.

A Quality Initiative to Improve Mother's Own Milk Feeding in Preterm Neonates

Background: The rates of "any" human milk use in neonatal intensive care units have improved during the last decade. However, efforts to help mothers in expressing and maintaining mother's own milk (MOM) through discharge remain a concern. This study aims to improve MOM in preterm neonates. Methods: The study was a quality improvement (QI) initiative conducted from May 2018 to April 2019. All preterm neonates <34 weeks were included. In the "initiation phase" (May 2018 to August 2018), a breastfeeding support group was formed and mothers were given structured antenatal and postnatal counseling regarding MOM using videos and leaflets. This improved MOM rates when compared with retrospective controls. In the continuation phase (August-2018 to April-2019), various plan-do-study-act cycles were conducted to test strategies such as frequent telephonic reminders, standardization of Kangaroo mother care, nonnutritive sucking protocols, and involving family members during daily counseling sessions. The initiation and continuation phases were compared with the retrospective baseline data. Results: Of a total of 125 preterm neonates, 27 were excluded for various reasons. Within 3 months of initiating the study, the proportion of neonates who received MOM within first 24 hours improved from 24% in retrospective controls to 82.9% in the initiation phase (p < 0.0001) and remained stable at 90.3% in the continuation phase. The amount of MOM received on day 1 increased significantly (p < 0.0001) from a median of 0 mL to 1 mL in the initiation phase and was maintained at 3 mL in the continuation phase. Amount of MOM increased significantly on day 3 (p = 0.0003) and day 7 (p = 0.03). Babies discharged on MOM also improved significantly (p = 0.005) from 48.3% in the retrospective cohort to 77.4% in the continuation phase. The number of babies receiving total parenteral nutrition decreased significantly (p = 0.02) from 54.6% to 26.7%. Conclusions: QI has shown promising results in improving MOM in preterm neonates.

Quality improvement initiative to improve mother's own milk usage till hospital discharge in very low birth weight infants from a tertiary care NICU

IMPORTANCE

Mother's own milk (MOM) for premature infants is a complete nutrition. It is an ideal issue for a quality improvement (QI) initiative.

OBJECTIVE

To increase the proportionate usage of MOM as enteral feeds.

METHODS

A QI study conducted in Tertiary care NICU involving all eligible very low birth weight (VLBW) infants and mother dyads. The proportionate usages of MOM as enteral feeds were the main outcomes.

EXPOSURE

Education, milk expression, and mother-infant interaction formed the key drivers.

RESULTS

We studied 282 mother infant dyads during the QI period. The proportionate usage of MOM as the enteral feed increased from 55% (±34) at baseline to 80% (±27) during the intervention and to 88% (±16) in sustenance phase.

CONCLUSIONS

A QI initiative resulted in 60% relative improvement in proportionate usage of MOM as enteral feeds in VLBW infants during hospital stay.

A quality initiative to improve exclusive breast milk feeding in preterm neonates

Background and Objective

Preterm babies thrive well on exclusive breastfeeding with fewer complications. In a retrospective analysis, challenges were noticed in the form of delayed first milk expression and frequency of expression, which was limited to 2–3 times a day. A quality improvement initiative was designed to increase the exclusive breast milk feeding rates in admitted preterm babies. The purpose of the present study is to evaluate the proportion of preterm neonates receiving mother's own milk by day 7 of life after such an initiative.

Methods

The quality improvement initiative was conducted at a level 3 neonatal intensive care unit from May 10, 2018, to August 10, 2018. Inborn preterm neonates <34 weeks with a minimum hospital stay of 7 days were included. Neonates of critically sick mothers and neonates having major congenital malformations were excluded. Mothers were given structured antenatal counseling regarding expressing breast milk (EBM). Postnatal visits were conducted to provide information through a video and a leaflet and formation of breastfeeding support group.

Results

A total of 30 babies were recruited during a period of 3 months and compared to historical controls. The median age of the first EBM improved from 2.5 days to 1.16 days, and the amount of EBM on the first day improved from 0.24 ml to 2.6 ml (p = .002). The proportion of babies receiving EBM on the first day improved from 24% to 80% (p = .0001), and at the end of 7 days, it increased to 73% from 46% (p = .02). The factors time to reach full enteral feeds, time to regain birth weight, rate of necrotizing enterocolitis, rate of sepsis, and proportion of babies on exclusive mother's milk during discharge appear comparable in both the groups.

Conclusions

A simple quality improvement approach through the formation of breastfeeding support group, antenatal counseling, and postnatal support for breast milk expression has made a significant improvement in milk expression from mothers delivered prematurely. It reflects on a team approach using the available resources.