A Quality Improvement Project to Decrease Human Milk Errors in the NICU

Enhancing nutritional formula expiry monitoring: A quality improvement project in a tertiary-level hospital in Riyadh, Saudi Arabia

BACKGROUND

Nutrition is a vital part of any treatment plan. This may include providing nutritional formulas during hospitalization and afterward. However, reported incidents showed that we had issues with nutritional formula expiry monitoring at our hospital with low compliance to Joint Commission International Standards (MMU.3.1): "There is a process for storage of medications and nutritional products that require special consideration." Therefore, a "Nutritional Formula Expiry Monitoring" project was created to decrease hospital safety incidents related to expired nutritional formulas from an average of 28 in 2015 to zero by 2018.

MATERIALS AND METHODS

A quality improvement model was developed to map the existing formula processes. Several proposed ideas were tested including performing a hospital-wide audit to examine possible risks and practices, developing a hospital policy, flow charts, forms, and audit tools, and providing educational presentations.

RESULTS

A total of 40 units in the hospital were included in the implementation. After implementing all the change ideas, the system for monitoring the expiry of the nutritional formula was standardized, and the number of reported incidents related to the nutritional formula decreased from 28 in the third quarter of 2015 to one in the first quarter of 2018.

CONCLUSION

This project provided step-by-step instructions for improving storing, delivering, and monitoring of nutritional formula. Consequently, the incidences of expired formula and cost wasting were successfully decreased, which increased safe administration and prevented patients from receiving expired nutritional formula. This project can be implemented in various healthcare settings.

Increasing the Percentage of Neonates Consuming Human Milk in a Pediatric Cardiothoracic Intensive Care Unit: A Quality Improvement Initiative

OBJECTIVE

To address a known nutritional deficit and enhance the overall health of critically ill babies, this project sought to increase the percentage of cardiothoracic intensive care unit (CTICU) neonates consuming human milk from a 2019 baseline of 55% to 75% by December 2020 and 90% by December 2021.

STUDY DESIGN

This was a quality improvement initiative targeted to all neonates admitted to the CTICU, with baseline data obtained from January 2019 through February 2020. We implemented 11 interventions from March 2020 to January 2022 to address the key drivers of "education of parents and providers," "environment/equipment," and "process." We tracked the monthly percentage of neonates who were human milk fed with a statistical process control p-chart. The balancing measure of critical human milk feeding errors was also monitored.

RESULTS

The baseline percentage of CTICU neonates consuming human milk was 55%. This percentage increased to 73% by the end of 2020 and 92% by the year end 2021. Most neonates who received human milk were fed mother's milk with a minority receiving donor human milk. The number of aborted, critical human milk administration errors decreased during the intervention period.

CONCLUSIONS

In this quality improvement initiative, we significantly increased the percentage of CTICU neonates consuming human milk without an increase in critical human milk errors. Interventions directly increasing the ease with which lactating mothers can provide/store their milk were likely the most effective.

Survey on human milk feeding and enteral feeding practices for very-low-birth-weight infants in NICUs in China Neonatal Network

BACKGROUND

The breastfeeding rate in China is lower than that in many other countries and the extent of adoption of the "Feeding Recommendations for Preterm Infants and Low Birth Weight Infants" guideline in NICUs remains unclear.

METHOD

A web-based survey about the current status of human milk feeding and enteral feeding practices at NICUs was sent to all China Neonatal Network's cooperation units on September 7, 2021, and the respondents were given a month to send their responses.

RESULTS

All sixty NICUs responded to the survey, the reply rate was 100%. All units encouraged breastfeeding and provided regular breastfeeding education. Thirty-six units (60.0%) had a dedicated breastfeeding/pumping room, 55 (91.7%) provided kangaroo care, 20 (33.3%) had family rooms, and 33 (55.0%) routinely provided family integrated care. Twenty hospitals (33.3%) had their own human milk banks, and only 13 (21.7%) used donor human milk. Eight units (13.3%) did not have written standard nutrition management guidelines for infants with body weight < 1500 g. Most units initiated minimal enteral nutrition with mother's milk for infants with birth weight ˂1500 g within 24 h after birth. Fifty NICUs (83.3%) increased the volume of enteral feeding at 10-20 ml/kg daily. Thirty-one NICUs (51.7%) assessed gastric residual content before every feeding session. Forty-one NICUs (68.3%) did not change the course of enteral nutrition management during drug treatment for patent ductus arteriosus, and 29 NICUs (48.3%) instated NPO for 1 or 2 feeds during blood transfusion.

CONCLUSION

There were significant differences in human milk feeding and enteral feeding strategies between the NICUs in CHNN, but also similarities. The data obtained would be useful in the establishment of national enteral feeding guidelines for preterm infants and quality improvement of cooperation at the national level.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot

Background

Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system.

Aim

To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies.

Method

We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study.

Results

Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth.

Conclusion

A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Evidence summary of human milk fortifier in preterm infants

BACKGROUND

To search for and collect evidence on human milk fortifier in preterm infants, and to summarize the latest and best evidence, so as to provide reference for clinical work.

METHODS

We searched the databases of UpToDate, American Guide Network, Cochrane Library, Joanna Briggs Institute (JBI), PubMed, ResearchGate, China National Knowledge Infrastructure (CNKI), Wan Fang, Chinese Biology Medicine disc (CBM), and Yi Maitong, and collected relevant guidelines, systematic reviews, evidence summaries, expert consensuses, and randomized controlled trials (RCTs). The retrieval time limit was from the database establishment to July 2021. The quality of the literature was independently evaluated by 2 researchers, who then extracted and summarized the evidence from qualifying articles.

RESULTS

A total of 16 articles were selected, including 3 guidelines, 3 systematic reviews, 5 expert consensuses, 3 RCTs, and 1 best practice guideline, including indications, time for usage, methods, monitoring and management, time of cessation, health education, and post-discharge feeding.

CONCLUSIONS

This study summarized the best evidence for human milk fortifier in preterm infants. Medical staff should assess the specific clinical conditions and parental wishes when applying the best evidence to ensure the effectiveness and safety of human milk fortifier, thus improving the quality of clinical nursing.

Barcode scanning of human milk and enteral formulas improves efficiency and patient safety: A 7-year review

BACKGROUND

Safe handling of human milk (HM) and enteral formulas for patients of all ages is critical in healthcare. Barcode scanning is commonly used to reduce errors. The purpose of this study was to evaluate the impact of barcode scanning for HM and formulas on patient safety.

METHODS

Scanning is used at the time of feeding preparation for HM, facility-prepared formulas, and ready-to-feed enteral formulas for patients of all ages to confirm the feeding matches the provider order, record lot numbers, and ensure expired items are not used. HM feedings are scanned at the time of administration and discharge to ensure the correct milk is being provided to the correct patient. All formulas dispensed as samples to hospital inpatients and outpatients are scanned to record patient and product information in the event of a recall.

RESULTS

Seven-year data showed that scanning has prevented HM misadministration 1226 times. Data for 2 and a half years of fortifier and formula scanning show 480 errors have been prevented. The results show benefits for both patient safety and staff efficiency.

CONCLUSION

The benefits of barcode scanning systems in healthcare are well documented. Beyond the scanning of HM, scanning of fortifiers and formulas can improve patient safety by preventing misadministration for patients of all ages. Systems that offer features such as calculating fortified HM and formula recipes, tracking product lot numbers, and verifying correct products to the provider order can further improve safety as well as efficiency.

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother’s own milk or pasteurised donor human milk (PDHM) is a challenge in neonatal setups, like ours, without an attached human milk bank. Hence, this quality improvement initiative was taken to improve donor human milk collection in our urban tertiary-care teaching hospital, to at least 500 mL per week in 4 weeks. After analysing the problem, our quality improvement team identified a shortage of human milk donation that was due to low awareness among the stakeholders and lack of a system to collect and store human milk and transport it to a milk bank. The team first established a system of supplies needed for milk collection, storage and transportation. It then tested change idea of information, education and counselling to increase milk donation. The team carried out a few plan-do-study-act cycles (individual and group counsellings, and usage of videos and information leaflets) to test the change ideas and adapted a few and abandoned some. During this journey, the milk collection increased to above the target amount. Various challenges were addressed, and there was a need for constant motivation of the stakeholders, especially the mothers, and now there is sustained milk donation in the setup. This is incorporated in the standard operating procedure and as a quality indicator of the unit for sustaining the changes in the unit. Our initiative can be replicated in other setups for increasing collection of donor human milk. Greater PDHM availability for sick neonates will, in effect, reduce NEC and feeding intolerance rates, leading to reduced hospital stay, morbidity, mortality and economic burden.

The Role of Breast Milk in Infectious Disease

Human milk has many advantageous anti-infective and immunologic properties, making it the ideal nutritional source to optimize the well-being of infants. There are certain infectious circumstances where breast milk feedings should be withheld or strict precautions followed, and this article addresses these rare events. Contamination and misadministration when handling human milk is also a safety concern, especially when caring for vulnerable preterm infants. This article addresses ways to decrease these occurrences to maintain the inherent anti-infectious properties of human milk and preserve the health of our neonatal population.

Does Feeding Previously Frozen (Thawed) Fortified Human Milk Increase the Incidence of Lactobezoar (Milk Curd) Obstruction? A Retrospective Cohort Study in One Large Neonatal Intensive Care Unit

BACKGROUND

Current recommendations suggest that it is appropriate to store human milk (HM) for up to 24 hours following fortification despite any changes that may occur in fortified HM over time. However, a recent publication suggested fortified frozen HM should be thawed and fed within 12 hours of fortification due to the risk of lactobezoar or milk curd obstruction.

OBJECTIVE

This study investigated whether lactobezoar (milk curd) formation increased when frozen fortified HM was thawed and fed within 12 hours vs 12 to 24 hours postfortification in the neonatal intensive care unit (NICU) at Children's Hospital of Orange County to determine if practice changes were warranted.

DESIGN

This study was a retrospective cohort study.

PARTICIPANTS/SETTING

All infants admitted to the Children's Hospital of Orange County NICU for calendar years 2018-2019 who were fed fortified human milk (n = 802) were included in the study.

EXPOSURE VARIABLE

Feedings using previously frozen (thawed) fortified HM.

MAIN OUTCOME MEASURE

Lactobezoar or milk curd formation.

STATISTICAL ANALYSIS

Descriptive analyses were used for statistical analysis.

RESULTS

Of the 107,602 feedings prepared with fortified thawed HM, 68% (72,602) were used within 12 hours of preparation and 32% (34,499) were stored for 12 to 24 hours before administration. The NICU at Children's Hospital of Orange County did not identify any lactobezoar formation or milk curd obstruction in either group.

CONCLUSIONS

Data from this study support recommendations for a maximum storage time for thawed, fortified HM of 24 hours.

The business case for quality improvement

Value in healthcare can be defined as providing the optimal outcome per health dollar spent. Improving the value of healthcare for patients and healthcare organizations requires an understanding and evaluation of the costs and benefits. Investing in quality improvement (QI) work can bring about financial results for healthcare organizations over time, have beneficial organizational effects, and improve outcomes for patients. This article continues a series of QI educational papers in the Journal of Perinatology, and reviews financial and economic measures used to create the business case for QI. Ultimately, the business case for QI is better defined as a business strategy for success.

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.

Introduction of enterprise risk management in neonatal intensive care unit to reduce breast milk errors

Preterm infants born before 34 weeks gestation are unable to feed by mouth. Mothers of these preterm infants are thus asked to pump breast milk to be fed to infants through a nasogastric tube. Each mother's pumped breast milk must be carefully labelled and stored so that it is not fed to the wrong baby during the infants stay in the neonatal intensive care unit, which can range from days to months. All hospitals have strict policies and procedures in place to ensure infants are fed their mother's milk but still occasional errors are reported. We looked at the effect of introducing the enterprise risk management method in preventing breast milk errors in our neonatal intensive care unit.

Evaluation of Key Factors Impacting Feeding Safety in the Neonatal Intensive Care Unit: A Systematic Review

BACKGROUND

Individualized feeding care plans and safe handling of milk (human or formula) are critical in promoting growth, immune function, and neurodevelopment in the preterm infant. Feeding errors and disruptions or limitations to feeding processes in the neonatal intensive care unit (NICU) are associated with negative safety events. Feeding errors include contamination of milk and delivery of incorrect or expired milk and may result in adverse gastrointestinal illnesses.

PURPOSE

The purpose of this review was to evaluate the effect(s) of centralized milk preparation, use of trained technicians, use of bar code-scanning software, and collaboration between registered dietitians and registered nurses on feeding safety in the NICU.

METHODS/SEARCH STRATEGY

A systematic review of the literature was completed, and 12 articles were selected as relevant to search criteria. Study quality was evaluated using the Downs and Black scoring tool.

FINDINGS/RESULTS

An evaluation of human studies indicated that the use of centralized milk preparation, trained technicians, bar code-scanning software, and possible registered dietitian involvement decreased feeding-associated error in the NICU.

IMPLICATIONS FOR PRACTICE

A state-of-the-art NICU includes a centralized milk preparation area staffed by trained technicians, care supported by bar code-scanning software, and utilization of a registered dietitian to improve patient safety. These resources will provide nurses more time to focus on nursing-specific neonatal care.

IMPLICATIONS FOR RESEARCH

Further research is needed to evaluate the impact of factors related to feeding safety in the NICU as well as potential financial benefits of these quality improvement opportunities.

Best Practices for Handling and Administration of Expressed Human Milk and Donor Human Milk for Hospitalized Preterm Infants

The importance of human milk for the preterm infant is well established (1-3). However, the feeding of human milk to preterm infants is typically much more complicated than the mere act of breastfeeding (3, 4). The limited oral feeding skills of many preterm infants often results in human milk being administered via an enteral feeding tube (4). In addition, fortification is commonly required to promote optimal growth and development-particularly in the smallest of preterm infants (2, 4, 5). Consequently, a mother's own milk must be pumped, labeled, transported to the hospital, stored, tracked for appropriate expiration dates and times, thawed (if previously frozen), fortified, and administered to the infant with care taken at each step of the process to avoid microbial contamination, misadministration (the wrong milk for the wrong patient), fortification errors, and waste (1-5). Furthermore, the use of pasteurized donor human milk (DHM) for preterm infants when a mother's own milk is not available has been endorsed by many organizations (1). Therefore, appropriate procurement, storage, thawing (if received frozen), fortification, labeling, and administration must occur with the same considerations of preventing contamination and fortification errors while ensuring the correctly prepared final product reaches the correct patient (1). Many professional organizations have published best practices to provide hospitals with guidelines for the safe and accurate handling and preparation of expressed human milk (EHM) and DHM feedings for preterm infants (1-5). These best practices emphasize the importance of preparation location, trained staff, proper identification of human milk to prevent misadministration, and strategies to prevent fortification errors (1-6). The purpose of this mini-review article is to summarize current published best practices for the handling of human milk for preterm infants within the hospital setting (1-6). Emphasis will focus on the use of aseptic technique with proper sanitation and holding times/temperatures to limit microbial growth; use of technology to prevent misadministration of human milk and fortification errors as well as for tracking of expiration dates/times and lot numbers; and workflow strategies to promote safety while improving efficiencies (1-7).

Identifying a quality improvement project

An important step on the roadmap to a successful quality improvement (QI) project is careful selection of topics and aims to be addressed by QI projects. Using information from a variety of data monitoring systems as well as individual events and experiences, leaders of neonatal units and QI teams should first identify quality and safety gaps in their unit. They should then use an explicit, formal process for selecting the best projects to which their limited time and resources should be allocated. Priority should be given to projects that address a quality gap of high magnitude and impact, have a high likelihood of success, have a champion, fit with the unit's state of readiness for change, have organizational support and align with organizational priorities. The scope of the project should also match the experience and expertise of the QI team.