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Abstract
Background Extreme variation in provider nutritional practices in the NICU leads to poor growth of premature infants. Standardization of current feeding practices through quality improvement may improve growth trajectory and developmental outcomes.
Objectives Increase the mean delta Z score for weight (difference in z-score between birth weight and discharge weight) from −1.8 to −1 within 6 months and sustain for 1 year, for neonates with birth weight (BW) <1500 grams, admitted within the 1 st week of life.
Methods A multidisciplinary team evaluated nutrition practices for VLBW infants and key drivers were determined (figure 1). Re-education around our current feeding protocol and intolerance decision aid, sharing growth information during rounds using an in-house assessment tool (figure 2), increased accessibility to breast pump rentals, standardization of lactation consultation ordering, and development of an infographic to assist mothers in choosing breast milk over formula (figure 3) were interventions tested using the IHI Model for Improvement. Mean delta Z score for weight (primary outcome measure) and number of lactation consultation orders per week (process measure) were recorded and analyzed.
Key driver diagram
Growth assessment for individualized nutrition (GAIN) status tool
Mom’s own milk infographic
Results Mean delta weight Z-score increased from −1.8 to −1.08 (figure 4) following the implementation of all of the noted interventions with centerline shift that has lasted for 8 months (40% improvement). Mean number of lactation consults ordered per week increased from 1 to 4.
Mean Δ weight Z score for every 5 discharged VLBW infant from the CN NICU (XmR chart)
Mean delta weight Z score for every 5 discharged very low birth weight infant from the CN NICU (XmR Chart). GAIN= growth assessment for individualized nutrition. *This PDSA is not annotated on the graph as the growth chart was updated in the electronic medical record in July 2018 and there are no additional data points available beyond 5/2/2018
Conclusions Reducing nutrition practice variation shows marked improvements in infant nutrition status. We continue to test other interventions with the hope of further decreasing growth failure.