Details of the PDSA cycles
| PDSA | I (n=13) | II (n=33) | III (n=47) | IV (n=29) |
| When | 2.7.16 to 10.7.16 | 13.7.16 to 28.7.16 | 4.8.16 to 17.8.16 | 12.10.16 to 28.10.16 |
| Plan | Assess feasibility and safety of three-hourly feeding in two areas: TN and LBW room | Extend the test to neonates with birth weight >1000 g and to relatively sicker area (NNN) apart from TN and LBW room | New system of managing Katoris Qualitative experience of nurses Assess expressed breastmilk volume in a subset of women | Simplify eligibility criteria and update standard operating protocol |
| Do | Try three-hourly schedule in infants >32 weeks PMA and >1250 g birth weight; Track compliance, hypoglycaemic and feed intolerance; Record maternal fatigue scores | Three-hourly feeding in TN, LBW room and NNN, in infants >32 weeks PMA and >1000 g birth weight Track compliance, hypoglycaemia and feed intolerance; Record maternal fatigue scores | Continue three-hourly feeding in all three care areas in infants >32 weeks PMA and >1000 g birth weight Increase Katoris in circulation from 20 to 50, and change sterilisation schedule from two hourly to six-hourly Record qualitative experience of nurses Record volume of expressed breastmilk in seven randomly selected mothers Track compliance, hypoglycaemia and feed intolerance, maternal fatigue scores | Three-hourly feeding in all babies >32 weeks PMA and >1000 g birth weight in TN, LBW room and NNN, if currently not on respiratory support or having GER, irrespective of previous morbidities. Continue tracking compliance, hypoglycaemia and feed intolerance; maternal fatigue scores |
| Study | Compliance 16%. Safe in 13/13 (100%) Maternal fatigue scores marginally lower (median 12 (5–13)) compared with baseline (13 (8–23)) | Compliance 57%. Safe in 32/33 (97%) Feed intolerance in 1 (apnoea actually attributed to stoppage of caffeine). No case of hypoglycaemia. Two neonates switched to two-hourly feeds due to perceived excessive weight loss (not confirmed on chart review). Maternal fatigue scores lower- median (IQR) 4 (1–8) Difficulties encountered in clustering of nursing activities in NNN due to some sicker babies on two-hourly feeds and others on three-hourly feeds | Compliance 71%. Safe in 45/47 (96%) Mild asymptomatic transient hypoglycaemia in 2 (blood glucose 35 and 36)-switched to two-hourly, No feed intolerance Maternal fatigue scores median (IQR) 6 (4–7) Qualitative feedback of nurses favoured three-hourly feeds; New problem-confusion in eligibility criteria in NNN area due to previous morbidities of neonates transferred in from NICU. | Compliance 84%. Safe in 29/29 (100%) No case of hypoglycaemia, Two neonates changed to two-hourly feeds due to suspected GER. Maternal fatigue scores median (IQR) 3 (1–6) No problems with the new Katori sterilisation schedule. |
| Act | Extend the new feeding schedule to infants >32 weeks PMA and >1000 g birth weight and in NNN | Reorganise the nursing activities related to sterilisation of Katoris . Obtain qualitative feedback from nurses | Address the confusion in eligibility criteria and continue with new sterilisation schedule | Final written policy and SOP for three-hourly feeding in TN, LBW room and NNN. Periodic monitoring plan for compliance and any unexpected problems |
GER, gastro-oesophageal reflux; LBW, low birthweight; NICU, Neonatal Intensive Care Unit; NNN, neonatal nursery; PDSA, plan–do–study–act; PMA, postmenstrual age; TN, transitional nursery.