- Email: [email protected]
Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State
Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State Joy Henderson RNC-NIC, MSN, MPhil, CPNP, Adriann Combs RN, BSN PII: DOI: Reference:
S1527-3369(14)00055-5 doi: 10.1053/j.nainr.2014.06.005 YNBIN 50562
To appear in:
Newborn and Infant Nursing Reviews
Please cite this article as: Henderson Joy, Combs Adriann, Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State, Newborn and Infant Nursing Reviews (2014), doi: 10.1053/j.nainr.2014.06.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State
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Primary Contact: Joy Henderson, RNC-NIC, MSN, MPhil, CPNP
City, NY
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Manager, Regional Perinatal Centers at New York Presbyterian Hospital, New York
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600 W. 165th St, Ste 1 J,New York City NY 10032
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[email protected] cell: 646-341-1593
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From New York Presbyterian Hospital Regional Perinatal Center at Columbia University
Adriann Combs, RN, BSN
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CE
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Medical Center, Morgan Stanley Children’s Hospital
Coordinator, Regional Perinatal Center University Hospital Health Sciences Center SUNY Stonybrook, NY 11744 [email protected]
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 1 Abstract
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Through regionalization and collaboration driven by data, neonatal outcomes can be
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evaluated and improved. In addition to the nationally accepted regionalization recommendations, New York State has an additional level. The additional level referred
SC
to as Regional Perinatal Centers (RPCs) provide oversight to birthing hospitals within
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their regions. The improvement project discussed in this article is related to improving extra-uterine growth in very preterm babies born less than 31 weeks gestation. This
MA
improvement was driven by the RPCs in collaboration with the New York State Department of Health’s Bureau of Women’s Health through the New York State
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Perinatal Quality Collaborative.
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Regionalization of care
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Key Words: Very Low Birth Weight, Enteral Feeds, Quality Improvement,
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 2 Introduction
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The initiation and advancement of enteral feeds in the Neonatal Intensive Care Unit
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(NICU) remains a challenging practice for neonatal practitioners with the effects of extrauterine growth restriction persisting after discharge, placing the premature infant at
SC
risk for long term growth and neurodevelopmental problems following discharge.1-3 Despite advances in neonatal care, the very premature (28-32 weeks gestational age)
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and extremely premature (less than 27 weeks gestational age)3 infant’s functional and
MA
developmental immaturity, severity of illness, inability to coordinate suck swallowing and breathing and variations in practice often present formidable barriers to be overcome in
ED
order to initiate and advance feeds in the NICU. Moreover, although mother’s own milk is considered optimal nutrition for very premature infants by the American Academy of
PT
Pediatrics (AAP), supply is often limited and available for a shortened period of time in
CE
the NICU.2 Questions arise regarding how early to start enteral feeds, how quickly to advance the feeds and how to maintain production of human milk until an infant can
AC
transition to full breastfeeding. This article describes an improvement project related to improving extra-uterine growth in very preterm babies born less than 31 weeks gestation, driven by the Regional Perinatal Centers (RPCs) in collaboration with the New York State Department of Health’s Bureau of Women’s Health through the New York State Perinatal Quality Collaborative (NYSPQC). Background New York is one of the top 5 states in the United States in birth rate and accounted for 38% of all live births in the US in 2010.4 The other states are California, Texas, Illinois
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 3 and Florida. In 2011 the total live birth rate in New York State (NYS) was 241,312 of
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which 26,302 were premature births resulting in a prematurity rate of 10.9%.5
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New York State’s regionalization system is based on a perinatal designation matrix and involves application by a birthing hospital to NYS for the desired level. Levels include
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Level I through Level III and the RPCs and are closely aligned with AAP and American
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College of Gynecology (ACOG) Guidelines for Perinatal Care.6 RPCs are differentiated from Level III centers in that they provide highly specialized services including
MA
extracorporeal membrane oxygenation, cardiac surgery, neurosurgical services and intrauterine procedures. The RPC has additional responsibilities for teaching, research
ED
and outreach. Additionally, RPCs have data review responsibilities with their affiliates. In addition to collaboration with their affiliates, the RPC is responsible to provide an
PT
infrastructure to integrate perinatal services within their region. These organizations
CE
include hospitals, health departments and other perinatal stakeholders. As of 2010 there were 137 birthing hospitals in NYS. Eighteen of these are categorized as RPCs, thirty
AC
six Level III, twenty five Level II and fifty eight Level I services as shown in Table 1. NYS utilizes an electronic system for birth registration and collection of data for quality initiatives. In addition to the State Perinatal Database System (SPDS), there is additional data entry for any newborn admitted to a Level II, III or RPC NICU. This specific subset of the database is called the NICU module of the SPDS. Data collection is mandatory based on NYS regulations. The data collection is extensive including maternal and birth data, data collection based on body systems, nutrition, disposition and follow up information. The system provides standardized patient and summary
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 4 reports. A discharge summary and data elements can be exported for further review
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and analysis.
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New York State Perinatal Quality Collaborative
There are many successful state wide perinatal collaboratives. Some of the best
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examples include California (www.cpqcc.org) and Ohio (www.opqc.net). More state
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collaboratives can be found on the CDC web page at www.cdc.gov. Utilizing the collaborative model, states have demonstrated marked improvement in a variety of
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outcomes including the rate of non-medically indicated delivery at less than 39 weeks and central line associated blood stream infections(CLABSI) in newborns. The
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NYSPQC is built upon the common purpose of improving maternal and newborn outcomes. This is accomplished through shared experiences and challenges at
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interactive learning sessions, data sharing, monthly coaching calls, a password
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protected website and an active listserv. The first efforts of the collaborative focused on standardizing the elements of central line
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insertion and maintenance bundles and measuring bundle usage in RPC NICUs. This project was done utilizing data from the NICU module of the SPDS and data submitted to the National Healthcare Safety Network (NHSN) database for hospital acquired infections. The pre-implementation period data collection epoch was from January December 2007. Implementation included collaborative learning sessions identifying the evidence supporting best practices, exemplars of successful programs to reduce CLABSI, data collection and entry and frequent feedback to the participating units on their bundle usage and CLABSI rates. The post implementation period measured bundle usage and CLABSI rates from March - December 2008. Both time periods
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 5 included more than 55,000 central line days and 200,000 patient days. The project
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67% reduction using the 2008 revised definition (p<.005).7-8
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resulted in a 40% decrease in CLABSI rate using the pre-2008 CDC definition and a
In addition to the success of this individual initiative, it exemplified the fact that the
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RPCs collectively could improve outcomes. The project increased awareness related to
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the importance of timely and accurate data collection and entry to the NICU module and the utility of its existence. More importantly, individual RPC CLABSI rates were de-
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identified and at the completion of the project, rates and successes were shared openly. The RPC group then met to identify the next improvement to develop. In reviewing
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baseline data from 2009 for babies born less than 31 weeks gestation a large variation was found between hospitals in the percent of infants discharged at the less than tenth
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percentile on the Fenton growth curve.9 At the baseline for the project (2009), 1300
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infants were members of the cohort born less than 31 weeks and discharged from the RPC NICUs. Totals in individual RPC NICUs ranged from 17 neonates to 135 neonates.
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The rate of extra-uterine growth restriction ranged from 18.8-65.9%, with a statewide RPC average of 32%.
After much discussion and data review, the group, composed of nurses, nurse practitioners, physicians and nutritionists decided to address extra-uterine growth in infants born at less than 1500 grams. This was later revised to less than 31 weeks gestation to prevent confounding outcomes related to older small for gestational age infants. Ultimately the primary goal of the project was to optimize enteral nutrition in newborns less than 31 weeks gestational age. Secondary goals were to reduce the incidence of sepsis, especially CLABSI by decreasing catheter days, promote healthy
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 6 neurologic outcomes and not increase rates of necrotizing enterocolitis (NEC). The
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enteral feeding initiative’s measureable aim was to reduce, within one year the
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proportion of newborns less than 31 weeks gestation at birth being discharged from the NICU below the 10th percentile growth parameter statewide. Issues that present
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challenges to optimizing enteral feeds such as variations in nutritional management
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practices, enteral feeding tolerance and advancement of feeds were seen as areas open to improvement across all regional centers. Evidence based practices identified in
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the literature included the benefits of a standardized feeding protocol, early minimal enteral nutrition, defining feeding intolerance and encouraging the use of human milk.10This led to the development of the following four key drivers of the initiative. Each
NICU was encouraged to:
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13
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1) Develop a system for optimal use of human milk;
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2) Establish hospital and physician enteral feeding policies; 3) Establish awareness of risk and expected benefits of early enteral feeds
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4) Establish communication across all systems of care promoting a culture of safety and improvement.
A summary of details that were to be addressed in each of these drivers are described in Table 2. The ability to monitor nutritional advances was made easier due to the availability of a standard data collection system, the NICU Module of the SPDS. The web based system captures aspects of enteral feeding including initiation, type of advancement to full enteral feeds and over 300 other data fields. The SPDS also captures morbidities linked to enteral feeding such as NEC, nosocomial sepsis and CLABSI. Using the NICU
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 7 Module of the SPDS reduced the burden of additional data collection by utilizing only
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information that was currently input into the SPDS, with which personnel at all perinatal
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centers in NYS were already familiar. Additional data points were identified in September 2009 and added to the existing database. The data parameters added
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included birth and discharge head circumference, birth and discharge length and the
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number of days to regain birth weight. These parameters were added to be able to calculate the Ponderal Index, a measure of overall growth rather than simply utilizing
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weight which does not necessarily reflect appropriate growth. The Ponderal Index accounts for weight, head circumference and length.14
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Although the intent of the neonatal collaborative was to reduce the burden of mortality and morbidity associated with preterm birth by facilitating the use of evidence-based
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clinical practices to improve care, a review of the literature and a nutritional survey
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developed by the expert panel and distributed to neonatologists statewide uncovered wide variations in practice. Due to the lack of evidence that one specific nutritional
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advancement or intolerance plan is better than another,15-16 it was decided that each RPC NICU develop or improve their own standardized nutritional practice. It was proposed that the use of the individual standardized nutritional practices would result in an increase in weight for age at NICU discharge compared with NICU admission. Methods All RPCs in NYS were invited to participate in the neonatal nutrition collaborative. The project aim was identified; centers were charged with identifying a team of collaborators and informed of baseline data collection and analysis of 2009 SPDS NICU Module; and the impending distribution of an enteral feeding practices survey. Following the
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 8 collection of baseline data, the enteral feeding practices surveys were distributed to all
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neonatologists in the RPCs throughout the state in December 2010. The surveys were
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distributed to the RPC coordinators who then distributed the surveys to the neonatologists in their individual units. The surveys were then returned to the NYSDOH
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for review and tabulation. Survey response rates varied between RPCs. The response
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rate was 81% with all 18 regional centers represented. Items surveyed included timing of initiation of minimal enteral nutrition, duration and advancement of minimal enteral
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nutrition, timing of initiation of enteral feeds, advancement of enteral feeds, guidance regarding evaluation of feeding tolerance, and feeding practices during specific clinical
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circumstances such as medication use (e.g. vasopressors, prostaglandin), blood transfusions and presence of indwelling umbilical catheters (venous and arterial).
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Analysis of survey results showed that the RPC NICUs that showed the lowest
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discharges at less than the 10th percentile had practice guidelines in place to address most issues raised by the survey questions. Those NICUs with the highest discharges
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less than the 10th percentile addressed fewer issues consistently in a standardized manner. The survey was repeated again in 2013 to evaluate improvement. Interestingly, the interim focus on nutrition increased the number of survey responses in 2010 from 116 individual neonatologists to 167 in 2013. A great improvement was found in most areas and a slight improvement in the number of centers that focused on feeding intolerance (Table 3). In addition to the survey results, Fenton growth curves were compiled for the state and individual RPCs based on the 2009 data and individual data was shared at learning collaborative sessions in an un-blinded fashion in order to keep focused on the overall
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 9 aim of the project. The growth curves are available for the entire collaborative and each
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RPC for each year of the project beginning in 2009 and currently available through
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2012. 2013 Fenton growth charts will be available in late 2014.
At the first collaborative learning session attended by teams from all regional centers in
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January 2011, the project aim was reiterated and the first draft of the key drivers was
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reviewed. In addition to the initial drivers shown in Table 2 and based on information and data collected, recommendations for actions were suggested by the expert
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neonatal group of the NYSPQC at this first collaborative learning session. These included:
Standardization of enteral nutrition practices, including practices related to initiation
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•
of enteral feedings, enteral feeding advancement and evaluation of enteral feeding
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intolerance, would be created by each NYS regional perinatal center for
•
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implementation in their own NICU. RPC specific and NYS-wide baseline data on growth outcomes will be presented to
•
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each RPC in order to identify those RPCs achieving strong growth outcomes. Though benchmarking to identify potentially better practices will be encouraged and facilitated through workshops, conference calls and site visits to centers with favorable indicator values, each individual RPC will be solely responsible for developing and implementing standardized practices in their NICU. The collaborative committed to make no attempts to standardize nutritional or feeding practices among RPCs, only to discover potentially better practices from existing variation across the state. Improvements
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 10 The RPCs have been able to drive down the median age in days to first trophic feed,
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from 5 days to 3 days, and time to first full volume feed from 14 days to 13 days. Time
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to full enteral feeds has been reduced from 20 days to 17 days overall. Most importantly, rates of sepsis and NEC have not increased despite a more progressive
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advancement of enteral feeds. Initially, there was concern about discharging shorter,
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over weight infants. With the addition of head circumference and length data for admission and discharge, the calculation of the Ponderal Index was possible in order to
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ameliorate this concern.
So, did we reach the overall project aim - in one year to reduce the number of infants
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discharged at less than the 10th percentile of growth? Table 4 shows the differences in primary outcome at our pre-project time point in 2009 compared to post-improvement
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through 2012. The percent discharged at less than the 10th percentile has been
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decreased from a baseline of 32% to 28%. In spite of this improvement, we believe additional improvements are possible.
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Future Improvement Work
Currently there still remains a risk of discharge below the 10th percentile based on individual RPCs practices. Certain trends have been identified, including a “slowing” of growth around feeding transitions beginning with providing parenteral nutrition immediately after birth for a pre-identified group of high risk infants, standardization of the process of transition and unit based standards for kilocalorie/kilogram volumes when parenteral nutrition is discontinued. Closer scrutiny to the patterns of weight gain at the time of transition from gavage feeding to breastfeeding and/or bottle feeding will also be an important area of focus. For many centers in the collaborative, the focus is
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 11 on increasing the early and continued use of human milk through the NICU stay and
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incorporating donor breast milk more efficiently for these high risk babies in NYS.
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Feeding intolerance remains an issue that requires further exploration and evidence. The increased use of human milk and the introduction of donor human milk to many
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RPCs may reduce episodes of feeding intolerance, but, a standardized approach to
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managing residuals and other evidence of intolerance needs to be emphasized. Currently the initiative is only being conducted in the RPCs. This cohort represents
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approximately 60% of the babies less than 31 weeks in 18 hospitals. Therefore close to 40% of outcomes at the remaining 119 perinatal birth centers have not yet been
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explored. Best practices continue to be identified for this specific cohort of babies to demonstrate that improvements in perinatal outcome can be achieved through
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regionalization of care and collaboration driven by data.
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 12 Table 1: New York State Hospital Perinatal Designation Levels as of 2010
36
Level II*
25
Level I
58
Total Birthing Hospitals
137
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Level III*
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18
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Regional Perinatal Centers
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Number
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Designation
*All perinatal centers that are required to enter data into Statewide Perinatal Database
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System (SPDS)
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 13 Table 2: Key Drivers for NYS Perinatal Quality Collaborative Neonatal Enteral Feeding
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Source: New York State Perinatal Quality Collaborative
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Initiative (First Draft, 2010)
GOAL: Optimize early enteral nutrition in newborns less than 1500 grams.
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PROJECT AIM: In one year, reduce the percentage of newborns statewide that are
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below the 10th percentile
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Hospital and physician
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Optimal use of human milk
• Educate mother re: nutritional benefits of breast milk • Develop a system for early lactation discharged from the NICU support • Promote use of neonatal nutritionist • Provide optimal storage systems for breast milk • Educate NICU staff on nutritional benefits of breast milk • Include the use of breast milk in enteral feeding policy • Collect data on use and trends to inform policy • Collect existing hospital policies to enteral feeding practices review and compare, identify common elements • QI Panel to complete a peer/literature review • Develop essential components as guidelines for RPC protocols • Collect data on time to first feed, time to accelerate • Consistently educate and promote use of policies amongst NICU staff-especially new physicians • Engage all NICU staff to provide feedback on protocol • Educate staff on the evidence base for early enteral feeds, including disseminating relevant data • Family awareness campaign: benefits of early enteral feeds and use of human milk • Staff education: proper implementation of feeding protocol • Provide periodic inservices on relevant topics to keep awareness raised • Provide frequent reinforcement of family • Continuous monitoring and dissemination of data with discussion at staff/administration meetings • Develop ways to include all NICU staff input about feeding practices and data results • Develop processes for family feedback on NICU
Awareness of risks and expected benefit of early enteral nutrition
Culture of safety and improvement
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 14
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environment relative to feeding practices • Encourage NICU staff to propose new ideas for improvement based on experience with implementing protocols
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Table 3: Survey Results: Baseline and Current Practice regarding enteral feeding practices in NYS RPCs
Year/survey response (n)
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Source: New York State Perinatal Quality Collaborative 2010 (n=116)
2013 (n=167)
90%
92%
59%
92%
Nutritional feeding: Criteria for Initiation
55%
92%
Nutritional feeding: Criteria for feeding advancement
41%
93%
Guidance regarding feeding tolerance
60%
69%
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Trophic feeding: Criteria for initiation
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Trophic feeding: Criteria for duration and advancement
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 15 Table 4: Proportion of Discharges Less Than 10th Percentile for Postmenstrual age
2009
2012
Total less than 10th percentile*
416
Total cohort**
1300
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(PMA) 2009 and 2012, NYS all RPCs
Percent of total less than 10th percentile
32%
28%
388
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1386
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*Includes 6 newborns discharged at 51 or more weeks adjusted GA weighing < 10 th percentile for Fenton at 50 weeks (2009)
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** Excludes 8 newborns discharged at 51 or more weeks adjusted GA weighing at or
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above the 10th percentile for Fenton at 50 weeks (2009)
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Source: New York State Perinatal Database System ( SPDS)
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 16 References
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1. Su, BH. Optimizing nutrition in preterm infants. Pediatrics and Neonatology. 2014;
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55:5-13.
2. Cricco-Lizza,R. Everyday nursing practice values in the NICU and their reflection on
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breastfeeding promotion. Qualitative Health Research. 2011; 21(3): 399-409.
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3. Ross ES, Browne, JV. Feeding outcomes in preterm infants after discharge from the neonatal intensive care unit (NICU): a systematic review. Newborn & Infant Nursing
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Reviews. 2013; 13:87-93.
4. Martin, JA, Hamilton, BE, Ventura, SJ, et al. Births: final data for 2010. National Vital
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Statistics Report. 2012; 61(1).
5. National Center for Health Statistics. Final natality data for 2011. Retrieved 1 April,
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2014 from www.marchofdimes.com/peristats.
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6. American Academy of Pediatrics and ACOG. Guidelines for perinatal care, (7th Edition). Editors: Riley LE, Start AR. 2012; 7:1-10.
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7. Schulman, J, Stricof, R, Stevens, TP, et al. Statewide NICU central-line associated bloodstream infection rates decline after bundles and checklist. Pediatrics. 2011; 127(3): 436-444. 8. Schulman J, Stricof, RL, Stevens TP, et al. Development of a statewide collaborative to decrease NICU central line – associated bloodstream infections. Journal of Perinatology.2009; 29:591-599. 9. Fenton, TR. A new growth chart for preterm babies: Babson and Benda’s chart updated with recent data and a new format. BMC Pediatrics. 2003; 3:13. doi:10.1186/1471-2431-3-13.
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 17 10. McCallie KR, Lee HC, Mayer O, Cohen RS, Hintz SR, Rhine WD. Improved
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outcomes with a standardized feeding protocol for very low birth weight infants.
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Journal of Perinatology. 2011;31(Suppl 1):S61-7.
11. Morgan J, Bombell S, McGuire W. Early trophic feeding versus enteral fasting for
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very preterm or very low birth weight infants. Cochrane Database of Systematic
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Reviews 2013, Issue 3. Art. No.: CD000504. DOI:
10.1002/14651858.CD000504.pub4 - See more at:
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http://summaries.cochrane.org/CD000504/early-trophic-feeding-versus-enteralfasting-for-very-preterm-or-very-low-birth-weight-infants#sthash.4Ubzhgko.dpuf
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12. Lays, C., Maucort-Boulch, D., Guy, B., et al. Extremely Low Birthweight Infants: How Neonatal Intensive Care Unit Teams Can Reduce Postnatal Malnutrition and
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Prevent Growth Retardation. Acta Paediatricia. 2013; 102:242-248.
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13. Thureen, P. Early Aggressive Nutrition in the Neonate, Neoreviews 1999: 9:e45-e55. 14. Olsen, IE., Lawson, L., Meinzen-Derr, J, et al. Use of a Body Proportionality index
491.
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for Growth Assessment of Preterm Infants. Journal of Pediaitrics. 2009; 154:486-
15. Adamkin DH, Nutrition Management of the Very Low Birth Weight Infant II. Optimizing Enteral Nutrition and Post Discharge Nutrition. NeoReviews 2006; 7; e608-e614. 16. Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001241. DOI: 10.1002/14651858.CD001241.pub4.
S1527-3369(14)00055-5 doi: 10.1053/j.nainr.2014.06.005 YNBIN 50562
To appear in:
Newborn and Infant Nursing Reviews
Please cite this article as: Henderson Joy, Combs Adriann, Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State, Newborn and Infant Nursing Reviews (2014), doi: 10.1053/j.nainr.2014.06.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Attention to Enteral Feeding Practices Can Improve Growth Outcomes in VLBW Infants in New York State
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T
Primary Contact: Joy Henderson, RNC-NIC, MSN, MPhil, CPNP
City, NY
SC
Manager, Regional Perinatal Centers at New York Presbyterian Hospital, New York
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600 W. 165th St, Ste 1 J,New York City NY 10032
MA
[email protected] cell: 646-341-1593
ED
From New York Presbyterian Hospital Regional Perinatal Center at Columbia University
Adriann Combs, RN, BSN
AC
CE
PT
Medical Center, Morgan Stanley Children’s Hospital
Coordinator, Regional Perinatal Center University Hospital Health Sciences Center SUNY Stonybrook, NY 11744 [email protected]
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 1 Abstract
T
Through regionalization and collaboration driven by data, neonatal outcomes can be
RI P
evaluated and improved. In addition to the nationally accepted regionalization recommendations, New York State has an additional level. The additional level referred
SC
to as Regional Perinatal Centers (RPCs) provide oversight to birthing hospitals within
NU
their regions. The improvement project discussed in this article is related to improving extra-uterine growth in very preterm babies born less than 31 weeks gestation. This
MA
improvement was driven by the RPCs in collaboration with the New York State Department of Health’s Bureau of Women’s Health through the New York State
ED
Perinatal Quality Collaborative.
AC
CE
Regionalization of care
PT
Key Words: Very Low Birth Weight, Enteral Feeds, Quality Improvement,
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 2 Introduction
T
The initiation and advancement of enteral feeds in the Neonatal Intensive Care Unit
RI P
(NICU) remains a challenging practice for neonatal practitioners with the effects of extrauterine growth restriction persisting after discharge, placing the premature infant at
SC
risk for long term growth and neurodevelopmental problems following discharge.1-3 Despite advances in neonatal care, the very premature (28-32 weeks gestational age)
NU
and extremely premature (less than 27 weeks gestational age)3 infant’s functional and
MA
developmental immaturity, severity of illness, inability to coordinate suck swallowing and breathing and variations in practice often present formidable barriers to be overcome in
ED
order to initiate and advance feeds in the NICU. Moreover, although mother’s own milk is considered optimal nutrition for very premature infants by the American Academy of
PT
Pediatrics (AAP), supply is often limited and available for a shortened period of time in
CE
the NICU.2 Questions arise regarding how early to start enteral feeds, how quickly to advance the feeds and how to maintain production of human milk until an infant can
AC
transition to full breastfeeding. This article describes an improvement project related to improving extra-uterine growth in very preterm babies born less than 31 weeks gestation, driven by the Regional Perinatal Centers (RPCs) in collaboration with the New York State Department of Health’s Bureau of Women’s Health through the New York State Perinatal Quality Collaborative (NYSPQC). Background New York is one of the top 5 states in the United States in birth rate and accounted for 38% of all live births in the US in 2010.4 The other states are California, Texas, Illinois
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 3 and Florida. In 2011 the total live birth rate in New York State (NYS) was 241,312 of
T
which 26,302 were premature births resulting in a prematurity rate of 10.9%.5
RI P
New York State’s regionalization system is based on a perinatal designation matrix and involves application by a birthing hospital to NYS for the desired level. Levels include
SC
Level I through Level III and the RPCs and are closely aligned with AAP and American
NU
College of Gynecology (ACOG) Guidelines for Perinatal Care.6 RPCs are differentiated from Level III centers in that they provide highly specialized services including
MA
extracorporeal membrane oxygenation, cardiac surgery, neurosurgical services and intrauterine procedures. The RPC has additional responsibilities for teaching, research
ED
and outreach. Additionally, RPCs have data review responsibilities with their affiliates. In addition to collaboration with their affiliates, the RPC is responsible to provide an
PT
infrastructure to integrate perinatal services within their region. These organizations
CE
include hospitals, health departments and other perinatal stakeholders. As of 2010 there were 137 birthing hospitals in NYS. Eighteen of these are categorized as RPCs, thirty
AC
six Level III, twenty five Level II and fifty eight Level I services as shown in Table 1. NYS utilizes an electronic system for birth registration and collection of data for quality initiatives. In addition to the State Perinatal Database System (SPDS), there is additional data entry for any newborn admitted to a Level II, III or RPC NICU. This specific subset of the database is called the NICU module of the SPDS. Data collection is mandatory based on NYS regulations. The data collection is extensive including maternal and birth data, data collection based on body systems, nutrition, disposition and follow up information. The system provides standardized patient and summary
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 4 reports. A discharge summary and data elements can be exported for further review
T
and analysis.
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New York State Perinatal Quality Collaborative
There are many successful state wide perinatal collaboratives. Some of the best
SC
examples include California (www.cpqcc.org) and Ohio (www.opqc.net). More state
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collaboratives can be found on the CDC web page at www.cdc.gov. Utilizing the collaborative model, states have demonstrated marked improvement in a variety of
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outcomes including the rate of non-medically indicated delivery at less than 39 weeks and central line associated blood stream infections(CLABSI) in newborns. The
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NYSPQC is built upon the common purpose of improving maternal and newborn outcomes. This is accomplished through shared experiences and challenges at
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interactive learning sessions, data sharing, monthly coaching calls, a password
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protected website and an active listserv. The first efforts of the collaborative focused on standardizing the elements of central line
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insertion and maintenance bundles and measuring bundle usage in RPC NICUs. This project was done utilizing data from the NICU module of the SPDS and data submitted to the National Healthcare Safety Network (NHSN) database for hospital acquired infections. The pre-implementation period data collection epoch was from January December 2007. Implementation included collaborative learning sessions identifying the evidence supporting best practices, exemplars of successful programs to reduce CLABSI, data collection and entry and frequent feedback to the participating units on their bundle usage and CLABSI rates. The post implementation period measured bundle usage and CLABSI rates from March - December 2008. Both time periods
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 5 included more than 55,000 central line days and 200,000 patient days. The project
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67% reduction using the 2008 revised definition (p<.005).7-8
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resulted in a 40% decrease in CLABSI rate using the pre-2008 CDC definition and a
In addition to the success of this individual initiative, it exemplified the fact that the
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RPCs collectively could improve outcomes. The project increased awareness related to
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the importance of timely and accurate data collection and entry to the NICU module and the utility of its existence. More importantly, individual RPC CLABSI rates were de-
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identified and at the completion of the project, rates and successes were shared openly. The RPC group then met to identify the next improvement to develop. In reviewing
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baseline data from 2009 for babies born less than 31 weeks gestation a large variation was found between hospitals in the percent of infants discharged at the less than tenth
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percentile on the Fenton growth curve.9 At the baseline for the project (2009), 1300
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infants were members of the cohort born less than 31 weeks and discharged from the RPC NICUs. Totals in individual RPC NICUs ranged from 17 neonates to 135 neonates.
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The rate of extra-uterine growth restriction ranged from 18.8-65.9%, with a statewide RPC average of 32%.
After much discussion and data review, the group, composed of nurses, nurse practitioners, physicians and nutritionists decided to address extra-uterine growth in infants born at less than 1500 grams. This was later revised to less than 31 weeks gestation to prevent confounding outcomes related to older small for gestational age infants. Ultimately the primary goal of the project was to optimize enteral nutrition in newborns less than 31 weeks gestational age. Secondary goals were to reduce the incidence of sepsis, especially CLABSI by decreasing catheter days, promote healthy
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 6 neurologic outcomes and not increase rates of necrotizing enterocolitis (NEC). The
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enteral feeding initiative’s measureable aim was to reduce, within one year the
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proportion of newborns less than 31 weeks gestation at birth being discharged from the NICU below the 10th percentile growth parameter statewide. Issues that present
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challenges to optimizing enteral feeds such as variations in nutritional management
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practices, enteral feeding tolerance and advancement of feeds were seen as areas open to improvement across all regional centers. Evidence based practices identified in
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the literature included the benefits of a standardized feeding protocol, early minimal enteral nutrition, defining feeding intolerance and encouraging the use of human milk.10This led to the development of the following four key drivers of the initiative. Each
NICU was encouraged to:
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13
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1) Develop a system for optimal use of human milk;
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2) Establish hospital and physician enteral feeding policies; 3) Establish awareness of risk and expected benefits of early enteral feeds
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4) Establish communication across all systems of care promoting a culture of safety and improvement.
A summary of details that were to be addressed in each of these drivers are described in Table 2. The ability to monitor nutritional advances was made easier due to the availability of a standard data collection system, the NICU Module of the SPDS. The web based system captures aspects of enteral feeding including initiation, type of advancement to full enteral feeds and over 300 other data fields. The SPDS also captures morbidities linked to enteral feeding such as NEC, nosocomial sepsis and CLABSI. Using the NICU
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 7 Module of the SPDS reduced the burden of additional data collection by utilizing only
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information that was currently input into the SPDS, with which personnel at all perinatal
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centers in NYS were already familiar. Additional data points were identified in September 2009 and added to the existing database. The data parameters added
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included birth and discharge head circumference, birth and discharge length and the
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number of days to regain birth weight. These parameters were added to be able to calculate the Ponderal Index, a measure of overall growth rather than simply utilizing
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weight which does not necessarily reflect appropriate growth. The Ponderal Index accounts for weight, head circumference and length.14
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Although the intent of the neonatal collaborative was to reduce the burden of mortality and morbidity associated with preterm birth by facilitating the use of evidence-based
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clinical practices to improve care, a review of the literature and a nutritional survey
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developed by the expert panel and distributed to neonatologists statewide uncovered wide variations in practice. Due to the lack of evidence that one specific nutritional
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advancement or intolerance plan is better than another,15-16 it was decided that each RPC NICU develop or improve their own standardized nutritional practice. It was proposed that the use of the individual standardized nutritional practices would result in an increase in weight for age at NICU discharge compared with NICU admission. Methods All RPCs in NYS were invited to participate in the neonatal nutrition collaborative. The project aim was identified; centers were charged with identifying a team of collaborators and informed of baseline data collection and analysis of 2009 SPDS NICU Module; and the impending distribution of an enteral feeding practices survey. Following the
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 8 collection of baseline data, the enteral feeding practices surveys were distributed to all
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neonatologists in the RPCs throughout the state in December 2010. The surveys were
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distributed to the RPC coordinators who then distributed the surveys to the neonatologists in their individual units. The surveys were then returned to the NYSDOH
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for review and tabulation. Survey response rates varied between RPCs. The response
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rate was 81% with all 18 regional centers represented. Items surveyed included timing of initiation of minimal enteral nutrition, duration and advancement of minimal enteral
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nutrition, timing of initiation of enteral feeds, advancement of enteral feeds, guidance regarding evaluation of feeding tolerance, and feeding practices during specific clinical
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circumstances such as medication use (e.g. vasopressors, prostaglandin), blood transfusions and presence of indwelling umbilical catheters (venous and arterial).
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Analysis of survey results showed that the RPC NICUs that showed the lowest
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discharges at less than the 10th percentile had practice guidelines in place to address most issues raised by the survey questions. Those NICUs with the highest discharges
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less than the 10th percentile addressed fewer issues consistently in a standardized manner. The survey was repeated again in 2013 to evaluate improvement. Interestingly, the interim focus on nutrition increased the number of survey responses in 2010 from 116 individual neonatologists to 167 in 2013. A great improvement was found in most areas and a slight improvement in the number of centers that focused on feeding intolerance (Table 3). In addition to the survey results, Fenton growth curves were compiled for the state and individual RPCs based on the 2009 data and individual data was shared at learning collaborative sessions in an un-blinded fashion in order to keep focused on the overall
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 9 aim of the project. The growth curves are available for the entire collaborative and each
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RPC for each year of the project beginning in 2009 and currently available through
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2012. 2013 Fenton growth charts will be available in late 2014.
At the first collaborative learning session attended by teams from all regional centers in
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January 2011, the project aim was reiterated and the first draft of the key drivers was
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reviewed. In addition to the initial drivers shown in Table 2 and based on information and data collected, recommendations for actions were suggested by the expert
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neonatal group of the NYSPQC at this first collaborative learning session. These included:
Standardization of enteral nutrition practices, including practices related to initiation
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•
of enteral feedings, enteral feeding advancement and evaluation of enteral feeding
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intolerance, would be created by each NYS regional perinatal center for
•
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implementation in their own NICU. RPC specific and NYS-wide baseline data on growth outcomes will be presented to
•
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each RPC in order to identify those RPCs achieving strong growth outcomes. Though benchmarking to identify potentially better practices will be encouraged and facilitated through workshops, conference calls and site visits to centers with favorable indicator values, each individual RPC will be solely responsible for developing and implementing standardized practices in their NICU. The collaborative committed to make no attempts to standardize nutritional or feeding practices among RPCs, only to discover potentially better practices from existing variation across the state. Improvements
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 10 The RPCs have been able to drive down the median age in days to first trophic feed,
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from 5 days to 3 days, and time to first full volume feed from 14 days to 13 days. Time
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to full enteral feeds has been reduced from 20 days to 17 days overall. Most importantly, rates of sepsis and NEC have not increased despite a more progressive
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advancement of enteral feeds. Initially, there was concern about discharging shorter,
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over weight infants. With the addition of head circumference and length data for admission and discharge, the calculation of the Ponderal Index was possible in order to
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ameliorate this concern.
So, did we reach the overall project aim - in one year to reduce the number of infants
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discharged at less than the 10th percentile of growth? Table 4 shows the differences in primary outcome at our pre-project time point in 2009 compared to post-improvement
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through 2012. The percent discharged at less than the 10th percentile has been
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decreased from a baseline of 32% to 28%. In spite of this improvement, we believe additional improvements are possible.
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Future Improvement Work
Currently there still remains a risk of discharge below the 10th percentile based on individual RPCs practices. Certain trends have been identified, including a “slowing” of growth around feeding transitions beginning with providing parenteral nutrition immediately after birth for a pre-identified group of high risk infants, standardization of the process of transition and unit based standards for kilocalorie/kilogram volumes when parenteral nutrition is discontinued. Closer scrutiny to the patterns of weight gain at the time of transition from gavage feeding to breastfeeding and/or bottle feeding will also be an important area of focus. For many centers in the collaborative, the focus is
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 11 on increasing the early and continued use of human milk through the NICU stay and
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incorporating donor breast milk more efficiently for these high risk babies in NYS.
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Feeding intolerance remains an issue that requires further exploration and evidence. The increased use of human milk and the introduction of donor human milk to many
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RPCs may reduce episodes of feeding intolerance, but, a standardized approach to
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managing residuals and other evidence of intolerance needs to be emphasized. Currently the initiative is only being conducted in the RPCs. This cohort represents
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approximately 60% of the babies less than 31 weeks in 18 hospitals. Therefore close to 40% of outcomes at the remaining 119 perinatal birth centers have not yet been
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explored. Best practices continue to be identified for this specific cohort of babies to demonstrate that improvements in perinatal outcome can be achieved through
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regionalization of care and collaboration driven by data.
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 12 Table 1: New York State Hospital Perinatal Designation Levels as of 2010
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Level II*
25
Level I
58
Total Birthing Hospitals
137
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Level III*
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18
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Regional Perinatal Centers
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Number
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Designation
*All perinatal centers that are required to enter data into Statewide Perinatal Database
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System (SPDS)
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 13 Table 2: Key Drivers for NYS Perinatal Quality Collaborative Neonatal Enteral Feeding
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Source: New York State Perinatal Quality Collaborative
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Initiative (First Draft, 2010)
GOAL: Optimize early enteral nutrition in newborns less than 1500 grams.
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PROJECT AIM: In one year, reduce the percentage of newborns statewide that are
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below the 10th percentile
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Hospital and physician
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Optimal use of human milk
• Educate mother re: nutritional benefits of breast milk • Develop a system for early lactation discharged from the NICU support • Promote use of neonatal nutritionist • Provide optimal storage systems for breast milk • Educate NICU staff on nutritional benefits of breast milk • Include the use of breast milk in enteral feeding policy • Collect data on use and trends to inform policy • Collect existing hospital policies to enteral feeding practices review and compare, identify common elements • QI Panel to complete a peer/literature review • Develop essential components as guidelines for RPC protocols • Collect data on time to first feed, time to accelerate • Consistently educate and promote use of policies amongst NICU staff-especially new physicians • Engage all NICU staff to provide feedback on protocol • Educate staff on the evidence base for early enteral feeds, including disseminating relevant data • Family awareness campaign: benefits of early enteral feeds and use of human milk • Staff education: proper implementation of feeding protocol • Provide periodic inservices on relevant topics to keep awareness raised • Provide frequent reinforcement of family • Continuous monitoring and dissemination of data with discussion at staff/administration meetings • Develop ways to include all NICU staff input about feeding practices and data results • Develop processes for family feedback on NICU
Awareness of risks and expected benefit of early enteral nutrition
Culture of safety and improvement
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 14
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environment relative to feeding practices • Encourage NICU staff to propose new ideas for improvement based on experience with implementing protocols
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Table 3: Survey Results: Baseline and Current Practice regarding enteral feeding practices in NYS RPCs
Year/survey response (n)
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Source: New York State Perinatal Quality Collaborative 2010 (n=116)
2013 (n=167)
90%
92%
59%
92%
Nutritional feeding: Criteria for Initiation
55%
92%
Nutritional feeding: Criteria for feeding advancement
41%
93%
Guidance regarding feeding tolerance
60%
69%
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Trophic feeding: Criteria for initiation
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Trophic feeding: Criteria for duration and advancement
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 15 Table 4: Proportion of Discharges Less Than 10th Percentile for Postmenstrual age
2009
2012
Total less than 10th percentile*
416
Total cohort**
1300
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(PMA) 2009 and 2012, NYS all RPCs
Percent of total less than 10th percentile
32%
28%
388
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1386
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*Includes 6 newborns discharged at 51 or more weeks adjusted GA weighing < 10 th percentile for Fenton at 50 weeks (2009)
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** Excludes 8 newborns discharged at 51 or more weeks adjusted GA weighing at or
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above the 10th percentile for Fenton at 50 weeks (2009)
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Source: New York State Perinatal Database System ( SPDS)
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 16 References
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1. Su, BH. Optimizing nutrition in preterm infants. Pediatrics and Neonatology. 2014;
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55:5-13.
2. Cricco-Lizza,R. Everyday nursing practice values in the NICU and their reflection on
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breastfeeding promotion. Qualitative Health Research. 2011; 21(3): 399-409.
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3. Ross ES, Browne, JV. Feeding outcomes in preterm infants after discharge from the neonatal intensive care unit (NICU): a systematic review. Newborn & Infant Nursing
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4. Martin, JA, Hamilton, BE, Ventura, SJ, et al. Births: final data for 2010. National Vital
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Statistics Report. 2012; 61(1).
5. National Center for Health Statistics. Final natality data for 2011. Retrieved 1 April,
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6. American Academy of Pediatrics and ACOG. Guidelines for perinatal care, (7th Edition). Editors: Riley LE, Start AR. 2012; 7:1-10.
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7. Schulman, J, Stricof, R, Stevens, TP, et al. Statewide NICU central-line associated bloodstream infection rates decline after bundles and checklist. Pediatrics. 2011; 127(3): 436-444. 8. Schulman J, Stricof, RL, Stevens TP, et al. Development of a statewide collaborative to decrease NICU central line – associated bloodstream infections. Journal of Perinatology.2009; 29:591-599. 9. Fenton, TR. A new growth chart for preterm babies: Babson and Benda’s chart updated with recent data and a new format. BMC Pediatrics. 2003; 3:13. doi:10.1186/1471-2431-3-13.
ACCEPTED MANUSCRIPT Henderson / Combs Enteral Feeding Practices 17 10. McCallie KR, Lee HC, Mayer O, Cohen RS, Hintz SR, Rhine WD. Improved
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outcomes with a standardized feeding protocol for very low birth weight infants.
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Journal of Perinatology. 2011;31(Suppl 1):S61-7.
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http://summaries.cochrane.org/CD000504/early-trophic-feeding-versus-enteralfasting-for-very-preterm-or-very-low-birth-weight-infants#sthash.4Ubzhgko.dpuf
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12. Lays, C., Maucort-Boulch, D., Guy, B., et al. Extremely Low Birthweight Infants: How Neonatal Intensive Care Unit Teams Can Reduce Postnatal Malnutrition and
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Prevent Growth Retardation. Acta Paediatricia. 2013; 102:242-248.
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13. Thureen, P. Early Aggressive Nutrition in the Neonate, Neoreviews 1999: 9:e45-e55. 14. Olsen, IE., Lawson, L., Meinzen-Derr, J, et al. Use of a Body Proportionality index
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15. Adamkin DH, Nutrition Management of the Very Low Birth Weight Infant II. Optimizing Enteral Nutrition and Post Discharge Nutrition. NeoReviews 2006; 7; e608-e614. 16. Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001241. DOI: 10.1002/14651858.CD001241.pub4.