As a NICU nurse at Children’s Hospital of Orange County in Orange, Calif., Karen MacGillivray, RN, BSN, is used to working with tiny infants. But nothing warms her heart more than when one of those premature babies gets just a tiny bit bigger.
That important weight gain has happened a lot more since the hospital implemented a standardized nutritional intervention program in the NICU in 2005. Everybody is following the standard and doing the same thing, MacGillivray says, which has led to a significant 300-gram increase in mean weight at discharge for the neonates.
Three hundred grams doesn’t sound like a lot to some people, but that’s half the birth weight for some of this population, notes Mindy Morris, RNC, MS, NNP-BC, a neonatal nurse practitioner on the unit. In the three years since the hospital began the program, other significant results include:
- administration of protein via IV 30 hours earlier than before implementation, which has improved infants’ overall nutritional intake;
- removal of central lines an average of 16 days earlier, which has subsequently decreased risk of infection;
- a 50% reduction in the number of infants discharged home with a head circumference lower than the third percentile, which is a risk factor for poor neurodevelopmental outcomes.
Multidisciplinary effortKaren MacGillivray, RN, BSN, and Mindy Morris, RNC, MS, NNP-BC, show a mother the feeding guideline for her son.
The standardized approach began as a multidisciplinary, staff-driven quality improvement project. Our overall goal was to improve nutrition in extremely low-birth-weight infants, which are infants with a birth weight less than 1,000 grams, Morris says.
The group of nurses, dieticians, pharmacists, and neonatologists based their plan on a review of the literature and evidence-based practices. Their multi-level approach includes adding protein to the first IV fluids administered, a protocol for advancing feedings, and a feeding intolerance algorithm — a decision tree of the common factors, such as the presence of a significant amount of residual from the previous feeding, that may indicate a need to stop feeding.
It’s still a physician’s decision of when is the right time to feed the patient, Morris says. But once that decision’s been made, and clinically, the infant is safe to start receiving enteral nutrition, then feeding should occur via the guidelines.
There are four guidelines, which progress at different rates based on the infant’s birth weight. The guideline for the smallest neonates (less than 750 grams) proceeds the most slowly. It starts at 10 milliliters of 20 calorie/ounce breast milk per kilogram of the baby’s weight per day, and progresses with incremental advances in volume no more than 10 ml/kg/day. By the 22nd day of enteral feeding, the infant should be up to 150 ml/kg/day of 24 calorie/ounce breast milk with the addition of Beneprotein.
So on the first day of enteral feeding, a baby with a birth weight of 600 grams (0.6 kilograms) would receive 6 milliliters of breast milk a day, or 0.75 milliliters every three hours.
The staff has been very happy with implementation of the guidelines, Morris says. They know what the plan for feeding is. It does not change every day depending on who’s rounding.
The standardization also helps parents know what to expect. The families appreciate knowing where their baby is [on the feeding progression] and what’s to come in the future, MacGillivray says. With the feeding guidelines being right there in the chart, the parent can follow along each day and see the progress.
Knowing what to expect can help parents understand difficulties that may arise. When we add human milk fortifier to breast milk, sometimes there are tolerance issues, Morris says. We can show when that’s going to happen [using the guidelines] and give the parents a heads up that this may be a day that feedings may not go as well. It’s a nice education tool.
The project helped the hospital earn a third place award in the 2008 Child Health Corporation of America’s RACE for Results award program, which annually spotlights quality improvement initiatives that have proven effective in resolving critical issues in children’s hospitals.
The staff has been sharing the guidelines at quality improvement meetings across the country. Morris estimates that 25 to 30 other NICUs have adapted them for themselves.
Morris encourages other NICUs to tackle quality improvement initiatives. These types of practice changes can be made at the bedside, she says.
But as gratifying as it is for staff to see their efforts put into practice, what’s even better is seeing the impact on patient outcomes, she says. That changes that we are making here have the potential to reduce poor developmental outcomes is encouraging for us, Morris adds.
Every gram gained is a cause for celebration.