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  • Quality Improvement Article
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Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition

Journal of Perinatology (2024)Cite this article

Subjects

Abstract

Background

Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation.

Method

Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation.

Results

Reduced growth failure at discharge was observed in four of five NICUs, 11–32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2–5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable.

Conclusion

Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

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Fig. 1: Key driver diagram.
Fig. 2: ICN Nutrition Numbers Card.
Fig. 3: Infant Feeding Advancement Tool (IFAT).
Fig. 4: GBG collaborative rounding tool template.
Fig. 5: Nutrition process tool value and ease-of-use survey results.

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References

  1. Goldberg DL, Becker PJ, Brigham K, Carlson S, Fleck L, Gollins L, et al. Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. J Acad Nutr Dietetics. 2018;118:1571–82.

    Article  Google Scholar 

  2. Horbar JD, Ehrenkranz RA, Badger GJ, Edwards EM, Morrow KA, Soll RF, et al. Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 Grams: 2000–2013. Pediatrics. 2015;136:e84–92.

    Article  PubMed  Google Scholar 

  3. Thiess T, Lauer T, Woesler A, Neusius J, Stehle S, Zimmer KP, et al. Correlation of Early Nutritional Supply and Development of Bronchopulmonary Dysplasia in Preterm Infants <1,000 g. Front Pediatr. 2021;9:741365.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Makker K, Ji Y, Hong X, Wang X. Antenatal and neonatal factors contributing to extra uterine growth failure (EUGR) among preterm infants in Boston Birth Cohort (BBC). J Perinatol. 2021;41:1025–32.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Martínez-Jiménez MD, Gómez-García FJ, Gil-Campos M, Pérez-Navero JL. Comorbidities in childhood associated with extrauterine growth restriction in preterm infants: a scoping review. Eur J Pediatr. 2020;179:1255–65.

    Article  PubMed  Google Scholar 

  6. Wight, N, Kim, J, Rhine, W, Mayer, O, Morris, M, Sey, R, et al. Nutritional Support of the Very Low Birth Weight (VLBW) Infant: A Quality Improvement Toolkit Available from: https://www.cpqcc.org (2018).

  7. Ruys CA, van de Lagemaat M, Rotteveel J, Finken MJJ, Lafeber HN. Improving long-term health outcomes of preterm infants: how to implement the findings of nutritional intervention studies into daily clinical practice. Eur J Pediatr. 2021;180:1665–73.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Young A, Beattie RM, Johnson MJ. Optimising growth in very preterm infants: reviewing the evidence. Arch Dis Child Fetal Neonatal Ed. 2023;108:2–9.

    Article  PubMed  Google Scholar 

  9. Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: Establishing Habits for Improvement in Neonatal Intensive Care Units. Pediatrics. 2003;111:e397–410.

    Article  PubMed  Google Scholar 

  10. Adams M, Bassler D, Bucher HU, Roth-Kleiner M, Berger TM, Braun J, et al. Variability of Very Low Birth Weight Infant Outcome and Practice in Swiss and US Neonatal Units. Pediatrics. 2018;141:e20173436.

    Article  PubMed  Google Scholar 

  11. Stevens T, Shields E, Campbell D, Combs A, Horgan M, La Gamma E, et al. Variation in Enteral Feeding Practices and Growth Outcomes among Very Premature Infants: A Report from the New York State Perinatal Quality Collaborative. Am J Perinatol. 2015;33:009–19.

    Article  Google Scholar 

  12. McLeod G, Farrent S, Gilroy M, Page D, Oliver CJ, Richmond F, et al. Variation in Neonatal Nutrition Practice and Implications: A Survey of Australia and New Zealand Neonatal Units. Front Nutr. 2021;8:642474.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kaplan HC, Edwards EM, Soll RF, Morrow KA, Meyers J, Timpson W, et al. Variability in the systems of care supporting critical neonatal intensive care unit transitions. J Perinatol. 2020;40:1546–53.

    Article  PubMed  PubMed Central  Google Scholar 

  14. McCormick K, King C, Clarke S, Jarvis C, Johnson M, Parretti HM, et al. The role of breast milk fortifier in the post-discharge nutrition of preterm infants. Br J Hosp Med. 2021;82:42–8.

    Article  Google Scholar 

  15. Kaplan HC, Poindexter BB. Standardized Feeding Protocols: Evidence and Implementation. In: Koletzko B, Cheah FC, Domellöf M, Poindexter BB, Vain N, van Goudoever JB, editors. World Review of Nutrition and Dietetics. S. Karger AG; 2021. 289–300. Available from: https://www.karger.com/Article/FullText/514746.

  16. Stevens TP, Shields E, Campbell D, Combs A, Horgan M, La Gamma EF, et al. Statewide Initiative to Reduce Postnatal Growth Restriction among Infants <31 Weeks of Gestation. J Pediatrics. 2018;197:82–89.e2.

    Article  Google Scholar 

  17. Dhanireddy R, Scott PA, Barker B, Scott TA. Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants. Hospital Pediatrics. 2022;12:173–81.

    Article  PubMed  Google Scholar 

  18. Lagerquist E, al‐Haddad BJS, Irvine J, Muskthel L, Rios A, Upadhyay K. Feeding volume advancement in preterm neonates: A level 4 neonatal intensive care unit quality improvement initiative. Nut in Clin Prac. 2023;38:1175–80.

  19. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. Available from: https://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx.

  20. Groh-Wargo S, Barr SM. Parenteral Nutrition. Clin Perinatol. 2022;49:355–79.

    Article  PubMed  Google Scholar 

  21. Sniderman S, Hetherton M. Fluids and Electrolytes and Parenteral Nutrition. In The William H. Tooley Intensive Care Nursery House Staff Manual, 8th edition. San Francisco: University of California; 2003.

  22. Street JL, Montgomery D, Alder SC, Lambert DK, Gerstmann DR, Christensen RD. Implementing feeding guidelines for NICU patients<2000 g results in less variability in nutrition outcomes. JPEN J Parenter Enter Nutr. 2006;30:515–8.

    Article  Google Scholar 

  23. Jasani B, Patole S. Standardized feeding regimen for reducing necrotizing enterocolitis in preterm infants: an updated systematic review. J Perinatol. 2017;37:827–33.

    Article  CAS  PubMed  Google Scholar 

  24. Parker LA, Desorcy-Scherer K, Magalhães M. Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review. Adv Neonatal Care. 2021;21:493–502.

    Article  PubMed  Google Scholar 

  25. McKinley LT, Przystac L, Tucker R, Trail-Burns E, Vohr BR, Laptook AR, et al. Implementation of a Nutrition Care Bundle and Improved Weight Gain of Extremely Preterm Infants to 36 Weeks Postmenstrual Age. J Pediatrics. 2022;241:42–47.e2.

    Article  Google Scholar 

  26. Abiramalatha T, Thanigainathan S, Ramaswamy VV, Rajaiah B, Ramakrishnan S, Cochrane Neonatal Group. Routine monitoring of gastric residual for prevention of necrotising enterocolitis in preterm infants. Cochrane Database Syst Rev. 2023. Available from: https://doi.org/10.1002/14651858.CD012937.pub3.

  27. Hale G, McNab D. Developing a ward round checklist to improve patient safety. BMJ Qual Improv Rep. 2015;4:u204775.w2440.

    Article  PubMed  PubMed Central  Google Scholar 

  28. McConnell RA, Kerlin MP, Schweickert WD, Ahmad F, Patel MS, Fuchs BD. Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention. Respir Care. 2016;61:902–12.

    Article  PubMed  Google Scholar 

  29. Barimani B, Ahangar P, Nandra R, Porter K. The WHO Surgical Safety Checklist: A Review of Outcomes and Implementation Strategies. Perioper Care Operat Room Manag. 2020;21:100117.

    Article  Google Scholar 

  30. Taylor SN, Martin CR. Evidence-based Discharge Nutrition to Optimize Preterm Infant Outcomes. Neoreviews. 2022;23:e108–16.

    Article  PubMed  Google Scholar 

  31. Lowe J, Wong J. Primary Care for Preterm Infants & Children: A CPQCC Provider Toolkit. 2020; Available from: www.cpqcc.org.

  32. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a Mechanism to Improve Safety in Health Care. Jt Comm J Qual Saf. 2004;30:5–14.

    PubMed  Google Scholar 

  33. Rolnitsky A, Bell CM. Sustaining Improvement Initiatives: Challenges and Potential Tools. Clin Perinatol. 2023;50:307–20.

    Article  PubMed  Google Scholar 

  34. Balasundaram M, Land R, Miller S, Profit J, Porter M, Arnold C, et al. Increasing early exposure to mother’s own milk in premature newborns. J Perinatol. 2022;42:1126–34.

    Article  PubMed  Google Scholar 

  35. Celenza JF, Zayack D, Buus-Frank ME, Horbar JD. Family Involvement in Quality Improvement. Bedside Advocate Syst Advisor Clin Perinatol 2017;44:553–66.

    Google Scholar 

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Acknowledgements

We would like to thank the interdisciplinary team members of the 22 California NICUs who participated in the CPQCC Grow, Babies, Grow Collaborative.

Author information

Authors and Affiliations

  1. California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA

    Mindy Morris & Courtney Breault

  2. John Muir Medical Center, Walnut Creek, CA, USA

    Stacie Bennett & Kimberly Larson

  3. Children’s Hospital Orange County Mission Hospital, Mission Viejo, CA, USA

    Liz Drake

  4. UCSF Benioff Children’s Hospital, San Francisco, CA, USA

    Maria C. Hetherton

  5. University of California, Irvine Medical Center, Irvine, CA, USA

    Robin Clifton-Koeppel

  6. Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA

    Holly Schroeder

  7. Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Courtney Breault

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Contributions

MM conceived and designed the concept, designed the survey, performed data collection, and drafted and revised the manuscript. SB interpreted the results and critically reviewed and revised the manuscript. LD contributed to writing and critically reviewing the manuscript. MH contributed to writing and critically reviewing the manuscript. RK contributed to writing and reviewing the manuscript. HS contributed to writing, critically reviewing, and editing the manuscript. CB designed the survey, interpreted the results, assisted with data analysis, and reviewed the manuscript. KL contributed to writing the manuscript, interpreted the results and created the survey figures, and critically reviewed the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for the work.

Corresponding author

Correspondence to Mindy Morris.

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The authors declare no competing interests.

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Morris, M., Bennett, S., Drake, L. et al. Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition. J Perinatol (2024). https://doi.org/10.1038/s41372-024-01963-x

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