1. Feeding Error Reduction in Neonatal Intensive Care Unit Graduates During the Transition from Hospital to Home
Rupalee Patel, DNP, C-PNP, C-PHN, IBCLC, Matthew Nudelman, MD, Sunshine Pooley, MD,
Priya Jegatheesan, MD, Dongli Song, MD, PhD, Sonya Misra, MD, MPH, Balaji Govindaswami, MBBS, MPH
Santa Clara Valley Health & Hospital System (SCVHHS), San Jose, California, USA.
Background
Measures
Discussion
Home feeding plans are tailored to promote ideal growth and body composition of high risk infants at the time of discharge from Neonatal Intensive Care Unit (NICU) graduates.
Identify the presence of feeding errors that occur in the home after discharge.
Examine type and frequency of errors.
Develop standardized interventions based on identified post discharge caregiver needs for error reduction.
SCVHHS is a public safety net county hospital with a California regional level IV NICU, serving diverse urban, suburban, and rural areas. The study was conducted in the homes of NICU graduates after discharge from the NICU.
Home visits were conducted by SCVHHS Babies Reaching Improved Development and Growth in their Environment (BRIDGE) program Pediatric Nurse Practitioners (PNPs). Caregiver vulnerabilities such as limited knowledge, lack of resources, and stress have the potential to lead to feeding errors.
BRIDGE PNPs developed standardized formula preparation and breastmilk fortification interventions that NICU nurses used for caregiver discharge education. Interventions included instructional recipe cards in caregivers’ native language and providing caregivers with appropriate measuring spoons.
Study included NICU infants born between January 2011 and June 2015 who received two or more BRIDGE visits after discharge. Infants who expired within two weeks of discharge, moved out of the County, were lost to follow up, or whose parents declined were excluded. PNP observation during home visits consisted of structured assessment and documentation of errors. Data were prospectively collected and Institutional Review Board approved as a quality improvement project.
Feeding errors were defined as deviations from the prescribed plan of care. Errors were further subcategorized as mixing formula incorrectly (preparing formula incorrectly, incorrect breastmilk fortification, preparing incorrect volume or concentration), administering wrong type of formula, and inappropriate volumes (feeding too often or not often enough). Feeding errors were counted and documented based on number of errors identified by BRIDGE PNP. A single patient could have more than one error type (incorrect mixing, administration, and/or volume) per visit.
Summary:
Feeding errors were observed in NICU graduates with all types of discharge diets.
The observation of feeding errors during the transition from NICU to home led the BRIDGE PNPs to develop targeted, standardized interventions to help decrease errors.
Standardization and simplification of feeding types and coordination pre and post discharge minimizes errors at home.
Our intervention showed a reduction in breastmilk fortification errors. We also observed a reduction of formula errors in recent years.
Future Directions:
Evaluate the growth velocity and outcomes of infants with and without errors.
Examine growth velocity changes following feeding error correction and post discharge feeding plan modification may elucidate further opportunities to help NICU graduates grow.
This work would not have been possible without the extreme dedication of high risk infant families, and BRIDGE program PNPs: Adebola Olarewaju, MS, C-PNP, Carley Goldberg, MS, C-PNP, and Happy Baumann, MS, C-NP; NICU Lactation Coordinator: Alga Kifle, BSN, IBCLC; NICU Database Coordinator: Angela Huang, BSN; NICU nurses and neonatologists; SCVHHS Administration, First 5 Santa Clara County; VMC foundation.
Aim
Data
1463 home visits were made to 454 infants (median=3 visits, range 2-8), 21% (95/454) were born <1500 grams and 79% (359/454) were ≥1500 grams.
NICU discharge diet categorized (Figure A).
Feeding errors were identified in 18% (82/454) of infants.
A total of 107 errors were identified, of which 71% (76/107) were formula related and 29% (31/107) were breastmilk fortification related.
All feeding errors were further subcategorized (Figure B).
Feeding error rate reduction calculated (Figure C).
Setting
Figure A: NICU Discharge Diet
Mechanisms
Team Acknowledgments
Drivers of Change
Figure B: Home Feeding Errors
Year (Number of infants on diet)
Error Rate
Methods
Contact information
Rupalee Patel, DNP, MS, BSN, C-PNP, RN, IBCLC
751 South Bascom Avenue
San Jose, California 95126
Figure C: Home Feeding Error Rate Reduction