1. Mitigation of Inadequate Growth GROWTH AIM NPC QIC Interstage growth failure * rate will decrease from every 2 patients to every 5 patients by June 30, 2014 Interstage Care Parents monitor daily weights and respond per Red Flag Action Plan** Clinic team conducts Pre-visit Planning to assure comprehensive weekly contact** or visit including Dietician consult**, monitor and address insufficient caloric intake***, update Nutrition Plan Readmit for Red Flags, weight loss, failure to gain, or low intake Change Concepts and Interventions Key DriversOutcomes National Pediatric Cardiology Quality Improvement Network (NPC QIC) Growth Key Driver Diagram Global Aim: Improve survival and optimize quality of life in infants between discharge after Stage 1 Norwood and admission for Bidirectional Glenn # Care Transition Bundle *defined as decreasing 2 or more weight for length percentile bands over the course of the interstage (Norwood discharge to Glenn admission) **Variation in Growth of Infants with a Single Ventricle; National Pediatric Cardiology Quality Improvement Collaborative. J Pediatr. 2012 Feb 14. Jeffrey B. Anderson, Srikant B. Iyer, David N. Schidlow, Richard Williams, Kartik Varadarajan, Megan Horsley, Julie Slicker, Jesse Pratt, Eileen King, Carole LannonVariation in Growth of Infants with a Single Ventricle; National Pediatric Cardiology Quality Improvement Collaborative. J Pediatr. 2012 Feb 14. *** Nutrition Algorithms for Infants with Hypoplastic Left Heart Syndrome; Birth through the First Interstage Period. Slicker J, Hehir DA, Horsley M, Monczka J, Stern KW, Roman B, Ocampo EC, Flanagan L, Keenan E, Lambert LM, Davis D, Lamonica M, Rollison N, Heydarian H, Anderson JB. Congenit Heart Dis. 2012 Aug 14Nutrition Algorithms for Infants with Hypoplastic Left Heart Syndrome; Birth through the First Interstage Period Parent Preparation for Interstage (prior to discharge) Establish a standardized discharge process using a checklist to assure and document comprehensive parental preparation # Employ rooming in or other experiential activity prior to discharge # Employ teach / demonstrate back methods to assure parental competency # Train parents in formula mixing using recommended recipes Provide scales and other monitors, and train parents in their use** Provide culturally and language appropriate written Red Flag Action Plan (RFAP)** # including Nutrition, Feeding and Home Monitoring Plans (02 sat, intake, weight) # Parents Prepared and Competent in Growth Related Activities Effective Transition from Inpatient to Outpatient Care Providers Conduct conference call with all interstage Care Team members (family, Cardiologist, PCP / Medical Home, Home Health et al) assuring support of RFAP and growth activities # Schedule appointments convenient to family with PCP, HH, Cardiology Clinic et al # Collaborate with non-NPC QIC referring cardiologists to receive clinic visit information Sufficient Caloric Intake Implement Interstage Feeding Program*** Evaluate feeding readiness** and continuously monitor feeding safety** Add oral feeding once feeding safety is confirmed Remove NG when oral volume and weight goals are reached Supplement parenteral feeding with human or donor milk once feeding safety and hemodynamic stability are confirmed (NG standard formula last choice) Advance volume and calories to expected weight gain