1. The Breast Feeding Initiative 2006 – 2007 Quality Improvement at the Audubon Clinic

2. Project BIB: AIM Statement To improve infant and maternal health and foster positive relationships between mother and child by increasing the duration of breast- feeding amongst new mothers, exclusively or in conjunction with formula feeding by educating, encouraging, and empowering women to continue giving breast milk to their new infants.

3. Specific Goals 90% 4-week visits 90% 4-week visits for patients breastfeeding at 2 week visit 65% breastfeeding 65% breastfeeding at 2 months (previously 41%)

4. Benefits for Baby Bonding with mother Bonding with mother Immunological Immunological ↓ bacterial meningitis, otitis media, NEC, UTIs, URIs, bacteremia, sepsis ↓ bacterial meningitis, otitis media, NEC, UTIs, URIs, bacteremia, sepsis Nutritional Nutritional Cognitive development Cognitive development Other: Other: ↓ SIDS, DM, obesity, asthma ↓ SIDS, DM, obesity, asthma ↓ leukemia, lymphoma ↓ leukemia, lymphoma

5. Benefits for Mother ↓ post-partum bleeding ↓ post-partum bleeding Positive bonding experience with baby Positive bonding experience with baby Improved weight loss post-partum Improved weight loss post-partum ↓ risk breast/ovarian cancer ↓ risk breast/ovarian cancer

6. Other Benefits Economic: Economic: ↓ U.S. health costs by estimated $3.6 billion ↓ U.S. health costs by estimated $3.6 billion ↓ W.I.C. costs ↓ W.I.C. costs ↓ Parental absence from employment as a result of ↓ Parental absence from employment as a result of ↓ infant illness Environmental: Environmental: ↓ energy demands for production and transport of artificial feeding products ↓ energy demands for production and transport of artificial feeding products ↓ disposal of formula cans and bottles ↓ disposal of formula cans and bottles

7. Obstacles to Initiation of Breastfeeding Insufficient prenatal education and encouragement of BF Insufficient prenatal education and encouragement of BF Early hospital discharge with late follow-up Early hospital discharge with late follow-up Formula promotion @ hospital, WIC, media Formula promotion @ hospital, WIC, media Maternal employment — poor support for pumping at work, demanding schedules Maternal employment — poor support for pumping at work, demanding schedules Lack of physician encouragement, guidance & recognition of obstacles with subsequent referrals Lack of physician encouragement, guidance & recognition of obstacles with subsequent referrals

8. Baseline Measurement Initial chart review (29 charts) Initial chart review (29 charts) 10% exclusively BF at 2 weeks 10% exclusively BF at 2 weeks 82% any BF at 2 weeks (BF + formula) 82% any BF at 2 weeks (BF + formula) 75% any BF at 4 weeks 75% any BF at 4 weeks 18% any BF at 4 months 18% any BF at 4 months 4% any BF at 6 months 4% any BF at 6 months

9. Cycle 1 Plan: Initiate 4 week visit for all babies who are BF at newborn visit Plan: Initiate 4 week visit for all babies who are BF at newborn visit Do: Plan communicated via didactic Do: Plan communicated via didactic Study: Providers offer greater BF support as primary goal of 4 week visit Study: Providers offer greater BF support as primary goal of 4 week visit Act: Further improve BF reinforcement by providing more education Act: Further improve BF reinforcement by providing more education

10. Cycle 2 Plan: Generate handout with BF resources Plan: Generate handout with BF resources Do: List of resources available for all providers to give BF moms Do: List of resources available for all providers to give BF moms Study: Handout not used routinely by providers, but list of resources helpful Study: Handout not used routinely by providers, but list of resources helpful Act: Further investigate how to encourage/support BF moms Act: Further investigate how to encourage/support BF moms

11. Cycle 3 Plan: Improve educational resources Plan: Improve educational resources Do: Do: Posters in all waiting room and clinic rooms Posters in all waiting room and clinic rooms Extensive BF handouts available in all clinic rooms Extensive BF handouts available in all clinic rooms Study: With handouts more readily available, increased use by providers Study: With handouts more readily available, increased use by providers Act: Look into how BF educational resources are impacting moms Act: Look into how BF educational resources are impacting moms

12. Cycle 4 Plan: Determine when & why moms decide to BF Plan: Determine when & why moms decide to BF Do: 10 newborn moms interviewed Do: 10 newborn moms interviewed Study: Most newborn moms at least 50% BF Study: Most newborn moms at least 50% BF Decision made very early in pregnancy - primary reason for BF is their mom/GM/friends told them it was best for their baby Decision made very early in pregnancy - primary reason for BF is their mom/GM/friends told them it was best for their baby PNC at Audubon or Broadway – were asked once if planning on BF, but did not receive significant support/information PNC at Audubon or Broadway – were asked once if planning on BF, but did not receive significant support/information Act: Meet with OB nurses and improve educational resources Act: Meet with OB nurses and improve educational resources

13. Cycle 5 Plan: Improve prenatal BF support Plan: Improve prenatal BF support Do: Interview OB nurses at Audubon Do: Interview OB nurses at Audubon Study: Study: Focus is in the third trimester Focus is in the third trimester Nurses are responsible for majority of BF counseling Nurses are responsible for majority of BF counseling Patients receive handbooks on pregnancy, but no specific information on BF Patients receive handbooks on pregnancy, but no specific information on BF Every patient is offered a referral to a one-time prenatal class given at the Allen Pavilion Every patient is offered a referral to a one-time prenatal class given at the Allen Pavilion Act: Collaborate with OB to improve BF support Act: Collaborate with OB to improve BF support

14. Cycle 6 Cycle 6 Plan: Meet with OB personnel to help partner in our initiative Plan: Meet with OB personnel to help partner in our initiative Do: Communicate goals to OB side in monthly staff meeting Do: Communicate goals to OB side in monthly staff meeting Study: Study: OB nurses supportive of project BIB OB nurses supportive of project BIB Suggestions: BF video in waiting room, lactation consultant in OB once a week Suggestions: BF video in waiting room, lactation consultant in OB once a week Act: Provide BF pamphlets and posters to OB nurses Act: Provide BF pamphlets and posters to OB nurses

15. Are we making progress? Initial chart review (n = 29) Secondary chart review (n=29) # of 4 week visits 75%94% BF at 4 weeks 75%53% BF at 2 months 41%38% (77% of those BF at 4 wks) BF at 4 months 18%33% ( 88% of those BF at 2 mo) * One mom increased breastfeeding to greater than 50% after one month visit!

16. Current Cycle Plan: Focus on prenatal BF support Plan: Focus on prenatal BF support Do: Continue collaborating with OB to implement specific interventions (video, lactation consultant) Do: Continue collaborating with OB to implement specific interventions (video, lactation consultant) Study: Study: Identifying one nurse or MA who is excited about the project will be more useful than a “top-down” approach Identifying one nurse or MA who is excited about the project will be more useful than a “top-down” approach Act: Continue to re-stock brochures, encourage 4 week visits, and partner with OB. Act: Continue to re-stock brochures, encourage 4 week visits, and partner with OB.

17. Future Goals/Directions Enhance interdisciplinary approach with OB Enhance interdisciplinary approach with OB Evaluate 1 month visits again and assess rates of breastfeeding Evaluate 1 month visits again and assess rates of breastfeeding Assess usefulness of educational information Assess usefulness of educational information

18. The Audubon Experience: Past QI Initiatives 2004-2005 BMI: 20% of charts had BMIs documented and plotted 2004-2005 BMI: 20% of charts had BMIs documented and plotted 2005-2006 Lead Screening: 53% of charts had documented lead screening 2005-2006 Lead Screening: 53% of charts had documented lead screening

19. The Audubon Experience: Past QI Initiatives Why such poor sustainability? Why such poor sustainability? Both initiatives relied on providers solely to implement and carry out project. How can we do better? How can we do better? Design system-based changes: electronic medical record, new clinic encounter forms, all medical personnel with designated roles and responsibilities. Design system-based changes: electronic medical record, new clinic encounter forms, all medical personnel with designated roles and responsibilities.

20. The Audubon Improvement Team! Residents: Residents: Melissa Dhundale, Tas Hoque, Heather Liu, Paul Planet, Tania Small, Emily Greenstein, Rebecca Locke, Christal Forgenie, Jason Freedman, Anil Kesavan, Angkana Roy, Tal Alon, Hannah Famiglietti, Dan Weiser, Gunjan Kamdar, Stephanie Leonard, Annika Hofstetter, Daniel Vo Attendings: Attendings: Valerie Niketakis, Larry Williams, Christine Krause, Roy Brown, Connie Kostakos, Nikki Timko, Betsy Wedemeyer, Melissa Stockwell And on the OB side: And on the OB side: Marian McEwan