Rapid Cycle Improvement Collaborative (RCIC): Optimizing Human Milk Use in the Neonatal Intensive Care Unit (NICU) Cincinnati Children s Hospital Medical Center, Cincinnati, OH USA Emily Wiland MD, Pam Pockras, MSN, NNP-BC, CL, Andrew South, MD, MPH, Carrie Smith, RD, LD Keri Robison, BSN, RN, IBCLC, Cindi Acree, DNP, MEd, NNP-BC, and Amanda Luciano, RN Primary Author / Contact: Emily Wiland, MD; Emily.Wiland@cchmc.org Phone: (614) 348-2249 Aim: Exclusive breast milk feeding for the first 6 months of neonatal life is recommended for optimal nutrition. Our aim was to increase the percentage of infants discharged from the NICU on any maternal breast milk from 63% to 70% by June 5, 2014. Our goal was modest to make it attainable within a short period of time. Setting: Freestanding children s hospital, level 3C, 59 bed NICU. 2013: 655 admissions (430 VON eligible admissions) with 35% surgical admissions; Average length of stay-29.7 days. Mechanisms: This project was part of Cincinnati Children s Hospital s Rapid Cycle Improvement Course (RCIC). The goal of the course is to quickly assess and implement interventions over a 4- month period using a multi-disciplinary team. Key drivers and interventions are outlined in Figure 1. Methods: Population included all infants admitted to the NICU at < 7 days of life. We excluded infants with a diagnosis of Neonatal Abstinence Syndrome, infants placed for adoption, or infants who died prior to discharge. Processes for problem identification included creating a process map, performing root cause analysis, identifying failure modes, and constructing a paredo chart based upon maternal survey results (Figure 2A and 2B). Interventions were implemented and analyzed with PDSA (Plan, Do, Study, Act) cycles. Baseline data was collected from 9/2013 to 1/2014. A run chart was used to assess the impact of changes and monitor for outcome improvement (Figure 3). Measure: Weekly percentage of infants being discharged from the NICU on any human milk Data / Results: A full list of PDSA cycles completed during this quality improvement project is included in Table 1. The most successful changes included: (1) Adding pumping rooms showed improved waiting times to pump, (2) Interdisciplinary breast milk supply discussion on rounds with NICU dietitian, bedside nurse, lactation, and neonatologist improved awareness of mom s supply, (3) Optimizing EPIC to record mom s preference for providing breast milk and documentation of infant receiving maternal breast milk allowed for better identification, supply awareness, and data collection, and (4) Breast feeding champion NICU nurses who promote breastfeeding were re- engaged as a resource for moms. Some changes that were tested on a small scale, but proved to be less successful included: (1) A pumping buddy craft was offered to moms which used their baby s picture so moms could see their baby while pumping, and (2) Holistic health consults were offered to mothers. Prior to interventions, the baseline rate of infants being discharged from the NICU receiving any human milk was 63%, which recently significantly improved to 84% (Figure 3). Discussion: I nitially, our interventions did not result in an increase in the percentage of infants discharged home on human milk upon completion of the RCIC course. Possibly, our results did not immediately reflect the impact of our interventions as often our infants have a prolonged hospital stay. Other unique contextual features of our NICU that impacted our project include: (1) patients are transferred to our NICU therefore, initiation of pumping is often dependent on birth hospital, (2) the high proportion of surgical patients in our NICU necessitates mothers to provide breast milk though pumping as feeding tolerance is achieved, (3) few single rooms with most infants in large pod spaces made having
dedicated pumping rooms critical to success, and (4) our NICU has a robust lactation department and routine access to holistic health. As our improvement efforts continued, our initial goal of 70% for the baseline weekly percentage of infants discharged home on maternal breast milk was surpassed- significantly increasing to 84%. Our next steps are to assess the sustainability of our interventions and establish a new goal for our baseline. Figure 1: Key Driver Diagram
Figure 2: A and B: Paredo Graphs: Based on Maternal Survey Questions Figure 2A: What changes would have made your lactation experience easier? 100% 91.7% 100.0% 90% 83.3% 80% 75.0% Number of Responses 70% 60% 50% 40% 30% 25.0% 41.7% 58.3% 20% 3 10% 0% Time to pump 2 2 2 Obtaining pump through insurance Pump initiation outside hospital lactation support 1 1 1 Child care Identified issues by NICU mothers N=12 history of low milk supply lack of storage space Individual Quantities & Percentages Cumulative Percentages Figure 2B: What was the most difficult issue with providing Breast Milk? 100% 91.7% 100.0% 90% 83.3% 80% 75.0% Number of Responses 70% 60% 50% 40% 30% 33.3% 4 50.0% 66.7% 20% 10% 0% Pumping frequency 2 2 Timing of initiation Night time pumping 1 1 1 1 Supply Child care Tired of pumping Engorgement and pain Stated difficulties by NICU mothers N=12 Individual Quantities & Percentages Cumulative Percentages
Table 1: PDSA Cycles: Interventions and Decisions Intervention PDSA Outcome Measure Decision Additional pumping room made Waiting time to pump surveys Adapt-> Permanent additional available for moms for moms pumping room since waiting Interdisciplinary breast milk supply discussion on rounds focusing on breast milk availability and percent intake Evidence-based Lactation Information placed in pumping room for mom Lactation reminder card placed in NICU sign-in book if lactation was having difficulty contacting mom Updating Breast feeding champion nursing list* to determine who would like to be a resource for breast feeding moms Holistic Health consult and relaxation techniques** were offered to moms by lactation consultants Epic Optimization by recording use of maternal breast milk on flow sheet and in discharge summary using a smartphrase Pumping Buddy Craft-: moms put their baby s picture on a popsicle stick so they can see their baby wherever they Discussion happened and what information was found about available milk Utilization through survey for moms Utilization of reminder cards List updated Surveyed moms if helpful Able to be implemented and used by clinical team Utilization times improved Adapt-> incrementally spread to entire NICU Adapt-> put information closer to moms to improve utilization Abandoned- mothers did not contact lactation after receiving reminder cards. Adapt-> process of engaging nurses interested in supporting moms Adapt-> Institute earlier in hospital stay, as these were not well utilized by moms who had been in NICU for a long time Adopted Abandoned due to poor utilization are pumping. *Personal connections with health care workers encouraged breastfeeding better than literature or other media forms (Raider, 2000). **In a randomized control trial, relaxation and imagery techniques increased breast milk production by 63% (Jackson, 2010)
Figure 3: Run Chart with baseline prior to interventions and Rapid Cycle Improvement Collaborative (RCIC) Interventions