Improving Human Milk and Breastfeeding Practices in the NICU.

JOGNN CNE Continuing Nursing Education (CNE) Credit A total of 1.6 contact hours may be earned as CNE credit for reading “Improving Human Milk and Breastfeeding Practices in the NICU” and for completing an online posttest and evaluation. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

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Improving Human Milk and Breastfeeding Practices in the NICU Karen Fugate, Ivonne Hernandez, Terri Ashmeade, Branko Miladinovic, and Diane L. Spatz

ABSTRACT Objective: To determine if systematic implementation of the Spatz Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants (Ten Steps) would result in an improvement in the percentage of infants receiving mother’s own milk (MOM) at initiation of feedings and at hospital discharge.

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Design: Continuous quality improvement (QI) process.

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Patients: Very- low-birth-weight (VLBW) infants weighing fewer than 1500 grams.

Setting: Urban, 82-bed, Level-III NICU.

Intervention: The Ten Step method was implemented during a 3-year period. Keywords breastfeeding very low birth weight VLBW human milk quality improvement NICU neonate

Correspondence Karen Fugate, BSN RNC-NIC, CPHQ, Tampa General Hospital, PO Box 1289, Tampa, FL 33601-1289. [email protected]

Measurements: Process measurements included percentage of VLBW infants receiving MOM at initiation of feeds, number of mothers of VLBW infants with hospital-grade electric breast pump at hospital discharge, and number of mothers of VLBW infants initiating pumping within 6 hours of delivery. Outcome measurements included percentage of VLBW infants with any human milk at discharge to home and parent satisfaction with nurses’ support of mother’s efforts to breastfeed. Balancing measurements included percentage of VLBW infants at less than the third percentile for growth on the Fenton growth chart at discharge and receiving pasteurized donor milk (PDM). Results: Significant improvements were achieved in the percentages of mothers expressing their milk within 6 hours of delivery, infants receiving MOM at initiation of feeds, and mothers with a hospital-grade pump at discharge. Improvements in these processes resulted in increased parent satisfaction with nurses’ support of breastfeeding and a 3.1-fold greater odds of the VLBW infant receiving MOM at discharge in 2013 compared to 2010 (odds ratio [OR]= 3.01, 95% confidence interval [CI] [1.75, 5.17], p < .001). Despite an increase in the use of MOM, there was not a significant increase in VLBW infants discharged at less than the third percentile for growth, and initiation of PDM did not negatively affect the percentage of VLBW infants with any human milk at discharge. Conclusions: Implementation of the Ten Steps method using QI methodology resulted in significantly improved rates of use of MOM at initiation of feeds and at hospital discharge.

JOGNN, 44, 426-438; 2015. DOI: 10.1111/1552-6909.12563 Accepted December 2014

Karen Fugate, BSN, RNC-NIC, CPHQ, is a quality specialist, Tampa General Hospital NICU, Tampa General Hospital, Tampa, FL. The authors and planners for this activity report no conflict of interest or relevant financial relationships. The article includes no discussion of off-label drug or device use. No commercial support was received for this educational activity.

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uman milk (HM) feeding should be viewed as an integral part of the care of preterm or critically ill infants. Human milk is nutritionally superior to infant formula and provides many well documented benefits including decrease in adverse neonatal outcomes such as necrotizing enterocolitis (NEC), sepsis, and retinopathy of prematurity (Menon & Williams, 2013). Very-low-birth-weight (VLBW) infants (fewer than 1500 grams) fed HM have improved visual acuity (Okamoto et al., 2007) and higher scores on tests of neurocognitive evaluations (Vohr et al., 2006; Vohr et al., 2007). In a recent policy statement, the National Association of Neonatal Nurses (NANN; 2011) indicated that “As the professional voice of neonatal nurses, the National Association of Neonatal Nurses (NANN) en-

H

courages all neonatal nurses to provide mothers of critically ill newborns the education, support, and encouragement needed to provide human milk for their infant.”. The American Academy of Pediatrics (AAP; 2012) recommended that all preterm infants should receive HM, and if the mother’s own milk (MOM) was unavailable, appropriately fortified pasteurized donor HM should be used. Human milk feeding is associated with a decrease in the risk and severity of NEC. NEC is one of the most serious and devastating neonatal diseases and is a leading cause of morbidity and mortality that can affect 7% to 14% of VLBW infants (Parker, 2013). The outcome of infants with NEC is variable and can produce devastating sequelae, with

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Fugate, K., Hernandez, I., Ashmeade, T., Miladinovic, B., and Spatz, D. L.

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mortality rates reaching 20% to 40% depending on disease severity and need for surgical intervention (Parker, 2013). Approximately 40% of infants diagnosed with NEC require surgical treatment that has been estimated to extend hospital stays by 43.1 days at a cost of $198,040. Medical treatment of infants with NEC may extend hospitalization by 11.7 days at a cost of $74,004 (Ganapathy, Hay, & Kim, 2012). Human milk feedings reduce the risk of NEC in infants during the hospital stay by 58% (Ip et al., 2007). Increasing the use of HM in the NICU is the only evidence-based practice to decrease the incidence of NEC in infants. Given the demonstrated benefits of HM feeding in the NICU, increasing the use of HM is critical. The U.S. federal government has increased awareness of the World Health Organization’s BabyFriendly Hospital Initiative (BFHI) through the Best Fed Beginnings grant program (National Institute for Children’s Healthcare Quality, 2014). However, the BFHI Ten Steps to Successful Breastfeeding (Baby-Friendly USA [BFUSA], 2012) are designed for healthy term infants. In 2004, Spatz adapted the principles of the BFHI into the Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants (Ten Steps).

Intended Improvement In 2010, our NICU HM feeding rates were suboptimal with only 80% of VLBW infants receiving MOM at initiation of feedings. The percentage of VLBW infants discharged home receiving HM was 35.8% compared to 53.6% in other Vermont Oxford Network (VON) centers (VON, 2014). The VON is a voluntary, not-for-profit collaboration of more than 1,000 NICUs worldwide (more than 500 in the United States) that submit data related the care and outcomes of infants in the NICU. The VON database holds information on more than 1.5 million infants and provides participating centers with comprehensive benchmarking reports to use for practice improvement (VON, 2015). The project goal was to determine if the systematic implementation of comprehensive lactation and breastfeeding support using the Spatz Ten Steps method (Spatz, 2004) (Table 1) would result in an increase in the percentage of infants receiving MOM at initiation of feeds and at discharge.

Methods This project involved the systematic implementation of evidence-based practices utilizing quality improvement (QI) strategies and thus did not

JOGNN 2015; Vol. 44, Issue 3

Given the demonstrated benefits of human milk feeding in the NICU, increasing the use of human milk is critical.

require Institutional Review Board approval. The project was implemented at an urban, 82-bed, Level-III NICU that cares for approximately 120 VLBW infants annually. The NICU is located within a 1,021 bed, not-for-profit tertiary care center. The predominant payor is Medicaid (85%). During the period of this project, breastfeeding rates for the healthy term population were also being improved by participation in the National Institute for Children’s Healthcare Quality (NICHQ) Best Fed Beginnings collaborative (NICHQ, 2015), which provided structure and processes for implementing the U.S. BFHI guidelines (BFUSA, 2012). The NICU indirectly benefited from the BFHI because of the increased awareness and focus on HM and breastfeeding. The NICU Breastfeeding Committee (BFC) was the driving force behind the initiative. The BFC is a multidisciplinary team comprising key stakeholders, including bedside nurses who are primarily certified lactation counselors (CLC), hospitalbased International Board Certified Lactation Consultants (IBCLCs), NICU dietitians, physicians, neonatal nurse practitioners, the unit-based educator, NICU parents, and the NICU quality specialist. The NICU quality specialist, a registered nurse with NICU experience and certification in health care quality, functioned as the team lead

Table 1: Spatz Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants Step

Description

1

Informed decision

2

Establishment and maintenance of milk supply

3

Human milk management

4

Oral care and feeding of human milk

5

Skin-to-skin contact

6

Non-nutritive sucking

7

Transition to breast

8

Measurement of milk transfer

9

Preparation for discharge

10

Appropriate follow-up

Ivonne Hernandez, PhD, RN, IBCLC, is an international board-certified lactation consultant, Tampa General Hospital Lactation Program, Tampa General Hospital, Tampa, FL. Terri Ashmeade, MD, CPHQ, is the medical director of the NICU, Tampa General Hospital and Chief of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL. Branko Miladinovic, PhD, is a statistician, University of South Florida Morsani College of Medicine, Department of Internal Medicine, Tampa, FL. Diane L. Spatz, PhD, RN, FAAN, is a professor of perinatal nursing and Helen M. Shearer Term professor of nutrition, University of Pennsylvania School of Nursing, Philadelphia, PA, and lactation program manager, The Children’s Hospital of Philadelphia, Philadelphia, PA.

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Improving Human Milk and Breastfeeding Practices in the NICU


and ensures monthly meetings are structured and goal oriented. In January 2011, the VON measure of “any HM at discharge” was adopted as an outcome measure with a goal of scoring in the VON top quartile. The Press Ganey parent satisfaction measure, nurses’ support of mother’s efforts to breastfeed, was selected as a second outcome measure; this outcome measure aligned with the NICU overall goal to improve parent satisfaction. Three process measures were chosen: (a) percentage of infants receiving MOM at initiation of feedings, (b) percentage of mothers of VLBW infants initiating pumping within 6 hours of delivery, and (c) percentage of mothers with a hospital-grade electric pump at hospital discharge. The VON measure, percentage of VLBW infants at less than third percentile for growth at discharge, was selected as a balancing measure. In 2013, the NICU began using pasteurized donor milk (PDM) when MOM was not available; subsequently a second balancing measure was added in 2013 to monitor the percentage of VLBW infants receiving PDM at discharge compared to those receiving MOM. The committee developed a 3-year agenda to systematically address each of the Spatz Ten Steps (2004). The timeline of the implementation process for each of the steps is presented in Table 2 (supplied as supplemental information to the online version of this article at http://jognn.awhonn.org).

Project Intervention and Implementation Step 1: Informed Decision Prior to project initiation, no systematic strategies were in place to ensure mothers of vulnerable infants were informed of the benefits of HM and risks associated with formula feeding. Edwards and Spatz (2010) demonstrated that prenatal lactation consults focused on informed decisions increased pumping initiation rates. Furthermore, mothers who intend to formula feed compared to mothers who intend to breastfeed do not have increased anxiety or guilt when asked to switch to providing HM (Miracle, Meier, & Bennett, 2004; Sisk, Lovelady, Dillard, & Gruber, 2006). Several changes were implemented to improve mother’s ability to make an informed decisions regarding feeding choice.

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medical team providers, (neonatologist, neonatology fellows, or neonatal nurse practitioners) providing consults to high-risk mothers to assess the mothers’ feeding plans and to discuss the benefits of HM and potential risks of formula feeding. In addition to the medical team consultation, an IBCLC consulted with high-risk mothers on antepartum to reinforce the benefits of HM, provided education on pumping initiation, and assessed the need for a pump after discharge. This dual approach to prenatal consultation reinforced the importance of MOM for vulnerable infants and demonstrated to families a team-oriented approach to care. In October 2011 we modified our EMR admission order set to include a lactation consult for all VLBW infants to ensure that mothers who did not receive a prenatal consult because of rapid delivery or neonatal transfer received the appropriate information to make informed decisions. The IBCLC encouraged the mother to view the video A Preemie Needs His Mother (Breast Milk Solutions & Morton, 2012a), which was added to the hospital closed circuit TV system in May 2013. This video provided anticipatory guidance on the NICU experience and practical pumping education. Mothers also received a handbook that contained targeted education and guided counseling on common talking points. The IBCLC reviewed the medical record to confirm that an informed decision to provide expressed milk, information regarding potential risk factors for decreased milk supply, and any specific maternal requests were documented. Mothers were provided education on pumping technique and frequency for a target of eight pumping sessions per day to establish optimal milk supply. Antepartum education on pumping allowed mothers to be active participants in their infants’ care immediately after birth.

Step 2: Establishment and Maintenance of Milk Supply

Just prior to the official January 2011 project kickoff, an Electronic Medical Record (EMR) template for neonatal prenatal consultations was developed by a neonatal fellow. This template reminded

To ensure the availability of MOM for initial feedings and at the time of hospital discharge, it is essential to attend to establishment and maintenance of milk supply. Prior to initiation of our improvement process, we lacked an adequate number of hospital-grade electric pumps for use by mothers of NICU infants during maternal hospitalization and postmaternal discharge. The first 2 weeks are a critical time for establishing milk supply and an important period of infant immune and intestinal development requiring an adequate supply of HM for initiation of feeds (Meier, Engstrom, Patel, Jegier, & Bruns, 2011). Milk production is

JOGNN, 44, 426-438; 2015. DOI: 10.1111/1552-6909.12563



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enhanced with pumps that mimic infant suckling patterns in the first few days of life (Meier, Engstrom, Janes, Jegier, & Loera, 2012). We purchased and outfitted all NICU pumps with information cards that facilitate the removal of colostrum and support the establishment of milk supply. In May 2012, grant monies were used to purchase an additional 10 pumps. Despite working with community partners to obtain a pump prior to mother’s discharge, delays of up to 2 to 3 weeks were common. To rectify this issue, in 2011 a hospital-funded loaner pump program was established with 10 pumps to improve access for NICU families that participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and received Medicaid. In January 2012, grant funding associated with breastfeeding-related research in the NICU provided monies for the purchase of 10 additional pumps. Based on demonstrated success and continued need, the hospital now funds 20 loaner pumps for a total cost of $6000 per year. Pumps have been provided for approximately 450 mothers. On average, pumps are loaned for 30 days until mothers are able to obtain a WIC pump and return the loaner. The IBCLCs manage the pump loaner program, assess maternal milk supply, and troubleshoot any lactation concerns. Lactation can be consulted at any time during the NICU stay, and all mothers are provided with our lactation warm-line number for any questions or concerns. The medical and nursing teams support mothers to initiate pumping within 6 hours of giving birth. At the start of our QI initiative, only 19% of our mothers were meeting this goal. To facilitate early initiation of pumping and the safe handling of milk, a Mother’s Breast Milk Success Kit was developed. The kit includes a pumping kit, pumping instructions with log, milk storage containers (35 ml), barcode labels, colored round dot labels, a permanent marker, and mild soap for cleaning (see Figure 1 supplied as supplemental information to the online version of this article at http://jognn.awhonn.org). The mother is taught to label each bottle of her milk with the infant’s identifying barcode information, date, time, and a colored dot to correspond with the pumping session. Nursing staff received training on the kit, the importance of early pumping, and how to use the pumps via hands on-education and our electronic learning management system (LMS). It is the primary responsibility of the nursing staff to educate


Despite the increased use of human milk, there was no increase in the percentage of infants discharged with severe growth restriction.

the mother on pump use and safe handling of HM. Data related to time to first pumping were shared at interdisciplinary neonatal and obstetric quality meetings to raise awareness. In interviews, postpartum mothers indicated that manual expression was not consistently taught. Pumping with a hospital grade pump with the addition of massage and manual expression facilitates milk production (Morton et al., 2009). Breastfeeding resources and the video Maximizing Milk Production with Hands-on Pumping (Breast Milk Solutions & Morton, 2012b) were placed on the hospital intranet providing ready access for staff and families.

Step 3: Human Milk Management Since moving to a single patient room NICU in October 2010, each room has a milk refrigerator; in January 2011, milk warmers were added. Prior to 2011, the NICU had only one freezer, which limited the ability to store HM. In January 2011, funding was obtained to purchase three additional industrial biomedical freezers at a cost of $8,000 each. All freezers function on a centralized automatic temperature tracking system. The tracking system automatically sends a message to the NICU charge nurse cell phone when the temperature is out of range to prevent loss of milk from unintentional defrosting. Bottles are stacked in storage bins labeled with patient name to maximize space and decrease the risk of misadministration (see Figure 2 supplied as supplemental information to the online version of this article at http://jognn.awhonn.org). Patient care technicians (PCTs) are responsible for organizing the freezers. Thirty-five milliliter bottles are used for collection of colostrum; 80 milliliter bottles are used for storing larger volumes. Maternal-child nurses are educated regarding proper handling, storage and labeling of HM through the online LMS. Focus on storage and labeling was emphasized to minimize the risk of misadministration of HM.

Step 4: Oral Care and Feeding of Human Milk Colostrum has greater concentrations of immunoglobulins, growth factors, and protective

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substances than HM, and these levels are higher in preterm than term colostrum. Oral care using colostrum has been identified as having the potential to serve as immune therapy (Gephart, 2014; Rodriguez et al., 2010) and has been demonstrated to be safe and feasible even during the first days of life for extremely-low-birthweight (ELBW) infants (Rodriguez et al., 2010). The importance of using MOM for oral care is emphasized in our Ventilator Associated Pneumonia Prevention Bundle implemented in November 2013. Expressed milk should be used in the order pumped for the first 2 weeks to maximize protein intake and immunological protection; therefore, NICU mothers are educated to label bottles of expressed milk in pumping session order from 1 to 60 (Meier et al., 2011). Compared to mature milk, colostrum has increased total antioxidant capacity that may support the neonate’s ability to manage oxidative stress (Zarban, Taheri, Chahkandi, Sharifzadeh, & Khorashadizadeh, 2009). Our standard of practice is to use MOM for initial trophic feedings for the ELBW infant. If by the second day of life, colostrum is unavailable, donor milk is fed after parental consent is obtained. Immunomodulatory proteins in HM are reduced by freezing (Akinbi et al., 2010); therefore, after bottles 1 through 60 are fed, fresh nonfrozen HM is preferred. To minimize risk of growth failure associated with HM feeding in VLBW infants, a standard procedure of bolus gavage feedings via gravity instead of continuous or intermittent pump feedings was implemented to decrease loss of nutrients that adhere to the tubing (Rogers, Hicks, Hamzo, Veti, & Abrams, 2010).

Step 5: Skin-to-Skin Care Skin-to-skin care was encouraged as soon as the infant was stable enough for holding. Skinto-skin care has numerous benefits for the infant, including improved oxygen and heart rate stability and successful transition to breastfeeding (Moore, Anderson, & Bergman, 2007). Benefits for the mother include improved milk production and longer breastfeeding duration (CondeAgudelo, Belizan, & Diaz-Rossello, 2000). Nurses have a key role in initiating early skin-to-skin care (Myers & Rubarth, 2013). In September 2013, a policy was developed, and staff education was completed in December 2013. A video on skin-toskin care is available on the hospital intranet that highlights the benefits and demonstrates transfer techniques. This video is used by staff to dis-

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JOGNN, 44, 426-438; 2015. DOI: 10.1111/1552-6909.12563

cuss the benefits and review the process to reduce maternal anxiety (Children’s Hospital of Philadelphia, 2005). Although the single family room provides privacy, the physical layout presents a significant barrier for providing skin-to-skin care for more infants requiring multiple, complex, medical interventions. Simulation training is being developed to mimic the skin-to-skin procedure for these infants.

Steps 6 and 7: Non-Nutritive Sucking and Transition to Breast Mothers’ decisions regarding breast feeding were respected, particularly mothers who elected not to feed directly at the breast and chose to provide expressed milk only. For all others, nonnutritive suckling, also referred to as “dry breastfeeding,” was used in conjunction with skin-toskin care. The mother emptied her breasts prior to the skin-to-skin session and positioned the infant as if to breastfeed. This allowed the infant an opportunity to practice breastfeeding at an empty breast before the infant has a physiologically mature suck/swallow/breathe pattern (Spatz, 2011). Non-nutritive sucking improves mother’s milk supply, transition to the breast, and increases duration of breastfeeding postdischarge (Spatz, 2011). At the time of this publication, the routine practice of non-nutritive suckling had not been implemented. In our NICU, transitioning to the breast was jointly facilitated by bedside nurses and IBCLCs. Prior to the implementation of this QI project, VLBW infants who showed signs of oral feeding readiness were routinely offered MOM in a bottle for first feedings. In February 2013, emphasis was placed on offering feedings at the breast prior to initiating bottle feeding. Nipple shields increase milk intake for premature infants by compensating for weak intraoral suction pressures to assist with latch (Meier et al., 2000). Meier et al. (2000) demonstrated that most infants need the nipple shield for an average of 32.5 days, and weaning off the nipple shield most likely will occur at home. Beginning in March 2013, 20- and 24-millimeter size nipple shields were purchased and made available to bedside nurses for use after a peer-led education process was completed; IBCLCs were available as resources. Nipple shield educational sheets and instructions were available on the intranet portal for parents and staff to reference.




Step 8: Measuring Milk Transfer In March 2011, a scale was purchased to initiate breastfeeding pre- and postweights (test weights). Test weights facilitate transitioning infants to breast feedings by providing an accurate estimate of the volume of HM transferred during a feeding (Haase, Barreira, Murphy, Mueller, & Rhodes (2009). Although infants initiate nutritive feedings at breast, weighing the infant helps to identify if supplementation is needed. This minimizes the risk of growth problems, improves maternal confidence in feeding, and prepares the dyad for discharge. Without use of test weights, intake is subjectively estimated from time at breast and infant sucking activity, which may lead to underor oversupplementation (Spatz, 2012). Only one scale was available and was used by IBCLCs only, which limited the use of test weights. Guidelines for staff are being developed to standardize the use of test weights in the NICU.

Step 9: Preparation for Discharge All infants received care in single family rooms that accommodate families throughout the infant’s NICU stay. These accommodations have been available since 2010. Mothers were encouraged to spend as much time as possible with their infants, which provided ample opportunity to practice breastfeeding prior to discharge. The medical team collaborated with IBCLCs to develop the home feeding plan that was implemented several days prior to discharge to ensure adequate intake and weight gain. Most preterm infants were not able to transition to the breast entirely prior to discharge; therefore, most mothers needed to continue pumping to maintain supply while the infants became more efficient at the breast (Spatz, 2011).

Step 10: Appropriate Follow-Up Care Mothers were encouraged to continue to breastfeed or provide their milk as the primary nutritional source for their infants for at least 6 months (AAP, 2012). An individualized, comprehensive, nutritional discharge support plan was developed based on the wishes of the family and with input from the medical team, lactation, dieticians, and other specialists as needed.

Baby Cafe´ breastfeeding support services (Baby Cafe, ´ 2014). Many discharged infants attended a Neonatal Follow-up Program for coordinated, comprehensive pediatric care. Future plans included incorporation of lactation services into the neonatal follow up program and routine follow up telephone calls to breastfeeding mothers.

Methods of Evaluation and Analysis Data were obtained by medical record review by the unit-based quality specialist for all infants with birth weights of 401 to 1500 grams or a gestational age of < 30 weeks. Data were entered into the VON VLBW database and an internal database and were retrieved for analysis. The previously described birth weight and gestational age criteria were selected because this population is included in the VON VLBW database. As a participating center, data were available to us and were collected in accordance with data definitions governed by VON.

Process Measures Time to first pumping was recorded within the lactation consult template as the hour of life the first pumping occurred. Data were manually abstracted from the medical record. Feeding substrate at initiation of feeds was manually abstracted from the medical record and entered into an internal database already in use prior to initiation of this QI project. Data were analyzed using a statistical process control (SPC) chart created R . The control in QI Macros for Microsoft Excel chart represents a low-cost and robust method for rapidly assessing change interventions over time; a p-chart was used secondary to the binomial nature of the data and variable sample size (Duclos & Voiron, 2010). To determine if an observed change was statistically significant, the presence of a shift indicated by eight or more consecutive points above or below the mean or center line was needed. Data related to the number of mothers of VLBW infants with a hospital-grade pump at discharge were manually abstracted from lactation documentation in the medical record and analyzed as a percent of total.

Outcome Measures NICU personnel partner with community organizations to provide outpatient breastfeeding assistance and support; however, the referral process was not standardized. Families were also provided with the phone number to hospital-based lactation services, and referrals were completed for


The outcome measure of parent satisfaction with breastfeeding support was obtained from the Press Ganey NICU survey question titled “nurses’ support of mother’s efforts to breastfeed” and reported by Press Ganey as a mean satisfaction percentage of all returned surveys and percentile

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ranking compared to other participating NICUs with 40 or more beds. Press Ganey data were filtered to include only those with a gestational age of 20 to 30 weeks. The measure “any HM at discharge,” defined as the percentage of infants weighing < 1500 grams or < 30 weeks gestation discharged home on any HM, was obtained from VON Nightingale (VON, 2014). Preimplementation (2010) and postimplementation (2013) binary variables were compared to calculate an odds ratio (OR) and 95% confidence interval (CI).

Balancing Measures The balancing measure, percentage of infants with a weight less than third percentile at initial discharge, defined as the percentage of infants < 1500 grams or < 30 weeks gestation with a weight at initial disposition less than the third percentile for gestational age on the Fenton growth chart, was obtained from VON Nightingale (VON, 2014). This balancing measure was chosen because VLBW infants fed HM are at increased risk for slow growth during hospitalization (Underwood, 2013). The second balancing measure, percentage of VLBW infants receiving any PDM during the NICU stay, was manually abstracted from the medical record and entered into an internal database for analysis. During introduction of donor milk, it was important to ensure the percentage of infants on any MOM at discharge did not decrease.

Statistical Analysis For non-normal data, the Wilcoxon rank-sum test was used; otherwise the t test was used. For categorical data, the Fisher Exact test was used. The statistical analyses were performed with Stata 13.1.

Outcomes

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Table 3: Demographic Characteristics of Infants Born in 2010 and 2013 2010 (n = 128)

2013 (n = 96)

p

1069.7 ± 270.9

1092.5 ± 273.6

0.536

28.1 ± 2.6

28.5 ± 3.0

0.304

Inborn

120 (93.8)

89 (92.7)

0.792

Outborn

8 (6.2)

7 (7.3)

No

92 (71.9)

74 (77.1)

Yes

36 (28.13)

22 (22.9)

Black

44 (34.4)

38 (39.6)

White

79 (61.7)

52 (54.2)

No

96 (75)

65 (67.7)

Yes

32 (25)

31 (32.3)

Female

65 (50.8)

48 (50)

Male

63 (49.2)

48 (50)

92 (71.9)

70 (72.9)

Birth weight, grams Gestational age, weeks Location

Hispanic 0.379

Race 0.339

Vaginal delivery 0.23

Sex 0.908

Multiple birth No Yes Length of stay,

36 (28.1)

26 (27.1)

74.2 ± 43.2

67.9 ± 34.4

0.863

0.241

days Note. Values reported as mean with standard deviation (±) or median with percent of total. Data were analyzed with the Wilcoxon rank-sum test, t test, and Fisher Exact test. No statistical differences were noted between the groups.

Preimplementation and postimplementation groups had similar demographic characteristics (Table 3). A combination of raising awareness, development of the Mother’s Breast Milk Success Kit, and increased access to pumps resulted in an increase in the percentage of mothers pumping at or before hour of life six from 6% to 43% (Figure 3). Efforts toward attaining Baby Friendly USA (BFUSA) designation with specific focus on Step 5 of the Ten Steps to Successful Breastfeeding also contributed to success in this outcome. Step 5 evaluation criterion requires pumping to be initiated within 6 hours of mother/infant separation (BFUSA, 2012). Measures aimed at improving the informed decision process resulted in significant improvement in VLBW infants receiving MOM at initiation of feeds as demonstrated by a shift

Process changes resulted in improvement in parent’s perception of breastfeeding support as demonstrated by an increase in the Press Ganey mean satisfaction score for “nurses’ support of mother’s efforts to breastfeed” from 75 to 93.8 (p = .188) and a percentile rank increase from the first percentile to greater than the 90th percentile compared to other NICUs with 40 or more beds

JOGNN, 44, 426-438; 2015. DOI: 10.1111/1552-6909.12563


depicted by eight or more consecutive data points above the p-chart mean (Figure 4). By increasing the loaner pump fleet from 10 to 20 in 2012, 90% of mothers are now discharged with a hospital-grade pump.



Figure 3. Percentage of infants less than 1500 grams whose mothers pumped ࣘ 6 hours of life.

(Table 4). Although not statistically significant secondary to the small sample size, the increase is of clinical significance. Additionally, the odds of the VLBW infant receiving the benefits of MOM at dis-

charge in 2013 was threefold greater compared to 2010 (OR = 3.01, 95% CI [1.75, 5.17], p < .001) (Figure 5). It should be noted that preterm infants are not discharged from our NICU on PDM. The

Figure 4. P-chart representing percentage of infants less than 1500 grams with any mother’s own milk (MOM) at initiation of feeds by birth year quarter (2010–2013). Red data points indicate a significant shift greater than the mean beginning in October 2011.


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Table 4: Press Ganey Satisfaction Scores for Nurses’ Support of Mother’s Efforts to Breastfeed by Discharge Year 2010–2013 Hospital Mean Score ∗

40+ Bed NICUs SD

N

Mean Score

Rank

chart from 2010 to 2013 (16.4%; 23.8%, p = .161) with the NICU remaining better than the VON mean (Figure 6). Additionally, MOM at discharge continued to increase despite the increased use of PDM beginning in 2013 (Figure 7).

2010

75

43.3

5

88.5

1

Discussion

2011

98.4

6.3

16

89.5

99

2012

96.4

9

21

89.3

99

13.8

20

90.7

91

The systematic implementation of the Spatz Ten Steps model (Spatz, 2004) resulted in significant improvement in the percentage of mothers expressing their milk within 6 hours of delivery, infants receiving MOM at initiation of feeds, and the percentage of mothers with hospital-grade pumps at discharge. Improvements in these processes contributed to significant improvements in parents’ perception of nurses’ support for mother’s efforts to breastfeed and in the odds of the VLBW infant receiving MOM at the time of hospital discharge. Despite the increased use of HM, there was no increase in the percentage of infants discharged with severe growth restriction, and the introduction of PDM did not negatively affect the use of MOM at discharge. This QI project represents the first published report to demonstrate

2013

∗

93.8

Note. Represents all returned surveys for 23- to 30-week gestation infants. ∗ p = .188.

data definition for VON does not exclude PDM; therefore we may compare more favorably to other Type B NICUs when taking this into consideration. Improvements in the use of HM in the NICU did not result in a statistically significant increase in the percentage of VLBW infants discharged with weights < third percentile on the Fenton growth

Figure 5. Percentage of infants less than 1500 grams discharged home from NICU on human milk compared to Vermont Oxford Network (VON) NICU Type B grouped by birth year 2010–2013. ∗ Infants in 2013 had three times the odds of receiving mother’s own milk (MOM) at discharge than those in 2010 (OR = 3.01, 95% CI [1.75, 5.17], p < 0.001).

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JOGNN, 44, 426-438; 2015. DOI: 10.1111/1552-6909.12563




the effectiveness of the systematic implementation of the Spatz methodology. Concurrent hospital participation in the BFHI may have provided additional support for improvement by raising family and staff awareness of the importance of HM feedings and by standardizing milk expression practices for mothers separated from their infants after birth. Published literature supports the use of QI methodologies to improve rates of HM feeding in the NICU (Meier, Engstrom, Mingolelli, Miracle, & Kiesling, 2004; Murphy, Warner, Parks, Whitt, & Peter-Wohl, 2014; Pineda, Foss, Richards, & Pane, 2009; Ward et al., 2012). Investigators have targeted selected processes in the pathway to successful breastfeeding of the vulnerable infant. Murphy et al. (2014) implemented standard physician perinatal consults to encourage mothers to express milk as soon as possible after discharge. Additionally, they increased lactation consultant staffing with the goal of providing consultations to all mothers of VLBW infants within 6 hours of delivery. Their project resulted in a trend toward more mothers pumping within the first 6 hours of life, and significantly more VLBW infants exclusively

The implementation of the Ten Steps method resulted in an increase in the number of infants receiving mother’s own milk at initiation of feedings and at hospital discharge.

receiving MOM at hospital discharge. Pineda et al. (2009) reported significant improvement in the rate of infants feeding at the breast as well as positive trends in HM feeding at initiation and discharge. Their QI interventions included a health care provider education initiative, the addition of key breastfeeding milestones to the infant’s individualized care plan, and development and distribution of an educational pamphlet to mothers that outlined the benefits of breastfeeding, instructed on expressing and storing milk, and provided information on cue-based feeding interventions. The Rush Mothers Milk Club (Meier et al., 2004) documented the success of their comprehensive, evidence-based breastfeeding interventions, including support of an informed decision, increasing access to breast pumps, preventing and treating low milk volumes, transitioning to breastfeeding, and breastfeeding peer support. Although the group demonstrated high rates of

Figure 6. Percentage of infants less than1500 grams or less than 30 weeks gestation plotting less than the third percentile on the Fenton Growth Chart at initial discharge compared to Vermont Oxford Network (VON) Type B NICU. Includes all infants regardless of feeding method. ∗ 16.4%; 23.8%, p = 0.161.


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Figure 7. Percentage of infants less than 1500 grams with any mother’s own milk (MOM) at discharge to home and percentage receiving any pasteurized donor milk (PDM) by birth year quarter.

MOM feeding particularly in African American women, it was not designed as a QI initiative, so comparisons of pr- and postprocess initiation rates were not made.

436

its success. Hospital administrators supported the process by providing necessary resources for the purchase of supplies and equipment.

The health benefits of HM feeding for the mother/infant dyad are well established (AAP, 2012; Menon & Williams, 2013). The findings of our QI initiative support those of other investigators and demonstrate that QI methodology can be used to improve rates of MOM feeding at initiation of feedings and at the time of hospital discharge and to provide the high-risk infant and mother with optimal benefit. Our project was strengthened by utilizing the Spatz Ten Steps model (Spatz, 2004), which offered a comprehensive platform for our QI process and allowed us to take a more complete approach to improving support for vulnerable mothers and infants than other investigators. We also included parental perception of lactation support as an outcome measure in addition to those measures evaluated in other projects. Our multidisciplinary approach included parents, nurses, lactation consultants, dieticians, nurse practitioners, and physicians in the planning and implementation of the QI project, which contributed to

One weakness of our project is that we have only fully addressed Steps 1 through 5 and as we continue in our progression for full implementation we acknowledge that additional efforts will be required to optimally address all 10 steps (Spatz, 2004). In retrospect, we should have provided comprehensive and standardized breastfeeding education for our NICU nursing staff at the project start, as NICU nurses are ideally situated to provide breastfeeding support for families; education is currently being developed. We recognize that the NICU nurse has many patient care responsibilities; however, support of HM use in our NICU is a priority given its broad effect on prevention of morbidities seen in the VLBW infant. We have made significant improvements without dedicated NICU lactation support; however, as we move forward and fully implement the 10 steps, we realize additional NICU lactation support will be necessary. A great deal of lactation support time is spent with loaner pump program administrative duties; the nonclinical duties should be delegated to

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IN FOCUS



ancillary personnel to increase the appropriate use of lactation support. The need for additional scales was identified; consequently we have increased our fleet to six.

Gephart, S. M. (2014). Colostrum as oral immune therapy to promote neonatal health. Advances in Neonatal Care, 14(1), 44–51. doi:10.1097/ANC.0000000000000052 Haase, B., Barreira, J., Murphy, P. K., Mueller, M., & Rhodes, J. (2009). The development of an accurate test weighing technique for preterm and high-risk hospitalized infants. Breastfeed-

Our NICU has successfully created an infrastructure of support for breastfeeding by implementing Spatz’s Ten Steps model (2004) and serves as an exemplar for similar organizations. The QI process will continue to ensure sustainability. Future goals include exploring the impact of our interventions from a racial and ethnic perspective, establishing support groups, and quantifying the dose of HM throughout the NICU stay. The Spatz Ten Steps model is replicable and results in statistically significant improvement in HM outcomes and patient satisfaction.

ing Medicine, 4(3), 151–156. doi:10.1089/bfm.2007.0125 Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., Devine, D., . . . Lau, J. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment, 153, 1–186. Meier, P., Brown, L., Hurst, N., Spatz, D., Engstrom, J., Borucki, L., & Krouse, A. (2000). Nipple shields for preterm infants: Effect on milk transfer and duration of breastfeeding. Journal of Human Lactation: Official Journal of International Lactation Consultant Association, 16(2), 106–114. Meier, P., Engstrom, J., Janes, J., Jegier, B., & Loera, F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: Greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32(2), 103–110. doi:10.1038/ jp.2011.64

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Figure 1. Mother’s Breast Milk Success Kit instruction insert. Figure 2. Breast milk freezer organized with storage bins for individual patients. Table 2. Timeline for Continuous Quality Improvement Processes for Implementation of Spatz Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants


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