Presented To Hospital Breastfeeding Council of Metro Chicago January 17, 2012 By Kimberly Carter, RN, MSN, APN

1. Breastfeeding Improvements and Data Collection Strategies Presented To Hospital Breastfeeding Council of Metro Chicago January 17, 2012 By Kimberly Carter, RN, MSN, APN

2. Objectives • Breastfeeding improvements 2009-2012 • Breastfeeding prevalence day • Breastfeeding model of care • Breastfeeding data collection sources • mPINC survey results • TJC exclusive breast milk feeding rate

3. Breastfeeding Improvements 2009-2012 • Breastfeeding Multidisciplinary Committee re-established 2009 • Group consisted of APN’s, RN’s from L&D/AP/PP/NICU, LC’s, BFC’s, EC’s, and MD’s • Enhanced breastfeeding policy by introducing 1st 12 hour process flow to be consistent with our hypoglycemia policy • Rolled out new policy to nursing staff in June, 2009 • Produced and rolled out breastfeeding education scripting cards and LATCH score card for nursing staff in December 2010 • Identified a need for data collection related to breastfeeding education and support for our patients • Started discussion of prevalence day in May 2009 from the concept of skin prevalence day

4. Breastfeeding Improvements (cont) • Breastfeeding survey composed to identify if patients are being adequately supported with breastfeeding • 1st prevalence day July 2009 (APNs surveyed only) • Modified questions after initial survey • Solicited feedback from CWISH hospitals on surveys October 2009 • First annual “Breastfeeding Prevalence Day” in October 2009 using modified survey • Patient survey is performed on a quarterly basis • Group of APN’s, EC’s, and BFC’s interview mothers on the postpartum units

5. Breastfeeding Improvements (cont) • Developed tool for inpatient NICU mothers and they were interviewed beginning in August, 2011 • Comparison results of postpartum units, NICU mothers, and 1st time mothers • Since October 2009, 369 patients have been surveyed • Hosted first annual breastfeeding conference in June 2011- “Breastfeeding and Evidence Based Practice: Bringing Knowledge to the Bedside”-135 attendees were present • July 2011, began partnership with Healthy Places • Healthy Places contract signed and CEO letter obtained in January 2012 • Completed policy review with BFUSA in January 2012

6. Breastfeeding Prevalence Patient Survey Information • Patient survey contains many breastfeeding quality measures in relation to data from the mPINC survey and includes the following information: • Location and timing of first breastfeeding • Skin to skin education and skin to skin contact between mother and baby • Assistance, observation, and support of staff while breastfeeding • Formula supplementation and reasons for supplement

7. Breastfeeding Prevalence Patient Survey Information • Recognition of infant feeding cues, proper latch, and output • Educational materials received/interactive TV education • Follow up resources given • Advice from nurse and physician about breastfeeding • If newborn was taken to the nursery during the night and if baby was brought out for feeds • Pain with breastfeeding • Preparation to breastfeed at home

8. Breastfeeding Model of Care Changes • A better defined model for breastfeeding mothers was implemented January 2011 • As a result of our multidisciplinary breastfeeding committee, work by our graduate student intern program (August 2010), and results from our breastfeeding data strategies, changes to our breastfeeding model included defining the expectations in breastfeeding support of the bedside nurse, PCT, breastfeeding counselor (BFC), and lactation consultant (LC).

9. Model of Breastfeeding Support January 2011 • LC • Consult advanced • breastfeeding issues • Integrated into unit practice • Communicate with staff, CC, and BFC daily • Available for timely consults • Accountable for offering RN/BFC education • Accountable for pt satisfaction • BFC • The goal is for 8-12 out of 24 hours there will be a BFC on each PP unit • See breastfeeding patients with issues after communicating with bedside RN • If unable to correct issues, consult LC • Role model breastfeeding messaging and behaviors • Accountable for pt satisfaction • Bedside RN • Primary responder and educator for mother and family • Consult BFC/LC if unable to resolve issues • Consistency in messaging to mother • Accountable for pt satisfaction • PCT • Support couplet as part of the team • No bottles unless requested by mother and documented • Accountable for pt satisfaction

10. Breastfeeding Data Sources at NMH • Electronic breastfeeding documentation: • Nurse documents feeding choice in patient profile upon admission • Nurse documents LATCH in newborn I&O record • Nurse weighs newborn daily after 10pm and weight loss calculation is completed – if loss is high, encourage more breastfeeding • Nurse enters order for an LC consult if needed • Nurse encourages patient to document feedings on white board in room or on feeding log (this is not electronic) • Prevalence day (Quarterly) • TJC exclusive breast milk feeding rate (Monthly) • mPINC Survey (Every 2 years)

11. Key improvements in mPINC results (2011 survey) • Patients have routine infant procedures performed while mother and infant are skin to skin? (Most) >90% • Skin to skin contact after vaginal delivery? (Most) >90% • Percentage of patients have the opportunity to breastfeed within 1 hour of uncomplicated vaginal birth? (Most) >90% • Percentage of breastfeeding infants receiving non breast milk feedings? 25% • How many patients received a directly observed breastfeeding assessment by facility staff? (Most)>90%

12. TJC Exclusive Breast Milk Feeding Data • The Joint Commission defines exclusive breast milk feeding as: “a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines. Breast milk feeding includes expressed mother’s milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast. While breastfeeding is the goal for optimal health, it is recognized that human milk provided indirectly is still superior to alternatives.” • If your average monthly patient sample group size (N) is >= 181, minimum required sampling group is 37

13. NMH Exclusive Breast Milk Feeding Rate • UHC provides us with a sample size of cases to review each month for the exclusive breastfeeding measure.  Due to our volume of deliveries, we review 37 charts a month. Infants with a stay in the NICU are excluded. • 9/2010 – 30% 5/2011 – 31% • 10/2010 – 39% 6/2011 – 48% • 11/2010 – 35% 7/2011 – 34% • 12/2010 – 29% 8/2011 – 26% • 1/2011 – 33% 9/2011 – 34% • 2/2011 – 39% 10/2011 – 24% • 3/2011 – 49% 11/2011 – 34% • 4/2011 – 37% 12/2011 - TBD

14. Next Steps for Improving Breastfeeding Support and Data collection • Preserve opportunity to breastfeed within 1 hour for an uncomplicated vaginal birth and 2 hours for an uncomplicated c-section birth • Continue and promote skin to skin contact in the NICU, L&D, and postpartum units • Further reduce percentage of breastfeeding infants receiving non-breast milk feedings • Continue to promote and increase rooming-in • Develop defined model of lactation support for the NICU • Maintain and increase breastfeeding education for MB, L&D, and NICU nurses, and pediatric residents and attendings

15. Next Steps (cont) • Establish consistent breastfeeding education for OB/Gyn residents and attendings • Continue to present breastfeeding data at the OB/Peds QM meeting (Quarterly) • Continue to present breastfeeding data at the OB/NICU/Peds Operational meetings (Monthly) • Re-establish breastfeeding multidisciplinary committee meetings including quality leader, NICU dietician, Erie clinic MD, NICU hospitalist, midwife representative • Develop and implement documentation for discharge feeding method