Refocus on Neonatal Nutrition Impacts Better Outcomes While Reducing Cost

1. Refocus on Neonatal Nutrition Impacts Better Outcomes While Reducing Cost Jack Sills MD, Jade Yang MPH,RD, Donna Penn RN and Robin Koeppel RNC University of California Irvine Medical Center Introduction Results III Initiative and Approach III In 2001 UCI Medical Center (UCIMC) was one of 30 University NICUs focused on best practices while identifying opportunities for improvement. The variability of outcomes was disturbing. For babies between 500 and 999 grams, hospital stays ranged from 70 to 120 days, with a mean of 88 days. In some centers babies did not receive their first enteral feeds for up to 67 days, while in others it took as little as 13 days. Preterm infant morbidities are limited when enteral nutrition is established and central lines are removed. Significant cost savings are realized by limiting nosocomial infections and reducing length of stays. In 2004-2005 our objectives shifted to standardizing parenteral nutrition to maximize energy, protein and mineral accretion and to prevent growth failure. Growth failure was defined as a discharge weight below the tenth percentile utilizing the intrauterine growth curve as our gold standard. The nutrition team partnered with the medical team and parenteral nutrition was advanced using a TPN worksheet. Feeding protocols were followed as before with greater emphasis placed on breast milk as the preferred diet and adhering to a uniform approach to feeding intolerance defined by abnormal physical exam and not necessarily by gastric residuals. A goal-directed tabular weight and length chart was used for completed post-conceptual weeks. Initiative and Approach I Initially, the NICU multidisciplinary performance improvement team focused on the introduction of a feeding protocol for VLBW infants less than 1000 gram birthweight. Protocols were individualized to birthweight and gestational age emphasizing the use of breast milk, trophic feedings and standardized volume advancement. Recommendations • Uniform TPN Ordering • Reviewed by Fellow/Attending/NNP • Completed TPN worksheet at bedside • Nutrition Service comments and plan at bedside • Begin Feeds by DOL 3 • 600-999 grams • Regain Birthweight by 2 weeks of life • Full enteral feeds by 30 days of life • By 36 weeks PCA weight should be at least 2000 grams • 1001-1500 grams • Regain Birthweight by 2 weeks of life • Full enteral feeds by 21 days of life • By 36 weeks PCA weight should be at least 2250 grams V. Exclusive Breast Milk feeds until a minimum PCA of 34 weeks Orange County’s First Quintuplets January 2005 Discharge Growth < 10th Percentile Results I Our feeding protocol led to more rapid initiation of enteral feeds while not increasing the incidence of necrotizing enterocolitis (NEC), decreased TPN days, and lowered costs despite no change in length of stay. Initiative and Approach II We then focused on larger preterm infants with birthweight between 1000 and 1500 grams. Conclusions Results II • Primary Objective Achieved • Standardized approach to parenteral and enteral nutrition • TPN ordering more uniform • Team approach solidified between medicine, pharmacy and nutrition services • Prevent growth failure • Despite no change in mean daily weight gain more infants discharged home on intrauterine growth curve • Focus on energy and protein intake from birth to discharge • Improved breast milk use through out hospital stay • Secondary Goals • Reduced medical and surgical NEC • Reduced isolated bowel perforation • Reduced Stage 3 ROP Applying a similar practice acceptable to physicians and nurses the nutrition performance improvement team demonstrated significant cost savings as the result of fewer nosocomial infections and a decreased length of stay. There were no  in patients with NEC and fewer patients with cholestatic jaundice. Key Lessons Learned • NICU performance improvement can effectuate change • Standardized feeding protocols and uniform evaluation of feeding intolerance enhances overall nutrition and decreases central line and TPN days • Better outcomes are achieved while reducing costs Future of the Initiative Study the impact of exclusive breastmilk feedings with mother’s own milk and donor breast milk on preterm morbidities such as ROP and NEC. ‘One piece at a time’ A collaborative effort of the NICU Staff