Roger A. Edwards, ScD Assistant Professor Bouv é College of Health Sciences

MBC Baby Friendly Collaborative – January 9, 2014 Theme: Supplementation Mary Ellen Boisvert, RN… Nurse Manager Southcoast Hospital Group 43 High St. Wareham, MA 02571 Phone (0ffice): 508 273 4011 Phone (mobile): 508 245 0488 E-mail: boisvertm@southcoast.org Roger A. Edwards, ScD Assistant Professor Bouvé College of Health Sciences Northeastern University 360 Huntington Ave , 140 The Fenway Building, R218 Boston, MA 02115 Phone (0ffice): 617 373 8344 Phone (mobile): 508 472 0406 E-mail: ro.edwards@neu.edu

Agenda • Welcome and Introductions • Planning for 2014 • Supplementation: What to Expect • Why is there a need to supplement with formula? • What is a Fishbone? • Fishbone Example • Data Sharing • Role of a collaborative • EBF at Discharge (Definitions-TJC criteria for measurement) • Planning for next meeting • Swim Lane Flow Chart: Supplementation

Theme for 2014: Supplementation • January 9, 2014: Root Causes • Feb/Mar: Process Analyses and Change • April: Experiences • May/June: TBD

Applications of CQI . . . A fishbone (cause-effect) diagram is a CQI tool that is used to identify, explore, and display the causes of a particular problem A case study using fishbone diagrams illustrates the process “There’s no free lunch” • One of the core concepts of economics is that for every benefit there is also a cost • The person who receives the benefit may not pay or even be aware of the cost, there is a cost paid by someone • This issue is recognized in medicine in terms of the recent recommendations that the health professions avoid conflicts of interest (and perceptions of conflicts of interest that could compromise patient care) • While formula industry ties have been exempt, changes in formula policies would be consistent with broader recommendations Steps in constructing a fishbone diagram: Establish process facilitator and team members Define problem Generate main causes of the problem and sort Brainstorm ideas related to the main causes Interpret results from diagram Identify any causes or ideas where immediate action can be taken Massachusetts Breastfeeding Coalition Baby Friendly Collaborative – 9/17/09 Theme: “Free” Formula

Applications of CQI . . . The root causes suggest ways to overcome some of the challenges related to changing the status quo We’ve done it for decades etc … Change takes energy Saves Money Change creates cognitive dissonance … etc… Value as a health professional is derived from experience Staff don’t like change Acceptance of Free Formula etc… Formula companies bring us perks when we do What did we learn from the “back to sleep” campaign?

Applications of CQI . . . The root causes suggest ways to overcome some of the challenges related to changing the status quo We’ve done it for decades etc … Change takes energy etc… Change creates cognitive dissonance … etc… Value as a health professional is derived from experience Staff don’t like change Supplementation of breastfed infants etc… etc…

Applications of CQI . . . Mothers • “not enough milk” • sore nipples • fatigue • FOB wants to help feed baby • baby not getting enough (fussy) • prior plan to supplement/combo feed (r/t work/school/family responsibilities) • uncomfortable/embarrassment (not in front of family/friends) • cultural beliefs • Misunderstanding of breastfeeding norms • Misreading newborn behaviors/cues • Acceptance by other mothers who supplemented (vs. subtle put-down for striving for EBF) • Formula company marketing creates doubt regarding importance/necessity to EBF • Others can help feed People … Nurses Physicians Supplementation of breastfed infants

Applications of CQI . . . People Mothers Nurses Physicians • Weight loss • Jaundice • Hypoglycemia • early gestational age (need for more calories) • Personal beliefs/experiences • It is OK/it does not matter if you supplement • Easier to recommend supplementing (so not have to ‘worry’ about mother/baby well-being as much • Formula company marketing creates doubt regarding importance/necessity to EBF • Mother needs sleep and it is my job to not wake her for breastfeeding, etc. Supplementation of breastfed infants

Applications of CQI . . . People Mothers Physicians Nurses • Uncomfortable with educating patients on risks of formula supplementation • Lack of education R/T breastfeeding support • Insufficient LC support available for challenging patient circumstances • Unable to provide maternal support • Culture • Hospital practices • Personal beliefs/experiences • Easier to manage mother who is formula feeding (more predictable/less fussy baby and less frustrated mother)—feeling good about keeping all ‘in order’ • Formula company marketing creates doubt regarding importance/necessity to EBF Supplementation of breastfed infants

Applications of CQI . . . Materials • Availability of formula (have some in case I need it) • Formula advertising • No access to breast pump • Being able to see how much the baby has consumed • Introduction of too many “gadgets” for breastfeeding Supplementation of breastfed infants

Applications of CQI . . . Environment • Visiting hours • Lack of support from family (FOB, grandparents) • Culture does not support breastfeeding • Mom needs rest • Delayed breastfeeding in L&D • No skin-to-skin at birth • Hospital practices take priority over promotion of breastfeeding • Breastfeeding is not the “norm” • Insufficient follow-up/support after hospital discharge Supplementation of breastfed infants

Applications of CQI . . . • Conflicting messages from staff/practitioners • inconsistent education r/t frequency, duration, latch • Going to OR – anesthesiologist/surgeon recommends pump & dump • Breastfeeding contraindicated with medication(s) • Breastfeeding contraindicated with ordered procedure i.e. radiology (exposure to medicine, prep/chemicals) • Less variation because it is not as dependent on individual characteristics of mother and baby • You have nipple trauma justification for ‘break’ from breastfeeding and supplementation • Maternal illness • Maternal anxiety • Mother/infant separation • History of breast surgery (supply issues) • Prior negative experience (lack of confidence) • Convenience of staff/more predictable timing of infant-related activities (e.g., weighing, bathing) Management/Process Supplementation of breastfed infants

Approach . . . Procedures Environment Lack of … Limited … Available services Time … Co-located … not available Supportive … but… Overall … Physical space … … … Space … … … ….. … Equipment People

Required components of PC-05 include the following: Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines TJC suggests the following sources for collecting data Feeding flow sheets Intake and output sheets Individual treatment plans Nursing notes Physician progress notes Discharge summary Context . . . 16 Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm

Required components of PC-05 include the following: Reasons for not exclusively feeding breast milk during the entire hospitalization must be clearly documented in the medical record These reasons are due to a maternal medical condition for which feeding breast milk should be avoided HIV Infection Human t-lymphotrophic virus type I or II Substance abuse and/or alcohol abuse Active, untreated tuberculosis Taking certain medications, i.e., prescribed cancer chemotherapy, radioactive isotopes, antimetabolites, antiretroviral medications and other medications where the risk of morbidity outweighs the benefits of breast milk feeding Undergoing radiation therapy Active, untreated varicella Active herpes simplex virus with breast lesions The mother’s refusal to feed the newborn breast milk does not constitute a reason for not exclusively feeding breast milk “Reasons must be explicitly documented” Context . . . 17 Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm

Required components of PC-05 include the following: Excluded Population of Newborns Discharged from the hospital while in the NICU Galactosemia Parenteral infusion Experienced death LOS > 120 days Enrolled in clinical trials Documented reason for not exclusively feeding breast milk Sampling Average quarterly inpatient sample group size >= 1501 (N), then minimum required group sample size is 301 (n) Average quarterly inpatient sample group size 376 - 1500 (N), then minimum required group sample size is 20% of the Initial Patient Population Size (n) Average quarterly inpatient sample group size 75 - 375 (N), then minimum required group sample size is 75 (n) Average quarterly inpatient sample group size is < 75 (N), then no sampling; 100% of the Initial Patient Population Size is required (n) Context . . . 18 Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm

Exclusivity calculation - • # Infants who meet eligibility criteria = 40 • # Mother/Infant pairs who exclusively breastfed = 32 32/41 * 100 = 78% Exclusive Breastfeeding

Swim Lane Flow Chart example

Swim Lane Flow Chart “Mom Needs Rest”- Pre

Swim Lane Flow Chart “Mom Needs Rest”- Post

Roger A. Edwards, ScD Assistant Professor Bouv é College of Health Sciences