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TABLE 1: Patient Demographics
Variable
Pre (N=49) Post (N=59)
Mean ± SD
p-value
Gestational Age (weeks)
Pre
28.7 ± 2.3
0.083
Post
27.9 ± 2.5
Birth Weight (grams)
Pre
1094 ± 253
0.514
Post
1061 ± 260
percent of previous feeing volume or
infants on trophic feeding volumes, bilious residuals are acceptable if there are no other changes in clinical status.
2012 thru June 30, 2012, was considered the pre-intervention phase, after which
the protocol was initiated on July 1, 2012. Data that were collected included: growth parameters at birth (weight, length, and head circumference); day of life (DOL) that enteral feeds were initiated; DOL infants reached 120ml/kg/d of enteral feeds; DOL
as 150ml/kg/d; number of days of total parenteral nutrition (TPN) during initial feeding advancement; total number of
days of TPN; length of stay; and growth parameters at discharge (weight, length, head circumference). Balancing measures were tracked including incidence of culture positive sepsis line days. Number of line days included presence of umbilical venous catheter (UVC), peripherally inserted central catheter (PICC), or surgically placed central venous line (CVL).
During this pre-intervention phase, nursing and medical teams were educated about the feeding protocol, which involved posters summarizing the changes, bedside reference charts for the nurses, and pocket- sized cards with the highlights and feeding advancement schedule for the medical team. The feeding protocol was initiated on July 1, 2012 and was applicable for all infants with BW <1500 grams and <34 weeks gestation born on or after this date.
The six months following the implementation of the feeding protocol, from July 1, 2012 thru infants born December 31, 2012 was considered the post-intervention phase, and the same data were tracked as during the pre-intervention phase. Immediately after the post-
implementation monitoring phase, a survey was developed and sent to staff to identify barriers to use of the protocol.
Statistical Methods
All infants that died or were transferred
enteral feeding volume of 150ml/kg/d, were excluded in the initial analysis. Analyses
of central line days, DOL to 120ml/kg/d, DOL to 150ml/kg/d, initial TPN days,
total TPN days, and growth velocity were controlled for GA. In analyses of culture positive sepsis, all infants were included. Data were analyzed using multivariable logistic regression and statistical process control. Statistical process control was used to monitor changes in the outcome variables and balancing measures after initiation of the feeding protocol at several points during the post-intervention phase and at the completion of the study, when the last infant born during the post-intervention phase had been discharged.
RESULTS
There were 108 infants included in the main analysis with 49 infants in the pre- intervention and 59 in the post-intervention group (Figure 1). In the pre-intervention group, there were four deaths and three transfers prior to reaching full feeds in the post-intervention group (p=0.72 for deaths and p=0.63 for transfers).
Demographics of the study population are shown in Table 1. BW and GA did not differ between the groups.
Central line days, DOL to 120ml/kg/d, DOL to 150ml/kg/d, initial TPN days,
and total TPN days did not differ between groups after controlling for GA (Table
2). Our main outcome, growth velocity, increased by 2 grams/d (p=0.039). The incidence of culture positive sepsis was not different between the groups.
Compliance to the protocol was not tracked during the study. In order to improve compliance, the medical and nursing
teams were surveyed to get some general feedback about the protocol. Questions included general thoughts about the protocol, perceived compliance, reasons for noncompliance, and ease of integrating protocol into the NICU routine. Over
75 percent of those surveyed were either “completely in favor” or “somewhat in favor” of the feeding protocol. Over
65 percent felt that the recommendations were being followed. Over 85 percent reported that the feeding protocol was either “very easy” or “somewhat easy” to integrate into the NICU routine.
DISCUSSION
The primary objective of this performance improvement project was to assess whether implementation of a standardized feeding
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Del Med J | June 2017 | Vol. 89 | No. 6
