Premature and hospitalized infants often need nutrient-enriched human milk and formula for growth in the neonatal intensive care unit (NICU) and postdischarge. Parents and caregivers must learn how to properly mix fortified human milk and formula to provide the proper caloric concentration. The consequences of incorrectly mixing infant feedings include hypernatremia, hyponatremia, electrolyte and renal disturbances, inappropriate growth, and hospital readmission.1–4 In recent years, Children's Hospital Colorado (CHCO) NICU and staff admitted several infants with these complications following discharge from outside facilities and recognized that their internal process could be improved.
In 2012 and 2013, the CHCO NICU follow-up clinic saw more than 70 NICU graduates for initial postdischarge visits. Of the patients seen for these initial postdischarge visits, nearly 50% of families were mixing their infant's feeding recipes incorrectly. In 2013, a serious case of inaccurate parental formula mixing occurred. A former extremely low birth-weight infant with a history of intrauterine growth restriction and chronic lung disease was discharged home from an outside NICU at 37 weeks' postmenstrual age and was readmitted to the CHCO NICU within 48 hours of discharge. The infant was admitted with severe dehydration, diarrhea, significant weight loss, and hypernatremia (serum sodium level of 186 mmol/L). Diet history was obtained, which revealed that the parents had misinterpreted the infant's discharge recipe. Parents reported that they were given a handout for preparing for a 24 calorie per ounce (cal/oz) transitional formula recipe at discharge. Inadvertently, the parents reversed the amount of water to be added to the bottle and the scoops of infant formula powder, which resulted in a 54 cal/oz formula recipe. The parents indicated that they had not practiced hands-on mixing of the infant's feedings before discharge. Parents were bilingual and this was their first child.
NICU parents and families need help preparing for their infant's transition to home to help prevent potential readmissions.4,5 It has been suggested in the literature that caregivers should be encouraged to demonstrate the specific mixing technique during observation of a feeding to reduce risk of adverse side effects.1,2
A recent publication described a case of a term infant admitted to a hospital with life-threatening hypernatremic dehydration, respiratory failure requiring extracorporeal life support, peritoneal dialysis, and multiple interventions for recovery.3 Authors reported that home inaccurate parental formula mixing and poor oral intake led to life-threatening hypernatremic dehydration (serum sodium level of 189 mmol/L).3
Common themes reported in the literature after NICU discharge include poor growth, neurodevelopmental outcomes, feeding difficulties, and feeding intolerance.1,4
Families that have stated that they felt unprepared for NICU discharge reported more problems postdischarge with mixing of infant feedings.1 Incorrect mixing is preventable.
At CHCO and an affiliated hospital, NICU team members recognized the importance of providing comprehensive and accurate teaching to their NICU parents prior to discharge. For this reason, a quality improvement (QI) initiative was implemented to improve discharge education, specifically focused on parents and caregivers demonstrating correct mixing of their infant's specific discharge feedings.
A multidisciplinary team of neonatal dietitians, advanced practice nurses, unit leadership, QI specialists, and staff nurses conducted a literature review, identified potential barriers, and developed strategies to identify the relationships between the aim to improve and the changes to be tested. The QI project purpose was to improve parental comfort and efficacy in infant feeding preparation recipes during hospitalization, improve safety, reduce mixing inaccuracy postdischarge, and prevent hospital readmission for all NICU patients. The project SMART aim was to improve the infant feeding mixing accuracy rate at follow-up to 75% within 12 months of intervention implementation (January-December 2014) and to sustain the infant feeding accuracy rate at follow-up to above 95% for an additional 24 months (January 2015-December 2016). See Driver Diagram (Figure 1).
The QI project took place in an 82-bed academic level IV NICU at CHCO and a 50-bed academic level III NICU at University of Colorado Hospital and the NICU follow-up clinic at CHCO in Aurora, Colorado, from January 2014 to December 2016. The CHCO NICU discharges approximately 1300 patients per year, and University of Colorado NICU discharges 520 patients per year. The CHCO NICU follow-up clinic sees an average of 100 infants per year who are discharged primarily from the aforementioned NICUs. For our data collection purposes, infants discharged from either CHCO or University of Colorado NICU were included to capture accuracy of discharge mixing postdischarge. Infants who were transferred to outside institutions prior to discharge and infants who had died prior to discharge were excluded from the data collection process.
Criteria for high-risk patients were identified and included the following: discharge weight less than 2000 g, those with language barriers, socioeconomic factors, and social determinants that may limit the contributions of parents who must learn how to mix formula for their infants (eg, level of education, other children, resources for adequate transportation). Other factors that contributed to high-risk discharge criteria included infants with alternative feeding routes (nasogastric, transpyloric, and surgically placed gastric tubes), multiple feeding recipes, knowledge of metric versus English measures (milliliters vs ounces), and families rarely present during hospital stay.
A standardized model was developed to teach families discharge recipes for infant feeding mixings. Education comprised a teaching tool (a laminated educational handout) that outlined steps to a teach-back method for teaching parents infant feeding mixing, access to hospital intranet written instructions of specific feeding recipe handouts, and instructions to contact professional interpreters for all non–English-speaking families.
The QI project's leadership team purchased measuring teaspoons for fortified human milk teachings and standardized the types of bottles used for formula and human milk recipes. The institution's Health Literacy Department was consulted to develop patient handouts that included pictorial images for formula or fortified human milk preparation. During the intervention period, NICU designated registered dietitians (RDs) and NICU leadership provided bedside education and assistance to nurses by reviewing the standardized teaching tool (Figure 2). Educated nursing staff members then were asked to teach families mixing demonstration and to provide written instructions. In return, parents were expected to correctly mix the recipe a minimum of 3 times within 3 days of discharge. Families were encouraged to use smartphones or tablets to record the mixing demonstration.
Baseline accuracy of discharge fortified human milk and formula mixing data was retrieved in 2012 upon initial visits to the NICU follow-up clinic at CHCO (N = 50). Neonatologists and NICU RDs confirmed accuracy of mixing by asking parents to describe specific mixing and compare with the specific calorie recipe given in the infant's discharge summary. Data were documented in a protected Excel spreadsheet by NICU QI team members. Data revealed a 50% mixing accuracy rate.
In 2013, after 2 infants were readmitted to the NICU because of life-threatening hypernatremia, implementation of interventions for improving infant discharge feeding recipes began.
In 2013, a feeding questionnaire was developed and documented in the nutrition template of the electronic medical record. This information was collected at each infant's initial postdischarge visit at the CHCO NICU follow-up clinic. The following terminology was used to obtain the baseline data: “Please describe how you are preparing your infant's feedings?” Mixing accuracy was validated by comparing parental responses with the patient's discharge instructions in the electronic medical record. For infants who did not attend the NICU follow-up clinic, postdischarge NICU leadership follow-up phone calls were completed within 1 week of discharge to assess parental understanding of mixing instructions using the feeding questionnaire. Mixing accuracy was validated with discharge instructions in the electronic medical record.
For 2013 NICU graduates seen in CHCO follow-up clinic (N = 65), data revealed 72% mixing accuracy. Data were collected using the standardized feeding questionnaire, which was included in the follow-up clinic initial visit prior to formal QI implementation.
The official QI project was implemented in January 2014. Follow-up mixing accuracy data were collected in the NICU follow-up clinic from 2014 to 2106, 2 years after implementing the standardized teaching method. Postimplementation data (2014-2106) were utilized to compare with baseline (2012) data in the NICU follow-up clinic.
For all infants who were discharged to community providers, phone call follow-up data were obtained from parents within a week of discharge and collected from January 2014 to 2016. Phone call follow-up mixing accuracy data were not collected prior to QI project implementation. Follow-up data at the initial clinic visit and phone call follow-up data were retrieved by NICU QI team members and documented in a protected Excel spreadsheet by NICU QI team members. The QI project was reviewed by the Organizational Research Risk and Quality Panel, and the study was deemed exempt from the need for consent.
For high-risk infants who were discharged to community providers, a teleconference with the infant's primary care provider was conducted when possible for complex cases. The NICU discharge coordinator and the neonatologist communicated via videoconferencing to review infant's NICU course and discharge recommendations. Primary care physicians and advanced practice practitioners who participated in the telemedicine conference shared that access to infant's feeding recipe was useful for ensuring parental accuracy at the first follow-up visit.
Baseline data (2012) at the initial NICU follow-up clinic revealed a 50% infant feeding accuracy rate (N = 50). Follow-up clinic mixing accuracy data in 2013 revealed 72% mixing accuracy (N = 65). At the NICU follow-up clinic, post-implementation (2014-2016) mixing accuracy data (N = 247) improved from 50% to 95% within 36 months of project implementation (a 45% improvement). For all infants who were discharged to the community and did not attend the hospital's NICU follow-up clinic, January 2014-December 2016 postdischarge phone call data revealed a more than 95% mixing accuracy rate for the families that responded to the phone calls (N = 3973). Phone call follow-up data were implemented with official QI project rollout in 2014; therefore, baseline phone call follow-up data were not available in 2012 and 2013. No readmissions were reported as a direct result of inaccurately preparing feedings (Figure 3).
After implementing the QI intervention, the percentage of families mixing feedings accurately at the clinic follow-up improved to greater than 95%. In 2014, the goal was met to improve the infant feeding mixing accuracy rate at follow-up to 75% within 12 months of implementation (January-December 2014). This project sustained the feeding accuracy rate at follow-up to above 95% for an additional 24 months (January 2015-December 2016).
A standardized education approach and inclusion of health literacy specialists who developed educational handouts resulted in a significant improvement of the mixing accuracy rate after hospital discharge. No readmissions have occurred that were directly related to inaccurate feeding mixing.
High-risk infant follow-up programs have the potential to act as multidisciplinary clinics by providing continuity of clinical care, providing education of healthcare trainees, and facilitating outcome data research.6 Kuppala and colleagues6 surveyed 170 academic NICUs from 2009 to 2010. Ninety-three percent of the respondents had a NICU follow-up program associated with their institution. Birth weight, gestational age, and critical illness in the NICU were the major criteria for follow-up care. Management of nutrition and neurodevelopmental assessments were the most common services provided.6
The nutrition management of NICU graduates is instrumental in follow-up clinics.1 In 2012, RD involvement was implemented in the CHCO NICU follow-up clinic. The improvement seen in mixing accuracy from 2012 to 2013 could be related to NICU designated RD interventions closer to NICU discharge. Increased awareness of adverse effects of inaccurate mixing was brought to NICU leadership during this time. The QI project committee was formed in 2013 after a NICU infant was readmitted with severe dehydration and hypernatremia (serum sodium level of 186 mmol/dL) due to incorrect parental formula mixing resulting in a 54 cal/oz final recipe. With ongoing communication to NICU staff members involved with formula and fortified human milk recipe education, much effort was focused on parent/caregiver involvement in the hands-on mixing of their infant's feeding recipes. Awareness of a mixing accuracy problem and communication among NICU staff could explain the improvement seen prior to official QI project implementation in 2014.
With the increased preparation of fortified human milk and formula in hospital human milk laboratories or formula laboratories, parents and caregivers have limited exposure to hands-on mixing of infant feedings at the bedside. Inaccurate infant feeding preparation is preventable. Involving families in hands-on practice of their unique infant discharge feeding recipe can lead to accuracy and improved outcomes.
The multidisciplinary team acknowledged the importance of nurses' ability to adequately educate parents at discharge and the association of nurses' individual education skills and NICU characteristics.7 Nurses who had provided greater lactation support to very low birth-weight infants who received human milk that required precise mixing were employed in NICUs where nurses had higher-level education/degrees.7 In addition, parental presence in the NICU has been significantly associated with better nurse work environments.7
Families are eager to have input and participate in the hands-on learning of their infant's discharge feeding recipes. This parental participation in collaboration with the QI team resulted in a positive culture change at both NICUs.
Standardized teaching methods can prevent readmissions and prevent negative consequences. Making the transition from the NICU to home involves both discharge readiness and discharge preparation. Lack of parental readiness can lead to feeding issues days after discharge. Bedside discharge teaching should be supplemented with written, video, photographic, and/or other multimedia materials whenever possible.8 Videos and Websites are convenient methods of enhancing parents' knowledge and decreasing their stress.8 Lack of adequate discharge readiness can lead to adverse outcomes for infants, families, and the healthcare systems.7–10
It was noted the hospital's nursing staff educating families using the teach-back method along with parental return demonstration of infant discharge feedings started to improve before the intervention processes were fully implemented. The authors speculate this was due to the heightened awareness of efforts by members of the NICU QI project team as well as families wanting to learn hands-on techniques.
The teach-back method is known to be an effective method used to educate, engage patients, assess, and improve learning.6–10 Manual return demonstration is known to improve retention compared with providing a patient handout and verbally discussing a feeding mixing recipe with a family. In addition, teach-back implementation has been linked to more effective discharge processes, thus ensuring safer hospital-to-home transitions.11 This QI project utilized these approaches and was able to improve outcomes that resulted in accurate preparation of infant feeding recipes during hospitalization and after discharge. Hands-on practice of infant feeding recipes can breed familiarity for families. Structured family education programs should be tailored to the family's specific needs and circumstances. Involving primary nurses in the infant mixing recipes for unique family situations can help with continuity in discharge teaching and may help improve outcomes. This intervention would produce similar results in other NICU settings, situations, or environments. Replication of the QI processes could be hindered by lack of consistent NICU personnel. This would include use of nursing float staff not familiar with having families practice discharge mixing recipes using return demonstration, lack of buy-in by the hospital administration, and lack of family involvement.
Regarding proper mixing of infant formula and higher calorie human milk recipes, healthcare providers must continue to reiterate these guidelines and the hazards of deviating from them, especially for high-risk infants. According to Burnham and colleagues, “Parents indicated a need for information and hands-on experience to enhance their readiness for discharge.”2 Labiner-Wolfe and colleagues12 found that the majority of formula-feeding mothers did not receive instruction on formula preparation.
Feeding issues are documented in the literature as the most common difficulty postdischarge.2,13,14 Bockli and colleagues14 surveyed NICU graduate clinics in academic institutions and private level III follow-up programs in the United States. In both settings, the hospital supported 60% of the funding required for clinic activities. Authors suggested that 45% of NICU graduates seen in both private and academic follow-up clinics had public aid as their primary insurance. Academic programs surveyed reported feeding issues as the most difficult postdischarge, whereas private programs found bronchopulmonary dysplasia and feeding issues equally challenging.14 Improved communications between hospital-based providers may decrease adverse events after discharge. Communication to primary care providers and advanced practice practitioners at NICU discharge outlining each infant's specialized discharge feeding recipe and nutrition plan may help reduce feeding issues postdischarge.6,8,13–15
Limitations included a small sample of NICU graduates who were followed up in the CHCO NICU follow-up clinic compared with infants who were discharged and followed up with providers in community settings. Baseline postdischarge phone call follow-up data were not collected because of risk of delaying safety interventions in 2013, prior to the formal QI project rollout. Additional limitations included lack of education handouts in languages other than English and Spanish. Literature search revealed limited publications with regard to the topic of safety and parental accuracy of infant discharge feeding recipes.
Development of a NICU discharge feeding bundle that involved a multidisciplinary team with good working relationships and support from the unit leadership and staff experienced with QI led to successful patient outcomes. Education and outcome revealed that inaccurate infant feeding preparation is preventable.
Providing comprehensive and accurate teaching to our NICU parents is an ongoing process, and literature suggests that discharge readiness is achieved, in part, through successful discharge preparation.6 Encouraging active parent participation in the mixing and preparation of their infant's feedings can help parents emerge from the NICU experience with increased competence and confidence in mixing accuracy as well as caregiving.6–8,14,15
For infants being discharged to community providers and advanced practice providers, detailed description of the infant's feeding recipe should be included in the discharge summary. For high-risk infants being discharged to the community, a teleconference between key NICU staff and community providers can be useful in relaying essential medical information and postdischarge care instructions including review of the infant's unique discharge feeding recipe.11–16 NICU discharge provider to pediatrician/advanced practice provider communication is essential at discharge. Providing discharge summaries to primary care physicians and advanced practice providers in a timely manner can help decrease discontinuity errors from the inpatient setting to the outpatient setting.6,14–16 Including the infant's exact discharge recipe in the discharge summary can help guide practitioners with compliance of the infant's specific discharge feeding recipe at the first follow-up visit.
Further outcomes of the QI project included working with community NICUs, providers, and advanced practice providers to standardize discharge recipes of infant feedings. This collaborative effort to spread standardization included multiple Denver area dietitians working with the Colorado WIC (Women, Infants, and Children) program leadership to develop uniform discharge recipes for higher calorie formulas and fortified human milk recipes.
This project affirms the widely accepted practice of return demonstration during which time the parents have the opportunity to ask questions and the staff can emphasize the important nature and scope of the procedure. Teach-back method, including return demonstration, is now a standard of care for parent education at discharge and is encouraged to be practiced in all institutions. Parental involvement at discharge is essential for successful discharge outcomes, and there is evidence to support that parents who are more apt to be present in a NICU where such QI initiatives have been implemented and supported by strong leadership in the NICU.7,8,14
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