pqcnc ehm nccc ls3 what we've accomplished
TRANSCRIPT
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The EHM NCCC Odyssey
April 10, 2013
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Use of Maternal Milk in the
NCCC
• “Of the various therapies used routinely in
the NICU, HM ranks among those with the
most empiric support for safety, efficacy,
availability and cost-effectiveness.”
• Maternal milk is medicine.
Breastfeeding Updates for the Pediatrician Supporting Breastfeeding in the Neonatal Intensive
Care Unit. Paula P. Meier, Aloka L. Patel, Harold R. Bigger, Beverly Rossman, and Janet L.
Engstrom. Pediatric Clinics of North America, 2013-02-01, Volume 60, Issue 1, Pages 209-226
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The Case for EHM
• Higher doses of Maternal Milk reduces:
– enteral feeding intolerance
– late-onset sepsis
– necrotizing enterocolitis
– chronic lung disease
– retinopathy of prematurity
– neurocognitive delay
– rehospitalization at 18 and 30 months of age.
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EHM NCCC
• Action Plan
– Early Pumping
– Skin to Skin
– Documenting milk production (500 cc/day at 2
weeks)
– Mom’s time to obtaining pump
– Frequency of mothers use of a breast pump
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EHM NCCC Data
• Admission
• Discharge
• Daily DOL 1-14• Day 21 and 28
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EHM NCCC
Goal:
Increase use of exclusive
maternal milk by 50% at 28
days
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EHM NCCC: Early Pumping
Challenges
• Benefits potentially of expressing/pumping
by 1 hour
– Sustain supportive milk production
• Coordination with Labor and Delivery
– Maternal order sets include pumping
• Education of staff and families
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Meier, Paula P., PhD, RN, Pediatric Clinics of North America, Volume 60, Issue 1, 209-226
Copyright © 2013
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( From Rush Mothers' Milk Club, Rush University Medical Center, Chicago, IL; with permission.)
Supporting Breastfeeding in the Neonatal Intensive Care Unit
Meier, Paula P., PhD, RN, Pediatric Clinics of North America, Volume 60, Issue 1, 209-226
Copyright © 2013
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EHM NCCC:Skin to Skin
Challenges
• Definition of stability – Only 40% of NICUs have formal guidelines for defining
stability
• Technology – Variable with vent, CPAP, central lines
• Institutional Factors – Orders required
– Education
• Familial Factors – Education
– Mother’s health
1. Lee HC, Martin-Anderson S, Dudley RA. Breastfeed Med. 2012 Apr;7(2):79-84.2. Franck LS. Bernal H. Gale G. Neonatal Netw. 2002;18:13–20.
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EHM NCCC: Skin to Skin
• Benefits of Skin-to-Skin Contact or
“Kangaroo Care”
– Increases maternal milk supply and guards
against insufficient lactation. 1,2
– Improves oxygen saturation 3
– Improves stress responses 4
– Reduces hypothermia, bradycardia, andstabilizes respiratory rates. 5
1. Hurst NM. Valentine CJ. Renfro L, et al. J Perinatol. 1997;17:213–217.2. Rojas MA. Kaplan M. Quevedo M, et al. J Dev Behav Pediatr. 2003;24:163–168.3. Roberts KL. Payntner C. McEwen B. Neonatal Netw. 2000;19:31–35.
4. Bier JB. Ferguson AE. Morales Y, et al. Arch Pediatr Adolesc Med. 1996;150:1265–1269.
5. Neu M. Laudenslager ML. Robinson J. Biol Res Nurs. 2209;10:226–240.7. Bergman NJ. Linley LL. Fawcus SR. Acta Pædiatr. 2007;93:779–785.
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Close to Me
• Partnership with March of Dimes
• Bilingual education for families & staff
• Educational materials
• Equipment
– Kangaroo Chairs
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Milk Volume Targets
• Milk output during the first 2 postnatal
weeks predicts the adequacy of milk
volume during the late NICU
hospitalization.
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Milk Volume Targets
• Support infant in the NICU at the time,
– Small amounts due to prematurity, surgical
complications, or fluid restrictions
• Protect and support the milk supply by
early programming that enables their
infants to receive exclusive HM feedings
after the NICU hospitalization. – Minimal milk volumes of 350 mL per day
– Volumes closer to 1000 mL per day ensure
enough milk later
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EHM NCCC Enrollment
UCL
16.485
CL
8.000
LCL
0.0000
10
20
30
40
50
60
70
80
Mar'12 Apr'12 May'12 Jun'12 Jul'12 Aug'12 Sep'12 Oct'12 Nov'12 Dec'12 Jan'13 Feb'13 Mar'13
M o n t h l y E n r o l l m e n t
EHMNCCCMonths
InfantsEnrolledinEHMNCCC
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SPC Charts
• Determining Significance
– 1 point outside the upper or lower control
limits
– 2 of 3 successive points in the outer third of
the control limit
– 8 successive points above or below the center
line – 6 consecutive points increasing or decreasing
Benneyan JC, Lloyd RC, Plsek PE Statistical process control as a tool for researchand healthcare improvement. Qual Saf Health Care. 2003;12(6):458–464
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EHM NCCC: Breastfeeding
Support
CL
0.3418
UCL
0.4074
LCL
0.2762
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
% D a y s W i t h B r e a s : e e d i n g s u p p o r t D e l i v e r e d
Interven?onMonth
%DaysWithBreas:eedingSupport
425%IncreaseinBreas:eedin Su ort!
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EHM NCCC: Skin to Skin
0.0850.108
0.3163
0.1010
0.1300
0.3806
0.0697 0.0857
0.2521
0.000
0.050
0.100
0.150
0.200
0.250
0.300
0.350
0.400
Mar'12 Apr'12 May'12 Jun'12 Jul'12 Aug'12 Sep'12 Oct'12 Nov'12 Dec'12 Jan'13
% o f D a y s W i t h S T S T i m e
Interven?onMonths
Daysin1stWeekofLifeWithSkinToSkin
450%increaseindaysofSTSTime!
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EHM NCCC: Pumping Events
CL 1.567
4.2348
UCL 1.6855
4.6367
LCL1.4488
3.8329
0.000
0.500
1.000
1.500
2.000
2.500
3.000
3.500
4.000
4.500
5.000
12-Mar Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
A v e r a g e D a i l y P u m p i n g E v e
n t s
Interven?onMonths
EHMNCCCAverageDailyPumpingEpisodesReported
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EHM NCCC: Daily Pumping
Volume
UCL
243.016
CL
200.533
LCL
158.050
0
50
100
150
200
250
300
Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
D e f e c t s
Mar-12-Jan-13
AverageReportedDailyVolumeofBreastMilkPumped
Averagereporteddailyvolumepumpedincreasedby645%!
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EHM NCCC: Pump Types
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EHM NCC Pump Delay
UCL 8.196
CL 3.000
0
1
2
3
4
5
6
7
8
9
1 2 3 4 5 6 7
D a y s
Months
EHMNCCCPumpDelay
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EHM NCCC: Exclusive Maternal
Milk
CL
0.3710
UCL
0.6313
LCL0.1107
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
% I n f a n t s W i t h
E x c l u s i v e M a t e r n a l M i l k
Interven?onMonths
EHMNCCCInfantsFedExclusiveMaternalMilkThru28Days
34%IncreaseinVLBWInfants
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Innovations
• Reducing time to first pumping
• Reducing time to mom’s getting a pump
– Supplying pumps
– Improving quality of pumps provided
• Pumping diaries
• Kangaroo Days/Kangaroo Marathons
• Increasing Lactation Support
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Metrics for Human Milk
• Proportion of infants received HM
• Average daily dose of HM, days 1 to 14
• Average daily dose of HM, days 1 to 28
• Average daily dose of HM, NICU
hospitalization
• Proportion of feedings from HM days1-14
• Proportion of feedings from HM, days
1-28
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Metrics for Human Milk
• Proportion of feedings from HM, NICU
hospitalization
• Total number of NICU days of any HM
feedings
• Total number of NICU days of exclusive
HM feedings
• HM feeding status (partial, exclusive,
none) at discharge
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Added Data
• VON PQCNC Data
– Identifier codes for facilities in 2009-2011
reports
• NEC
• Infection
• CLD
• Growth
• Any HM
• Have codes for Forsyth, Moore, Women’s,
CFV, UNC
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Going Forward
• This work must continue
• Data system will remain active
• Reporting will be operational