Objectives Doing What s Best: Applying Quality Improvement to Promote Human Milk Feeding Staci Bohling, BSN, RN; Froedtert and the Medical College St. Joseph s Hospital West Bend Angela Chivers, BS, IBCLC, CLC; St. Croix Regional Medical Center Lisa Lokken, MSN, RNC-OB, C-EFM, CNS-BC; Ascension St. Joseph and Elmbrook Memorial Deborah Schumacher, BSN, RN; Fort HealthCare Amanda Strom, BSN, BS, IBCLC; St. Croix Regional Medical Center At the end of this session, participants will be able to: Identify three strategies for promoting human milk feeding in the hospital Identify two strategies for tracking quality improvement 2 Conflicts of Interest Background Name Staci Bohling Angela Chivers Lisa Lokken Deborah Schumacher Amanda Strom Relevant Conflict of Interest Wisconsin Perinatal Quality Collaborative first meeting August 13, 2014 Stakeholders representing hospitals, health care systems, professional organizations, and others Received funding from DHS in 2016 to build infrastructure Selected maternal hypertension as first initiative 3 4 Human Milk Feeding Initiative selected for 2017 Goal: As many infants as possible receive human milk Nine measures selected (see handout) Data submission through WisPQC Web site St. Croix Regional Medical Center Rural hospital in St. Croix Falls, WI 4 LDRP rooms; 2 higher acuity beds Level II Nursery Annual deliveries: usually ~300/year; in 2017, ~250 L and D nursing staff: 12 (All nursing staff have taken the 18-hour CBC course) 2 IBCLCs on staff Two other hospitals in the county, averaging 50-15 deliveries/year 5 6 1
2017 Human Milk Feeding Measure 8: Human milk feeding after discharge Increase human milk feeding at 1-2, 3-4, 6, 12 months Measure 9: Exclusive human milk feeding after discharge Increase exclusive human milk feeding at 1-2, 3-4, 6 months Challenges Extracting data was time consuming. Data was manually extracted from each patient s chart at 2, 4, 6, 9, and 12 month well-baby visits. There were times when well-baby visits were late, thus we had to return to the chart. Each provider documents differently. This occasionally made it difficult to determine if supplementation was being received. 7 8 Challenges (cont.) Exclusivity at 6 months was often not conclusive. Some babies were documented as eating solid foods at six months. It was not clear if solids were started at, before, or after six months of age. This skewed the exclusivity. 9 Successes A hard look at the number of babies supplemented with formula propelled us to quickly proceed with offering human milk in our OB unit. As of April 1, we will have banked human donor milk for our patients. The amount of formula supplementation given to hypoglycemic babies pushed us to revise our hypoglycemia policy. In 2017, we were able to add an addition IBCLC to our staff. In 2018, we are adding an additional weekly breastfeeding support group: The Latch and The Latch After Hours. 10 Moving forward Our BF Coalition contributed a freezer to get the process rolling. Next step, become a depot and depository for milk bank. Moving forward (cont.) Recognized a need for consistent and continuous prenatal education. (We are working towards having an OB RN working with our providers in the clinic to ensure consistent, evidenced based prenatal care). Recognized that a discussion concerning solids would be more appropriate at the 2 or 4-month visit. 11 12 2
Action On April 1, 2018, we are implementing human milk to be used when supplementation is necessary. Working with Coffectivematerials and support partnership with our local WIC Director to implement the Coffective education. Action (cont.) Provide Getting Ready brochure to prenatal patients that attend classes (Goal of having this discussed with prenatal care coordinator). Staff training with LC led and video based learning on these areas. Implementation: A 4-hour mandatory lactation training for all OB staff. 13 14 Continuing Measures 8 and 9 Measure 2: Skin-to-skin after delivery Measure 5: Exclusive human milk feeding during hospitalization Measure 10: Human milk feeding at discharge 15 Froedtertand the Medical College St. Joseph s West Bend Only birth hospital in Washington County Froedtert academic facility; Community Memorial and St. Joseph s community division 12 LDRP Special Care Nursery-Level I-babies 35 weeks (supported by CHOW neonatology and NNPs) 682 deliveries in 2017 30 RN staff and 9 techs 16 2017 Human Milk Feeding Measure 2: Skin-to-skin after delivery Measure 3: Skin-to-skin for procedures Measure 4: Rooming-in Measure 5: Supplementation Less than 30% of healthy term ( 37 weeks 0 days gestation) human milk-fed infants are supplemented with something other than human milk Measure 6: Pumping or manual expression after separation 17 Challenges Rooming in 23 hours a day-nowhere to chart in and out of room. Now we have a place-numbers more accurate for rooming in Supplementation Doing extra education with parents about 2 nd night. Found not effective to teach 2 nd night information on day 2. Handout now given after delivery 18 3
Successes Skin to skin after delivery for at least 60 minutes made this a unit goal. Spot in EMR to chart start time/end time so RN can see times. Reeducate NNP to do assessment while skin to skin Pumping or manual expression after separation LCs did extra breastfeeding education with all nurses. Hand expression and /or pumping education done with mom. RN to encourage this every 3 hours. 19 Use of Coffective Clinic hands out sheet and encourages them to get the app on their phone. Great information on skin-to-skin and breastfeeding all in one place. Continue to encourage rooming-in with education of why we do it. Focus on safe sleep, especially teaching moms safe skin-to-skin positioning. 20 Action Adding prenatal education about breastfeeding to clinic appointments and documentation Annual breastfeeding education for all RNs LCs educate on benefits of hand expression vs pumping immediately Measure 1: Prenatal education Continuing Measures 2, 4, and 5 Measure 10: Human milk feeding at discharge 21 22 Fort Healthcare Over 400 deliveries/year 23 RN staff with day shift tech support Accredited by Baby Friendly Hospital Initiative Lactation Outpatient Clinic (LOC) sees 99% of all breastfeeding newborns on day 1 or 2 IBCLC rounds daily on breastfeeding moms 6 IBCLCs as OB nurses as well as LOC 100% completion of First Latch Baby Friendly 20 hour modules 23 2017 Human Milk Feeding Measure 1: Prenatal education Measure 5: Supplementation Measure 8: Human milk feeding after discharge Increase human milk feeding at 1-2, 3-4, 6, 12 months Measure 9: Exclusive human milk feeding after discharge Increase exclusive human milk feeding at 1-2, 3-4, 6 months 24 4
Challenges Unable to identify trends related to decisions to supplement or stop breastfeeding related to different cohorts followed for data submission Documentation forms inadequate for data collection Women transferring to clinic after 28 weeks may not have received prenatal education Supporting women breastfeeding higher-risk infants 25 Successes Engaged pediatrician changed practice regarding education on introducing solids Developed a safety net to assure prenatal education Developed procedure for addressing needs of higher-risk patients Meet with lactation consultant Show short video on hand expression 26 Successes (cont.) 16 high-risk women identified Infant outcomes 5/15: exclusively breastfed 15/15: received human milk 2/15: required IV fluids (only one for hypoglycemia) No infants required supplemental formula feeding for hypoglycemia Moving forward Include Coffectivematerials and videos in the prenatal visit to reinforce education and literature provided Move audits to the lactation nurses from the Cerner lead Audit all measures (minus the NICU measures) as a way we can ensure we are staying ready for our Baby Friendly re-designation in 2020. 27 28 Action Created a Back to Work While Breastfeeding handout Changed electronic documentation forms Measure 5: Exclusive human milk feeding during hospitalization To consider purchasing donor milk for supplementation Measure 10: Human milk feeding at discharge Encourage enrollment in InJoyBreastfeeding education by offsetting price for module 29 30 5
Create electronic reporting from EHR to decrease record audit time Audit skin-to-skin and/or breastfeeding for procedures (hearing screening, metabolic screening, CHD screening) Ascension St. Joseph Urban hospital in Milwaukee, WI Annual deliveries: > 2000/year Level 3 Obstetrics Level 3 -Neonatal Women s Outpatient Clinic (WOC), Antepartum/ Women s Care Center (WCC), Labor & Delivery, Family Birth Center (FBC - Mother/Baby), NICU 31 32 2017 Human Milk Feeding Measure 2: Skin-to-skin after delivery Measure 3: Skin-to-skin for procedures Measure 4: Rooming-in Measure 5: Supplementation Measure 6: Pumping or manual expression after separation Measure 7: Human milk in the NICU NICU HMF VLBW Just a couple of NICUs participating let s recruit more! Low numbers of babies Encouraging results so far 33 34 Challenges Major reorganizations and priority changes within the system. Retirements, cost center changes, slow job postings, reduction of resource allocation. Several nursing units sometimes challenging to fully coordinate practice. Suspect data compared to what would be expected in practice. In December 2017 Challenges (cont.) WisPQC Summary reported only 4 mother/babies were separated after birth, out of 184 deliveries. When in fact, in our EPIC charting there were 36 patients that were separated. In EPIC we DID chart the first pumping of our NICU moms. We missed recording this information on our PeriData.Net sheets so we did not reflect that 19 moms were separated from their babies or that the first pumping was done. 6 moms on FBC had their babies in NICU and didn t have M/B separation documentation 1 mom on Antepartum didn t have M/B separation documented Needless to say, what we charted in EPIC was not accurately recorded on our PeriData.Net sheets. 35 36 6
Action BSN student Reviewed all cases for December 2017 Determined where disconnect was Created PowerPoint to share with nursing staff Developed reminder cards for computers Retired pumping audit tool focus on PeriData.Net for QI data reporting Plan to review April 2018 discharges for improvement 37 Successes L&D nurses have been working on encouraging skin to skin still have questions as to what constitutes unstable baby and how soon is immediate. Donor breast milk program in NICU Nursing student projects for QI 38 Successes (cont.) Distinct fields for several measures are built into EHR. IT is getting closer to being able to create a CSV file to allow direct import into PeriData.Net. Tighten up data processes. Regroup resources. Moving forward Use WisPQC reports for internal QI processes Measure 6 (retired): Pumping or manual expression after separation important for internal nursing quality projects. Engage teams to identify areas to work on. 39 40 Continue to participate in WisPQC initiative. Ascension St. Joseph Ascension Elmbrook Memorial Do at least the required* measures, and possibly others: Measure 2: Skin-to-skin after delivery Measure 4: Rooming-in Measure 5: Exclusive human milk feeding during hospitalization Measure 7: Mother s milk in the NICU* Measure 7a: Any human milk at discharge from the NICU Measure 7b: Exclusive human milk feeding at discharge from the NICU Measure 10: Human milk feeding at discharge* 41 42 7
2018 Activities Vision: As many infants as possible receive human milk. Facilities should address equity among the populations they serve. Aim: Decrease the number of infants not receiving human milk at discharge by 50% from baseline overall and in at least two population subgroups. 43 2018 Activities (cont.) Measure 1: Prenatal education* Measure 2: Skin-to-skin after delivery Measure 4: Rooming-in Measure 5: Exclusive human milk feeding during hospitalization Measure 7: Mother s milk in the NICU* Measure 7a: Any human milk at discharge from the NICU Measure 7b: Exclusive human milk feeding at discharge from the NICU Measure 8: Human milk feeding after discharge* Measure 9: Exclusive human milk feeding after discharge Measure 10: Human milk feeding at discharge* * Required for a specific setting 44 WisPQC Initiatives Future (pilot begins in 2018) Improving screening and standardizing care of infants with NAS Improving screening of women with opioid use disorder (OUD) Improving care of women with OUD Past, but still available Maternal hypertension For more information: wispqc@perinatalweb.org 45 46 8