Shimoga Institute of Medical All India Institute of Medical Sciences, Sciences, Karnataka New Delhi Quality Improvement(QI) Initiative to Increase the amount Of Mother’s Milk(EBM) to Neonates Admitted in SNCU Dr Manoj G M, Dr Vasanth Kumar D L, Dr R B Patil. Dr Venugopal, Dr Anu Sachdeva, Dr Ashok K Deorari, Lakshmi, Puttamma,
Introduction Human milk is nutritionally superior to formula feeds and it is well documented that it decreases adverse neonatal outcomes such as necrotizing enterocolitis (NEC), sepsis, and retinopathy of prematurity Preterm infants who are not able to suckle are regularly given expressed breast milk (EBM) treated and/or stored in a variety of ways.
Problem identified Average Proportion of EBM given for neonates on Postnatal day- 5, Mean = 20.92 Median = 12.92
AIIMS and Objective Aim To increase the percentage of Expresses breast milk received by neonates admitted to SNCU on Post natal day-5 (PND-5) from base line of 20% to 50%, by implementing a package of best practices, over a period of 8 weeks. P- All neonates admitted in SNCU I - Increase in EBM expression in mothers by PDSA cycles C- Compared to baseline enteral feeds O-To increase EBM enteral feeds on PND5
Methods It’s a before and after study Study was conducted in SNCU, Shimoga Institute of Medical Sciences, Shivamogga The project was carried out in a tertiary care SNCU from June 2019 to October 2019 .
Methods Inclusion criteria- All neonates who were admitted in SNCU and eligible for enteral feeds were enrolled in this study over a period of 4 months, Exclusion Criteria- Neonates who are not on enteral feeds in initial 4 PND, major congenital malformation, and neonates who are admitted after PND-5 were excluded Study was approved for ethical clearance from the Institute
SNCU set up description We run a 20 bedded SNCU with twenty nurses, three junior residents, twelve paediatricians working round the clock on a shift basis. The SNCU handles 150 admissions per month, catering to both inborn as well as out born neonates. Being a referral hospital, about 30- 40 percent of admissions are out born.
Baseline phase No new intervention All health care providers and mothers were observed in SNCU and Postnatal ward Expressed breast milk given to neonates on postnatal day-5 was documented
Intervention phase Workshop was conducted with the help of Neonatology team from AIIMS, New Delhi on quality improvement for all the health workers in Shimoga Institute of Medical Sciences. Use of breast milk for feeding neonates and EBM expression on PND5 was chosen as a priority. QI team was formed comprising of doctors, nurses, lactation counsellor and a computer operator. Root cause of decrease in EBM on PND5 was identified through fish bone analysis.
Workshop was conducted on QI
Formation of QI team The QI team consist of 2 pediatrician 3 sisters 2 junior residents 1computer operator 1 lactation councilor
Fish bone analysis Place People Decrease in EBM on Place for expression Lack of knowledge in sisters Lack of knowledge in mothers Place for sterilization Lack of knowledge in residents Storage place PND 5 Technique of manual expression No policy in unit Lack of breast pump No policy on EBM Knowledge of expression in sisters Policy Procedure
Intervention phase Multiple Plan-do-study-act (PDSA) cycle were done over a period of 3 month to achieve the aim, Monthly QI meetings were conducted, and the team was mentored through web call by AIIMS team. Data on the amount of EBM expressed by the mother was recorded by the attending sister in every shift
Study flow Implementation phase July JUNE Sept PDSA-2 Workshop Sustenance Baseline Workshop PDSA-1 PDSA-3 on phase phase on QI EBM Octob … JULY Aug Modified PDSA-1
Multiple PDSA cycles were done to achieve the goal PDSA 1: A policy was framed, wherein all mothers received mandatory counselling for expression of breast milk starting from postnatal day 1. PDSA 1( modified): The counselling method was modified when the PDSA1 failed to show a change PDSA 2: Workshop was conducted for all the nurses to train them in methods of expression of breast milk PDSA 3: A lactation counsellor was introduced to the unit
Workshop on EBM expression PDSA-2
Introduction of lactation counsellor PDSA-3
Postnatal ward counselling
Results Results were divided into base line data and intervention data In the base line data, the average Proportion of EBM given for neonates on Postnatal day- 5, Mean =20.92.24, Median = 12.9 Inter quadrantile range 28.38
Demographic characters characteristic Base line Intervention Post intervention N=80 phase N=120 N=185 Gestation age (weeks) 36.2 37 36.4 (mean) Birth weight (gms) 2100 2300 1950 (mean) Sex Male/Female M=54%. F=46% 55% / 45% 49%. / 51% In-born /Out-born 67% / 33% 60% /40% 62% / 38% Normal vaginal delivery 60 120 85 Caesarian section 20 65 35
Results Implementation phase July JUNE Sept PDSA-2 Post Baseline Workshop on PDSA-3 Workshop PDSA-1 intervention phase N=60 EBM N=63 on QI N=120 N=80 N=62 Octob … JULY Aug Modified PDSA-1 Enrolled N=186 Exclusion N=32
Results- Implementation phase PDSA-1 where all the mothers were counselled about EBM and the way to express, and were told them of giving formula feeding to neonates till adequate EBM is expressed After first PDSA cycle there was a fall in expressing of EBM to 14.4% from 20% as in counselling parents were told that formula feeding will be given till the expressed breast milk is in enough quantity, Therefore after 2 weeks of analysis we changed the way of counselling that formula feeding is inferior of breast milk and started counselling about importance of breast milk for brain, eye, prevention of NEC etc. Two weeks later we saw the improvement where mean was 34.1, median 32.0, inter quadrantile range was 14.39
Results-PDSA-1, Implementation phase
Results- Implementation phase PDSA-2, we conducted one day workshop to all the nurses of SNCU with the help of St johns' neonatologists' team and taught them the proper way of expressing of breast milk. PDSA -2 resulted in rapid increase in the percentage of EBM, Mean - 45.5, Median -43.93, Interquartile rang-12.87.
Results- Implementation phase PDSA-3, we appointed a lactation counsellor where she was well trained for manual expression of EBM, her work is to demonstrate EBM expression on mama breast in post-natal wards and post caesarean ward. After 2 weeks when we analysed the data there was a drastic improvement in the percentage of EBM from to Mean 55.8, Median 66 Interquartile range was 51.2,
Depicting on increase in EBM May June July Aug minimum 0 0 10.66 0 Q1 11.6125 27.4525 38.09 32 median 12.925 32 43.93 66 Percentage Q3 40 41.85 50.96 83.225 maxmim um 60 66.66 88.88 100 20.9296 34.1781 45.4096 55.8114 mean 9 4 8 5 range 28.3875 14.3975 12.87 51.225 IQR 28.3875 14.3975 12.87 51.225 42.5812 21.5962 5 5 19.305 76.8375 uppercut 82.5812 63.4462 160.062 off 5 5 70.265 5 lower - - cutoff 30.9688 5.85625 18.785 44.8375
Results- Implementation phase We analysed our data for not able to achieve up to 90% we understood that Ours is a referral hospital where 30%-40% of mothers were from different hospitals and were not counselled, But still there is a scope of further improvement.
Sustenance phase -To sustain the gains make system changes We are sustaining the achieved goal by making • Protocol in our unit • Permeant lactation councillor • Continuous education to all mothers • Run chart feedback every month
Key findings The mean percentage of expressed breast milk increased from 20% to 60% Improvement was sustained
Lessons learnt for practice 1. Multiple levels intervention is required to achieve the goal 2. Ongoing evaluation is very important 3. Teamwork can create wonders
What this study adds By using the principle of QI it is possible to increase the amount of expressed breast milk in a resource constrain setting
Acknowledgment The authors are deeply thankful to o AIIMS team, o St John’s team, o Nurses and junior residents for participating in this QI and making this project successful
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