PQCNC EHM NCCC LS3 What we've accomplished...

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The EHM NCCC Odyssey

April 10, 2013



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



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.



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



EHM NCCC Data

• Admission

• Discharge

• Daily DOL 1-14• Day 21 and 28



EHM NCCC

Goal:

Increase use of exclusive

maternal milk by 50% at 28

days



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



Meier, Paula P., PhD, RN, Pediatric Clinics of North America, Volume 60, Issue 1, 209-226

Copyright © 2013



( 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



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.



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.



Close to Me

• Partnership with March of Dimes

• Bilingual education for families & staff

• Educational materials

• Equipment

– Kangaroo Chairs



Milk Volume Targets

• Milk output during the first 2 postnatal

weeks predicts the adequacy of milk

volume during the late NICU

hospitalization.



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



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



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



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!



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!



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



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%!



EHM NCCC: Pump Types



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



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



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



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



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



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



Going Forward

• This work must continue

• Data system will remain active

• Reporting will be operational



PQCNC EHM NCCC LS3 What we've accomplished...

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