• Discarding Residuals: Implementing a Feeding Algorithm in a Neonatal Intensive Care Unit

      Ruccio, Lucy R.; Wilson, Janice (2021-05)
      Problem: Routine gastric residual (RGR) monitoring is not reliable in detecting necrotizing enterocolitis (NEC) or feeding intolerance (FI). This practice remains the primary cause of enteral feeding interruption in premature infants. It delays the achievement of full enteral feeds and increases the threat of poor growth and neurodevelopmental injury. Checking RGRs before feedings was standard practice at the target hospital’s Neonatal Intensive Care Unit (NICU). At baseline, over 40% of preterm infants had at least one checked per week. Purpose: The purpose of this quality improvement project is to implement and evaluate an evidence-based feeding guideline removing the use of RGR as an indicator of FI. Methods: The setting was a 30-bed Level III NICU and included all preterm infants, <37 weeks’ gestation, who required an oral or nasogastric feeding tube. Six weeks of background data and nine weeks of post-implementation data was collected using chart audits and informal interviews with key stakeholders. A survey of attitudes and knowledge was administered to all staff. Implementation consisted of in-service education with multiple visual aids, the dissemination of feeding algorithm cards and a “Fast Feeding Facts” bulletin. Data was collected and analyzed via run charts and descriptive statistics. Results: Data showed a decrease in patients with gastric residuals checked from 42% to 8%. The days to regain birthweight dropped from seven to six days. Staff knowledge of the role of RGRs and comfort with eliminating their routine use increased substantially. Conclusions: Implementation of an updated feeding guideline was associated with a decrease in the frequency of gastric residual checks, days with an IV in place and time to regain birthweight. This supports the research that monitoring of pre-feed RGRs should not be used for preterm infants.
    • Implementation of an Extubation Readiness Guideline for Preterm Infants

      Cobb, Emily B.; Fitzgerald, Jennifer (2022-05)
      Problem & Purpose: Intubated preterm infants ≤ 32 6/7 weeks gestation in a mid-Atlantic level IV Neonatal Intensive Care Unit (NICU) faced a high number of days on the ventilator. The literature supported that use of an extubation guideline will decrease ventilator days, and this NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. In 2020 this NICU had 22.0% of very low birth weight (VLBW) infants on a ventilator for > 28 days, compared to a median of 15.7% infants (in this subgroup) in other similar NICUs throughout the United States (U.S.). Based on six weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants ≤ 32 6/7 weeks were intubated for > 28 days, with an average of 23 days on a ventilator. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants ≤ 32 6/7 weeks gestation in a mid-Atlantic level IV NICU. Methods: This project occurred over a 17-week period in fall of 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, guideline dissemination, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre/post implementation data. Staff education completion, guideline use, guideline adherence, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Results: Post implementation data indicated decreased: average total ventilator days, need for intubation > 28 days, and days to first extubation attempt for preterm infants ≤ 32 6/7 weeks gestation. Conclusions: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants ≤ 32 6/7 weeks gestation.