Improving the Growth of Very Low Birthweight Babies During the First 28 Days.

Transcription

1 Improving the Growth of Very Low Birthweight Babies During the First 28 Days. Isolating and Implementing Meaningful Differences An application of the Best Demonstrated Process Methodology Elements of Rollout Pak: Observer Letter & Roster The Big Picture Meaningful Differences What to Do- Medical Director

2 TO: FROM: RE: All Neonatologist Best Demonstrated Processes Observers Improving Weight Gain of Very Low Birthweight Babies During the First 28 Days We are Neonatologists from a cross-section of Pediatrix units. Weight Gain during the first 28 days was selected by surveying Pediatrix neonatologists, and reviewing the list of submissions with the Medical Board. We critically reviewed the literature to find that: A focus on daily weights by physicians, nurses and parents indicates clinical value. NICU growth is lower than intrauterine growth. Weight gain after thirty days parallels the intrauterine curves. Growth curve related publications reflect an expectation that NICUs infants could grow better. Long term weight and height status is linked to early post-natal weight gain. Improvement in Mental and Developmental Status is associated with early weight gain. And finally, weight gain remains a significant determinant of length of stay. Therefore we concluded that, identifying and implementing processes which increase weight gain in the first 28 days should shorten length of stays, reduce costs, and improve long-term intellectual and developmental status of infants cared for in our Pediatrix NICUs. After a critical review of the literature (Medline past 10 years), we created an observation guide covering all processes possibly impacting weight gain. Using RDS weight gain data, we identified a set of Pediatrix units, having the highest weight gain and a set of units having the lowest weight gain in the first twenty-eight days. These units were visited and observed. After observing in the units, we rigorously compared and contrasted what we saw. Meaningful process differences between the high and the low weight gain units were isolated. Meaningful differences are things virtually all of the high weight gain units are doing but virtually none of the low weight gain units are doing or vice versa. We are sharing these meaningful differences directly with you in this pak. After reviewing please consider the following next steps Joan Davis to find out how your unit performs. (Number of patients and the weight gain) If you are in the bottom third, we encourage you to try to move to the mean during the next six months. FAX the current process checklist to we will need it for documenting the value of this project. Discuss with your group if weight gain is or could be a priority for improvement work. Try using a worksheet in this packet to review the meaningful differences in your unit. Please call or any team observer with questions. Regards, The BDP Team-- Our telephone numbers may be found in our resumes Observers Resource Folks Steve Moffitt Joan Davis Sharon Ellis Pam Thomas Cody Arnold Alyce Craddock Awilda Rivera Reese Clark Page 2 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

3 John Mulligan Sudhakara Kunamneni Joyce Peabody Barry Bloom Page 3 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

4 Big Picture Rationale. Each of our units has its own ways of doing things - processes, hand-offs, and approaches. Our 100+ units perform dozens of different processes in dozens of different ways, every day. If we pick any measure and study it across all our units, we re certain to find that some units get better results than others. It s really just common sense to observe and learn from each other. It s how having 100+ units can directly benefit our patients, our Neonatologists and our hospitals. The more units we have, in fact, the richer the field from which we can harvest meaningful differences. For this project daily weight gain in the VLBW infant was chosen. Our goal will be to move the lower third to the network mean and the network mean to the average of the upper third. Our Yard Stick 14 Weight Gain During in the First 28 Days (Weight at 28 days - Birth Weight) / Number of NICUs Low Mean Weight Gain (g/day) Network Mean High Mean Performance Distribution Curve The Lowest Third, The Network Mean, and The Highest Third (Mean +/- the standard deviation - i.e. Lowest third is 8.6 +/- 5.0 grams per day) Meaningful differences are actions, steps and details found in almost all of the highestperforming unit s processes and in almost none of the lower performing units. Here s how to identify and share the meaningful differences. Ask hands-on neonatololgists to visit and observe the most effective and the least effective units, to compare and contrast what they see, to isolate the meaningful differences, and then share the differences with their colleagues. Why hands-on? They re closest to the day-to-day processes and will notice even the smallest differences. Use a disciplined approach, so the most and least effective processes are compared based on performance data (not opinions); so we identify meaningful differences by first hand observation Page 4 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

5 (not second hand stories); and so the differences are real (not invented by a committee or a consultant). Share the observed discoveries. Because these are observed by clinical Neonatologists, they can be tried right away to make a difference in units. Page 5 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

6 What might keep meaningful differences from working for you in your unit? Hide-Behind We re different here. (Pick your reason!) We already do that. We don t have time. What makes these people experts? No one from my unit was on the team. Reality All patients, Neonatologists, hospitals, payers and staff have the same basic needs. Take a second look at each meaningful difference and ask yourself: Is this being done thoroughly 100% of the time? On all shifts? It won t take much. These are tried and true differences that will make your life easier. We don t claim to be experts. We re your peers, and we re just sharing what we saw when we observed the most/least effective processes around the country. This document contains confidential information owned by the Lombardy Group, LLC and is to be used by Pediatrix for this program only. Page 6 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

7 Meaningful Differences Leading.... believe that the benefits of enteral feedings outweigh the risks. state explicit weight gain targets as the unit expectation. advocate a specific feeding strategy which includes: starting early in their clinical course advancing faster stopping less often. let the feed early/advance faster/stop less strategy drive decisions at the bedside unless there s a clear-cut reason to deviate. low weight gain attend to other priorities first..... catch up on weight gain later. use intake & calories as nutritional targets. rely on parenteral nutrition while attending to protecting the GI tract and discontinuation of mechanical ventilation. question themselves first about other priorities-ventilation or feeding risks. Then address feedings. Asking themselves: Should I start? Should I advance? Should I stop? And, being satisfied if babies have gained any weight. Page 7 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

8 Meaningful Differences, continued Managing Respiratory... consider whether baby is gaining enough in the decision to extubate. ventilate consistently Neonatologist to Neonatologist. low weight gain extubate primarily according to respiratory criteria. ventilate according to what each Neonatologist thinks is best. Managing the environment utilize sound barriers and appear to be focused on keeping noise to a minimum. low weight gain... did not appear to focus on keeping sound to a minimum. Page 8 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

9 Meaningful Differences, continued Managing nutrition... focus early on weight gain /nutrition. maintain and refer to completed growth charts during rounds when feeding decisions are being made. start feedings early. Have low resistance to early enteral feedings. use and rely on non-physician nutritional input on feedings during decision-making. supplement feeding beyond 24 calories per ounce when weight gain is not reaching target. advance faster (not sure if there was a gain per day target) require specific gastrointestinal signs to stop feedings. tolerate residuals as long as the rest of the exam is benign. fortify breast milk early one-half/two-thirds of full feedings. low weight gain focus early on other priorities. didn t use growth charts or use inconsistently. had several reasons not to start enteral feedings. Lots of delays. get non-physician nutritional input after the feeding decisions are made, if at all. accept nutritional strategy if the baby has reached the caloric & fluid targets. advance only when no competing clinical priority. stop frequently for any clinical concern. stop advancement or hold feedings with minimal residuals even if no other physical signs are present. reach full feedings before fortifying breast milk. Page 9 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

10 What to Do: Medical Director Next Steps ALL UNIT DIRECTORS Fill out and return the Current Process Checklist to let us know which of the meaningful differences are in place in your center. If your unit is in the Third with the Lowest Baby Weight Gain, it is possible/likely that few or none of the meaningful differences are in place: Make this a high priority. The average of the Middle Third is 10.5 gm/day. Make that your target. Put the meaningful differences in place by getting everyone involved together to Question Yourselves against each meaningful difference. Decide what needs to be done to give each one a try. A BDP observer is always available if you have questions. If you need help, ask your Regional Medical Officer and Unit Nursing Director to help you remove any obstacles. Target dates Sept 15 th Immediately Start ASAP to have in place by November 1 st If your Unit ranks in the Middle or Highest Third for Weight Gain, it is likely that many of the meaningful differences are in place, but perhaps not all of them, 100% of the time. Check if this should be a priority, given your other opportunities for improvement in the next three to six months. The average Weight Gain in the Highest Third is 13.6 gm/day. Use that for your target, if you are already above that, go for any improvement. If this will be a priority, put the meaningful differences in place by getting everyone involved together to Question Yourselves against each meaningful difference. Decide what needs to be done to give each one a try. Call any Observer with questions about what was observed. Ask your Regional Medical Director to help you remove any obstacles. Immediately Start ASAP, having the changes in place by November 1 st Throughout. Page 10 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

11 Putting the Meaningful Differences in Place- Question Yourselves Leading.... believe that the benefits of enteral feedings outweigh the risks. state explicit weight gain targets as the unit expectation. advocate a specific feeding strategy which includes: starting early in their clinical course advancing faster stopping less often. low weight gain attend to other priorities first..... catch up on weight gain later. use intake & calories as nutritional targets. rely on parenteral nutrition while attending to protecting the GI tract and discontinuation of mechanical ventilation. let the feed early/advance faster/stop less strategy drive decisions at the bedside unless there s a clear-cut reason to deviate. question themselves first about other priorities-ventilation or feeding risks. Then address feedings. Asking themselves: Should I start? Should I advance? Should I stop? And, being satisfied if babies have gained any weight. Question Yourselves Aloud about Leading : When setting our unit goals, priorities, and strategies, as a unit, have we recently considered enteral feeding strategies relative to or in combination with other priorities? In general, are we more consciously focusing on other priorities, thinking that weight gain can be addressed later and therefore only sub-consciously focusing on weight gain? Are we using intake & calories as nutritional targets instead of explicit weight gain targets? Are staff members focusing on intake & calories instead of weight gain? At the bedside, do we more or less have to convince ourselves to start/advance feedings as opposed to vice versa? Have we done everything we can to make consideration of weight gain systematic and routine? What action steps need to be taken? By Whom & When? If you are in the Lowest 3 rd - Fill out the Question Yourself Follow-up Sheet Page 11 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

12 Putting the Meaningful Differences in Place- Question Yourselves- continued Managing Respiratory... consider whether baby is gaining enough in the decision to extubate. ventilate consistently Neonatologist to Neonatologist. low weight gain extubate primarily according to respiratory criteria. ventilate according to what each Neonatologist thinks is best. Question Yourselves Aloud about managing Respiratory: Are we deciding to extubate without factoring in weight gain? Routinely and systematically considering weight gain in extubation decisions? Are we each making our ventilation decisions with different criteria? What action steps need to be taken? By Whom & When? If you are in the Lowest 3 rd - Fill out the Question Yourself Follow-up Sheet Page 12 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

13 Putting the Meaningful Differences in Place- Question Yourselves- continued Managing the environment cycle light systematically. utilize sound barriers and appear to be focused on keeping noise to a minimum. low weight gain... cycle light irregularly, if at all. did not appear to focus on keeping sound to a minimum. Question Yourselves Aloud about the Environment: Are we really cycling light or does it happen only irregularly? Is it occurring every day/night? Are we really focused on reducing noise? All the time? During rounds, during admissions, during nursing report? What action steps need to be taken? By Whom & When? If you are in the Lowest 3 rd - Fill out the Question Yourself Follow-up Sheet Page 13 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

14 Putting the Meaningful Differences in Place- Question Yourselves- continued Managing nutrition... focus early on weight gain /nutrition. maintain and refer to completed growth charts during rounds when feeding decisions are being made. start feedings early. Have low resistance to early enteral feedings. use and rely on non-physician nutritional input on feedings during decision-making. low weight gain focus early on other priorities. didn t use growth charts or use inconsistently. had several reasons not to start enteral feedings. Lots of delays. get non-physician nutritional input after the feeding decisions are made, if at all. Question Yourselves Aloud: Is it part of daily routine of everyone to focus early on weight gain and nutrition? Are growth charts part of our actual daily routines especially when making decisions? Are we sometimes using growth charts only after the fact? Are we finding numerous reasons not to feed and allowing delays to creep in maybe not consciously? Are we sometimes getting input from non-md nutritional expertise after feeding decisions? Are we making sure that we have non-md nutritional advice during our decisions? What action steps need to be taken? By Whom & When? If you are in the Lowest 3 rd - Fill out the Question Yourself Follow-up Sheet Page 14 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

15 Putting the Meaningful Differences in Place- Question Yourselves- continued Managing nutrition... supplement feeding beyond 24 calories per ounce when weight gain is not reaching target. advance faster (not sure if there was a gain per day target) require specific gastrointestinal signs to stop feedings. tolerate residuals as long as the rest of the exam is benign. fortify breast milk early one-half/two-thirds of full feedings. low weight gain accept nutritional strategy if the baby has reached the caloric & fluid targets. advance only when no competing clinical priority. stop frequently for any clinical concern. stop advancement or hold feedings with minimal residuals even if no other physical signs are present. reach full feedings before fortifying breast milk. Question Yourselves Aloud: Are we sometimes satisfied if baby has reached caloric/fluid targets? Are we advancing only when there are no competing priorities? Are we /our staff stopping feeding when maybe not absolutely necessary or without conscious consideration? Are we sometimes holding or slowing feedings for minimal residuals even if no other sign present? Are we sometimes waiting to fortify until full feedings? What action steps need to be taken? By Whom & When? If you are in the Lowest 3 rd - Fill out the Question Yourself Follow-up Sheet Page 15 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.

16 Current Process and Follow up Checklist Please fill out the left and right-hand columns by Sept 30th and fax to Review this sheet again the first week in January and in March. If you initiate any changes based upon the meaningful differences, please complete and fax again so we can use this information in the publication. Checklist Unit Name: Your Name: Current Process Date / Was this in place? Was this in place? Was this in place? Leading: believe that the benefits of enteral feedings outweigh the risks. state explicit weight gain targets as the unit expectation. advocate a specific feeding strategy which includes: starting early in their clinical course advancing faster stopping less often. let the feed early/advance faster/stop less strategy drive decisions at the bedside unless there s a clear-cut reason to deviate Managing Respiratory... consider whether baby is gaining enough in the decision to extubate. ventilate consistently Neonatologist to Neonatologist.: Managing the environment utilize sound barriers and appear to be focused on keeping noise to a minimum Managing nutrition... focus early on weight gain /nutrition. maintain and refer to completed growth charts during rounds when feeding decisions are being made. start feedings early. Have low resistance to early enteral feedings. use and rely on non-physician nutritional input on feedings during decisionmaking. supplement feeding beyond 24 calories per ounce when weight gain is not reaching target. advance faster (not sure if there was a gain per day target) require specific gastrointestinal signs to stop feedings. tolerate residuals as long as the rest of the exam is benign. fortify breast milk early one-half/two-thirds of full feedings. Will you try this one? Will you try this one? Will you try this one? Will you try this one? Page 16 of , Inc. Reproduction of this material by any means without the express written permission of, Inc. is prohibited.