O2080: A Quality Improvement Initiative to Decrease the Rate of Extra-uterine Growth Restriction in Very Low Birth Weight Infants

Purpose/Objectives:

Background:
Suboptimal nutrition in preterm babies not only leads to growth failure, but increased morbidity and adverse neurodevelopmental outcomes. Internal data demonstrated that up to 75% of very low birth weight (VLBW; < 1500 g) infants had a >-0.8 change in their z-score for weight by discharge and 60% had a discharge weight < 10th percentile (z-score <-1.28), indicating that a significant proportion experience extra-uterine growth restriction (EUGR).

Objective:
To decrease the rate of EUGR [discharge weight z-score <-1.28 ( < 10th percentile)] in VLBW infants from 60% to 40% by June 2023.

Design/Methods: Methods:
Using the Model for Improvement, a multidisciplinary team consisting of dieticians, bedside nurses and neonatal providers implemented modifications to existing nutrition protocols, including increasing trophic feeding volumes, initiating intralipids on admission, fortifying human milk at 60 ml/kg/day, and increasing goal feeding volume to 165 ml/kg/day. Additionally, a feeding intolerance algorithm was developed to minimize feeding interruptions.

Data collection and analysis:
Pre-intervention data was collected retrospectively, and z-scores were calculated using the Fenton calculator. Post-intervention data was collected prospectively. Primary outcome is weight z-score >-1.28 (>10th percentile) at discharge or 36 weeks post-menstrual age (PMA), whichever comes first. Secondary outcomes include a change in weight z-score <-0.8, and discharge head circumference z-score. Process measures include use of the feeding intolerance algorithm, days to baseline feeding volume of 120 ml/kg/d, early fortification timing, and days to reach final goal feeding volume of 165 ml/kg/day. Balancing measures include necrotizing enterocolitis and late-onset sepsis. Process control charts were used to monitor outcomes and process measures. For process control charts, each data point represents a group of 7 infants to decrease the impact of individual outliers.

Results: Pre-intervention data (n=161) demonstrated EUGR in 60%. After implementation of the nutrition bundle in June 2022, EUGR decreased to 35% (n= 60). Change in weight z-score >-0.8 also decreased (75% vs 43%). Using standard process control chart methodology, results revealed that not only did discharge weight < 10th percentile and change in weight z-score both improve, but variation in change in weight z-score also decreased. Process measures of utilization of the feeding intolerance algorithm, fortification timing and attainment of goal volumes also improved. Balancing measures remained unchanged.

Conclusion/Discussion: Implementing a multi-pronged approach to improving early nutrition in VLBW infants is achievable and can impact discharge growth metrics. As part of our next PDSA cycle, we will work on streamlining the monitoring of serum sodium levels and enteral sodium supplementation to further optimize growth.