P2D187: Nutrition Guidelines for 32-34 Week Preterm Infants: A Quality Improvement Initiative

Purpose/Objectives: The authors aimed at decreasing the post menstrual age at discharge for 32-34w6d gestational age infants from 36weeks 5days to 36weeks 4 days by September 2023. This is to be achieved by decreasing process measures like days of IV fluids, time to first enteral feeds and time to full oral intake

Design/Methods: The QI is set in a 96-bed level IV NICU in an urban hospital. Participants include registered nurses, clinical nurse specialists, lactation specialists, dieticians, occupational therapists, neonatal fellows, and neonatologists.
PDSA Cycle 1: Chart review of all infants born at 34w-34w6d in 2021 to review volume, choice, and days of IV fluids, choice of enteral feeds, need for gavage feeds, days to full oral intake, and length of stay. A variation of nutrition practices was found among providers upon analyzing the data. The QI initiative was planned.
PDSA Cycle 2: Creation of nutrition guidelines following analysis of above data for 34w-34w6d GA infants to address IV fluids, enteral feeds, donor human milk (DHM), formula choice, and oral intake. This was launched in Sept 2022.
PDSA Cycle 3: Review of the nutrition guideline adherence and seeking of feedback from the medical staff. The resulting feeding guidelines were extended to include infants of gestational ages 32w-34w6d.
PDSA Cycle 4: Implementation of the revised nutrition guidelines as well as completing the 2021 data review to include 32w- 33w 6d infants

Results: Through multiple PDSA cycles and ongoing feedback from our medical team, we created our most updated nutrition guidelines. Following the fourth PDSA cycle, the authors observed 95% adherence to the feeding guideline in terms of total volume of fluid initiated at birth, 80% adherence to type of IV fluid initiated at birth, and 59% adherence to timing of insertion of NG tube. Thus far, we have noticed no change in the post menstrual age at discharge, a decrease in the timing of the first feed (from 21.2 to 13.7 HOL), a decrease in the average number of days of IV fluids and no observed change in the average number of days to full enteral feeds following the fourth PDSA cycle. Infants discharged with any amount of breastmilk or breastfeeding increased from 57% to 85%. In terms of balancing measures, no infant had escalation of respiratory support upon following the nutrition guideline. 96.5% of infants regained their birthweight by DOL 14 prior to discharge.

Conclusion/Discussion: Implementation of standardized nutrition guidelines for infants of 32-34w6d gestation showed a decrease in time to initiation of first feed, a decrease in the average number of days of IV fluids and average number of days to full feeds, increase in breastfeeding and breastmilk at discharge and no change in the post menstrual age at discharge at this time.