Problem: Infants with CDH are at an increased risk of malnutrition which is associated with hospital readmissions related to ongoing feeding difficulties. Retrospective review showed 20% of CDH patients were discharged with malnutrition at baseline, representing an opportunity to develop feeding guidelines to decrease the prevalence of malnutrition in CDH patients.
Measurement: The team utilized QI methodology to uncover the opportunities, starting with a process map and fishbone diagram encompassing the entire feeding process. Data analysis was used to prioritize and narrow the scope, and then a driver diagram was completed. An impact/effort matrix was then used to prioritize interventions.
Analysis: A QlikSense dashboard was created to track all outcome, process and balancing metrics and reviewed on a monthly basis. The dashboard also included patient level details to assist in discussion of feeds.
Implementation: CDH patient growth parameters, current nutritional state and goals were reviewed during daily patient rounds and during a weekly multidisciplinary patient management meeting. The existing enteral feeding process was evaluated, and guidelines were created consisting of feeding type, route, tolerance monitoring, volume advancement, fortification, and TPN wean.
Results/Discussion: CDH patients discharged with malnutrition decreased by 16.7% and time to full feeding decreased by an average of 11 days (53.9%). One and three month readmission also reduced. Conferring a multi-disciplinary team to work through the methodology was integral to success. Ongoing review of the tool will contribute to sustainment.
