Implementation of an InfantDriven Feeding Algorithm Brooke Welker

Implementation of an Infant-Driven Feeding Algorithm Brooke Welker, BSN, RN

Objectives • Describe implementation of an infant-driven feeding tool in the NICU • Identify barriers to implementation of an infant feeding readiness tool

Introduction • Oral feedings: most prevalent developmental challenge preterm infants face • Feeding difficulties increase LOS & cost of healthcare • Former premature infants: 40% referred to feeding disorder clinics • Growth and discharge

Background • Volume-driven (medical order) • Set intervals • Often the infant’s behavioral and physiological readiness is not taken into consideration

Significance • Stress to infant during feeding negative desire and capability to feed in the NICU and at home • >50% of parents with former NICU babies reveal feeding difficulties in their infant at the age of 1824 months • Infant-driven feeding • Reduces the time it takes to reach full feedings compared to volume-driven feedings reducing LOS and NICU costs

Significance • National Association of Neonatal Nurses (NANN) recommends infant-driven and patient-specific feedings to assure safety • To improve the chances for successful feeding outcomes for both the short and longterm transition to an infant-driven feeding approach

Local Problem • 24 -bed Midwestern level II-III NICU • Volume-driven approach • No infant feeding readiness tool • Inconsistencies in feeding practices among caregivers & parents • Force feed vs. gavage feed

Purpose Statement • The purpose of this quality improvement project was to implement an infant-driven feeding tool in an effort to transition to a uniform infant-driven feeding culture in the Neonatal Intensive Care Unit.

Literature Review • Preterm Infant Feeding Challenges • Physiologic complications • Immature gastrointestinal system • Immature neurologic system • Enteral and Oral Feeding Practices • • Variances among nurses Inconsistencies in clinical practice Infant-driven feeding practices Volume-driven feeding

Literature Review • Infant Feeding Readiness Scales • • Infant-Driven Feeding Scale (IDFS) Neonatal Oral Motor Assessment Scale (NOMAS) Early Feeding Skills (EFS) Supporting Oral Feeding in Fragile Infants (SOFFI) Method

Theoretical Framework • The Synactive Theory of Development • Premise: Infant must learn to self-regulate and balance the environment • Promotes idea that caregivers can assess the infant determine oral feeding readiness

Implementation • Initial Survey • Questionnaire: collect basic demographic information, in addition to questions considering the nurses’ perception regarding attitudes towards current enteral feeding practices within our NICU (Fall/Winter of 2015) • Results: Unsure about feeding readiness tool, diverse responses from participants • The physicians and NNPs were most involved in the decision to oral feed the infants • GA and respiratory status were primary criteria for initiation of oral feeds • Success: Able to consume entire volume (50%)

Implementation • Selection of Feeding Tools/Method • SOFFI Method • EFS documentation • Decision made to utilize SOFFI Method and documentation within EFS • EFS used to illustrate cues and infant states prior to, during, and after feedings (EFS closely aligns with SOFFI, checklist vs. algorithm)

Implementation • Education of Staff • Healthcare system hosted Dr. Erin Ross, creator of the SOFFI Method, to provide education on the method • I attended Dr. Ross’s lecture and used this information to provide education to the NICU staff • The education was provided to all NICU nursing staff at the monthly staff meetings • EFS education at nursing skills lab following SOFFI education • EFS flowsheet was placed on each nurse’s documentation layout (in EPIC) to assure access to flowsheet

Implementation & Documentation Audit • SOFFI algorithm, Pacing Protocol, and Flow Rate Protocol placed at the each bedside • Detailed SOFFI algorithm on main unit computers • Go Live for SOFFI Method and EFS documentation 12/1/16 • Weekly chart audits in December

Follow-up Survey • To reevaluate current enteral feeding practices in the NICU • Illustrate how nursing perceptions regarding feeding practices have changed following SOFFI implementation • Similar survey as pre-implementation

Results • Chart audits- adequate documentation? • Weekly x 6 weeks • Reviewed charts on infants currently in the NICU (n=29) • Compliance 16 -27%

Results • Survey: N=15 • Demographics • • • All RNs 57% <6 years experience as NICU RN 43% >7 years experience as NICU RN 73% NICU RN for same time as NICU RN at this facility Shifts worked: 47% day shifts, 47% rotating shifts, <1% night shift • 46% participated in previous survey, 23% did not; 31% unsure

Results • Oral feeding practices • 93% state unit used feeding tool

Results • Who decides when to orally feed?

Results • Criteria to initiate oral feedings • • Gestational age (85%) Respiratory status (92%) Infant displaying cues (100%) Infant successfully sucking on pacifier (85%)

Results • Oral feeding advancement • Volume (increased volume every few days) (92%) • Feeding orders • 54% stated their orders limit feeding volume • 62% stated their orders limit oral feeding frequency • 46% stated their orders limit feeding duration

Results • Factors that delay or alter oral feedings

Results • Factors to stop an oral feeding and switch to gavage • Infant appears disinterested (100%) • Infant choking (92%) • Infant experiences apnea/bradycardia during feeding (92%) • Infant desaturates (92%) • Infant appears sleepy (92%)

Results • Nurses measure feeding success by • Infant nipples with a strong, coordinated suck (100%) • Infant does not experience desaturation during feeding (92%) • Infant does not experience apnea/bradycardia during feeding (92%) • Infant consumes entire volume of feeding (46%)

Results • Feeding techniques to support bottling success • • • Chin support (58%) External pacing (83%) Modified side-lying (100%) Cheek support (58%) Oxygen modification (67%)

Discussion • Barriers with implementation • Nurses did not comply (low compliance rate) • Despite education, some respondents still unaware of infant-driven feeding tool • RNs still measure feeding success by volume consumed (poor infant-driven feeding culture) • Management turnover (less buy-in)

Discussion • Barriers with implementation • Majority identified working in this NICU for the same amount of time as they have been RNs • No experience of other NICU feeding cultures • Resistant to change • Non-NICU staff/Travelers/Float Pool • Mainly care for low acuity infants (feeders) • No education on SOFFI or EFS documentation • Follow-up emails only went to NICU staff

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