No spoiled milk in this NICU

Modern Healthcare - - BEST PRACTICES - By Maria Castel­lucci

In neona­tal in­ten­sive-care units, one of the most risky and de­tail-ori­ented tasks for nurses is feed­ing vul­ner­a­ble ba­bies. Nurses must be metic­u­lous to en­sure the ba­bies don’t re­ceive the wrong mother’s milk or ex­pired for­mula.

A mis­take can be life-threat­en­ing for ba­bies who are al­ready are al­ready frag­ile, es­pe­cially if the milk con­tains infectious agents or is spoiled. There is also an emo­tional toll on fam­i­lies if their in­fant re­ceives an­other mother’s milk. That kind of er­ror can break down the trust be­tween dis­tressed fam­i­lies and the NICU care team.

“Par­ents don’t need an added worry,” said Dr. Chris­tine Bixby, med­i­cal di­rec­tor of lac­ta­tion ser­vices at Chil­dren’s Hos­pi­tal of Or­ange County in Cal­i­for­nia.

So when the hos­pi­tal ex­pe­ri­enced 45 breast milk han­dling mis­takes from 2010 to 2012, Bixby said the staff was mo­ti­vated to over­haul the process.

The hos­pi­tal be­gan mak­ing changes in Jan­uary 2013 when it re­pur­posed a nu­tri­tion lab to be used solely for the prepa­ra­tion of breast milk and for­mula.

Six di­etetic tech­ni­cians were de­ployed to work in the lab. With ac­cess to elec­tronic health records, the tech­ni­cians mixed all the milk a pa­tient needed in a 12-hour pe­riod, fol­low­ing doc­tors’ or­ders. While one tech­ni­cian pre­pared the milk, an­other ob­served to dou­ble-check their work. La­bels were then printed with the pa­tient’s name and the milk or­der so nurses could ver­ify the bot­tle is go­ing to the right baby. On av­er­age, the tech­ni­cians pre­pared 400 feed­ings per day.

The use of the di­etetic tech­ni­cians was highly suc­cess­ful, with the hos­pi­tal re­port­ing a 74% de­crease in po­ten­tial er­rors for breast milk han­dling.

Things didn’t stop there. A bar code sys­tem was im­ple­mented in Novem­ber 2013.

All ba­bies in the NICU re­ceive a wrist­band with a bar code that is scanned by nurses to gen­er­ate a la­bel. The la­bel in­cludes the baby’s name as well as the physi­cian’s milk or­der. Physi­cians’ or­ders from the EHR in­ter­face with the bar code scan­ning sys­tem to make the con­nec­tion. That la­bel is printed and placed on a feed­ing bot­tle, which is given to the mother. The mother hand­writes the date and time the milk was pumped. The bot­tle is then given to the nurse, who dou­blechecks that the la­bel was filled out correctly by the right mother and places it in a re­frig­er­a­tor in the NICU.

Di­etetic tech­ni­cians come to the unit roughly four times a day to pick up the milk and bring it back to the nu­tri­tion lab for mix­ing. In the lab, the tech­ni­cians scan the bar code on the bot­tle where the physi­cian’s or­der is dis­played on a com­puter screen. About two to four tech­ni­cians are pre­par­ing feed­ings at a given time, but they no longer have to dou­ble-check each other’s work. The scan­ning sys­tem ver­i­fies that ev­ery bot­tle scanned be­longs to the cor­rect in­fant and the for­ti­fiers added match the doc­tor’s or­der in the EHR, Bixby said.

Af­ter the milk is mixed, the tech­ni­cian de­liv­ers the la­beled bot­tle back to the NICU.

Once the nurses or the moth­ers are ready to feed a baby, they scan both the bar codes on the bot­tle and on the baby’s wrist. The scan­ner an­a­lyzes both bar codes to en­sure they match. If they do, a green pop-up box on the scan­ner screen in­forms the nurse that the right bot­tle is go­ing to the right baby. If it doesn’t match, a red light pops up on the scan­ner warn­ing that there is an er­ror.

The ini­tia­tive con­tin­ues to drive im­prove­ments. The 45 breast milk han­dling mis­takes the hos­pi­tal ex­pe­ri­enced in a two-year pe­riod has now de­clined to al­most zero. The scan­ning sys­tem has saved the hos­pi­tal an av­er­age of $30,000 a year be­cause ad­di­tional tech­ni­cians are no longer needed to ver­ify each other’s work.

NICU nurses have also ben­e­fited by hav­ing more time to spend with in­fants and moth­ers. The unit ad­min­is­ters more than 10,000 breast milk feed­ings per month and one nurse han­dles breast milk at least 12 times per shift. Be­fore the tech­ni­cians were de­ployed, NICU nurses could eas­ily get over­whelmed as they tried to both prop­erly mix and ad­min­is­ter feed­ings to the ba­bies while car­ing for their other health needs, Bixby said.

Now nurses have an ad­di­tional hour of time to spend with the ba­bies and their par­ents be­cause they no longer have to mix milk and for­mula. “It freed the nurses up to talk to moth­ers about the im­por­tance of breast milk, reg­u­lar pump­ing and skin-to-skin con­tact with their baby,” Bixby said.

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