387 - Implementation of a Quality Improvement Initiative to Reduce Time to Full Feeds in Infants with Gastroschisis

Poster Number: 387
Publication Number: 387.435

Avani Vachhani, LAC+USC Medical Center, LOS ANGELES, CA, United States; Anne M. Zepeda-Tiscareno, CHOC Pediatric Subspecialty Faculty - PIH Health Whittier - Neonatology, Alhambra, CA, United States; Jessie E. Rosoff, Childrens Hospital Los Angeles, Los Angeles, CA, United States; Elmer S. David, Children's Hospital Los Angeles, Las Vegas, NV, United States; Ashley Walther, Children's Hospital Los Angeles, Los Angeles, CA, United States; Srikumar Nair, Children's Hospital Los Angeles, Los Angeles, CA, United States; Jennifer Shepherd, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States

Background: Enteral feeding advancement is a major healthcare concern for infants with gastroschisis. Quick advancement can predispose these infants to complications; however, slow advancement can lead to comorbidities associated with prolonged hospitalization.

Objective: A feeding guideline was created as part of a QI initiative with the primary aim to safely reduce median time from initiation to full feeds (140ml/kg/day) by 15%, a decrease from 13 to 11 days. Baseline data of patients prior to implementation of the guideline is presented along with three Plan-Do-Study-Act (PDSA) cycles.

Design/Methods: Retrospective data for infants who underwent gastroschisis repair at Children's Hospital Los Angeles from 2016 to 2019 is compared to prospective data collected since February 2020. Exclusions were complicated gastroschisis, gestational age < 32 weeks and birth weight < 1250 grams. A guideline to address feeding readiness, advancement schedule, and potential signs of intolerance was developed by a multidisciplinary team. PDSA cycle 1 included guideline implementation. PDSA cycle 2 focused on increased guideline awareness, including monthly reminders and notification of upcoming deliveries. PDSA cycle 3 introduced a “dot phrase” containing guideline details into provider notes.

Results: Baseline data included 32 infants and prospective data after guideline implementation included 13 infants. There were no significant differences in patient characteristics between pre and post-guideline groups (Table 1). Prior to guideline implementation, the median time from initiation to full feeds was 13 days. In PDSA cycle 2 (n=4) and PDSA cycle 3 (n=6), the median time from initiation to full feeds decreased to 10 and 11 days, respectively. This resulted in a cumulative median time to full feeds of 11 days after guideline implementation. A shift occurs in the data set (Patients 36-42) showing the impact of the feeding guideline and awareness in time to full feeds (Figure 1). There were no significant differences in balancing measures, including suspension of feeds (38% in both groups), and cases of necrotizing enterocolitis (1 case in pre-guideline group vs. 0 in post-guideline group) (Table 2).Conclusion(s): A guideline was implemented to standardize feeding advancement and reduce time to full feeds by 15% in gastroschisis patients. Current data support that we are meeting this goal.  Next steps include implementation of respiratory and sedation management guidelines to limit opioid exposure with the goals of improving gut motility, reducing feeding intolerance, and ultimately decreasing time to full feeds and length of stay.
Table 1: Demographic Variables+ Median (IQR), p-value Mann-Whitney U Test
* N (%), p value based on Fischer Exact Test
^ Column includes post guideline data for all 3 PDSA cycles
Note: no IQR reported for individual PDSA Cycles given small sample size
Table 2: Outcome Variables+ Median (IQR), p-value Mann-Whitney U Test
* N (%), p value based on Fischer Exact Test
^ Column includes post guideline data for all 3 PDSA cycles
Note: no IQR reported for individual PDSA Cycles given small sample size