Kresch Mitchell, Mehra Kashish, Jack Richard, Greecher Coleen
Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.
BMJ Open Qual. 2020 Mar;9(1). doi: 10.1136/bmjoq-2019-000672.
Postnatal growth failure (PGF) in very low birthweight (VLBW) infants is a result of factors such as prematurity, acute illness and suboptimal nutritional support. Before this project began, 84% of appropriately grown VLBW infants in our neonatal intensive care unit experienced PGF. The aims of this quality improvement project were to reduce the percentage of infants discharged with PGF to less than 50% within 2 years and to maintain a rate of PGF under 50%.
All inborn VLBW infants were eligible for this study. Infants with congenital anomalies were excluded. We determined key drivers for optimal nutrition and identified potentially better practices (process measures) based on a review of the literature, which included more rapid initiation of starter total parenteral nutrition (TPN), aggressive use and advancement of regular TPN, and fortification of human milk when the volume of intake reached 80 mL/kg/day. Three Plan-Do-Study-Act (PDSA) cycles were tested.
Time to initiation of starter TPN was significantly reduced from 5.5 hours to under 3 hours. Regular TPN provided the goals for amino acids and lipids at increased frequency after the first two PDSA cycles. The proportion of infants whose milk was fortified at 80 mL/kg/day increased after the third PDSA cycle.
We found a sustained decrease in the percentage of infants discharged with PGF from 84% at baseline to fewer than 50% beginning in 2010-2011 through 2016, with 23.1% of infants experiencing PGF in 2016. We have achieved improved nutritional support for VLBW infants using the model for improvement.
极低出生体重（VLBW）婴儿的出生后生长发育迟缓（PGF）是由早产、急性疾病和营养支持不足等因素导致的。在本项目开始之前，我们新生儿重症监护病房中84%生长发育正常的VLBW婴儿出现了PGF。本质量改进项目的目标是在2年内将出院时出现PGF的婴儿比例降至50%以下，并将PGF发生率维持在50%以下。
所有本地出生的VLBW婴儿均符合本研究条件。患有先天性异常的婴儿被排除在外。我们确定了实现最佳营养的关键驱动因素，并基于文献综述确定了可能更好的做法（过程指标），包括更快开始使用起始全胃肠外营养（TPN）、积极使用和推进常规TPN，以及当摄入量达到80 mL/kg/天时强化母乳。进行了三个计划-实施-研究-改进（PDSA）循环测试。
起始TPN的时间从5.5小时显著缩短至3小时以内。在前两个PDSA循环后，常规TPN更频繁地达到了氨基酸和脂质目标。在第三个PDSA循环后，每天摄入量达到80 mL/kg时强化母乳的婴儿比例有所增加。
我们发现，出院时出现PGF的婴儿比例从基线时的84%持续下降，从2010 - 2011年至2016年降至50%以下，2016年有23.1%的婴儿出现PGF。我们使用改进模型实现了对VLBW婴儿营养支持的改善。
