P2.N266: A Quality Improvement Initiative to Improve Growth in Surgical Infants Hospitalized in the NICU

Purpose/Objectives: Infants undergoing intestinal surgeries in the neonatal intensive care unit (NICU) are at risk for impaired growth. Our aim was to reduce moderate to severe malnutrition diagnosis by 20% among surgical infants cared for in a level IV NICU in a 24-month period.

Design/Methods: The study took place in a level IV NICU that participated in a statewide multi-site quality improvement collaborative to improve growth in surgical infants. Individual NICU data is reported here. Eligible infants underwent intestinal surgery and were hospitalized in the NICU between July 2021-June 2023. Plan-do-study-act cycles included post-operative feeding guideline development and implementation of routine multidisciplinary surgical nutrition rounds. Meetings were also held among collaborating sites to discuss progress and share resources. The outcome measure was % of infants discharged, transferred, or died in the NICU with moderate to severe malnutrition, defined as a decline in weight-for-age z-score >1.2 from birth. Process measures were 1) % of infants adherent to parenteral nutrition (PN) optimization guidelines, 2) % of infants adherent to a standardized surgical feeding protocol, and 3) implementation of weekly nutrition rounds. Balancing measures were % of 1) infants who developed necrotizing enterocolitis (NEC), 2) infants with a bicarbonate level < 20 mEq/L, and 3) infants with feeding intolerance. Metrics were collected weekly and assessed over a 12-month implementation and 12-month post-implementation period. P-Charts and Control charts were used for analysis.

Results: From July 2021-June 2023, there was a slight downward shift in infants discharged, transferred from or died in the NICU with a z-score > 1.2 from birth (Figure 1). Rate of moderate to severe malnutrition decreased from 29% in the implementation period to 18% in the post-implementation period. Upward shifts were seen in all process measures, particularly % infants adherent to a feeding protocol as well as the balancing measure, % infants with feeding intolerance (Figure 2). Rates of NEC were stable while rates of infants with low bicarbonate had a downward shift (Figure 2).

Conclusion/Discussion: Implementation of a post-operative feeding guideline, multidisciplinary surgical nutrition rounds, and collaboration with other NICUs were associated with slightly decreased rate of moderate to severe malnutrition among surgical infants leaving the NICU. Our interventions may be applied to other inpatient units aiming to improve growth in their surgical infant population. We also saw an increase in observed feeding intolerance that led to no feeding advancement, which may be a consequence of ensuring adequate growth. Given the low occurrence of NICU departure in this population, further data analysis and collaboration with similar centers could be beneficial.