Reducing Postnatal Growth Failure in the Neonatal Intensive Unit-- a Lean Six Sigma Quality Improvement Initiative

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 Background: Preterm infants are in a state of nutritional emergency after birth. Adequate nutrition in the neonatal unit has been shown to have significant impact on short and long term outcomes to include neurodevelopmental outcomes. One metric used to evaluate the nutrition of infants in neonatal units is postnatal growth failure (PnGF).  PnGF can be defined as discharge weight less than 10th percentile for corrected gestational age and severe PnGF defined as discharge weight less than 3rd percentile for corrected gestational age. The national rate of PnGF was approximately 65% in extremely low birth weight (ELBW) and very low birth weight (VLBW; bwt less than 1500 grams) infants in 2000.  In 2013 the same national network reported that the rate of PnGF had improved but is still high at 50%. Standardized feeding protocols focused on optimizing nutrition have been shown to decrease PnGF in preterm infants.

Objective: The postnatal growth failure rate at Walter Reed National Military Medical Center (WRNMMC) NICU was reported at 57% in between January 2018 to December 2019. We hypothesize that using Lean Six Sigma (LSS) can change key drivers to reduce postnatal growth failure to <40%, reduce central line days, and reduce waste in VLBW infants born at WRNMMC by January 2021.

Design/Methods: A multidisciplinary team of physicians, nurses, nutritionists, and pharmacists conducted the "define, measure, analyze, improve, and control" (DMAIC) process of LSS. Root cause analysis identified primary and secondary drivers to PnGF. Secondary counter measures were created to counter the primary drivers causing the high rate of PnGF in our NICU.  Interventions included creation of a new evidence-based feeding protocol, a nutrition order set in the EMR, and nutrition note templates. Multiple rounds of staff education was provided through the implementation of the project.

Results: From 2002 to 2008, 191 out of 337 infants (57%) had PnGF and 106 infants (32%) had severe PnGF.  Recently in 2018 and 2019, 29 out of 51 VLBW infants (57%) had PnGF and 11 infants (22%) had severe PnGF. Post implementation data begun January 2020.

Since implementation we have reduced the rate of PnGF to 40% in the VLBW infants born in 2020. Severe PnGF has been reduced to 7%. Growth velocity in this population has increased from 12 g/day to 14g/day. We have reduced the number of infants discharged with a head circumference less than 10th% from 43% to 7%. We have reduced the number of days on parenteral nutrition and central line days from 9 days to 5 days in 2020. We have reduced the number of days to full feeds from 11 to 6 days of life.

Conclusion: Through this project, we aim to reduce the PnGF in ELBW/VLBW infants discharged from WRNMMC NICU to less than 40% by January 2021. We have shown that for our unit a lean six sigma quality improvement project was able to reduce PnGF, improve growth velocity, improve time to full feeds and reduce central line days. 

Walter Reed national Military Medical Center
National Capital Consortium Neonatal-Perinatal Medicine Fellowship
National Capital Consortium Neonatal-Perinatal Medicine Fellowship
National Capital Consortium Pediatric Residency
National Capital Consortium Neonatal-Perinatal Medicine Fellowship

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