View
216
Download
2
Category
Tags:
Preview:
Citation preview
IMPROVING INTERSTAGE GROWTH IN SINGLE VENTRICLE HEART DEFECTSKristi Fogg MS, RD, LD, CNSC
Pediatric Cardiology Dietitian
Sodexo/MUSC Children’s Hospital
OBJECTIVES
Understand factors contributing to growth failure in infants with Hypoplastic Left Heart Syndrome (HLHS)
Discuss the National Pediatric Cardiology Quality Improvement Collaboration (NPC QIC)
Identifying the role of the dietitian as a member of the care team
Review the components of MUSC’s Interstage Growth Monitoring Pilot Program
Show the role of technology in improving communication with parents and care teams
ANATOMY OF THE SINGLE VENTRICLE HEART
SURGICAL PATHWAY
Week 1-2 of life Norwood Procedure Hybrid, central shunt
6-10 months BiDirectional Glenn
3-4 years old Fontan
GROWTH FAILURE IN HLHS
Poor prenatal growth (IUGR) Inability to feed preoperatively Slow progression of feedings post op Poor intestinal perfusion, NEC Reflux Oral Aversion Fluid Restriction Chromosomal abnormalities
Trisomy 21, 18; Turners syndrome, Digeorge Syndrome Other non cardiac malformations
Cleft lip/palate, imporforate anus, gut malrotation
NATIONAL PEDIATRIC CARDIOLOGY QUALITY IMPROVEMENT COLLABORATION
NPC-QIC Mission
Improve care and outcomes of infants with HLHS during the 4-6 month outpatient interstage period between surgeries Improving interstage growth Reducing readmissions due to major adverse events Improving communication and care coordination with the family,
referring cardiologists, and primary care clinic
Includes 42 pediatric cardiology centers Physicians, CT Surgery, NP’s, Dietitians, Speech Therapists
Parental Involvement
NPC QIC INVOLVEMENT
Learning Sessions (2x Year) Monthly Action Calls (MUSC presenting on 4 calls)
Working calls focused on Growth, Care transitions, discharge planning and emerging literature
PDSA Presentations Story Boards
Data Entry and Data Sharing Access to shared drive
LEARNING SESSION: JUNE 2012
Focus on Growth Failure Current growth trends between institutions Implementation of feeding protocols Engaging your RD Major red flag events Growth bundles Care transitions
DIETITIAN INVOLVEMENT
Goal: Dedicated Dietitian to Pediatric Cardiology Department to improve growth and reduce mortality Updated nutrition care plan Coordination of care w/ outlying facilities and families Phone availability when not physically present
93% Patients had dietitian available inpatient 69% had dietitian available as an OP
12% routine with clinic visit 57 % consulted as needed
CURRENT SUCCESSFUL INTERVENTIONS
MUSC QI IN INTERSTAGE GROWTH
INTRODUCTION OF GROWTH BUNDLE
Established Feeding Protocol After Hours TPN Establishing Interdisciplinary team
Addition of pharmacist and dietitan Participation in rounding, care coordination, QI
Non statistical significant improvement
LACTOENGINEERING
Hindmilk 5 minute separation of foremilk Evaluation of composite milk and hindmilk Ranging 25-33 cal/oz Eliminates need for fortification
Skim Breastmilk For patients with chylous effusions Requires supplementation with MCT based formula, ADEK
MVI
INTERSTAGE MONITORING
In the interstage, this is an extremely vulnerable time with a significant incidence of growth impairment, re-hospitilization, myocardial dysfunction and death
Implement an interstage growth surveillance program that performs outpatient growth, feeding, and nutrition monitoring between Norwood and Glenn surgery.
Develop and promote an interprofessional collaboration to reduce interstage growth failure
INTERSTAGE MONITORING PROGRAM
IP Grant ($15,000) Fosters an environment that rewards innovative and
integrated education, research and patient care. Scales, Pulse ox monitors, educational binders, Learning
sessions for NPC, Peapod maintenance Why is MUSC unique?
NO ONE is excluded Technology Interaction with outlying facilities Funding
INCLUSION CRITERIA
Neonates requiring surgical shunt placement, PA banding, Norwood procedure, or hybrid procedure for single ventricle anatomy
Once transferred to the stepdown unit, parents are consented and education is initiated
Discharge Teaching Started Discharge Educational Binder Use of Pulse Ox, Infant Scale Formula Preparation Red Flag Action Plan Use of Google Voice Correspondence
Peapod Measurement
PEAPOD MEASUREMENT
Body Mass Measurement Measured oxygen consumption, CO2 expelled, BSA
Infants and Body Mass Long term correlation with chronic disease Possible use in anesthesia Leaner babies have higher BMR Correlation in Cardiac Babies?
PEAPOD MEASUREMENT
WEIGHT MONITORING AND SAT MONITORING
Decrease interstage mortality Earlier feeding interventions Triaging red flag action plans Improved detection of important residual/recurrent
lesions and improved survival Avoiding unnecessary ER visits Earlier operative intervention
RED ACTION PLAN
O2
Saturations
≥ 70% and < 90%
Continue current therapy -Medical evaluation
- Respiratory distress? - Decreasing PO intake or increasing fatigue? - Changes in skin color or perfusion? - Poor weight gain?
≥ 90% < 70%
NO YES
Inadequate Weight Gain
30 gram weight loss in 24 hours
Less than 20 gram weight gain over 3 days
Has achieved goal calories of 110-150 cal/kg/day
- Signs of aspiration? - Respiratory distress? - Weak cry? - Emesis? - Diarrhea? - Bloody stools? - Decreasing PO intake or increasing fatigue? - Changes in skin color or perfusion?
- Medical evaluation - Possible inpatient admission
- Review feeding regimen - Review formula recipe/mixing - Daily weight reporting until consistent weight gain x 3 days
- Increase volume of feedings OR increase caloric density - Daily weight reporting until consistent weight gain x 3 days
- Is formula preparation correct? - Are weights being properly performed?
Signs of acute illness present
YES NO NO
YES
YES
NO YES
NO
USE OF TECHNOLOGY
Parents communicate daily using google voice Text/Call to adjust feedings or address red action plan Data entered into shared drive Weekly Rounding BiMonthly progress report to pediatrician and
cardiologist
GOOGLE VOICE FOR PARENTAL COMMUNICATION
Free! Need Google account Assigned local number Texting/Voicemail Voicemail Transcription Able to re-route to
multiple phones Allow on call schedule
GOOGLE VOICE
date weightgrowth x 7d sat growth regimen
1-Aug 4.51 27 8675 ml over 1hr, Alimentum 27 cal/oz. Going up 1ml at a time, every few days. Takes up to 55 ml at TID feeds
2-Aug 4.5 21 81
3-Aug 4.51 20 84
4-Aug 4.53 20 85
5-Aug 4.55 10 88119 cal/kg/day
6-Aug 4.59 16 85
7-Aug 4.62 18 83
8-Aug 4.67 23 81
9-Aug 4.69 27 8810-
Aug 4.71 29 8511-
Aug 4.73 29 8412-
Aug 4.73 26 8113-
Aug 4.74 21 81@ 77 ml q 3hr, added olive oil, giving 130 cal/kg
1 2 3 4 5 6 7 8 9 10 11 12 134.35
4.44.45
4.54.55
4.64.65
4.74.75
4.8
weight
weight
1 2 3 4 5 6 7 8 9 10 11 12 1376
78
80
82
84
86
88
90
sat
sat
THANK YOU! QUESTIONS????
Recommended