Feed Order Standardization in the NICU
Enhancing NICU Efficiency with Keriton
Dr. Eddie Chang, MD, MBA, FAAP
Whether it’s your favorite online store or food delivery service, we're accustomed to selecting a product or service and receiving it without hassle. But when was the last time what you ordered wasn't what you received?
In neonatal intensive care units (NICUs) worldwide, professionals spend countless hours deliberating over the best therapeutic feeding options before deciding on a course of action. Imagine if the prescribed treatment course wasn't executed as planned—disappointing, to say the least.
We partnered with Keriton to minimize the risk of administering one mother's breast milk to another mother's baby, and we successfully achieved this goal. However, we soon asked ourselves:
“Are we delivering and executing the diet plans we intended? If so, are we doing so as efficiently as possible?”
Our NICU's goal is to provide the best possible medical care to our fragile newborn patients. Clinicians need nutritional plans to be executed flawlessly. As feeding plans become more complex, the potential for confusion increases.
Here's a glimpse of the potential options in our NICU:
SSC, NS, EP, E22, ELF 5/25 - 5/50, SLF, Nutramigen, Alimentum, BM, EBM, FBM, DBM, ELF, SLF, Prolacta +4, +6, +8; Rice or Oatmeal Cereal; MCT oil, Liquid Protein, Hindmilk, Foremilk, DBM, 0.5 or 1 tsp/oz via PO, OG, NG, bolus or continuous over 30 to 120 min, with various specified advances as tolerated.
It's easy to see how confusing orders can be without a standard format. With computerized provider order entry systems working alongside the Keriton system, verifying complex feeding recipes is now more feasible.
The CAVEAT
This is only possible if orders are unambiguous. In many NICUs, complex diet orders were sometimes "free-typed" because electronic order pathways didn't allow for selecting feeding components and instructions. Selecting diet orders as discrete components rather than free-typing enables our teams to better understand and execute orders.
Convincing any team to change their practice is challenging. Neonatal clinicians, like many others, don't mind organizational change—as long as it's their way. The reality is that change is difficult. Using a roadmap for practice change can be helpful when embarking on any transformation.
The 8 Steps for Leading Change in NICU Feeding Management
One model for leading change is described by Harvard Professor Dr. John Kotter. It involves 8 steps—below is how we applied it for this initiative.
1. Create Urgency: Describe why today’s process is NOT good.
Highlight and measure current pain points. Examples:
Multiple calls for order clarification.
Poor execution of intended orders.
Inability to catch and manage expired products efficiently.
2. Build a Coalition of Change Makers: In our NICU, this included a multidisciplinary group of our dietitian, nurses, and physicians.
3. Create the Future Vision: We needed to describe the future BETTER state.
Why Will it Be Better?
Specific stories/examples of Success.
What’s In It For Me?
Who Will Win/Lose?
Why MUST we Do This?
4. Communicate the Vision.
5. Understand Barriers and Plan Strategy to Navigate.
Barrier: Difficulty in coming to consensus with order standardization.
Elimination of Barrier: Come to consensus with orders and work to eliminate free typing orders.
6. Empower Others to Act.
Gave change coalition members the ability to drive change with our technology partners.
7. Plan & Create Short Term Wins.
Successful measurement of near-misses.
Successful decrease of near-misses.
Successful decrease of order clarification “re-work”.
8. Consolidate Improvements and Create More Change.
Agreed upon order sets and pathways were solidified in our computer provider order entry system.
Benefits of Order Standardization
Our team has found the following benefits of order standardization along with the Keriton system:
Decreased chance of breastmilk misadministration.
Easier management of expired components.
Better tracking of feeds and nutritional components.
Fewer time-consuming calls to clinicians to clarify confusing or ambiguous orders.
In our experience, standardization of diet ordering is a prerequisite to clear execution and verification of neonatal diet plans. With our efforts, we have seen vastly improved compliance with intended orders, which ultimately allows our teams to better care for our most fragile newborn patients.
It’s true that ordering an infant’s diet in a NICU is different than ordering dinner from DoorDash or a book from Amazon. Universally, however, we all are much happier if our orders are carried out as we intend them. And patients are safer, too.
About the Author
Dr. Eddie Chang, MD, MBA, FAAP is Chief of Neonatology at Abington-Jefferson Health and Clinical Assistant Professor of Pediatrics for Sidney Kimmel Medical College at Thomas Jefferson University.