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Luton et al. (2015) estimated that one human milk error occurs in the Neonatal Intensive Care Unit (NICU) in every 10,000 feedings. Furthermore, this error can occur in the various stages of milk preparation, administration, storage, or even during discharge or disposal. Because of this, Axxxxxxx Hxxxxxxxxx has utilized the Bridge Milk Management System since 2015 to enhance the above-stated processes. Its utilization aimed to prevent adverse events to the infants in the NICU and Pediatric units by catching near misses prior to them reaching the patients. Bridge is a Cerner product; thus, they interoperate seamlessly. However, as the entire Axxxxxxx Axxxxx Hxxxxx transitions to Epic by the end of the year, stakeholders have to ensure the Bridge-Epic interoperability.

Literature Review

AXX employed three strategies to ensure human milk safety. These are particularly useful in the NICU settings where vulnerable babies are either premature or ill. These strategies are the following:

1. Each NICU employed a full-time milk technician.
2. Each site designated a centralized milk preparation area for the intake, preparation, and storage of the human milk.
3. The staff utilized the Bridge Milk Management System which has the barcode-scanning capability (Steele, Czerwin, & Bixby, 2015).

These measures have been proven to promote safe handling of human milk, reduce nursing time away from the patients, and increased verification points through positive patient and human milk identification via bar code scanning capabilities (Matus, Bridges, & Logomarsino, 2018). A study conducted by Settle, Coakley, and Annese (2017) concluded that nurses spend up to 40 hours weekly away from their patients without the above-stated measures.

The NICU staff will measure outcomes based on the reports from Bridge and from the Risk Management department. These reports include the breast milk bar code compliance (usage of the devices/application) and the breast milk errors committed. The latter will be compared with the human milk-related patient safety events. The pre-implementation data is already available.

The hypothesis asserts that the implementation of Bridge-Epic integration will decrease the commission of breast milk errors, particularly during the preparation stage. The initial goal for compliance and the utilization of accurate preparation processes is 97% within the first three months of implementation. The Bridge monthly report and the monthly human milk-related safety event report from the Risk Department will provide that data. The designee will average the findings quarterly. He or she will then update Bridge Team and the NICU/Maternal and Child department leadership.

            To summarize, the Bridge-Epic integration project aims to improve human milk safety within the NICUs by:

1. Increasing the compliance of milk technicians and/or nurses in accurately utilizing Bridge to a minimum of 97% during the preparation process within the first quarter post-implementation.
2. Reporting all human milk-related “near-misses” via the Patient Safety Event Form. The Bridge error reports should correspond with the safety event reports submitted to the Risk Department.
3. Minimizing interruptions during intake, preparation, administration, discharge, or disposal of human milk. Standardizing processes will help achieve this goal. For example, staff will only receive human milk in the dedicated centralized preparation area. Also, NICU nurses will only scan human milk at the respective patient’s bedside prior to administration).

Gap Analysis

The NICU staff have been effectively using the current Bridge system at 99.99% compliance. However, the designee identified a significant gap during the preparation process. The majority of the errors reported were committed during that particular process. Compliance during the preparation phase only accounts for 95%, which is equivalent to 20 errors out of 435. NICU staff should pay attention during the preparation phase. If necessary, they should rectify those mistakes before they cause adverse effects to the babies.

The published studies cited above all yielded improvement in user compliance when utilizing their respective organization’s bar-code scanning milk management system. They all concluded that the application has enhanced the safety of human milk handling, particularly in the NICU settings. However, there is no data that pertained to the preparation process alone which can be used as benchmark data.

Prior to the building and testing processes, AXX procured an Epic server for this integration. The NICU nurses from hospitals that are already using the Bridge-Epic system stated that the application is user-friendly. They further stated that the integrated system is accurate and has only minor technical issues when connectivity is poor. The Bridge-Epic system used in the first five AXX hospitals did not adversely affect the Bridge-Cerner interoperability in hospitals that have not yet transitioned to Epic.

PICOT Question

Does the utilization of the integrated Bridge-Epic system (I) compared to the current use of the Bridge-Cerner system (C) improve the safety of human milk preparation for the AXXXX NICU infants (P) to meet a minimum goal of 97% (O) within the first three months of implementation (T)?

Goal Statements

1. The end-users will accurately use the integrated Bridge-Epic system at least 99% across all human milk processes.
2. The NICU staff will commit error/s of less than 3% within the first three months of implementation.
3. The Patient safety event reports will have the same data as the Bridge application. More patient safety event reports mean users catch more “near-misses”  thereby preventing adverse effects from reaching the babies.

Process Change: Plan-Do-Study-Act

Plan

The Bridge Team did a gap analysis in October 2019. They performed an inventory and procured servers, hardware, and supplies right after the project kickoff. Once they completed the build, they proceeded with the integration and regression testing. Since the end-users are adept at using the Bridge system, they only identified a minimal practice change related to discharging the stored human milk. Principal trainers (PTs) communicated education to the Maternal and Child leaders via email.

The PTs created a tip sheet and uploaded it within the Epic EHR Learning Dashboard for easy and accessible reference. Trainers will incorporate this education during the Epic end-user training for the wave three hospitals. This project will be implemented in October 2020.

Do

The intervention is the use of Bridge which will interoperate with the Epic EHR. The NICU staff will perform the same processes during the human milk intake, storage, preparation, and administration. However, the trainers will emphasize the minor change in practice for discharging human milk during the end users’ Epic EHR virtual training. The stakeholders will test the equipment (e.g. human milk labels, scanners, etc.) prior to Go-Live in October 2020.

Study

So far, in the waves one and two hospitals, the staff only reported minor concerns regarding the application efficiency. For example, end-users were unable to scan Bridge labels using the Epic scanners. They have also identified sporadic connectivity issues which negatively affected the Bridge-Epic integration.

Since the project has not yet been implemented in AXXXX, the designee will monitor the plan and outcomes monthly post-implementation. The Bridge-generated reports will be compared with the patient safety event reports from the Risk Department. This way, the designee will be able to assess end-user compliance and application efficiency.

Act

With the Bridge application implementation in AXXXX, it is envisioned that this will enhance human milk safety within the NICU. Sustaining this initiative will require careful monitoring of the data derived from Bridge. Superusers must coach end-users who may have challenges utilizing the software. Comprehensive step-by-step education regarding Bridge-Epic integration utilization is being prepared for end-user that have not yet used the Bridge Milk Management System (i.e. AXX NICU and Pediatric clinicians). This education may be used for AXXXX end users who may have challenges in utilizing the integrated Bridge-Epic systems to improve compliance.

References

Luton, A., Bondurant, P., Campbell, A., Conkin, C., Hernandez, J., & Hurst, N. (2015). Got (the right) milk?: How a blended quality improvement approach catalyzed

change. Advances in Neonatal Care, 15(5), 345-353. doi: 10.1097/ANC.0000000000000228

Matus, B., Bridges, K., & Logomarsino, J. (2018). Evaluation of key factors impacting feeding safety in the neonatal intensive care unit. Advances in Neonatal           

            Care, 19(1), 11-20. doi: 10.1097/ANC.0000000000000516

Settle, M., Coakley, A., & Annese, C. (2017). Human milk management redesign: improving quality and safety and reducing neonatal intensive care unit nurse stress.

             Creative Nursing, 23(1), 47-52. doi: 10.1891/1078-4535.23.1.47

Steele, C., Czerwin, A., & Bixby, C. (2015). Breast milk barcode scanning results in time savings and staff efficiency. Journal of The Academy of Nutrition and

              Dietetics, 115(1), 23-26. doi: 10.1016/j.jand.2014.06.360