UpGrace

Brief Summary of the Project

The Bridge Human Milk Management System, henceforth will be referred to as Bridge, has been used within the majority of the neonatal and Pediatric settings within the AXXXXXXX XXXXXX XXXX (AXX). Since the merger between AXX and the AXXXXX HXXXXXXXXX, the whole AXXXXXXX AXXXXX XXXXXXX (AAX) adapted the Epic Electronic Health Record (EHR) system. The organization upgraded Bridge, one of the legacy applications, so that it will be interoperable with Epic EHR.

Bridge is a bar-code scanning software. Its purpose is to prevent human milk administration errors (Matus, et. al., 2019). Prior to the implementation of the Bridge-Epic integrated system, the Bridge-Cerner system identified 20 errors out of 435 during the preparation phase. While this number of errors (5%) may seem low, it is important to remember that any minor mistake done during any phase of the human milk processing particularly in the Neonatal Intensive Care Unit (NICU) may lead to adverse effects and even fatal consequences.

Plan

The team initiated this project in October 2019 and implemented at AXXXX on October 10, 2020. Finally, it was formally concluded by the end of December 2020. Analysts from the AAX Health and Informatics Department, consultants from Cerner and Epic, AXXXX NICU superuser nurses, and NICU leaders actively collaborated with the author to initiate and implement this project. The last two continued monitoring and improving the utilization of the Bridge application to maintain patient safety for NICU babies being fed with human milk. The milk was either from their respective mothers or from donor milk.

The Covid 19 pandemic stalled the project in March 2020. For that reason, retesting of the integrated system resumed on August 27, 2020. Meetings with the consultants ensured that the servers were functioning as expected. Site clinical informaticists and field services staff tested the devices (e.g. scanners, printers, etc.).

The author trained superusers during the NICU bootcamp (figure 1). End users reviewed the educational material via a PowerPoint presentation (figure 2). Charge nurses conducted shift change huddles regarding Bridge practice change in October 2020. Finally, trainers included tip sheets in the Epic Learning Home Dashboard.

The practice standard included the following workflow:

1. The NICU nurse, the NICU nurse tech, or the lactation consultant prints out the Bridge human milk label.
2. The morning shift NICU nurse fills up the NICU Milk Requisition Form which serves as the milk preparation guide for the milk tech. The NICU nurse fills up the form with information such as the caloric concentration, need for fortification, number of feedings needed, and if parents signed the donor milk consent.
3. The milk tech needs to pull up the baby’s Epic chart to verify if the request and the neonatalogist’s order are similar. For any discrepancies, he or she has to refer back to the nurse who filled up the form. The milk tech confirms all details, then proceeds to prepare the milk in a centralized milk preparation area that is free from distraction (Matus, et. al, 2019). The comparison between the request and Epic order is a recommended practice change from the usual workflow.
4. Another change of practice is to switch the preparation of milk that is good for 12 hours instead of the usual 24hours. This is to prevent wasting expired or unadministered milk.
5. The staff administering the milk or disposing of it is to use the Bridge application to document that administration and to maintain the inventory correctly.
6. Outgoing and incoming nurses should check that the human milk inventory of each baby is correct. This includes counting the milk in both the refrigerator and freezer bins and double-checking that the milk in those bins really belongs to that specific baby. Exemptions are the milk that is prepared for twins or triplets as that human milk bottle counts crossover babies. For example, twins will have a total of 10 bottles. One may have four and the other may have six bottles of milk.

Do

The above-stated practice change steps present several opportunities for committing an error. The milk tech or nurse uses the Bridge system in each of those processes to help mitigate and prevent mistakes from reaching the baby and causing adverse effects. The recommended workflow is loosely based on figure 3 below, as studied by Daus, et. al. (2018).

Since its implementation in October 2020, patient safety event forms have been monitored. Monthly human milk error reports have been obtained from Bridge and compared with the patient safety event reports. Compliance reports have also been reviewed. Coaching was done for team members who have made mistakes that were deemed to be potentially harmful to the patient (e.g. milk was administered first and when scanned after the feeding, the milk fed to the baby belonged to another baby in the same room). Common errors that have been identified from the reports and also reported as patient safety events include patient-bottle mismatch (near misses) which prevented the milk to be administered to the wrong baby and expired breast milk. Having expired prepared human milk sometimes happens when the milk tech prepares milk good for 24 hours and the mom breastfeeds the baby for two feedings, for example.

Critical Errors During the Human Milk Processes

A study conducted by Oza-Frank, et. al. (2017) listed some of the critical errors in the table included below as Figure 4. Similar errors have also been identified in AXXXX, although the application that the reference study used is different from the Bridge system.

The six-year study conducted by Dr. Oza-Frank’s team concluded that human milk-related errors were reduced significantly by using a human milk management system. For example, the total number of errors from scanned bottles declined from an incidence of 97.1 per 1000 bottles to 10.8 (Oza-Frank, et. al., 2017). Infant-bottle mismatch also decreased from 8.3 to 2 per 1000 bottles scanned (Oza-Frank, et. al., 2017).

In contrast, here are the results from AXXXX during both the pre-implementation (Sept. 2020) and the post-implementation periods obtained from Bridge reports and Risk Management:

Study

Based on the earlier set goals, here are the plans to sustain this project, moving forward:

1. User compliance is consistently within 98-100% for the receiving and administering phases.
2. During the preparation phase, compliance has been at an average of 97.2% post-implementation as compared to the 95% during pre-implementation. The recommendation to have the Epic EHR open during milk preparation has helped increased this compliance, and in turn, lessen the errors committed. Having a centralized milk processing room and a full-time milk tech also improved this aspect (Matus, et. al., 2019).
3. Human milk errors are still underreported as patient safety events. There is a need to reeducate staff about the importance of entering a patient safety event report for every human milk error identified as these will explain if those mistakes resulted in adverse effects on the babies.

Results

As evidenced by the graphs above, it can be concluded that there is a potential for improvement in Bridge utilization. The results for human milk disposal are fair to good at best. This can lead someone to ask why is the compliance low? Are the milk bottles being discharged although unscanned or are they being forgotten to be discharged with the baby?

These questions, needless to say, need to be answered. Hopefully, if someone will continue sustaining this project, the answers will be used to inform change in practice, as appropriate. At the end of the day, it is all about keeping the littlest patients as safe as possible, especially when they are reaping the benefits of consuming human milk.

References

Advocate Aurora Health. [Where to Find the Bridge Documentation] (2020 Sept. 28) NICU–SCN Boot Camp. Retrieved from https://web.microsoftstream.com/video/9e2337fb-851f-4bf7-9c0c-2a4cc80dfaf7

Daus, M. Y., Maydana, T. G., Rizzato Lede, D. A., & Luna, D. R. (2018). Implementation of a new traceability process for breast milk feeding. Studies in Health            Technology and Informatics, 247, 511-515. doi:10.3233/978-1-61499-852-5-511

Matus, B. A., Bridges, K. M., & Logomarsino, J. V. (2019). Evaluation of key factors impacting feeding safety in the Neonatal Intensive Care Unit: A systematic review. Advances in Neonatal Care, 19(1), 11-20. doi: 10.1097/ANC.0000000000000516.

Oza-Frank, R., Kachoria, R., Dail, J., Green, J., Walls, K., & McClead Jr., R. E. ((2017). A quality improvement project to decrease human milk error in the NICU.  Pediatrics,139(2). https://doi.org/10.1542/peds.2015-4451

Reyes, M. G. O. (2020, Oct. 1). Epic NICU/SCN Classes 200 and 300 [PowerPoint Slides].  https://advocatehealthmy.sharepoint.com/:p:/r/personal/marygrace_reyes_aah_org/_layouts/15/Doc.aspx?sourcedoc=%7BC9C4D1BE-BD2C-4146-        8D6F049886C2FBCF%7D&file=SE5_Epic_NICU_Tips.pptx&action=edit&mobileredirect=true