The goal of this blog is to provide my own “hindsight,” when building the NICU milk/formula lab; and things that helped me with its successful construction and implementation.
Throughout my career in neonatal and pediatric nursing, I’ve been fortunate to experience moving into new clinical units. My first was as a charge nurse, where our team relocated into a 45 private bed NICU. This was my first taste of challenges in change management: new clinical workflows, advanced technology, and the importance of effective transition planning.
In later years as a travel nurse, I supported nursing leadership teams in the construction, development, and transition into 2 other NICUs. One aspect of a new NICU build that I had never dealt with before was the creation of a centralized feeding preparation area, which has also been called a “milk lab” or “formula lab.”
Fast forward to 2020. I was recruited to serve as a Nurse Manager and lead the build of a new 40 bed level III NICU. This NICU would also have a milk/formula lab, staffed with technicians to prepare all human milk and formula products for our neonatal patient population.
This was foreign territory for me and I had to learn a lot quickly! One thing we can all agree upon as leaders is that hindsight is always 20/20. I’ve had time now to really reflect on what worked and what didn’t and made a list to help any future nurse leaders tasked with a similar challenge.
Staffing aka “Making the Case”
It’s essential to have a sound staffing plan for centralized feeding preparation. Things to consider are the following:
- How many FTE’s?
- Look at your average daily census of the population that will be served by the prep room. This is a good basis to calculate the number of feeds prepped per day.
- Review the number of units being served by the prep room. These numbers can also play a role in increased labor requirements due increased areas for deliveries. There is also an impact on when orders are written and ultimately processed.
- Decide shift length (8 or 12 hours) and hours of shift.
- How many deliveries to the clinical areas per day aka “milk runs”?
- Review your expirations of various formula and human milk products to assure that patients will not run out of unexpired feedings in a 24 hour period.
- What are the qualifications for the staff?
- Technicians for feeding preparation usually have a dietetic/nutrition background.
- There is also an online certification course offered by Ohio State designed specifically for NICU feeding technicians (https://foodindustries.osu.edu/infant).
- Registered Nurses can serve as backup support for any staffing challenges that may arise (a budget killer but always good to have in your back pocket).
- Consult your Human Resources leadership team if any job descriptions must be created and assure compliance with your HR policies.
- Who will oversee the staff?
- Depending on total FTE size, the team may require a lead or its own manager/director. Review this possibility with your senior leadership team if applicable.
Compliance & Regulatory
- Utilizing Donor Human Milk (DHM) Products
- If your organization will be initiating the use of DHM, it is vital that you work with your quality department to meet tissue bank requirements for your respective state.
- There must be adequate documentation of when the DHM is received, lot numbers (in case of recall), and the DHM state upon receipt (frozen vs. thawed). Other details may be required including temperature at receipt. Defer to your specific state’s regulations when developing policy and practice.
- If your organization will be initiating the use of DHM, it is vital that you work with your quality department to meet tissue bank requirements for your respective state.
- Equipment/Appliances
- Assure that all equipment/appliances used in milk preparation meet compliance for your specific regulatory bodies (e.g. The Joint Commission, OSHA, DNV, etc.)
- Bead baths for thawing milk
- Bead baths are waterless baths which support good infection control practice.
- Commercial dishwashers whose water temperature can be accurately measured
- a required wash temperature of 66°C (150°F) and a rinse temperature of 82°C (180°F) is needed to meet American National Standards (Steele 2018).
- Storage refrigerators and freezers with regularly monitored temperatures
- A strong recommendation is to use a wireless continuous monitoring system like TempTrak.
- Document temperatures on a regular basis (e.g. hourly) to assure your refrigerators and freezers temperatures are within acceptable parameters. If you use an electronic continuous monitoring system as mentioned above, assure that reports can be accessed (SURVEYORS CAN ASK FOR THEM).
- Have a system in place for incidents where these appliances may malfunction.
- Bead baths for thawing milk
- Assure that all equipment/appliances used in milk preparation meet compliance for your specific regulatory bodies (e.g. The Joint Commission, OSHA, DNV, etc.)
A large amount of the knowledge I gained in this journey was thanks to the following publication from the Pediatric Nutrition Dietetic Practice Group. This is truly your guideline to all things dealing with human milk and formula storage, handling, and preparation.
In addition to this resource, you have others in your own organization. During the development of feeding workflows, engage your nutrition and nursing staff. When ensuring appropriate compliance policy and protocols, seek out the knowledge from your Quality and Regulatory leaders.
There is a steep learning curve for all stakeholders, but one thing NOT to do is “fake it to make it.” When all else fails, follow one of the most important tenets of any High Reliability Organization (HRO): Defer to Expertise.
I hope this will help all of my fellow leaders as they take on this new adventure! I can guarantee it is very rewarding and adds one more tool to your leadership toolbox.
References:
- Steele, C. (2018). Best Practices for Handling and Administration of Expressed Human Milk and Donor Human Milk for Hospitalized Preterm Infants. Frontiers in Nutrition, 5(76). doi: 10.3389/fnut.2018.00076
- Steele, C., & Collins, E., eds. (2019). Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk & Formula in Health Care Facilities, 3rd Edition. Academy of Nutrition and Dietetics.
Dominic Petrovia MS, RNC-NIC, is Clinical Practice and Compliance Manager at Keriton. He’s a registered nurse and has worked in health care for over 16 years.
