Feed Order Standardization in the NICU

Whether it’s your favorite online store or food delivery service, we’re all used to choosing a product or service and having it delivered without difficulty. When was the last time what you ordered was not what you received? 

In neonatal intensive care units everywhere, professionals spend hours each day discussing the merits of one therapeutic feeding option over another, until carefully deciding on a course of action. Now, imagine that the discussed treatment course does not get executed as prescribed. This would be disappointing, to put it lightly.

We partnered with Keriton initially because we wanted to reduce the possibility administering one mother’s breast milk to another mother’s baby—and we successfully accomplished 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 goal in the NICU is to be able to deliver the best possible medical care to our fragile newborn patients.  In writing orders for nutritional plans, clinicians need orders to be carried out flawlessly.  As feeding plans have become increasingly complex, the potential for confusion has intensified.

Here’s a small sample of the alphabet soup of 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 isn’t difficult to imagine how confusing orders can be unless they are in a standard format—with computerized provider order entry systems working in conjunction with the Keriton system, order verification of complex feeding recipes has never been more possible. 

The CAVEAT: This is only possible if ordering is unambiguous. In many NICUs, complex diet orders were “free-typed” at times because electronic order pathways did not allow for selection of feeding components and feeding instructions. Diet orders that are selected as discrete components rather than free-typing allows our teams to better understand and, subsequently, carry out orders.

To be sure, convincing any team to change their practice is not an easy undertaking. Neonatal clinicians, like so many other humans, don’t mind organizational change, as long as it’s their way. The reality is that change is difficult. When embarking on any change, using a roadmap to change in practice can been helpful.

The 8 Steps for Leading Change

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 dietician, 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 in order 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 form Amazon. Universally, however, we all are much happier if our orders are carried out as we intend them. And patient’s are safer, too.

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.