PROCESS IMPROVEMENT TEAM

Supplementation of the Breastfed Infant

Date initiated:August 2010

F / Find A Process To Improve:
It was generally noted that a great many of our breastfed infants were being supplemented with formula. which we know effects the mothers ability to establish a sufficient milk supply as well as sabotages efforts for successful breastfeeding over time (riordan, J., 2005. Breastfeeding and Human Lactation, 3rd edition). The Lactation Consultants receive frequent calls from mothers at approximately 8 weeks postpartum with complaints that their babies are very fussy and do not seem to be getting enough to eat. Those calls from former patients revealed that some are supplementing their infants daily with formula without pumping their breasts. Many of those callers also revealed the fact that their infants were sleeping through the night already. There have also been readmissions for Breastfed infants with a diagnosis of Failure to Thrive. We did not have the exact number of Breastfed infants who were being supplemented on our unit which led us to an audit conducted on the Mother-Baby Unit to discover the magnitude of the problem.
O / Organize A Team:
Lactation Consultants: amy furfari RN, Denise Davidson RN, Brenda Schmidt RN
Unit Educator: Lou Ann Cox RN
Family Education Coordinator: Jolene Bedford RN
Management Team: Pat Tetterton RN, Manager, Nancy Marts RN, Clinical Coordinator
Mother baby charge Nurses
Staff Nurses
the team met at least monthly during Lactation Team Meetings and staff Meetings as we worked through the improvement process.
C / Clarify Knowledge of the Current Process:
Our customers are our mothers and newborns. As nurses working on a mother baby unit, we have a duty to educated breastfeeding mothers about what things will help to build a good milk supply and what things may interfere with long term breastfeeding and maintenance of a good milk supply.
We needed data to reflect what our current process is and the reasons why breastfed babies were being given formula supplementation.
U / Understand Variation:
Data collection completed in august 2010 revealed that 45% of the breastfed newborns on our unit were receiving formula supplementation. what we were unable to determine in the majority of cases is why the infants received formula , as there was no documentation to reflect the reason formula was given.
(See the Data Collection Tool and survey summary attached)
The data revealed approximately equal proportions of babies being supplemented due to Mother’s choice, Medical Necessity, and for Breastfeeding difficulties.
S / Select An Improvement Strategy:
June 2010 – dr. Marianne Neifert came to the hospital to present the “CAN DO FIVE” program to enhance long term breastfeeding success for mothers and infants. No pacifier signs posted in Nursery Circ Room and Hearing Screening room.
august 2010– data collection began.
– Formula take home gift Packs were removed from our shelves in accordance with “CAN DO FIVE” measures. Results of the survey were presented at staff meeting with a request that all staff start documenting under the feeding section on the infnat flow sheet, why formula was being given. this information is necessary to determine how many babies receive formula for medical reasons as opposed to non-medical reasons and to help clarify the magnitude of the problem
– a new teaching sheet was developed by the team for breastfeeding mothers who were supplementing their babies for other than medical reasons. this educational information was meant to assist mothers’ in understanding how their milk supplyis built and maintained and what influences the milk supply. Staff were asked to use the sheet as a means of teaching mothers about milk supply (See attached teaching sheet)
September-October 2010 – The teaching sheet was introduced to staff.
P / Plan The Pilot Improvement And The Data Collection:
Time was allotted for change to occur within our process and we plan to collect data again in November looking for a decrease in breastfed infants that are supplemented without a medical reason. Upon spot checking for documentation, it appeared as though staff were still not documenting the reason formula was given to the breastfed infant. There was also reluctance on the part of staff to offer the educational sheet to mothers because they felt it would induce guilt if the mother still chose to use formula. The sheet was evaluated by the team again and the team did not feel the teaching sheet was guilt inducing, infact, the sheet was carefully constructed so as not to induce guilt, but rather to educate the mother about milk production and sustaining a good milk supply. E-mail reminders were sent to staff and charge nurses were asked to support the improvement effort with staff. It was decided at the October Lactation Team meeting that the education sheet would be put into the discharge folder rather than asking staff to go over the information at the time mothers were choosing to give formula. Staff were to inform mothers of the breastfeeding information in the packet at the time of admission to the postpartum unit.
D / Do The Pilot Improvement And Collect The Data
Data was again collected for the month of december 2011.
Successful findings will include:
-improved documentation about why formula was introduced
-offering of Expressed Breastmilk rather than formula when available
-Formula will be given according to the breastfeeding plan of care for medical necessity
-teaching regarding breastfeeding will be documented in the record.
C / Check The Results Of The Implementation
What was found was that while the percentage of mothers choosing to offer formula was only minimally decreased, there was a predominate shift in the percentage of babies receiving formula for medical necessity (See attached PIE charts) from 37% in august to 61% in December.
Other positive changes coming out of the process improvement were improved documentation by staff with regard to the reason formula was given as well as documentation of education efforts by the nurses working with breastfeeding mothers and babies.
it was noted by Amy furfari that RNs were introducing pumping to the mothers and giving expressed breastmilk rather than formula when it was available.
A / Act To Hold The Gain And Continue Improvement
The information will be put into powerpoint format for staff meeting. Staff who were doing a good job with the process changes were recognized by email sent to the entire staff. Those staff (15 were identified) who were not documenting the reason formula was introduced and/or not following the breastfeeding plan of care were counseled by the Clinical Coordinator with improvement noted in most cases.
We will continue to spot check through periodic review of charts and feedback to staff as a means of maintaining the gain.

Submitted by : Lou Ann Cox RN, BSN, MAED Mother-Baby Educator for SFMC