The The BreastBreastFeeding Feeding

InitiativInitiativee

2006 – 2007

Quality Improvement

at the Audubon Clinic

Project BIB: AIM StatementProject BIB: AIM Statement To improve infant and maternal health and foster positive relationships between mother and child by increasing the duration of breast-feeding amongst new mothers, exclusively or in conjunction with formula feeding by educating, encouraging, and empowering women to continue giving breast milk to their new infants.

Specific GoalsSpecific Goals

90% 4-week visits 90% 4-week visits for patients breastfeeding for patients breastfeeding at 2 week visitat 2 week visit

65% breastfeeding 65% breastfeeding at 2 months at 2 months (previously 41%)(previously 41%)

Benefits for BabyBenefits for Baby Bonding with motherBonding with mother ImmunologicalImmunological

↓ ↓ bacterial meningitis, otitis media, bacterial meningitis, otitis media, NEC, UTIs, URIs, bacteremia,NEC, UTIs, URIs, bacteremia, sepsissepsis

NutritionalNutritional Cognitive developmentCognitive development Other: Other:

↓ ↓ SIDS, DM, obesity, asthmaSIDS, DM, obesity, asthma ↓ ↓ leukemia, lymphomaleukemia, lymphoma

Benefits for MotherBenefits for Mother

↓ ↓ post-partum bleedingpost-partum bleeding Positive bonding experience with Positive bonding experience with babybaby

Improved weight loss post-partumImproved weight loss post-partum ↓ ↓ risk breast/ovarian cancer risk breast/ovarian cancer

Other BenefitsOther Benefits Economic:Economic:

↓ ↓ U.S. health costs by estimated $3.6 U.S. health costs by estimated $3.6 billionbillion

↓ ↓ W.I.C. costs W.I.C. costs ↓↓ Parental absence from employment as a Parental absence from employment as a result of result of ↓↓ infant illnessinfant illness

Environmental:Environmental: ↓ ↓ energy demands for production and energy demands for production and transport of artificial feeding productstransport of artificial feeding products

↓ ↓ disposal of formula cans and bottlesdisposal of formula cans and bottles

Obstacles to Initiation of Obstacles to Initiation of BreastfeedingBreastfeeding

Insufficient prenatal education and Insufficient prenatal education and encouragement of BFencouragement of BF

Early hospital discharge with late Early hospital discharge with late follow-upfollow-up

Formula promotion @ hospital, WIC, Formula promotion @ hospital, WIC, mediamedia

Maternal employment — poor support Maternal employment — poor support for pumping at work, demanding for pumping at work, demanding schedulesschedules

Lack of physician encouragement, Lack of physician encouragement, guidance & recognition of obstacles guidance & recognition of obstacles with subsequent referralswith subsequent referrals

Baseline MeasurementBaseline Measurement

Initial chart review (29 Initial chart review (29 charts)charts) 10% exclusively BF at 2 weeks10% exclusively BF at 2 weeks 82% any BF at 2 weeks (BF + 82% any BF at 2 weeks (BF + formula)formula)

75% any BF at 4 weeks75% any BF at 4 weeks 18% any BF at 4 months18% any BF at 4 months 4% any BF at 6 months4% any BF at 6 months

Cycle 1Cycle 1

Plan:Plan: Initiate 4 week visit for Initiate 4 week visit for all babies who are BF at all babies who are BF at newborn visit newborn visit

Do:Do: Plan communicated via Plan communicated via didacticdidactic

Study:Study: Providers offer greater Providers offer greater BF support as primary goal of 4 BF support as primary goal of 4 week visitweek visit

Act:Act: Further improve BF Further improve BF reinforcement by providing more reinforcement by providing more educationeducation

Cycle 2Cycle 2

Plan:Plan: Generate handout with BF Generate handout with BF resourcesresources

Do:Do: List of resources available List of resources available for all providers to give BF momsfor all providers to give BF moms

Study:Study: Handout not used routinely Handout not used routinely by providers, but list of by providers, but list of resources helpfulresources helpful

Act:Act: Further investigate how to Further investigate how to encourage/support BF momsencourage/support BF moms

Cycle 3Cycle 3 Plan:Plan: Improve educational Improve educational resourcesresources

Do:Do: Posters in all waiting room and Posters in all waiting room and clinic roomsclinic rooms

Extensive BF handouts available in Extensive BF handouts available in all clinic roomsall clinic rooms

Study:Study: With handouts more With handouts more readily available, increased readily available, increased use by providersuse by providers

Act:Act: Look into how BF Look into how BF educational resources are educational resources are impacting momsimpacting moms

Cycle 4Cycle 4 Plan:Plan: Determine when & why moms Determine when & why moms decide to BFdecide to BF

Do:Do: 10 newborn moms interviewed 10 newborn moms interviewed Study:Study: Most newborn moms at least Most newborn moms at least 50% BF50% BF Decision made very early in pregnancy - Decision made very early in pregnancy - primary reason for BF is their primary reason for BF is their mom/GM/friends told them it was best for mom/GM/friends told them it was best for their babytheir baby

PNC at Audubon or Broadway – were asked PNC at Audubon or Broadway – were asked once if planning on BF, but did not once if planning on BF, but did not receive significant support/informationreceive significant support/information

Act:Act: Meet with OB nurses and improve Meet with OB nurses and improve educational resourceseducational resources

Cycle 5Cycle 5 Plan:Plan: Improve prenatal BF support Improve prenatal BF support Do:Do: Interview OB nurses at Audubon Interview OB nurses at Audubon Study:Study:

Focus is in the third trimesterFocus is in the third trimester Nurses are responsible for majority of Nurses are responsible for majority of BF counselingBF counseling

Patients receive handbooks on Patients receive handbooks on pregnancy, but no specific information pregnancy, but no specific information on BFon BF

Every patient is offered a referral to Every patient is offered a referral to a one-time prenatal class given at the a one-time prenatal class given at the Allen PavilionAllen Pavilion

Act:Act: Collaborate with OB to improve Collaborate with OB to improve BF supportBF support

Cycle 6 Cycle 6 Plan:Plan: Meet with OB personnel to Meet with OB personnel to help partner in our initiativehelp partner in our initiative

Do:Do: Communicate goals to OB side Communicate goals to OB side in monthly staff meetingin monthly staff meeting

Study:Study: OB nurses supportive of project BIBOB nurses supportive of project BIB Suggestions: BF video in waiting Suggestions: BF video in waiting room, lactation consultant in OB room, lactation consultant in OB once a weekonce a week

Act:Act: Provide BF pamphlets and Provide BF pamphlets and posters to OB nurses posters to OB nurses

Are we making progress?Are we making progress?

Initial Initial chart chart

review review (n = (n = 29)29)

Secondary Secondary chart chart

review review (n=29)(n=29)

# of 4 week # of 4 week visitsvisits 75%75% 94%94%

BF at 4 weeksBF at 4 weeks 75%75% 53%53%

BF at 2 BF at 2 monthsmonths 41%41%

38%38%(77% of those BF at (77% of those BF at

4 wks)4 wks)

BF at 4 BF at 4 monthsmonths 18%18%

33%33%((88% of those BF at 88% of those BF at

2 mo)2 mo)

* One mom increased breastfeeding to greater than 50% after one month visit!

Current CycleCurrent Cycle Plan:Plan: Focus on prenatal BF support Focus on prenatal BF support Do:Do: Continue collaborating with OB to Continue collaborating with OB to implement specific interventions implement specific interventions (video, lactation consultant)(video, lactation consultant)

Study:Study: Identifying one nurse or MA who is excited Identifying one nurse or MA who is excited about the project will be more useful than about the project will be more useful than a “top-down” approacha “top-down” approach

Act:Act: Continue to re-stock brochures, Continue to re-stock brochures, encourage 4 week visits, and partner with OB.encourage 4 week visits, and partner with OB.

Future Goals/DirectionsFuture Goals/Directions

Enhance Enhance interdisciplinary interdisciplinary approach with OBapproach with OB

Evaluate 1 month Evaluate 1 month visits again and visits again and assess rates of assess rates of breastfeedingbreastfeeding

Assess usefulness of Assess usefulness of educational educational information information

The Audubon Experience: The Audubon Experience: Past QI InitiativesPast QI Initiatives

2004-2005 BMI: 20% of 2004-2005 BMI: 20% of charts had BMIs charts had BMIs documented and plotteddocumented and plotted

2005-2006 Lead 2005-2006 Lead Screening: 53% of charts Screening: 53% of charts had documented lead had documented lead screeningscreening

The Audubon Experience: The Audubon Experience: Past QI InitiativesPast QI Initiatives

Why such poor sustainability?Why such poor sustainability?Both initiatives relied on providers Both initiatives relied on providers solely to implement and carry out solely to implement and carry out project.project.

How can we do better?How can we do better? Design system-based changes: Design system-based changes: electronic medical record, new clinic electronic medical record, new clinic encounter forms, all medical personnel encounter forms, all medical personnel with designated roles and with designated roles and responsibilities. responsibilities.

The Audubon The Audubon Improvement Team!Improvement Team!

Residents: Residents: Melissa Dhundale, Tas Hoque, Heather Liu, Paul Planet, Tania Small, Emily Greenstein, Rebecca Locke, Christal Forgenie, Jason Freedman, Anil Kesavan, Angkana Roy, Tal Alon, Hannah Famiglietti, Dan Weiser, Gunjan Kamdar, Stephanie Leonard, Annika Hofstetter, Daniel Vo

Attendings: Attendings: Valerie Niketakis, Larry Williams, Christine Krause, Roy Brown, Connie Kostakos, Nikki Timko, Betsy Wedemeyer, Melissa Stockwell

And on the OB side: And on the OB side: Marian McEwan