No spoiled milk in this NICU

In neonatal intensive-care units, one of the most risky and detail-oriented tasks for nurses is feeding vulnerable babies.

Nurses must be meticulous to ensure the babies don't receive the wrong mother's milk or expired formula.

A mistake can be life-threatening for babies who are already are already fragile, especially if the milk contains infectious agents or is spoiled.

There is also an emotional toll on families if their infant receives another mother's milk. That kind of error can break down the trust between distressed families and the NICU care team.

“Parents don't need an added worry,” said Dr. Christine Bixby, medical director of lactation services at Children's Hospital of Orange County in California.

So when the hospital experienced 45 breast milk handling mistakes from 2010 to 2012, Bixby said the staff was motivated to overhaul the process.

The hospital began making changes in January 2013 when it repurposed a nutrition lab to be used solely for the preparation of breast milk and formula.

Six dietetic technicians were deployed to work in the lab. With access to electronic health records, the technicians mixed all the milk a patient needed in a 12-hour period, following doctors' orders. While one technician prepared the milk, another observed to double-check their work. Labels were then printed with the patient's name and the milk order so nurses could verify the bottle is going to the right baby. On average, the technicians prepared 400 feedings per day.

The use of the dietetic technicians was highly successful, with the hospital reporting a 74% decrease in potential errors for breast milk handling.

Things didn't stop there. A bar code system was implemented in November 2013.

All babies in the NICU receive a wristband with a bar code that is scanned by nurses to generate a label. The label includes the baby's name as well as the physician's milk order. Physicians' orders from the EHR interface with the bar code scanning system to make the connection. That label is printed and placed on a feeding bottle, which is given to the mother. The mother handwrites the date and time the milk was pumped. The bottle is then given to the nurse, who double- checks that the label was filled out correctly by the right mother and places it in a refrigerator in the NICU.

Dietetic technicians come to the unit roughly four times a day to pick up the milk and bring it back to the nutrition lab for mixing. In the lab, the technicians scan the bar code on the bottle where the physician's order is displayed on a computer screen. About two to four technicians are preparing feedings at a given time, but they no longer have to double-check each other's work. The scanning system verifies that every bottle scanned belongs to the correct infant and the fortifiers added match the doctor's order in the EHR, Bixby said.

After the milk is mixed, the technician delivers the labeled bottle back to the NICU.

Once the nurses or the mothers are ready to feed a baby, they scan both the bar codes on the bottle and on the baby's wrist. The scanner analyzes both bar codes to ensure they match. If they do, a green pop-up box on the scanner screen informs the nurse that the right bottle is going to the right baby. If it doesn't match, a red light pops up on the scanner warning that there is an error.

The initiative continues to drive improvements. The 45 breast milk handling mistakes the hospital experienced in a two-year period has now declined to almost zero. The scanning system has saved the hospital an average of $30,000 a year because additional technicians are no longer needed to verify each other's work.

NICU nurses have also benefited by having more time to spend with infants and mothers. The unit administers more than 10,000 breast milk feedings per month and one nurse handles breast milk at least 12 times per shift. Before the technicians were deployed, NICU nurses could easily get overwhelmed as they tried to both properly mix and administer feedings to the babies while caring for their other health needs, Bixby said.

Now nurses have an additional hour of time to spend with the babies and their parents because they no longer have to mix milk and formula. “It freed the nurses up to talk to mothers about the importance of breast milk, regular pumping and skin-to-skin contact with their baby,” Bixby said.