Registered Nurse Children's Healthcare of Atlanta Tucker, Georgia, United States
Abstract: Introduction/Objective The purpose of this project was to educate Cardiac Intensive Care Unit (CICU) nurses on strategies to bottle feed neonatal CHD patients safely and effectively. Oral (PO) feeding in neonatal patients with congenital heart disease (CHD) is a high risk but essential part of care and development. A recent study noted that CHD patients, regardless of STAT category, are at risk for both dysphagia and aspiration. Half of the patients experienced both pharyngeal dysphagia and aspiration. Feeding these patients can be a source of anxiety for providers, nurses and parents. Historically, this CICU focused on the total quantity of the feed with a low threshold for switching to tube feeds for safe weight gain. From 2016 to 2019 there was an intentional shift away from tube feeds to PO feeds, particularly among single ventricle patients. A 2019 survey of CICU nurses revealed a feeding-related knowledge deficit on subjects including positioning, bottle nipple selection, and ability to recognize signs of aspiration. CICU nurses must be able to safely feed neonates with CHD, and quickly respond to any difficulty or distress. Methods A subgroup of CICU nurses were trained as PO champions by our speech language pathologist (SLP) team. These trained nurses and SLPs collaborated to deliver one-on-one bedside education to all CICU nurses. Elements included anatomy, positioning technique for feeding, bottle selection and recognizing potential aspiration. Education was centered on safely providing quality-focused, infant-driven feeding. New nurses onboarding to the CICU were given both didactic and hands-on practice with an SLP. SLPs provided cross-training to other team members including CICU Physicians, Fellows and Advanced Practice Providers. A NICU feeding flowsheet was adapted to allow for consistent and thorough documentation of both the quality and quantity of the feed, signs of difficulty, type of bottle nipple used, etc. This information was used by nurses and providers for patient management. Results Nurses report increased confidence in their ability to recognize early signs of aspiration and feel empowered to reach out to SLPs for help more readily. Subsequently, there was an increase in speech consults and OPMS studies for evaluation of PO feeding. Individualized signage was added to the bedside as a visual cue with feeding strategies outlined for each patient. A neonatal oral feeding order set was created to include the feeding flowsheet, position, and bottle nipple to be used. Extra-slow-flow bottle nipples were added to CICU inventory to impact nurse selection. Standard flow bottle nipples were removed to direct use of the slower flow options. Bottle feeding will be added to continuing education skills lab for CICU nurses. Data collection is active and we look forward to presenting PO feeding rates and growth data. Conclusion PO feeding rates in the CICU have had a dramatic and steady rise since 2016, with a marked increase among SV patients. Safe and effective feeding of the CHD neonate is a crucial skill for the bedside CICU nurse. Thorough and consistent education by nurse champions and SLPs provides nurses feeding and assessment skills to feel confident and prepared when feeding a high risk neonate.
