Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute

Abstract

Introduction:Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS.Methods:We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a “sentinel” FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm.Results:Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance.Conclusions:This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.

Toward standardization of care: The feeding readiness assessment after congenital cardiac surgery

“…However, it is often difficult to determine precisely where a patient falls on the continuum of feeding abilities, especially after congenital heart surgery. Our heart institute found this to be a key driver in variability of practice, whereby individual biases and subjective decisions about feeding skills contributed to prolonged hospital length of stay . This challenge is shared by many other centers .…”

“…Our heart institute found this to be a key driver in variability of practice, whereby individual biases and subjective decisions about feeding skills contributed to prolonged hospital length of stay. 16 This challenge is shared by many other centers. 7,11,20,21 We therefore promoted a shared mental model (ie, the FRA score) to maximize consistency and minimize the subjectivity involved in feeding skill assessments.…”

“…This investigation was approved by the Children's Hospital Colorado Organizational Research Risk & Quality Improvement Review Panel as part of a larger quality improvement project focused on improving the quality and consistency of our postoperative feeding practices . A retrospective review of electronic health records of patients ≤3 months old admitted to the CICU for their first cardiac surgery between January 1, 2015, and December 1, 2015, was performed.…”

“…Our center has employed a postoperative feeding algorithm since 2012 that similarly relies on group consensus. We recently found our adherence to be suboptimal, which was driven by clinician attempts to subjectively predict improvement in feeding abilities. This was associated with a trend toward resulting in increased LOS.…”

Feeding infants with complex congenital heart disease: a modified Delphi survey to examine potential research and practice gaps

“…Instead, there remains centre-and provider-dependent variation in feeding practice. 14,[30][31][32][33][34] Many of these variations can lead to suboptimal outcomes for growth and development, 33,[35][36][37] and can result in inconsistent communication between the healthcare team and family caregivers. 20,33,38 Healthcare providers, family caregivers, and affected children would all benefit from increased clarity of understanding in regard to feeding.…”