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I MPROVING I NTERSTAGE G ROWTH IN S INGLE V ENTRICLE H EART D EFECTS Kristi Fogg MS, RD, LD, CNSC Pediatric Cardiology Dietitian Sodexo/MUSC Childrens.

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Presentation on theme: "I MPROVING I NTERSTAGE G ROWTH IN S INGLE V ENTRICLE H EART D EFECTS Kristi Fogg MS, RD, LD, CNSC Pediatric Cardiology Dietitian Sodexo/MUSC Childrens."— Presentation transcript:

1 I MPROVING I NTERSTAGE G ROWTH IN S INGLE V ENTRICLE H EART D EFECTS Kristi Fogg MS, RD, LD, CNSC Pediatric Cardiology Dietitian Sodexo/MUSC Childrens Hospital

2 O BJECTIVES Understand factors contributing to growth failure in infants with Hypoplastic Left Heart Syndrome (HLHS) Discuss the National Pediatric Cardiology Quality Improvement Collaboration (NPC QIC) Identifying the role of the dietitian as a member of the care team Review the components of MUSCs Interstage Growth Monitoring Pilot Program Show the role of technology in improving communication with parents and care teams

3 A NATOMY OF THE S INGLE V ENTRICLE H EART

4 S URGICAL P ATHWAY Week 1-2 of life Norwood Procedure Hybrid, central shunt 6-10 months BiDirectional Glenn 3-4 years old Fontan

5 G ROWTH F AILURE IN HLHS Poor prenatal growth (IUGR) Inability to feed preoperatively Slow progression of feedings post op Poor intestinal perfusion, NEC Reflux Oral Aversion Fluid Restriction Chromosomal abnormalities Trisomy 21, 18; Turners syndrome, Digeorge Syndrome Other non cardiac malformations Cleft lip/palate, imporforate anus, gut malrotation

6 N ATIONAL P EDIATRIC C ARDIOLOGY Q UALITY I MPROVEMENT C OLLABORATION NPC-QIC Mission Improve care and outcomes of infants with HLHS during the 4-6 month outpatient interstage period between surgeries Improving interstage growth Reducing readmissions due to major adverse events Improving communication and care coordination with the family, referring cardiologists, and primary care clinic Includes 42 pediatric cardiology centers Physicians, CT Surgery, NPs, Dietitians, Speech Therapists Parental Involvement

7 NPC QIC I NVOLVEMENT Learning Sessions (2x Year) Monthly Action Calls (MUSC presenting on 4 calls) Working calls focused on Growth, Care transitions, discharge planning and emerging literature PDSA Presentations Story Boards Data Entry and Data Sharing Access to shared drive

8 L EARNING SESSION : J UNE 2012 Focus on Growth Failure Current growth trends between institutions Implementation of feeding protocols Engaging your RD Major red flag events Growth bundles Care transitions

9 D IETITIAN I NVOLVEMENT Goal: Dedicated Dietitian to Pediatric Cardiology Department to improve growth and reduce mortality Updated nutrition care plan Coordination of care w/ outlying facilities and families Phone availability when not physically present 93% Patients had dietitian available inpatient 69% had dietitian available as an OP 12% routine with clinic visit 57 % consulted as needed

10 C URRENT S UCCESSFUL I NTERVENTIONS

11 MUSC QI IN INTERSTAGE GROWTH

12 I NTRODUCTION OF GROWTH BUNDLE Established Feeding Protocol After Hours TPN Establishing Interdisciplinary team Addition of pharmacist and dietitan Participation in rounding, care coordination, QI Non statistical significant improvement

13 L ACTO E NGINEERING Hindmilk 5 minute separation of foremilk Evaluation of composite milk and hindmilk Ranging cal/oz Eliminates need for fortification Skim Breastmilk For patients with chylous effusions Requires supplementation with MCT based formula, ADEK MVI

14 I NTERSTAGE M ONITORING In the interstage, this is an extremely vulnerable time with a significant incidence of growth impairment, re- hospitilization, myocardial dysfunction and death Implement an interstage growth surveillance program that performs outpatient growth, feeding, and nutrition monitoring between Norwood and Glenn surgery. Develop and promote an interprofessional collaboration to reduce interstage growth failure

15 I NTERSTAGE M ONITORING P ROGRAM IP Grant ($15,000) Fosters an environment that rewards innovative and integrated education, research and patient care. Scales, Pulse ox monitors, educational binders, Learning sessions for NPC, Peapod maintenance Why is MUSC unique? NO ONE is excluded Technology Interaction with outlying facilities Funding

16 I NCLUSION C RITERIA Neonates requiring surgical shunt placement, PA banding, Norwood procedure, or hybrid procedure for single ventricle anatomy Once transferred to the stepdown unit, parents are consented and education is initiated

17 Discharge Teaching Started Discharge Educational Binder Use of Pulse Ox, Infant Scale Formula Preparation Red Flag Action Plan Use of Google Voice Correspondence Peapod Measurement

18 P EAPOD M EASUREMENT Body Mass Measurement Measured oxygen consumption, CO2 expelled, BSA Infants and Body Mass Long term correlation with chronic disease Possible use in anesthesia Leaner babies have higher BMR Correlation in Cardiac Babies?

19 P EAPOD MEASUREMENT

20 W EIGHT M ONITORING AND S AT M ONITORING Decrease interstage mortality Earlier feeding interventions Triaging red flag action plans Improved detection of important residual/recurrent lesions and improved survival Avoiding unnecessary ER visits Earlier operative intervention

21 R ED A CTION P LAN

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23 U SE OF T ECHNOLOGY Parents communicate daily using google voice Text/Call to adjust feedings or address red action plan Data entered into shared drive Weekly Rounding BiMonthly progress report to pediatrician and cardiologist

24 G OOGLE V OICE FOR P ARENTAL C OMMUNICATION Free! Need Google account Assigned local number Texting/Voic Voic Transcription Able to re-route to multiple phones Allow on call schedule

25 G OOGLE V OICE

26 dateweight growth x 7dsatgrowth regimen 1-Aug ml over 1hr, Alimentum 27 cal/oz. Going up 1ml at a time, every few days. Takes up to 55 ml at TID feeds 2-Aug Aug Aug Aug cal/kg/day 6-Aug Aug Aug Aug Aug Aug Aug ml q 3hr, added olive oil, giving 130 cal/kg

27 T HANK YOU ! Q UESTIONS ????


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