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Improving Interstage Growth in Single Ventricle Heart Defects

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Presentation on theme: "Improving Interstage Growth in Single Ventricle Heart Defects"— Presentation transcript:

1 Improving Interstage Growth in Single Ventricle Heart Defects
Kristi Fogg MS, RD, LD, CNSC Pediatric Cardiology Dietitian Sodexo/MUSC Children’s Hospital

2 Objectives 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 MUSC’s Interstage Growth Monitoring Pilot Program Show the role of technology in improving communication with parents and care teams

3 Anatomy of the Single Ventricle Heart
Underdevelopment of mitral and aortic valve w/ secondary small LV. Can have severe stenosis or atresia of the MV/AV and have hypoplastic ascending aortic arch PDA allows systemic circulation Norwood goal: establish unobstructed pulmonary and systemic venous mixing, unobstructed systemic outflow and limited pulmonary circulation. BDG goal: to unload the RV. More normal systemic circulation

4 Surgical Pathway Week 1-2 of life 6-10 months 3-4 years old
Norwood Procedure Hybrid, central shunt 6-10 months BiDirectional Glenn 3-4 years old Fontan

5 Growth Failure 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 National Pediatric Cardiology Quality Improvement Collaboration
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, NP’s, Dietitians, Speech Therapists Parental Involvement

7 NPC QIC Involvement 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 Learning session: June 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 Dietitian Involvement
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 Current Successful Interventions


12 Introduction 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 LactoEngineering Hindmilk Skim Breastmilk
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 Interstage Monitoring
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 Interstage Monitoring Program
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 Inclusion Criteria 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 Peapod Measurement Body Mass Measurement Infants and Body Mass
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? Poor growth during early life assc. With HTN, Heart disease, stroke, diabetes, decreased longevity in adult life Blanket for determining kcals in this population, can help avoid overfeeding in this population that would encourage cyanosis and mortality

19 Peapod measurement

20 Weight Monitoring and Sat Monitoring
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 Red Action Plan


23 Use of Technology 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 Google Voice for Parental Communication
Free! Need Google account Assigned local number Texting/Voic Voic Transcription Able to re-route to multiple phones Allow on call schedule

25 Google Voice

26 date weight growth x 7d sat growth regimen 1-Aug 4.51 27 86 75 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 4.5 21 81 3-Aug 20 84 4-Aug 4.53 85 5-Aug 4.55 10 88 119 cal/kg/day 6-Aug 4.59 16 7-Aug 4.62 18 83 8-Aug 4.67 23 9-Aug 4.69 10-Aug 4.71 29 11-Aug 4.73 12-Aug 26 13-Aug 4.74 @ 77 ml q 3hr, added olive oil, giving 130 cal/kg

27 Thank you! Questions????

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