持续母乳喂养质量改进对极/超低出生体重儿的影响

Evaluation of continuous quality improvement on breastfeeding in very/extremely low birth weight infants

目的利用持续质量改进的方法提高新生儿重症监护病房(neonatal intensive care unit,NICU)中极低出生体重儿(very low birth weight infants,VLBWI)和超低出生体重儿(extremely low birth weight infants,ELBWI)亲母母乳喂养率,并探讨亲母母乳喂养改善后对VLBWI及ELBWI并发症的影响。方法回顾性分析2014年7月1日至2017年12月31日在南京医科大学附属妇产医院收治的587例VLBWI及ELBWI的病历资料。2015年8月1日本院开始实施母乳喂养质量改进相关措施,2016年底进行改进效果评估,2017年起对改进流程做出调整,确保母乳喂养质量持续改进。将2014年7月1日至2015年7月31日收治的病例分为改进前组(141例),2015年8月1日至2016年12月31日为改进后组(243例),2017年1月1日至2017年12月31日为持续改进组(203例)。比较3组患儿住院期间亲母母乳喂养率、初次亲母母乳喂养时间、肠外营养持续时间、达到全胃肠喂养的时间、住院时间、住院费用,以及喂养不耐受、新生儿支气管肺发育不良(bronchopulmonary dysplasia,BPD)、坏死性小肠结肠炎、迟发型败血症等发生率。采用方差分析、秩和检验、χ^2检验及Bonferroni检验进行统计学分析。结果生后0~7、0~14、0~28 d及住院期间,改进后组和持续改进组中位亲母母乳喂养率较改进前组增加[0~7 d:72.8%(42.6%~84.2%)、75.5%(49.8%~87.2%)与38.2%(0.0%~69.0%);0~14 d:91.9%(79.1%~96.0%)、92.0%(71.0%~96.8%)与37.8%(29.9%~80.5%);0~28 d:96.6%(90.3%~ 98.9%)、96.4%(83.1%~98.9%)与58.2%(30.0%~90.1%);住院期间:96.6%(89.5%~99.1%)、96.8%(83.0%~99.3%)与50.0%(30.0%~ 85.5%)];亲母母乳摄入量也较改进前组增加[0~7 d:82(0~506)、95(0~ 510)与31(0~397) ml;0~14 d:622(0~1 828)、717(0~1 868)与198(0~1 596) ml;0~28 d:2 707(0~7 074)、2 893(0~10 238)与1 458(0~4 960) ml;住院期间:4 071(0~22 961)、3 979(0~17 260)与2 000(0~18 767)ml];生后0~7 d持续改进组亲母母乳摄入量较改进后组增加(P值均<0.05)。改进后组和持续改进组初次亲母母乳喂养时间较改进前组提前[69(16~633)、68(3~456)与73(8~348) h];持续改进组达到全胃肠喂养的时间较改进后组和改进前组均提前[14(5~40)与17(6~53)、19(11~56) d];改进后组、持续改进组及改进前组肠外营养持续时间、喂养不耐受发生率、BPD发生率、迟发型败血症发生率及住院时间分别为15(8~50)、13(3~38)和17(11~39) d,34.2%(83/243)、31.5%(64/203)和47.5%(67/141),20.1%(49/243)、8.9%(18/203)和36.1%(51/141),35.0%(85/243)、31.5%(64/203)和47.5%(67/141),39(10~93)、32(1~73)与34(1~91)d,其中持续改进组肠外营养持续时间、喂养不耐受及BPD发生率均较改进前组减少,持续改进组迟发型败血症发生率及住院时间较改进后组减少,改进后组住院时间较改进前组延长(P值均<0.05)。结论持续实施母乳喂养质量改进措施可提高VLBWI及ELBWI亲母母乳喂养率,降低喂养不耐受、迟发型败血症及新生儿BPD等并发症的发生风险。

Objective To implement a continuous quality improvement (QI) initiative to increase the breastfeeding rate of mother's own milk(MOM) in very low birth weight infant (VLBWI) and extremely low birth weight infant (ELBWI) in neonatal intensive care unit (NICU) and to evaluate its impact on the morbidity of these infants.Methods A retrospective analysis was performed to analyze the clinical data of VLBWIs and ELBWIs who were admitted to the Nanjing Maternity Hospital Affiliated to Nanjing Medical University from July 1,2014 to December 31,2017 (n=587).The QI initiative was implemented in the hospital on August 1,2015,the effect was assessed at the end of 2016 and the QI process was adjusted from 2017 to ensure continuous quality improvement of breastfeeding,based on which the 587 infants were divided into three groups: those in pre-QI group admitted from July 1,2014 to July 31,2015 (n=141),post-QI group admitted from August 1,2015 to December 31,2016 (n=243) and continuous QI group admitted from January 1,2017 to December 31,2017 (n=203).Differences in breastfeeding rates of MOM,the time of first breastfeeding of MOM,duration of parenteral nutrition,time to achieve full enteral feeding,average length and costs in NICU stay and the incidence of feeding intolerance,bronchopulmonary dysplasia (BPD),necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) were compared between the three groups.Statistical analysis was performed using analysis of variance,rank-sum test,Chi-square test and Bonferroni test.Results Compared with the pre-QI group,both the post-QI and continuous QI groups had significantly increased breastfeeding rates of MOM [0-7 d: 38.2%(0.0%-69.0%) vs 72.8%(42.6%-84.2%) and 75.5%(49.8%-87.2%);0-14 d: 37.8%(29.9%-80.5%) vs 91.9%(79.1%-96.0%) and 92.0%(71.0%-96.8%);0-28 d: 58.2%(30.0%-90.1%) vs 96.6%(90.3%-98.9%) and 96.4%(83.1%-98.9%);during hospitalization: 50.0%(30.0%-85.5%) vs 96.6%(89.5%-99.1%) and 96.8%(83.0%-99.3%);all P<0.05] and volume of MOM intake [0-7 d: 31 (0-397) vs 82 (0-506) and 95 (0-510) ml;0-14 d: 198 (0-1 596) vs 622 (0-1 828) and 717 (0-1 868) ml;0-28 d: 1 458 (0-4 960) vs 2 707 (0-7 074) and 2 893 (0-10 238) ml;during hospitalization: 2 000 (0-18 767) vs 4 071 (0-22 961) and 3 979 (0-17 260) ml] within 7,14 and 28 d after birth and during hospitalization.Moreover,the volume of MOM intake in the continuous QI group was higher than that in the post-QI group during the first 7 d after birth (all P<0.05).The time on first MOM breastfeeding in the post-QI and continuous QI groups were earlier than that in the pre-QI group [69 (16-633) and 68 (3-456) vs 73 (8-348) h,P<0.05].Full enteral feeding was achieved earlier in the continuous QI group than the post- and pre-QI group [14 (5-40) vs 17 (6-53) and 19 (11-56) d,P<0.05].The length of parenteral nutrition,incidence of feeding intolerance,BPD and LOS and hospital stay in the continuous QI group,post- and pre-QI group were 13(3-38),15(8-50) and 17(11-39) d;31.5%(64/203),34.2%(83/243) and 47.5%(67/141);8.9%(18/203),20.1%(49/243) and 36.1%(51/141);31.5%(64/203),35.0%(85/243) and 47.5%(67/141);32 (1-73),39 (10-93) and 34 (1-91) d,respectively.The length of parenteral nutrition and incidence of feeding intolerance and BPD in the continuous group were less than the pre-QI group,and the incidence of LOS and hospital stay were less than the post-QI group (all P<0.05).However,the post-QI group had longer hospital stay than the pre-QI group (P<0.05).Conclusions Continuous QI initiative improves MOM feeding rates and reduces the incidence of feeding intolerance,LOS and BPD in VLBWI and ELBWI.