Transforming the electronic health record from a documentation application to an automated diet program for personalizing neonatal nutrition and improving feeding administration safety through process improvement.

Delivering adequate nutrition to preterm and sick neonates is critical for growth. Infants in the neonatal intensive care unit (NICU) require additional calories to supplement feedings for higher metabolic demands. Traditionally, clinicians enter free-text diet orders for a milk technician to formulate recipes, and dietitians manually calculate nutrition components to monitor growth. This daily process is complex and labor intensive with potential for error. Our goal was to develop an electronic health record (EHR)-integrated solution for entering feeding orders with automated nutrition calculations and mixing instructions. The EHR-integrated automated diet program (ADP) was created and implemented at a 52-bed level III academic NICU. The configuration of the parenteral nutrition orderable item within the EHR was adapted to generate personalized milk mixing recipes. Caloric, macronutrient, and micronutrient constituents were automatically calculated and displayed. To enhance administration safety, handwritten milk bottle patient labels were substituted with electronically generated and scannable patient labels. The program was further enhanced by calculating fortifier powder displacement factors to improve mixing precision. Order entry was optimized to allow for more complex mixing recipes and include a preference list of frequently ordered feeds. The EHR-ADP's safeguarded features allowed for catching multiple near-missed feeding administration errors. The NICU preterm neonate cohort had an average of 6-day decrease (P = 0.01) in the length of stay after implementation while maintaining the same weight gain velocity. The EHR-ADP may improve safety and efficiency; further improvements and wider utilization are needed to demonstrate the growth benefits of personalized nutrition.

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery.

BACKGROUND AND OBJECTIVES: An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis. METHODS: This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders. RESULTS: During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001). CONCLUSIONS: An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.