652 - Implementation of a Feeding Guideline Decreases Time to Initiation of Enteral Feeds After a NEC Diagnosis: A Quality Improvement Initiative

Necrotizing enterocolitis (NEC) is characterized by necrosis of intestinal mucosa in premature infants. Providers are cautious when restarting enteral feeds, typically waiting 7-14 days post-diagnosis. This practice is not evidence-based, and meta-analyses have shown that earlier introduction of feeds can reduce the time to full enteral feeds, as well as reduce likelihood of recurrent NEC and stricture. A consensus-based guideline from Patel et al. resulted in a decrease in days to initiation of and reaching full volume feeds. At our institution, there had been no attempt to standardize feeding after a NEC diagnosis; thus, there was substantial provider variability.

Objective: Our global aim was to decrease the time to initiate enteral feeds after a diagnosis of NEC. Our specific aim was to decrease the time to enteral feed initiation by 20% in 12 months.

Design/Methods: Our primary drivers included a lack of standardization in initiating and advancing feeds, as well as provider discomfort with earlier feeding post-NEC. We adapted our institution’s NEC Feeding Guideline based on the recently published consensus-based guideline to address feed initiation and advancement for Stage IIA, IIB, and IIIA NEC (Modified Bell’s staging system). We addressed the primary drivers through Plan Do Study Act cycles, using the Institute for Healthcare Improvement (IHI) Model for Improvement. Our process measures included documentation of NEC stage and when pneumatosis resolved. Our balancing measures included NEC recurrence, intestinal stricture, and mortality.

Results: Since guideline implementation in January 2022, nine infants in our unit have been diagnosed with NEC through December 2022. We collected baseline data from 13 infants with NEC from 2018 to 2020. After guideline implementation, the mean time to initiation of enteral feeds decreased from 10.7 days to 4.9 days (Fig. 1). This surpassed our specific aim of reducing the time to feed by 20% or 2.1 days.  However, there was no change in the mean days to full enteral feeds (Fig. 2). We have had one case of NEC recurrence since guideline implementation, compared to two cases in the pre-guideline years. Similarly, we have had no strictures since implementation, compared to one prior. No deaths occurred in patients when the guideline was used.

Conclusion(s): Our new protocol resulted in a significantly earlier reintroduction of enteral feeds as designed; however, it did not reduce the overall time to full enteral feeds post-NEC as seen in other studies.  We are currently examining factors contributing to the slower rate of increasing feeds post-NEC in our unit.