Improving Exclusive Breast Milk Feeding at Hospital Discharge: A Regional Quality Improvement Project

Introduction: Exclusive breastfeeding (EBF) at discharge is a core measure of hospital perinatal care quality. Hospital practices that support breastfeeding significantly impact success, exclusivity, and duration. However, there is variation in both hospital practices and provider recommendation of formula supplementation to breastfed infants, impacting EBF rates. Introduction of formula supplementation in the hospital can have a negative impact on breastfeeding outcomes post-discharge. We are an academic, regional practice providing newborn care at multiple sites. Publically available data from Joint Commission's Quality Check website revealed that EBF rates ranged from 28-75% across delivery hospitals in our region. Our specific aim was to increase aggregate exclusive breast milk feeding rates from 50 - 55% at hospital discharge across five delivery hospitals in our region for which monthly data was available by June 2018. Our target population included singleton newborns born ≥37 weeks gestation, not admitted to the Neonatal Intensive Care Unit, without galactosemia. Methods: A multidisciplinary team (including nurses, managers, nurse practitioners, physicians, and lactation consults) was assembled with representatives from area hospitals for which newborn coverage is provided. Using the Model for Improvement, the team developed a Key Driver Diagram (Figure 1). The individual facilities identified strategies to standardize and improve breastfeeding practices. Multi-site tests of change commenced in July 2015. The primary outcome measure was the Joint Commission Perinatal Core Measure 05: Exclusive Breast Milk Feedings at Hospital Discharge at five area hospitals. Results: Exclusive breast milk feeding at hospital discharge increased from a baseline of 40% in 2014 to 50% in early 2016 (average yearly live births 14,815 at these five sites, Figure 2). Successful interventions have included standardizing methods to facilitate skin to skin after medically appropriate deliveries, involvement of obstetrics colleagues in breastfeeding education during the prenatal outpatient appointment, monthly SKYPE meetings with team members across a geographically diverse area for learning and collaboration, establishment of outpatient lactation clinics, improved and expanded staff breastfeeding education, and increased lactation coverage. In reviewing reasons for failure, maternal request was the most common reason for formula supplementation, followed by hypoglycemia. Co