Optimizing Computer Physician Order Entry Workflows for Breastmilk and Infant Formula

Purpose: This is a large urban safety-net hospital that contains a 20-bed level-3 designated NICU. There are roughly 3000 deliveries per year, with 250 neonates being admitted to the NICU. Workflow challenges were identified with breastmilk and formula feedings. This resulted in inconsistencies with order entry, milk preparation, and milk delivery. Studies show that 74.83% of feeding-related errors in the neonatal intensive care unit (NICU) have led to differing levels of harm to patients.

Description: Feeding neonates breastmilk can help support growth, immune system development, neurological development, and gastrointestinal absorption of fats and minerals. Additional calories by fortification and formula may be added to the breastmilk to promote rapid weight gain and maturity. For premature infants, neurodevelopmental outcomes are strongly linked to growth. Due to the complex needs of the neonatal population, it is imperative that their nutritional needs are met.
Utilizing lean six sigma principles, the work was initiated by performing a multidisciplinary Gemba walk. Next, the team mapped the process from order entry to milk delivery. It was identified that the area with the greatest opportunity was related to order translation. Due to the excess amount of nonessential information and lack of pertinent elements within the order, providers were forced to enter written instructions into a comment box. This led to inconsistency in order entry and incorrect milk preparation. The downstream impacts were delays in patient care and discharge to the home. The electronic health record (EHR) breastmilk and formula order revamps were initiated to replace the nonessential order questions with order questions pertinent to milk preparation and delivery. Leveraging the EHR, the new order was able to ensure clear, transparent, and consistent administration instructions. Additionally, the team created a printable patient list from the EHR which translated the order questions into a report. The list creates a separate column for each order question, allowing the milk technician to see all the selections the providers have chosen. The list is then used by the milk preparation technician to match the milk recipe to the order.

Evaluation/outcomes: From October 2022 to October 2023, an analysis was performed of the total number of breastmilk and formula orders. In a 1-year timeframe, the number of incorrectly prepared and delivered milk orders was reduced by 50%. The physicians, nursing staff, and milk technicians all reported increased satisfaction with the improved workflow and reduction of order reentry due to unclear instructions. It was also reported the reduction from 18 questions to the new order of 10 questions improved efficiency. The new order build ensures patients are provided with the correct nutrition and helps sustain a reduction in errors related to order clarity.