Evaluating Provider Readiness to Adopt an Early Enteral Nutrition Guideline for Infants Undergoing Therapeutic Hypothermia: A Needs Assessment

The incidence of hypoxic-ischemic encephalopathy (HIE) in the United States is one per 1,000 live births, has not improved in recent years, and is associated with increased mortality despite advances in perinatal care. The long-standing practice of withholding enteral nutrition during therapeutic hypothermia (TH) is linked to a concern for decreased intestinal perfusion. While this concern is valid in many infants undergoing TH, some infants may tolerate enteral nutrition and evidence-based literature suggests that this practice improves patient outcomes such as decreased time to reach full enteral feeds and decreased hospital length of stay without increasing morbidity including complications related to decreased intestinal perfusion. Local Problem: The current practice in two neonatal intensive care units (NICUs) in Salt Lake City, Utah is to withhold enteral nutrition during the three-day TH procedure but emerging evidence and the practice of many NICUs suggests that feeding during TH is safe, feasible, and improves patient outcomes. An average of 15.5 infants are admitted to these NICUs annually for TH and have the potential to benefit from a practice change that promotes early enteral nutrition. Methods: A needs assessment was conducted to evaluate current evidence-based literature, the practices of other international and domestic NICUs, the current state of readiness of stakeholders to provide early enteral nutrition during TH, and for the presence of improved readiness with creation of and introduction to a clinical practice guideline (CPG). Interventions: This scholarly project was carried out in four phases. The first phase included an initial survey to evaluate readiness and an in-depth chart review of HIE infants admitted between 2022-2023. The second phase included the creation of an evidence-based CPG. The third phase included a strengths, weaknesses, opportunities, and threats (SWOT) analysis to better understand catalysts and inhibitors to future implementation. The final phase sought to evaluate for a change in stakeholder readiness and to assess the feasibility, usability, and satisfaction of the guideline. Results: The most impactful outcome of this scholarly project was the improved readiness of stakeholders to adopt this change after introduction to current evidence and the CPG. Nearly every respondent in the final survey expressed an increased readiness to provide enteral nutrition during TH in eligible infants and that the CPG was a feasible, detailed, and realistic tool. An in- depth literature review revealed that this practice is occurring in many NICUs with successful patient outcomes. Conclusion: Continuation of this project is recommended including implementation, use of rapid PDSA (plan, do, study, act) cycles to adjust for real-time clinical considerations, and creation of a sustainability plan. While the concern for decreased intestinal perfusion is likely to persist amongst a large portion of stakeholders, emerging evidence should be monitored to observe for necessary recommendation changes and/or further evidence to support this change.