De-implementing the Routine Measurement of Gastric Residual Volumes in an All-Referral Newborn Intensive Care Unit

Background: Routine gastric residual volume measurement has historically been the standard of care in many neonatal intensive care units to monitor for feeding intolerance and necrotizing enterocolitis. However, current evidence suggests that gastric residual volume is a poor indicator of these pathologies. Furthermore, the routine measurement of gastric residual volumes is associated with adverse outcomes in neonates including prolonged time to full enteral feeds, longer hospitalization, and more late-onset sepsis. Local Problem: In this 51-bed, all-referral neonatal intensive care unit, the clinical practice guideline recommended the routine measurement of gastric residual volumes in all infants receiving enteral feeds via enteric feeding tube. There was a need to de-implement this practice to be consistent with current evidence. Methods: Pre- and post-intervention data were compared to evaluate the success of this quality improvement project. Staff practice and opinions were assessed with surveys before and after the educational interventions. Patient outcome data were obtained by retrospective chart review prior to the commencement of the interventions and by prospective chart review following the completion of the interventions. Interventions: This quality improvement project began with the removal of the clause recommending gastric residual volume measurement from the clinical practice guideline. Educational interventions including Situation-Background-Assessment-Recommendation descriptions of the change, presentations at charge nurse and leadership meetings, in-person and small group discussions with nursing staff, informational pamphlets, and reminder signs in patient rooms were used to inform staff about and garner support for the practice change. Results: Nursing practice prior to the educational interventions was varied. Following the interventions, nursing practice changed significantly away from routine gastric residual volume measurement, with only 5.1% of nurses continuing to aspirate gastric residual volumes in all patients and 82.1% of nurses not measuring gastric residual volumes in any patients. Nursing opinion on discontinuing gastric residual volume measurement also became significantly more favorable; assessment by Likert scale demonstrated an increase from mean 3.44 to 4.05 out of 5, p=.005 (N=127). Advanced practice providers expressed high favorability of discontinuing residual volume measurement both before and after the interventions, with mean Likert scores of 4.78 and 4.90 respectively (N=28). No changes were evident before versus after the practice change in patient outcomes of time to full enteral feedings (5.5 versus 7.6 days, p=.052, N=51), weight gain (ΔZ-score/days hospitalized -0.017 vs. -0.005, p=.986, N=117), episodes of feeding interruptions for feeding intolerance (3.09 vs. 8.05 episodes, p=.156, N=117), incidence of bacteremia (1.03 vs. 2.01 episodes, p=.683, N=117), or incidence central line infections (3.08 vs. 2.01 episodes, p=.670, N=117). There were no episodes of necrotizing enterocolitis or culture-positive pneumonia in either patient group. Conclusion: Educational interventions for staff were effective in de-implementing routine gastric residual volume measurement in an all-referral neonatal intensive care unit, with success both in changing practice and gaining staff acceptance of the change. While benefit in patient outcomes was not observed at this institution, there was importantly no increase in adverse events for patients following the practice change.