Implementation of a Probiotic Protocol at an Urban Level 3 NICU

Background: Necrotizing enterocolitis (NEC) is a common cause of morbidity and mortality among premature and low birth weight infants. Infants who suffer from NEC are at increased risk for death and other poor outcomes, including problems associated with prolonged parenteral nutrition, long-term gastrointestinal problems, recurrent sepsis, and neurodevelopmental deficits. Probiotic use in the neonatal intensive care unit (NICU) has shown to be protective against NEC. Numerous studies show rates of NEC decreased by 40%-75% following the introduction of a prophylactic probiotic protocol.Local Problem:A level 3 NICU in an urban area of Utah had a high rate of NEC, 10.8% for 2019, and had not yet adopted the use of probiotics in their facility. The objective of this quality improvement project was to create a standardized approach to the prescribing of prophylactic probiotics in this level 3 NICU, implement the protocol, and evaluate the success of the implementation. Methods:First, a chart review was done in the BabySteps electronic health record to determine the rate of NEC and risk factors for all babies in the NICU for the current year and in the 3 months before protocol implementation using the GutCheckNECsurvey. Next, an evidence-based prophylactic probiotic protocol was adapted from a successful protocol, including a new probiotic product, Similac Probiotic Tri-Blend, with the approval of key stakeholders. Training materials were then created, including a PowerPoint presentation, and instructional handouts were made and approved by key stakeholders. Several in-person training sessions were held over 2 days to train nurses and techs in probiotic preparation, safety, and administration. Following training sessions, the protocol was implemented. The charts of all babies were audited for 3 months following implementation, and all infants who qualified for probiotics were evaluated with the GutCheckNECsurvey and compared to pre-implementation group data. Results were analyzed. In addition to the screening tool, we also tracked four other measures to assess the success of implementation, including feeding tolerance. Additional measures included: (a) days of intravenous (IV) nutrition, (b) days to reach full enteral feedings, (c) incidence of NEC Bell stage 2 or greater, and (d) incidence of probiotic sepsis as a balancing measure. Results: The prescribing practices of probiotics to babies at risk for NEC increased significantly with the introduction of the guideline from 0/26 (0%) in the pre-implementation group to 10/14 (71%) in the post-implementation group, p < .001. There were no cases of probiotic sepsis in the NICU during the post-implementation period. There was no significant difference in rate of NEC Bell stage 2 or greater, days to reach full feedings, or total days of IV nutrition between pre- and post-groups.Conclusions: Implementation of a prophylactic probiotic protocol provided a consistent approach for prescribing probiotics in the level 3 NICU. There was no difference in the rate of NEC with the introduction of probiotics. However, we suspect this is likely due to the short time and small sample size. More time is needed to determine the effectiveness of the intervention. Similac Probiotic Tri-Blend is likely safe for use in the NICU population.