Transforming the electronic health record from a documentation application to an automated diet program for personalizing neonatal nutrition and improving feeding administration safety through process improvement

Delivering adequate nutrition to preterm and sick neonates is critical for growth. Infants in the neonatal intensive care unit (NICU) require additional calories to supplement feedings for higher metabolic demands. Traditionally, clinicians enter free-text diet orders for a milk technician to formulate recipes, and dietitians manually calculate nutrition components to monitor growth. This daily process is complex and labor intensive with potential for error. Our goal was to develop an electronic health record (EHR)-integrated solution for entering feeding orders with automated nutrition calculations and mixing instructions. The EHR-integrated automated diet program (ADP) was created and implemented at a 52-bed level III academic NICU. The configuration of the parenteral nutrition orderable item within the EHR was adapted to generate personalized milk mixing recipes. Caloric, macronutrient, and micronutrient constituents were automatically calculated and displayed. To enhance administration safety, handwritten milk bottle patient labels were substituted with electronically generated and scannable patient labels. The program was further enhanced by calculating fortifier powder displacement factors to improve mixing precision. Order entry was optimized to allow for more complex mixing recipes and include a preference list of frequently ordered feeds. The EHR-ADP's safeguarded features allowed for catching multiple near-missed feeding administration errors. The NICU preterm neonate cohort had an average of 6-day decrease (P = 0.01) in the length of stay after implementation while maintaining the same weight gain velocity. The EHR-ADP may improve safety and efficiency; further improvements and wider utilization are needed to demonstrate the growth benefits of personalized nutrition.