Along with infants experiencing serious illnesses and surgical needs, the 30-bed Intensive Care Nursery (ICN) at Dartmouth-Hitchcock Medical Center (DHMC) cares for premature babies who are stable and growing. While families receive tremendous support from the Neonatology staff, being in the ICN for days—–or weeks—–is stressful. Thanks to the new Hope Grows at Home Program, that time is significantly shorter for preterm babies known as “feeders and growers.”
“We have 10 to 12 babies at home with tracheotomies or on ventilators, and realized if they can be home, why can’t the feeders and growers?” explains Tyler K. Hartman, MD, Neonatology, DHMC. “We conducted more than 50 interviews of those ICN parents and discovered they wanted the same level of care they were receiving in the ICN—–at home.”
Neonatology’s existing Transitional Long-Term Care Clinic provides special care to babies who leave the ICN but require home monitoring. Staffed by Hartman, Kate Richards, MSN, APRN, and Laura Cogswell, RN, nurse clinician, the team developed the Hope Grows at Home program as a Transitional Long-Term Care Clinic subset. It is modeled after similar programs at the University of Virginia Children’s Hospital, Duke University Hospital and Oregon Health & Science University Hospital.
Eligibility for Hope Grows at Home includes passing sleep apnea (pausing in breathing) countdown, maintaining body temperature outside of incubation and taking some feeds by mouth. If families agree to participate—–they’re often crying tears of joy, Hartman shares—–they receive education about nasogastric tube placement, CPR, home feedings (by nasogastric tube and mouth) and monitor use.
Babies are discharged home with a nasogastric tube placement and a secure, 24-hour oxygen saturation monitor connected to Neonatology. While the monitors offer an extra layer of security, they are likely unnecessary. Hope Grows at Home is the only program using them in the six-member Neonatal Enteral Feeding Tube Collaborative the team launched with hospitals featuring similar ICN programs. Every weekday, the Hope Grows at Home babies are part of the team’s morning rounds, providing families reliable check-ins. Most of these babies are discharged at 48 weeks of age.
Uncovering the key to improved growth
An important aspect of the program is focused on increasing protein intake. Hartman and Richards noticed feeders and growers were smaller than full-time babies, even months past discharge. They consulted with their 15-member New England-wide ICN collaborative and discovered between 20 and 40 percent of feeders and growers were below the 10th percentile for growth at two years of age.
Knowing most mothers in the ICN don’t want to supplement breastmilk with formula, they had a hunch about protein: formula is high in it, but breastmilk doesn’t have enough for preterm babies. Hartman says preterm babies need 4 grams of protein per kilo, but breastmilk only provides 1.5 grams per kilo early, typically increasing to 2.5 grams by the time they go home. The pair went back through the histories of 14 of their feeders and growers, manually calculating protein deficits based on U.S. Food and Drug Administration (FDA) recommendations and realized they were correct—–all their preterm babies were protein-deficient.
The team now teaches the Hope Grows at Home parents to add the human milk fortifier supplement in breastmilk (with a syringe by mouth or mixed in a bottle) until their babies are 48 weeks old. Richards says the growth data has been exceptional.
With initial one-year support of the pilot program provided by the Susan and Richard Levy Health Care Delivery Incubator, the team enrolled its first patient on July 29, 2020, and has graduated 31 babies to date. “There have been zero adverse events, zero emergency room visits and zero readmissions,” Richards reports. “It’s a unique opportunity for one team to manage ICN patients while helping parents take autonomy over the care of their baby’s health and nutrition.”
After analyzing the data, it has also proven to save up to $500,000 annually by freeing beds for babies requiring more care. Most importantly, Hartman says, is that outcomes for babies are markedly improved.
“We were thrilled to learn about the Hope Grows at Home program after our daughter was identified as a good candidate,” a participating parent shares. “We’ve received incredible support and care from the Hope Grows at Home team, which has allowed us to focus on our daughter’s long-term health while jumpstarting our day-to-day life with her much earlier than we would have otherwise.”