Each day, neonatal intensive care units face a critical task: calculating and monitoring caloric intake for critically ill infants. Premature babies or babies afflicted with serious maladies require this stewardship to ensure their survival and recovery, but there are two main problems that persist. One is that many NICUs -- a majority, in fact -- lack clinical decision support to make these critical calculations.
Two is that, even among the NICUs with CDS, the majority don't have an automated CDS system for nutrition received. The findings were uncovered in a recent study, published in the Journal of Perinatology, which delivered the verdict that most NICUs are unable to reliably and consistently monitor the caloric intake of their most vulnerable infants.
What this means is that clinicians have to retype data from the electronic health record into a calculator to compute the proper feeding. Old-world technology is being used to address a new-world problem.
And these calculations take place frequently, as they must. Children in these situations are typically fed small amounts of food every two to four hours -- a process that could benefit from technology that exists today.
"CDS can be so incredibly valuable in automating and aggregating that data … to allow clinical teams more time to tend to patient care and nutritional ordering," said Tracy Warren, venture capitalist and founder and CEO of Astarte Medical, a company that uses precision medicine to improve neonatal outcomes. "The tools haven't been there for them."
What makes this especially vexing for clinicians is that the expansion of knowledge in the digital age has been exponential, said Dr. Bill Hay, Astarte Medical's chief medical officer and top neonatologist.
"Throughout medicine, but especially in critical care, in all aspects of neonatal care, information technology has expanded way beyond the capacity of any normal human being, no matter how well-trained, to be on top of things and not only plan accordingly but do timely follow-ups," said Hay. "This is a general phenomenon going on, and this area of nutrition is reflecting what's going on in other areas of neonatal care."
To truly get things right, said Hay, clinicians need the confidence that they're not going to make a mistake. Everything needs to be documented and checked off in the right way, but the overwhelming wealth of data is beyond the capacity of any one person's capacity to handle.
"When I started, we had a couple of formulas," said Hay. "We had mother's milk, but the nutrient product was disastrous, it caused all kinds of problems. The correct dosing was not known. Over my career, we've seen a tremendous expansion in what products are available, (but) we still don't know the components of breast milk that lead to improvements in development. Things have just expanded beyond any one person's capability."
THE EFFECT ON BABIES AND CAREGIVERS
What's unique to premature babies is the frequency by which they're fed. Feeding usually begins intravenously since the babies are too small to swallow, which from a physical standpoint makes the process labor intensive for caregivers. The numerous calculations needed only add to that.
The advent of electronic health records has helped to document reams of information, but the EHR itself does nothing to liberate that data for any kind of clinical utility. Nurses document a lot of information manually, but are often unable to organize the data in a way that makes a tangible impact at the bedside.
"These are very fine people who can't deliver everything to you all at once," said Warren. "Knowing the right amount is a fair amount of science, but a fair amount of art."
Assessing a child's growth by looking at biochemical measurements, which are primarily entered by hand or extracted by the EHR, eats up an incredible amount of time. Often clinicians are reliant on dieticians and pharmacists to contribute these measurements, but according to Hay, this doesn't contribute to doctors' and nurses' knowledge of how they should be nourishing babies.
"That's where the advantage of having information accurately analyzed on a more timely basis will lead to more understanding of what's been given and what's needed," said Hay.
Gathering even deidentified data can provide insight back to the medical community with a degree of real-world evidence that can't be accomplished in even a randomly controlled trial. The broad knowledge of proper nutrition can then be whittled down into an actionable insight, allowing for better understanding and the establishment of best practices that most NICUs can't achieve on their own.
BRIDGING THE GAP
To better bring technology to the fore, the team at Astarte Medical began implementing a tool called NICUtrition, creating bedside tools and analytics capacity to standardize care protocols. It also provides an assessment of how the delivery of care has been affecting certain milestones for babies' development, allowing teams to develop more holistic care plans.
"We think that nutrition is the new way to get these kids healthy and keep them healthy," said Warren. "Health systems are starting to realize that, not just in the NICU but in all critical care settings."
Hay has been proselytizing this for years. Tasked with co-writing a book on the topic, Hay filled six chapters just covering all of the different components of intravenous nutrition and what should be done to assess its impact on the youngest of children.
"It struck me that it takes that much just for one component of a preterm baby, who's changing on a daily basis," Hay said. "You're going to need something more than just a dietician. That's a full-time job, and that's just one aspect of nutrition. You're going to need a computerized approach, solidly and scientifically based."
In all areas of medicine, computerized approaches are developing at a rapid pace, meaning many NICUs may soon receive the technological assist they need. Hay expects universal expansion of automation technology is inevitable due to clinicians' ongoing struggles in keeping up with the data.
"You can't clone Bill Hay and put him in every NICU," Warren said. "This is really only the start. Once the clinical teams see what this data can do, they're going to take the field in a new and exciting direction."