778 - Improving Breast Milk Oral Care (BMOC) in the NICU through an Equity-Focused QI Initiative

Publication Number: 1754.778

Sheetal Sriraman, Columbia University Irving Medical Center, New York, NY, United States; LaRae P. Miller, NewYork-Presbyterian Morgan Stanley Children's Hospital, 28 Gaffney Place, NY, United States; Christine Scheinman, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Monique Woodley, NewYork-Presbyterian Morgan Stanley Children's Hospital, NY, NY, United States; Sandhya S.. Brachio, Columbia University Vagelos College of Physicians and Surgeons, 622 W. 168th St, PH17, NY, United States

Background: Breast milk oral care (BMOC) promotes immunity and improves outcomes in vulnerable NICU infants. At our institution, only 21.6% of eligible infants received BMOC within 5 days of admission.

Objective: The SMARTIE (Specific, Measurable, Achievable, Relevant, Timebound, Inclusive, Equitable) aim of this equity-focused quality improvement (EF-QI) initiative is to increase the rate of BMOC administered in the NICU from a baseline of 21.6% to over 80% within one year and to sustain this change for at least an additional year.

Design/Methods: Using the Model for Improvement and sequential Plan-Do-Study-Act (PDSA) cycles, a multidisciplinary team (physicians, lactation consultants, nurses, and educators) tested change ideas, including parent education, provider training, stakeholder engagement, and EPIC optimization. All NICU admissions were eligible. The primary outcome was the proportion of infants receiving BMOC within 5 days. Data were extracted and analyzed using run charts and statistical process control (SPC) charts weekly.

Results: Baseline BMOC was 21.6% (July to August 2024). After interventions, rates initially showed common cause variation. Rates dropped to as low as 4% following the introduction of Keriton, a new documentation system, prompting renewed education and engagement. SPC analysis demonstrated special cause variation, with an astronomical data point observed after individualized messages to nurses, which shifted the median to 42% in May 2025. In response to this improvement, these messages were scaled across the unit. Our process measure was the proportion of infants who had a BMOC order placed, which increased after the introduction of the BMOC order into the order set. The balancing measure included infants who experienced a cardiopulmonary event as a result of BMOC administration; no such adverse events were reported. A review of 166 missed opportunities found that early initiation of oral feeding within 72 hours accounted for 54.8%, while a lack of breast milk explained only 16%. Importantly, BMOC rates were lower among non-English-speaking individuals during the initial period, revealing disparities in access. However, this disparity improved with the implementation of targeted interventions.

Conclusion(s): This EF-QI initiative improved BMOC rates but has not yet achieved the 80% goal. Most missed opportunities were due to early oral feeds rather than breast milk availability. Language-based disparities highlight the need for culturally and linguistically tailored strategies. Ongoing efforts will refine workflows and embed equity-focused practices to sustain BMOC.

Figure 1: Key Driver Diagram


Figure 2: Statistical Process Control (SPC) Chart with weekly Brest Milk Oral Care (BMOC) rates
A - RN Education; B - BOMC order included in admission order set; C - Introduction of Keriton; D - RN and provider handout disseminated; E - Data sharing at Coffee Hour; F - Gemba walk in the NICU; G - APP education; H - Individual reminders to RNs

Figure 3: Run chart with monthly mean BMOC rates stratified by patients' preferred language