ISSUE: Inconsistent confirmation of infant’s identity before feeding has been associated with increase incidence of incorrect administration of EBM. Our Epidemiology and Infection Control Department set out to reduce the risk of infectious disease transmission to infant’s from incorrect EBM feedings and develop guidelines for screening the donor mother in the event of EBM exposure.

PROJECT: A Breastmilk Exposure Task Force was organized to evaluate the current EBM infection control and exposure guidelines and devised a plan to prevent further incidence of incorrect EBM administration in our 80-bed Level III NICU. A key intervention was the development of an EBM Audit Tool. This tool was used to verify that two Registered Nurse’s (RN’s) confirmed infant’s identity with EBM identification. Both RN signatures were required similar to procedure used for blood transfusion verification prior to administration. We established a breastfeeding subcommittee to assist with weekly auditing and provided positive reinforcement and timely feedback to nursing staff.

RESULTS: EBM audits began in May of 2005, which resulted in a compliance rate of 100% with the newly revised, evidence-based EBM guidelines. During the months of July and August 2005 there was a noticeable decrease in compliance to 80%. These results lead to aggressive auditing and staff education by infection control, NICU management and the lactation consultant. Weekly audits by breastfeeding subcommittee volunteers, monthly auditing by the Infection Control Practitioner, in-services and counseling by NICU Supervisor for failure to comply with guidelines have proved to increase compliance rates to 100%. Since applying these interventions there had been one EBM exposure in the month of September 2005 and none reported for the months of October, November, and December 2005. This multifaceted team approach was designed to reduce incidence of transmitting infectious diseases to neonates and provide guidelines for the nurse to follow in the event an infant receives the incorrect EBM.

LESSONS LEARNED: Consistent compliance with guidelines for Expressed Breast Milk (EBM) reduces the risk of administering a mothers’ potentially infected breastmilk to another infant. Development of a Breastfeeding Task Force was crucial to identifying the need for process improvement. Utilizing a standard audit tool to assess nurse’s compliance with EBM guidelines provides the team with the information needed to make necessary changes in the practice of verifying infant’s identity before feeding EBM. Due to the success of the interventions, auditing for compliance with EBM guidelines will continue to be a part of the NICU patient safety and quality improvement activities.