UPMC Children’s Multidisciplinary NICU/GI Intestinal Care Collaborative Program Works to Improve Patient Outcomes and Facilitate Transitions in Care

Multidisciplinary teams from the Newborn Medicine, Pediatric Surgery, and Pediatric Gastroenterology divisions at UPMC Children’s Hospital of Pittsburgh have joined forces to create a collaborative partnership focused on intestinal care for critically ill newborns experiencing intestinal failure and other severe disorders that may adversely affect a child’s ability to take in or process nutrition.

Working to develop the collaborative program and leading its efforts are Abeer Azzuqa, MD, clinical director of the neonatal intensive unit (NICU) at UPMC Children’s; Jeffrey Rudolph, MD, director of the Intestinal Care and Rehabilitation Center(ICARE) at UPMC Children’s; and Paul Waltz, MD, NICU surgical director at UPMC Children’s.

"The patient population we are focused on with this program includes children with intestinal dysfunction or intestinal failure stemming from various causes – congenital anomalies or acquired conditions," says Dr. Azzuqa.

Because of the complexities of these cases, the need for prolonged parenteral nutrition, and specialized nutrition plans, the team recognized the need to develop a more uniform collaborative care process, one that begins shortly after diagnosis, and continues through the various transitions of care a patient may experience – from the NICU to ICARE Center, and ultimately to the patient’s home.

"Establishing a formalized transition plan, one that binds the perspectives and care from the NICU, surgical teams, and GI teams, leads to improved communications between our different divisions, but critically with the families and parents who are an essential part of their child's care in the hospital and eventually when they go home," says Dr. Rudolph. "We have a more active management approach with these complex cases, which goes a long way in ensuring we manage all of the expectations we have as provider teams but also that the families may have."

"We spent about a year in the planning phases, aligning our strategic approach, goals, and operational plans,” says Dr. Azzuqa. “It also entailed developing a set of standardized guidelines for patient care that will improve short and long-term outcomes for these young patients."

These guidelines, for example, included the types of fats appropriate for babies depending upon the condition and function of the liver. The policies also cover micro and macronutrients.

It’s Never Too Early to Start the Conversation

For these complex medical and surgical cases, engaging families, who at some point will be central to caring for their child when they go home, is critical to long-term outcomes.

As Dr. Rudolph explains, this understanding between the program leaders and providers was a central pillar in its development.

"The earlier in the diagnosis and care we can begin to coach parents and train them on how to handle TPN at home or care for a central line to minimize potential complications is a key part of the program. Getting the GI teams into that process sooner means more time with the families," says Dr. Rudolph. "It also helps with the transition when they leave the NICU and come to our center. They already know us and what to expect, and it's a warm and expected handoff."

Measuring Success and Tracking Outcomes

Short- and long-term patient outcomes are the driving forces behind the plans of care and collaborative development of the program. And there are a number of critical measures and areas of patient health and progress that Drs. Azzuqa, Rudolph, and the rest of the teams are using to measure just how well the patients are doing but how successful the program's guidelines and care pathways are at achieving these ends.

"We're looking at the various nutritional strategies and tracking whether growth is optimal," says Dr. Azzuqa. "We're looking for strategies to prevent nutritional deficiencies and complications, and we're also keenly aware of the importance of introducing oral feeding in a timely manner.”

"TPN days is also a measure we are tracking and will eventually help us to better understand our successes on this front," says Dr. Rudolph.

Multidisciplinary Weekly Rounds

The program was designed with a multidisciplinary weekly rounding by the program teams to discuss patient care and progress. However, Dr. Azzuqa explains that this entirely depends on a patient's status.

"For critical cases, we round on these patients daily. As things progress or stabilize, we move to once or twice a week," says Dr. Azzuqa. "You can't take a one-size fits all approach with this patient population. They're too complex and fragile at varying points in their care journey. We let the circumstances of each case dictate pattern."

Communication, Education, Collaboration

Communication, education, collaboration. These are the guiding principles driving the quality improvement in intestinal care patients at UPMC Children's.

"Collaboration is never a process that is finished. We’re always looking for ways to improve our care," says Dr. Azzuqa.

Learn More about the UPMC Newborn Medicine Program, the Division of Pediatric Gastroenterology, Hepatology and Nutrition, and the Division of Pediatric Surgery at UPMC Children’s Hospital of Pittsburgh.