#312 - Rupa's Fellows Friday - Quality Improvement project on early fortification of preterm infants

Hello friends 👋

Today we are joined by Dr Radhika Madali, who is a third year NICU fellow from Children's Hospital at Montefiore, Montefiore Medical Center, Bronx, NY. We talked about the QI efforts that she took during her fellowship in implementing faster enteral feed advancement and early fortification in a level IV neonatal intensive care unit. She shared the multidisciplinary experience that she developed with this project and also appreciates the support and mentorship she received. Radhika also shared insights on other projects that she got involved in- notably investigating the impact of glycemic variability on treatment-requiring ROP. She shared about her experience being a representative to the Fellowship Recruitment Action Team (FRAT) from the AAP Section on Pediatric Training.

----

Short Bio: Dr. Radhika Maddali  is originally from India, completed her Pediatric residency at Flushing Hospital Medical Center, NY and is currently a Neonatology fellow at the Children's Hospital at Montefiore, Montefiore Medical Center, Bronx, NY. She is passionate about advancing medical education and aspires to mentor the next generation of neonatologists. Her primary research focuses on hemodynamics in premature infants. 

----

The transcript of today's episode can be found below 👇

Srirupa (00:01.047)

Hello everyone. Welcome to another episode of the Fellows Corner at the Incubator podcast. I am so excited that a lot of the fellows are showing interest and this is just an honor for me to give you a platform to talk about your passions, your interests and anything and everything that fires you in the world of neonatology. Neonatology is such a beautiful and amazing world and it's so beautiful about the kind of research that all of the fellows, all of you fellows globally are involved in.

But without further ado, it's my pleasure to welcome Dr. Radhika Madali today, who is from the Children's Hospital, Monifier Medical Center, all the way from New York to talk a little bit about the great things that she's achieved in the last three years of her fellowship. Welcome, Radhika. How's it going today?

Radhika Maddali (00:50.188)

Hi Rupa, thank you so much for inviting me to this podcast. It has been going great. How are you doing?

Srirupa (00:55.789)

Good. So just for our listeners, Radhika was born and raised in India, did her residency and fellowship program both in New York. Her fellowship is currently at the Montefiore Medical Center in New York. And she's here to talk about a very interesting and impactful quality improvement project that she undertook during her fellowship on early fortification of babies who are very low birth weight in her level four unitology unit.

Radhika, why don't you tell us a little bit about your project and how it evolved over your course of fellowship.

Radhika Maddali (01:31.246)

Sure. So this is a quality improvement project. So this is mainly about faster internal feed advancement and early fortification in a level four unit. I did this project with my mentor, Dr. Jillian Connors and my NICU nutritionist, Eric Bessel and pediatric resident Carmen Alvarez. So I simply call it as 30, 30, 60, because these mnemonics are very easy to remember and they're very catchy. So the first 30 means we initiate the feeds.

by 30 ml per kg per day. The next 30 means we advance the feats by 30 ml per kg per day. And the last number 60 means we fortify the feats at 60 ml per kg per day. So we included the babies with gestational age from 27 to 32 weeks. And we excluded babies who are small for gestational age or who have any kind of congenital anomalies, any gastrointestinal anomalies as such.

And someone who is less than 1,000 grams, those are the babies who got excluded, but we included other babies. And by using these initiatives, our main primary outcomes are to decrease the duration to achieve full enteral feeds. And the other outcome that we looked was to decrease the centerline usage. From the baseline, we wanted to cut it down by 20 % in our unit. So yeah, that's about it in a nutshell.

Srirupa (02:57.387)

Yeah, no, that's fantastic. I think we all want those central lines to be gone because there's so much risk of infection. There's so much risk of malposition and all the complications. And I feel like all of us in fellowship have had at least one bad traumatic story with central lines. And it really makes you think about how can we get this out as fast as possible? So that's...

Radhika Maddali (03:02.593)

Absolutely.

Radhika Maddali (03:22.186)

Yes, that's absolutely right.

Srirupa (03:24.107)

Yeah, and that's brilliant. And it's so nice that you created a mnemonic in the process too. 30, 30, 60 is a good mnemonic to remember. I'm curious, what was the feeding regimen before this and how was the reaction that you got from the rest of the medical staff when you introduced this? Because quality improvement is a change and human nature is not very good with change. So tell me a little bit about what was there before and how people took this as a new change that was implemented.

Radhika Maddali (03:27.968)

You

Radhika Maddali (03:53.27)

Yeah, sure. So our unit, we usually use the online feeding calculator. Like we just put in the birth weight and then put the total fluid in the online calculator. And that gives us the how much to advance every day or how much to initiate. But I think these feeding protocols or feeding guidelines are always there in every single NICU. But I think it varies. Sometimes it varies from NICU to NICU. Sometimes it varies from baby to baby. So the uniformity is sometimes missing.

And it was during my first year of fellowship when I was on service, I have seen some of the baby speeds were advanced very slowly. At some point, sometimes I saw like 10 ml per kg per day, 15 ml per kg per day. Some of them were advanced by 20 ml per kg per day, which is good. But I felt like by the time the UBC was about to be removed, they were getting pick lines placed and then the pick line lasts for like another week or 10 days more. that.

totally extended the central line duration. As you were pointing out rightly, longer central line duration, more TPN dependence, more CLEPSYs, like you know, the complications keep adding on and that would definitely impact the outcomes of these premature babies. So that's how this idea came in. And then I realized, okay,

let me do some literature research. And then I read about the SIFT trial and I read about lot of studies that they have advanced faster feeds in this population. The Cochrane analysis was also published as well. So I, after looking at all the research, I designed this 30-30-60 where rather than going up like by 10 ml or 15 ml, why don't we advance it by 30 ml per kg per day. And then by, I think by day seven, day eight, we reached to full feeds, take the UBC out.

And that's how the baby would be completely feeder grower from day seven or day eight. Yeah.

Srirupa (05:45.269)

That's fantastic. That's really fantastic. So what was the reaction of the rest of your unit for this advancement, the early advancement?

Radhika Maddali (05:54.538)

As you were pointing out, call the improvement project. Like if we bring up any change, it's really hard to accept in the initial few days. I think I noticed the same. It was quite challenging in the initial few days for to buy in people to convince everyone because it's a bigger amount of volume. And I think historically we have been always concerned about the neck. Like if we advance feet faster, everyone would be worried about neck. So, but.

I brought up the evidence. I showed the literature to everyone and our providers, nurses, once looking at the evidence, I think they were convinced. And as soon as I started having some good results, I brought up the charts and then I started showing them. I think that's where I started to find more more nurses and our providers. And from then, I think everyone started loving this project and they were so impressed that, you know, our

Unit speak line placements have definitely gone down and sample line usage has gone down. So I would definitely say that providing the evidence and then showing the results will help them a lot.

Srirupa (06:57.963)

No, that's fantastic. Could you share with us your results that you got out of this project? Because I see, I mean, I have access to your image, but the viewers don't. And I see a very beautiful control chart here. And that's one of, as we all know, is one of the basic things in quality improvement project. And you want that little line to go down. And I can see that. And I would love for you to describe it in your own words, what measures you looked at and what your control charts finally showed.

Radhika Maddali (07:18.925)

Yeah.

Radhika Maddali (07:27.819)

Sure. So the primary outcomes, the first one we looked at was the number of days to full internal feeds. So it was closer to 11.4 days as a baseline. And once we implemented this project, our goal was to cut it down by 20%, but we were so successful, we were able to bring it down by 28%. And it went down to 8.4 days. So that's the total duration to reach two full feeds in our unit now.

Srirupa (07:54.657)

That's awesome.

Radhika Maddali (07:55.63)

Yeah, the second outcome was also really good. That was to reduce the duration to centerline days. That one on a baseline, was closer to 8.6 days. And after implementing this QI, we saw a mean drop by almost like 25%. We were already past our goal. So we dropped it to closer to 6.6 days. And the biggest thing that I would say is the

pick line placements has tremendously gone down. think overall in our unit it was 37 % and it dropped down by 70 % and it went down to such a low number, it's like 11 % right now in our unit.

Srirupa (08:37.409)

Well, that's fantastic. And I see that you implemented three PDSA cycles. Can you tell me what these PDSA cycles were and what actually had the most impact on your improving your quality here?

Radhika Maddali (08:49.506)

Yes. So I totally connected three PDSA cycles. So the first cycle, farming a QI champion team, I think that made a big impact on my QI. So I included APPs, both from day team and also the night team, and even the nurses as well from day and night team. had pediatric resident and I have my nutritionist who played a significant role. So I think

This QI team played a very important role because for a fellow, it's not possible to be in the NICU every single day. And it's not possible for me to be in NICU every day. whenever one of us are in the NICU, we used to follow up the babies. this baby qualifies to the QI. And we openly communicated with each other. We sent emails saying that this baby qualifies and that person used to go and talk to the providers and then the nurses explaining about

how the feeding process goes in that baby. So I would definitely say that farming QI team made a big impact. And the second thing that we did was me and my mentor have designed the QI flyer. We made it so colorful. We made it this mnemonic 30, 30, 60s, although it's so catchy. That flyer went more viral in my unit. And also we put a QR code as well.

I used to paste it on all the babies who over-qualified at their bedside so the nurses could easily screen it and then it shows how much to advance every day, when to fortify. So everything is very clearly written. That helped as well. For the further PDSA cycles, I did some meetings with my nursing coordinator and also meetings with the lactation specialist as well, just talking to them about this QI and then they in turn educated parents and also the

nurses as well to follow these guidelines.

Srirupa (10:45.023)

No, that's fantastic. speaking of nurses and parents, think one of the biggest things for parents in the NICU is it's so hard for them to understand that these babies have to be advanced in these like tiny increments. And it's so, so supportive that they can get over a course of period two. And they're very understanding towards, you know, like whatever the team wants, but I would love to get your perspectives on how did parents take

this change in a way and how much support or lack of support did you get from the parents as well?

Radhika Maddali (11:20.558)

So every parent would love if their babies have less IVs on their body. So when I was talking to parents, I explained in that way that we should follow the natural way, which is feeding them by gut. That's going to be the natural way. But I think some of the babies, because they're born premature, it's going to take a little longer time. But I told them that we are advancing a little faster.

by seven, day seven or day eight, your baby will be on full phase and we don't have to place an extra central line onto your baby. That gave them immense happiness because they love the idea of no extra IV, no extra IV fluid or like the central line on their baby. So that was a big buying for me. The other thing I counseled them was to produce more and more milk because it's bigger chunk of volume now compared to before. So that's where the lactation specialist also have played a role.

like making them to do early pumping and then more skin to skin care, more production of milk, we were able to advance feeds faster.

Srirupa (12:23.831)

Was there any concern of using too much donor breast milk? And the reason I say that is because, you know, being in that position, I feel like one, you're preterm, one, you're like a mother who is just your postpartum. On top of that, you know, we all kind of understand that preterm lactation for mothers can be a little challenging as well. That, you know, one, they are stressed enough that that affects their milk production. And second, you know, trying to do this

literally every two to three hours while also looking at their baby with all of these tubes and lines and everything can add to the stress and that can sort of impact their milk production in a way. So considering that and considering that with your new study, you were the expectation was to produce a lot more volume. Now, you can definitely try to do that, but you are gonna have some challenges as you go through these steps.

So I'm curious to know how did you balance that with donor milk usage? Because I think that most institutions have this wonderful concept of donor breast milk. And so could you share with me how that went about?

Radhika Maddali (13:35.106)

Yes, that's absolutely a valid concern. And even our unit attendings have raised that concern as well. Like we are giving bigger amount of volume to these babies than we are using more amount of donor milk rather than the mom's milk. So what we did was we used that donor breast milk usage as one of the balancing measure. So we looked at the data before we implemented this QI and we calculated how much amount of the donor milk versus the mom's milk was used.

And after implementing, also, we looked at how much amount donor versus the mom's milk was used. And when we looked at this balancing measure, there was no difference compared to previous versus after implementing this QI guidelines. That gave us a lot of reassurance that, we are not overusing donor breast milk. We are still using mom's milk, that's actually best for the babies. So yeah, that was the thing that we did as a balancing measure.

Srirupa (14:31.403)

That's fantastic. You mentioned a little bit about concerns for neck. So tell me a little bit about that. Because with fortification, there's always this concern. But we've also had good outcomes with fortification in terms of improvement and growth in these pre-term babies. Tell me a little bit about where there did you notice any change in the rate of neck after implementation of this QI project?

Radhika Maddali (14:55.534)

So yes, we actually we didn't include the neck as the balancing measure because when we are advancing the feeds faster when we are 45 feet faster, the first thing that we're going to see mainly is the feeding intolerance, right? So that was the main thing. We put feeding intolerance as the balancing measure. And when we looked at the pre and post implementation, the feeding intolerance rates have remained the same.

But I also did look at the neck rates as well, because neck is something that happens usually a little later, like maybe closer to three or four weeks somewhere there. I'm actually following neck rates as well in both before pre and post implementation. And they have been really stable. I did not see any increase in neck rates after implementing this new QI.

Srirupa (15:41.197)

Yeah, no, that's fantastic. And there are centers that fortify as early as 40 ml per kick per day. So 40 to 60 seems to be the sweet, sweet range where people want to think about fortification. And again, I do believe that you are chosen. I wouldn't call them the safe gestational age because there are 27 weekers that can be pretty bad in terms of the clinical status too. I feel like the younger age group is when we are a lot more careful. The 25, 24, 23 are when we are like,

Radhika Maddali (15:47.075)

Yes.

Radhika Maddali (16:01.25)

That's true.

Srirupa (16:11.125)

let's just be very careful about things. So I think I understand and I can relate why 27 to 32 was your chosen age group for this QI. So I'm curious to know, do you think you'll have buy-in to sort of implement something similar, not as fast, but something similar to the younger age group as well?

Radhika Maddali (16:31.63)

So that was our next, I would say in the next PDSA cycle, maybe we might be bringing it up. So the initial, when I designed this QI project, our cutoff was to include any babies more than 750 grams. But then we realized, okay, that's the smaller population. Let's be just very careful. And we thought, okay, we will choose 27 to 32 and birth weight more than 1000 grams. We wanted to see how this...

this advancement works in this population and then slowly, slowly, if this is going in a great way to move the gestational age little higher up. But I think that's what me and my mentor has discussed, like slowly including this SDA population and then little younger birth weight population, maybe it might work in them as well.

Srirupa (17:18.423)

Yeah, no, I think every QI project starts with a safe goal to like, right? Like you have to first prove that this works because as you probably know, and you pointed out several times that QI is not an individual game, it's such a teamwork. And so the first thing obviously is proving that it works in a specific population before we include the risky population. So I do think that.

Radhika Maddali (17:23.66)

That's true.

Radhika Maddali (17:34.764)

Mm-hmm.

Srirupa (17:43.571)

Overall, this might be a fantastic project implementing in other areas of NICU as well. You've done a fantastic job. And just for the viewers, just highlighting that she has presented this topic at several national meetings and won the best poster award in her own institution's research day as well. So kudos to that, Radhika.

Radhika Maddali (18:06.99)

Thank you.

Srirupa (18:07.253)

While I was kind of reviewing your honors and awards, one of the things that also caught my attention was you had worked on another project, which is very commendable on the impact of glycemic variability on treatment requiring retinopathy of prematurity. Can you give us a little bit of an insight about that project? Because that seems interesting as well.

Radhika Maddali (18:29.39)

Thanks, Rupa. Sure. So this is mainly a case control study. We all know that ROP is one of the common premature related problem that we see in our unit, right? So the risk factors, they are varied, but the hyperglycemia and hyperglycemia are being linked to cause ROP because they are very well studied. But then we were looking at something, a new factor called as glycemic variability, which is nothing but the fluctuations in the glucose levels.

just like how we see the fluctuations in the oxygen levels could be causing ROP. In the same way, we thought maybe the fluctuations in the glucose levels could also be causing the ROP. That's where the thought came from. And then we followed the same AIP guidelines of screening, and then we included those patients who had severe ROP, who got the treatment into the cases group. the control group is mainly the patients who had ROP, but didn't require the treatment.

And then we looked at their glucose levels and then the fluctuations. When we found out with the results, we found out that there was no significant difference between the cases versus the controls with regards to the glucose fluctuations. Finally, we concluded that glycemic variability is not a big risk factor, but I think maybe my sample size was really very small. Probably if we recruited a good number of patients and if it is like multi-center study, maybe we might be finding some.

good positive results.

Srirupa (19:57.527)

So it's not just oxygen, but also control your glucose for ROP. That's wonderful. That's pretty amazing. The other thing that I kind of wanted to delve into, which I didn't know that that was there. And I think it's something good for a lot of us trainees, not us trainees. I'm not a trainee anymore. So I don't know why I feel that way, but still for a lot of the other trainees to kind of understand and know about.

Radhika Maddali (20:00.64)

Yes.

Srirupa (20:22.609)

is the Fellowship Recruitment Action Team from the American Academy of Pediatrics. Very nicely called the FRAT Team, which is really fun. But you are a representative of this team. So tell us a little bit more about that, because that's the first time I even knew that that existed. So that's fantastic. And I would love to know more about that. And so would our viewers and listeners.

Radhika Maddali (20:45.774)

Sure. So yes, I think this FRAC team is the main team who works on all of these. Like you know, it works with the program directors and all the pediatric subspecialties as well. So they work in the background. They help the applicants to find their goal programs to match their career goals. I think we only see the main, like the programs in the HRS, but there is a lot of groundwork that has been done by this.

FRAC team and also the Resident Recruitment team as well. They do this virtual cafes. They talk to all the program directors. They also work on this minority and underrepresented groups as well. How to make applicants get the best from these programs. I think there's a lot of groundwork that's being done by this FRAC team. I'm very happy to be part of this FRAC team as well.

Srirupa (21:34.091)

That's fantastic.

Yeah, no, I think you get a lot of knowledge about what happens behind the the scene, you know, like you you like you rightly pointed out when you apply you never think about how much effort goes behind all of this. And so it's fantastic that you're getting to understand the building blocks of every, you know, program, which is fantastic. And it seems like it's not just for neonatology. It's all subspecialty training. Is that correct? Okay. Okay, that's fantastic.

Radhika Maddali (22:00.754)

Yes, yes.

Srirupa (22:04.097)

Well, I think you've done such great things in your career and your interests seem to be above and wide, I think. So that's fantastic. Now, I would love to ask you this question. When you did start fellowship, what was your pathway of finding your mentor and how did that or how do you think that impacted your interest in neonatology research?

Radhika Maddali (22:27.778)

My mentor is Dr. Jillian Connors. when I started my fellowship, I had seen one of her successful projects. So she implemented skin-to-skin care in improving the skin-to-skin care in premature infants with one of our fellows. So I looked at the positive outcomes of that study and that definitely gave a good kickstart to me because

I found out that I wanted to do QI in nutrition of premature infants. And then I saw my mentor who has extensive knowledge in the QI methodology by looking at the positive outcomes of her QI, decided, okay, let me do my QI with her. as soon as I found out what I'm gonna do, I quickly approached her early on and then she agreed. She played a very instrumental role in designing this QI project along with me.

She's the one who explained to me how PDSA cycle works and how to read this run charts, SPC charts. I think it's like more hand on, like driven road for me when I worked with her. So, yeah.

Srirupa (23:32.715)

Yeah, no, fantastic. That's amazing. I think that your mentor plays such an important role during fellowship, like you rightly pointed out, it's hand holding, right? Like you literally are pulled into doing all of these things. And then after a point, there's no one holding you and you're like, okay, now I got to do this on my own. So it's a wonderful feeling. And I think that...

Radhika Maddali (23:51.854)

you

Srirupa (23:56.941)

Fellowship is such a beautiful time of your life that you get to explore your absolute most favorite topics, which is just great. And as opposed to things that you have to do, as opposed to things that you want to do. So there's a lot of difference between that. So that's fantastic that you found the rightful mentor in your life to guide you through. And I am close to finishing our episode today, but I'd like to end my episodes with two important topics. One.

Radhika Maddali (24:16.514)

Yes, yes.

Srirupa (24:26.283)

I want you to provide one key piece of advice for anyone, any incoming fellow who might be interested in your line of research. It seems like quality improvement, nutrition are all of some of the highlights of your research. So what is one advice that you would give to any incoming fellow interested in that?

Radhika Maddali (24:43.928)

So my key advice would be focus on collaboration. Make sure you find your mentor early on. Just come up with some good ideas and then reach out to your mentor early on. And then form a QI team, like QI champion team. That really is going to make a big impact on the results or the success that you're going to achieve.

Like as I said, open communication with all the QA champions and then make sure that you're all on the same page and provide good education to all the providers and nurses and constant get constant feedback from them because those are the hurdles. If someone is having some concern, you always have to go back and address them, get their feedback because they are the ones who are working with with the babies. So getting feedback from the nurses will help you a lot. And then that runs the QA very smoothly.

Srirupa (25:36.801)

Yeah, no, absolutely. That's very good and interesting and important advice to incoming fellows. Collaboration is the key for fellowship research. It's like, I feel like you cannot do anything alone as a fellow because you're like balancing so many things in your life. So I absolutely agree that collaboration is the key for being successful in fellowship research for sure. Especially in QI research for sure. Yep. My last question.

Radhika Maddali (25:44.974)

absolutely.

Radhika Maddali (25:59.545)

Yes, yes.

Srirupa (26:03.381)

You have done some fantastic things in your career and I see that you're almost six months into your last year of fellowship, hopefully your last year of training. So tell me where is life going to take you next? If you'd like to.

Radhika Maddali (26:17.986)

Yes, I would like to. So at this point, I'm almost closer to wrapping up my interviews. And I think soon within the next few days, two months, I would be finalizing where I'm going to go and signing up the offer later and everything. I'm really excited to start my new journey in the next six to eight months. And as I learned a lot in my...

fellowship more about the QIs. I'm going to definitely, wherever I go, I'm going to implement the QI project successfully there with all the knowledge that I got.

Srirupa (26:49.217)

Yeah, no, that's fantastic. we wish you a very good luck with all of the things that you're going to do in your career. And any place that you're going to go to is going to be lucky having you with such a dynamic interest in all aspects of neonatology. So congratulations, and thank you so much for being on the show.

Radhika Maddali (27:08.376)

Thank you, Rupa. Thank you so much for giving me this opportunity.