Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute

INTRODUCTION: Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS. METHODS: We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a “sentinel” FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm. RESULTS: Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance. CONCLUSIONS: This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.