• An Algorithm for Diaper Dermatitis Management in the Neonatal Intensive Care Unit

      Crampton, Laura K.; Fitzgerald, Jennifer (2021-05)
      Problem: Diaper dermatitis (DD) is inflammation of the skin in the perianal area that ranges from mild erythema to broken skin and bleeding. At baseline, 20% of infants ≥ 30 weeks gestation had DD in the target Level IV Neonatal Intensive Care Unit (NICU). Historically, DD was managed based on individual nursing judgment due to a lack of current standardization of care for infants with DD and resulted in inconsistent care of infants with DD. Purpose: The purpose of this quality improvement project was to implement and evaluate the effectiveness of an algorithm for the prevention and treatment of DD in infants ≥ 30 weeks gestation in a Level IV NICU in an urban, academic medical center. Methods: Bedside nurses were given education on DD and the new algorithm for the management of DD. They also completed pre-and post-knowledge surveys. The algorithm was placed at the bedside of each infant for reference and the educational PowerPoint was emailed to all bedside nurses. Once a week, bedside nurses documented incidence of DD, if prophylactic or therapeutic treatment was performed, and if the algorithm was followed. Continued education was provided throughout implementation, reminder cards were placed on each nurse computer, and reminder texts to document DD data were sent out via unit phones each Monday. Results: The use of the algorithm and the use of prophylactic petroleum jelly increased from 0% at baseline to 100% over the 15-week data collection period. The prevalence of diaper dermatitis decreased from 20% (9/46) prior to implementation to 18% (2/11) on the last week of data collection. Following the education on DD and the implementation of the algorithm, the majority of nurses stated that they were more aware of DD and monitored for it more closely during diaper changes. Conclusions: The use of an algorithm for the management of diaper dermatitis helped to increase the use of prophylaxis and education on the algorithm increases bedside nurses’ awareness of DD in their patients on this unit.
    • Bathtime Shenanigans: Implementing Evidence-Based Bathing Practices

      Williams, Keiara D.; Felauer, Ann (2020-05)
      Problem: Bathing practices vary among neonatal intensive care units (NICU), despite guidelines developed by the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN). Bathing should occur allowing for optimal outcomes in the neonate, while attempting to minimize negative physiologic effects due to the stress of bathing. Purpose: The purpose of this project was to implement evidence-based bathing practices in a level IV NICU, where practices vary. Through the utilization of AWHONN’s Neonatal Skin Care Guidelines (NSCG), the goal was to reduce signs of neonatal stress, particularly temperature and behavioral signs of distress during bathing. Methods: The population consisted of neonates ranging in age from 24 to 40 weeks’ gestation in a 52 bed NICU. Implementation occurred over a twelve-week period in the fall of 2019, which included collection of baseline data, identification of unit-based champions, staff education, competency assessments, and development of resources and reminders for staff. Guideline-based algorithms were created, which determined inclusion and exclusion criteria for bathing. Documentation on bedside charts included the age of the infant, the type of bath given, and measures of tolerance to bath assessed by pain/sedation scores and patient temperature 15 minutes post bath. Results: Training resulted in guideline competency among 16% of the NICU nurses. The bedside documentation tool was completely filled out 36 times over the six-week period of implementation, on a unit where the patient census averages 45-52 patients a day. Although, limited, there were some apparent trends in the data that suggests evidence-based bathing practices are needed on this unit. There were no negative effects of increased pain/sedation scores when the infants were swaddle bathed, pain/sedation scores remained < 3, requiring no interventions. Normal temperatures were more likely if the infant was swaddled bathed. However, about 36% of the documented temperatures were <36.5, despite the type the bath. Conclusion: Evidence-based bathing practices help to reduce negative outcomes in the neonatal population. Implementing a practice change within a large unit requires continuing education to enforce the strategies set forth by AWHONN and cement strategies for sustainability and accountability into practice.
    • Bundle to Improve Safe Sleep Modeling by Neonatal Intensive Care Unit

      Schmidt, Katelyn E.; Fitzgerald, Jennifer (2021-05)
      Problem: Neonatal Intensive Care Unit (NICU) nurses in a level IV NICU were noted to provide inconsistent safe sleep environments for hospitalized infants. The NICU population is at high risk for Sudden Infant Death Syndrome (SIDS). Nurses should provide consistent safe sleep modeling to educate and influence families. At the inception of this project, no structures were in place to evaluate infant readiness to receive safe sleep or to document sleep environments. Purpose: The purpose of this quality improvement project was to implement nurse-driven safe sleep modeling in the form of a safe sleep bundle. The bundle consisted of an inclusion algorithm, bedside crib reminder cards, and nursing documentation. Methods: A root cause analysis was conducted with nursing to determine appropriate bundle components. Nurse safe sleep champions provided unit education and performed bedspace audits. Measures included safe sleep compliance comprised of six components supported by the American Academy of Pediatrics, bundle utilization rates, and adverse events. Data was a convenient random sample and bedspaces were selected randomly by champions. The baseline compliance rates were then compared to implementation rates and nursing documentation. Results: Pre-implementation data was obtained from all seventy bed spaces. Overall, the rate of safe sleep compliance (all six categories) increased 37%. The greatest improvement in individual categories was “no position aids” (18% increase) and “no extra bedding” (58% increase). The other categories were mostly unchanged post-implementation with rates greater than 90%. Nursing documentation showed a greater than 80% compliance rate in all categories. No new adverse events were recorded for those infants receiving safe sleep. Nursing used the bundle routinely (algorithm use 20-92%; crib card 67-80%; documentation 4%). Conclusions: Results indicate a bundle improves compliance with safe sleep modeling. Some components gained wider acceptance than others. It appears a bundle has no detrimental effects on sleep environments and does not increase rates of adverse events. Overall, the bundle implementation improved awareness of safe sleep environments by nurses, and it has the potential to significantly increase safe sleep modeling and environments for hospitalized infants.
    • Discarding Residuals: Implementing a Feeding Algorithm in a Neonatal Intensive Care Unit

      Ruccio, Lucy R.; Wilson, Janice (2021-05)
      Problem: Routine gastric residual (RGR) monitoring is not reliable in detecting necrotizing enterocolitis (NEC) or feeding intolerance (FI). This practice remains the primary cause of enteral feeding interruption in premature infants. It delays the achievement of full enteral feeds and increases the threat of poor growth and neurodevelopmental injury. Checking RGRs before feedings was standard practice at the target hospital’s Neonatal Intensive Care Unit (NICU). At baseline, over 40% of preterm infants had at least one checked per week. Purpose: The purpose of this quality improvement project is to implement and evaluate an evidence-based feeding guideline removing the use of RGR as an indicator of FI. Methods: The setting was a 30-bed Level III NICU and included all preterm infants, <37 weeks’ gestation, who required an oral or nasogastric feeding tube. Six weeks of background data and nine weeks of post-implementation data was collected using chart audits and informal interviews with key stakeholders. A survey of attitudes and knowledge was administered to all staff. Implementation consisted of in-service education with multiple visual aids, the dissemination of feeding algorithm cards and a “Fast Feeding Facts” bulletin. Data was collected and analyzed via run charts and descriptive statistics. Results: Data showed a decrease in patients with gastric residuals checked from 42% to 8%. The days to regain birthweight dropped from seven to six days. Staff knowledge of the role of RGRs and comfort with eliminating their routine use increased substantially. Conclusions: Implementation of an updated feeding guideline was associated with a decrease in the frequency of gastric residual checks, days with an IV in place and time to regain birthweight. This supports the research that monitoring of pre-feed RGRs should not be used for preterm infants.
    • Implementation of a Clinical Decision Support System for Peripheral Intravenous Extravasation Management

      Bozel, Tara S.; Fitzgerald, Jennifer (2022-05)
      Problem & Purpose: Neonates are particularly vulnerable to peripheral intravenous (PIV) infiltration and extravasation that can lead to necrotic tissue injuries and long-term complications. In an urban mid-Atlantic Level IV Neonatal Intensive Care Unit (NICU), there has been a 2.2-fold increase in the rate of extravasations in the last five years with poor documentation compliance of a paper checklist as part of the unit’s PIV extravasation guideline. Evidence shows that the use of clinical decision support systems (CDSS) improves compliance with unit-based protocols. The purpose of this quality improvement (QI) project is to implement and evaluate the utilization of a CDSS into the EHR to improve PIV extravasation detection and guide management in a Level IV NICU. Methods: This QI project was implemented over a 15-week period in Fall 2021. Interventions included integration of a nursing PIV flowsheet in the EHR with staging guidance and updated SmartText for provider documentation. Weekly data collection consisted of the number of infants with PIV access, monthly adverse event reporting system reports of extravasations and chart audits for nursing and provider documentation. Results: At the end of implementation, the data reflected a rise in documented extravasations indicating utilization of the CDSS. Compliance with all elements of the CDSS documentation demonstrated a trend of increased documentation by nurses. An increase in provider notes for injuries with CDSS documentation reflected improved early recognition and RN to provider notification of injuries. Standardized CDSS documentation led to a decrease in incidence of stage 3 and 4 extravasations in the NICU. Conclusions: The implementation of a PIV clinical decision support system in the electronic charting system improved early recognition of extravasations and decrease severe tissue injuries resulting from stage 3 and 4 injuries. The sustainability of this project was achieved by integrating the CDSS into the EHR and next steps include continued refinement of the EHR-generated reports for data collection, addition of the educational module to annual nurse competencies and clarifying language for signs of different stages of injuries in the unit guideline.
    • Implementing a Neuro-Bundle in a Level III Neonatal Intensive Care Unit

      Steiner, Itta; McComiskey, Carmel (2019-05)
      Background: Intraventricular hemorrhage (IVH) is a complication primarily associated with preterm birth, specifically those born before 32 weeks gestation and weighing less than 1500 gram. With increasing survival rates for the most premature infants, IVH rates have remained stagnant at approximately 20% with severe IVH at approximately 5%. The incidence of IVH is highest within the first 24 hours of life and approximately 90% of cases occur within the first 3 days of life. IVH is associated with long term neurologic consequences such as hydrocephalus, seizures, and cerebral palsy. Midline positioning and minimal handling as part of a bundleintervention have been proven to decrease the incidence of IVH. Local Problem: This Level III NICU recognizes the risk IVH poses to its patients and wants to put in place all measures that will improve their outcomes. Prior to Implementation the unit did not utilize a neuro-bundle for IVH prevention. The purpose of this project was to implement a neuro bundle consisting of midline positioning and minimal handling for the first 72 hours of life for preterm infants born before 32 weeks and weighing less than 1500 grams. Interventions: A quality improvement project measuring nursing education and utilization of a neuro-bundle was implemented in a Level III NICU in a community hospital in Baltimore, Maryland. The project took place over a 14 week period. The first 2 weeks consisted of a presurvey and nursing education module to be completed via the hospital’s online education system. This was followed by the implementation of the neuro-bundle during weeks 3-13 and concluded with a post-implementation survey during week 14 to evaluate the change in practice. During implementation, a checklist was completed for each infant meeting criteria for the neuro-bundle. The checklist documented midline positioning, minimal handling, reasons for not adhering to the bundle, and other pain/stress reducing techniques that were used. Results: The bundle was utilized for 94% of babies admitted to the NICU meeting inclusion criteria. For those whom the neuro-bundle was utilized, midline position was maintained 97.59% of the time and minimal handling was used 86.4% of the time with pain/stress minimizing measures used 100% of the time. Only a single baby in the project had an IVH. Conclusion: Use of a neuro-bundle has been proven to decrease IVH rates. The neuro-bundle was successfully implemented and during this time the IVH rate was low. More information is needed to quantify the benefits since the sample size and duration of the project were small. The unit should continue to monitor the use of the neuro-bundle and its associated outcomes.
    • Implementing the Early Onset Sepsis Calculator in a Neonatal Intensive Care Unit

      Levy, Stephanie R.; Fitzgerald, Jennifer (2022-05)
      Problem& Purpose: While intrapartum antibiotics have decreased the incidence of early onset sepsis (EOS) in infants > 34 weeks, there has not been an equal decrease in how often antibiotics are administered to treat suspected EOS. The use of an EOS calculator to help guide management has been shown to safely decrease the use of antibiotics. In this 52-bed neonatal intensive care unit (NICU), providers did not use an EOS calculator and the interpretation of the recommendations across providers greatly varied. There is no standard algorithm to stratify at risk infants for EOS in order to differentiate infants requiring antibiotics from those who can be safely observed. The purpose of this quality improvement project is to implement and evaluate the effectiveness of the early onset sepsis calculator in a level IV NICU for infants > 34 weeks gestational age on reducing antibiotics usage. Methods: Over a 15-week period in the fall of 2021, a multidisciplinary team implemented the EOS calculator to be utilized in the electronic health record (EHR). Data collection occurred through chart review of any infant > 34 weeks gestation that was admitted to the NICU. Data that was collected included gestational age, calculator use and recommendations, antibiotic administration, was a CBC and a blood culture obtained, and was there adherence to the calculator recommendations. Results: Post implementation 10% (n=110) of infants admitted to the NICU that were eligible for use of the EOS calculator had documentation of use within the EHR. The goal remains that 100% of infants > 34 weeks will have recommendations documented on the EOS calculator. Approximately, 50% of infants received antibiotics on admission. Conclusions: The education disseminated on the location and use of the EOS calculator has led more providers to utilize the calculator than prior to the implementation. The use of the EOS calculator has created better communication amongst providers about how to manage infants at risk for EOS.
    • Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit

      Buchynsky, Ivanna; Connolly, Mary Ellen (2022-05)
      Problem: Infants in the neonatal intensive care unit (NICU) are at increased risk for long-term complications and disability. Developmentally supportive positioning improves neurodevelopmental outcomes in this patient population. Infants hospitalized in NICUs with standardized positioning practices benefit from enhanced developmental outcomes. The valid and reliable Infant Positioning Assessment Tool (IPAT) promotes appropriate infant positioning and encourages caregiver accountability in developmentally supportive positioning practices when used with bedside education. In an academic community medical center NICU, there was no standardized positioning practice in place. Baseline data indicated that 75.1% of infants were being positioned in a developmentally supportive manner. Purpose: The purpose of this quality improvement project was to implement the IPAT to improve consistency in developmentally supportive positioning by promoting appropriate positioning and encouraging accountability in positioning practices. The goal was for 100% of eligible patients to have an acceptable IPAT score of ≥9 by completion of the implementation period. Methods: The project took place in a 26 bed, Level III NICU from November 2021 to January 2022. All infants over 32 weeks gestation, 1,500 grams, past the first 72 hours of life, and admitted to the unit for more than one twelve-hour shift were eligible. Implementation involved a bedside IPAT reference, an online educational training module, informational reference posters, and ongoing bedside education. Data was collected semiweekly on IPAT scores of eligible patients once per shift. A percentage of IPAT scores ≥9 was calculated for weekly averages.
    • Improving On-Time Vaccine Administration in a Neonatal Intensive Care Unit

      Erickson-O'Brien, Myreda; Connolly, Mary Ellen (2019-05)
      Background Infants hospitalized in neonatal intensive care units for a prolonged period of time are at risk for not being immunized against vaccine preventable diseases per guidelines outlined by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. The guidelines recommend that premature infants receive routine childhood vaccines at chronologic age versus corrected gestational age. Multiple studies completed in the United States, Europe and Canada demonstrated that these patients lag behind their term gestation peers in receiving their vaccines in a timely manner. This delay places them at risk for acquiring these diseases, and requiring primary care providers caring for these babies after discharge to determine “catch-up” schedules to ensure up to date vaccine status. Local Problem Data collected from a chart review completed prior to the initiation of the implementation plan revealed an on time immunization rate of 60%. The chart review did not reveal reasons for delay. Intervention This quality improvement project evaluated the use of a best practices alert in the electronic medical record to improve on-time administration of two month vaccines (within 60-70 days of age) or documentation reflecting specific reason for deferral. The project was conducted in a 52 bed, Level IV academic neonatal intensive care unit in the Mid-Atlantic region. Inclusion criteria included all patients hospitalized in the neonatal intensive care unit and two months of age. A query was submitted to the institution’s Investigational Review Board, and determined to be non-human subjects research. Prior to implementation of the best practices alert, a survey was developed and distributed to neonatal intensive care unit nurses and providers to establish baseline knowledge, attitudes and beliefs regarding immunization practices. The findings of the survey were used to develop and provide education sessions providing clarification of immunization requirements and practices. The education sessions also introduced the use of the best practice alert. A best practices alert was developed and placed into the electronic medical record to remind providers beginning on the infant’s day of life 55 that two-month immunizations were due. The best practices alert provided guidance to providers to discuss immunizations with the parent/guardian and also provided a link to an order set within the electronic medical record to the vaccine products. Results Simple descriptive data of the proportion of patients receiving vaccines on time was collected prior to the use of the best practice alert to establish a baseline rate of on-time administration of vaccines. Post-implementation of the best practices alert, data collected via chart audits over the next 13 weeks revealed an on-time administration rate (or documentation of specific reason for deferral) of 83%. Conclusion A best practices alert, along with education, is a useful tool for improving vaccination rates in a Level IV neonatal unit. The results of this project showed an increase of on-time immunization from a rate of 60% immediately pre-implementation of the best practices alert to 85% during the project implementation period.
    • Intubation Timeout Tool Implementation in a Level IV Neonatal Intensive Care Unit

      Brennan, Ashley M.; Wilson, Janice (2021-05)
      Problem & Purpose: Endotracheal intubation is a common lifesaving, but technically challenging procedure performed in the neonatal intensive care unit (NICU). Based on a chart review of intubations performed in a Level IV NICU, use of a timeout protocol was reported 86% of the time, and 48% of intubations were associated with at least one adverse event. In this setting, adverse events occur more often when patients are acutely unstable and when providers demonstrate variable intubation proficiency. The purpose of this quality improvement project was to implement and evaluate an evidence-based pre-procedural intubation-specific timeout tool in a Level IV NICU in order to improve neonatal intubation process consistency and safety, leading to improved patient outcomes. Methods: Project implementation occurred over a ten-week period in a 49-bed Level IV NICU. Implementation included collection of baseline data, identification of champions, staff education, and development of project resources and reminders. The intubation task-specific tool was initiated by the nursing staff for eligible intubation events and involved all intubation providers. A chart audit tool was used to extract demographic and intubation timeout tool data from the electronic health record (EHR). Results: The pre-intubation timeout tool was used for nine intubation events (60%) over the ten-week period. With implementation of the tool, the incidence of intubation-associated adverse events decreased by 8% from baseline chart review. Conclusion: Results suggest that the use of an evidence-based pre-procedural intubation-specific timeout tool improves intubation process, consistency, and safety across multiple intubating neonatal providers. Continuing education tactics are necessary to promote sustainability and accountability leading to improved patient outcomes.
    • Let’s Talk: Post Critical Incident Debriefing Project

      Wiseman, Tamara L.; Wise, Barbara V. (2020-05)
      Problem and Purpose: Structured debriefings inconsistently occur in a level IV Neonatal Intensive Care Unit (NICU). Lack of a structured debriefing process negatively impacts provider physical/emotional health and patient outcomes. Lack of debriefing conversations leads to unconstructive feedback and unidentified areas for team and patient outcome improvement. The purpose of this quality improvement (QI) project is to implement, the Team Strategies and Tools to Enhance Performance and Patient Safety Debriefing Tool (TeamSTEPPS) following high-risk deliveries in infants 22-32-week gestation and emergency/resuscitation codes in a 52 bed, level IV NICU in the mid-Atlantic region. The goal is to facilitate debriefings after 100% of the critical events and enhance positive team communication during debriefings. Methods: The project was implemented for 12 weeks. The population included a multidisciplinary NICU staff. The project involved training staff on the use of the standardized debriefing tool, documenting high-risk deliveries, frequency of debriefing guided by the TeamSTEPPS debriefing tool, and evaluating debriefing outcomes using the REFLECT Tool. The primary QI metrics included the number of staff trained and educated, patient gestational age, high-risk delivery and emergency codes, occurrence of debriefing, debriefings guided by TeamSTEPPS Debriefing Tool, and staff assessment of the debriefings using the REFLECT Tool. Data was analyzed using descriptive statistics to identify trends in the percentage of debriefings that occurred following 22-32 weeks gestation deliveries and emergency/resuscitation codes. Results: During implementation phase, twenty percent of the NICU staff were trained/educated in the debriefing process. A total of four debriefings occurred using the TeamSTEPPS Debriefing Tool. Post critical events debriefings increased from one percent to fifteen percent. Team communication, role delineation, and patient stabilization time improved during a subsequent critical event. Conclusions: This QI project demonstrated the feasibility of implementing a structured debriefing tool in a high acuity NICU, to improve team communications and patient outcomes following critical events. Increased nursing and provider staff engagement, and ongoing training would enhance debriefing facilitation. Future considerations include expanding debriefing after all emergent deliveries, including the labor and delivery team, and piloting in smaller NICUs.
    • Neonatal Nurses' Work in a Single Family Room NICU

      Doede, Megan; Trinkoff, Alison M. (2019)
      Background: In the past twenty years, neonatal intensive care units (NICUs) have undergone changes in layout from open-bay (OPBY) to single family room (SFR). SFR layout may be advantageous to nurses’ work in that it improves the quality of the physical environment, patient care, and parent-nurse interactions. SFR layout may disadvantage nurses’ work in terms of decreased interaction among the NICU patient care team, increased nurse workload, and decreased visibility on the unit. It is unclear exactly how SFR layout is producing these changes. Purpose: This study asked: what is it like for neonatal nurses to work in a SFR NICU? Methods: Interpretive description, a qualitative methodology, guided this study. Interviews and observations were conducted in one SFR NICU over a six-month period. Data were coded broadly, then collapsed into themes as patterns within the data emerged. The Systems Engineering Initiative for Patient Safety model aided interpretation of nurses’ job demands. Emotional work was conceptualized as being preceded by emotional demands and anteceded by stress and burnout. Results: A total of 15 nurses participated. Overall, privacy, visibility, and proximity were integral in shaping nurses’ work. Regarding job demands, four themes emerged: challenges in infant surveillance and informal communication, alarm fatigue, and increased walking distances. Regarding emotional work, four themes emerged: families “living on the unit,” isolation of infants, ability to form trust and bonds, and sheltering. Emotional demands increased when families were living on the unit or when infants were left in isolation but were absent when nurses were able to form trusting relationships with parents and shelter them. Privacy gains on SFR NICUs may serve to balance losses in visibility and proximity for nurses. Conclusions: NICU layout impacts nurses’ job demands and emotional work. Future research should investigate unit layouts that maximize visibility and proximity for nurses while maintaining privacy. Neonatal clinicians transitioning to SFR layout should consider overall visibility and proximity of patients, equipment, and staff members from any point on the unit as a primary avenue for decreasing nurses’ work demands. Neonatal nurses will benefit from tactics that improve their communication skills with families.
    • Simulation to Improve Confidence and Competence of the Neonatal Nurse Practitioner

      Williams, Julie E.; McComiskey, Carmel A. (2019-05)
      Background: Neonatal nurse practitioners must maintain competence in low-volume, high-risk procedures to provide timely, high-quality, and safe care. In institutions with multiple providers e.g. fellows, residents, and neonatal nurse practitioners, the number of procedures available per provider may be very low. Simulation education provides an opportunity to practice procedures without compromising the care of patients or competition. Local Problem: The project institution is an academic center with a high level of procedural competition due to the presence of physicians, physician trainees, and nurse practitioners. The purpose of this quality improvement project was to implement and evaluate the impact of a needle thoracentesis simulation on the confidence and competence of neonatal nurse practitioners. Interventions: A simulation was implemented for 15 full-time neonatal nurse practitioners in the Neonatal Intensive Care Unit. A pre-simulation survey to assess each neonatal nurse practitioner’s perception of procedural confidence and competence was conducted. Subsequently, each neonatal nurse practitioner received PowerPoint slides with an embedded video on the correct performance of a needle thoracentesis. Following the pre-survey and PowerPoint slides, each neonatal nurse practitioner participated in the needle thoracentesis simulation. Utilizing a procedural checklist adapted from the National Association of Neonatal Nurse Practitioner Competency and Orientation Toolkit for Neonatal Nurse Practitioners, the nurse practitioners needle chest thoracentesis skills were assessed. After completing the simulation, the nurse practitioners received an identical post-simulation survey to re-evaluate their perception of their procedural confidence and competence. Results: Neonatal nurse practitioners reported an increase in confidence in their 1) ability to determine when a needle thoracentesis was necessary versus allowing spontaneous resolution (p<0.01); 2) and in their ability to perform an emergency needle thoracentesis competently without or with minimal procedural guidance (p=0.04). They also reported an increase in confidence in their ability to troubleshoot unexpected problems that might occur during the procedure (p<0.01) and an increase in confidence in their ability to incorporate patient safety measures in the event of an emergency thoracentesis (p=0.03). Conclusions: This quality improvement project provided support for the use of simulation to increase the confidence and competence of the neonatal nurse practitioner in performing a chest needle thoracentesis and to assist neonatal nurse practitioners in maintaining competency in low volume high risk procedures.
    • Standardization of the Neonatal Intensive Care Unit Discharge Process

      Shafer, Andrea; Gourley, Bridgitte (2019-05)
      Background Discharges are complex and any delay in discharge has significant impacts on NICU infants. Caring for infants in the NICU costs billions of dollars annually, with each day costing thousands of dollars. Accordingly, discharging these infants once they meet discharge criteria is vital for institutions to control expenses, but is also a quality and safety measure for these infants to successfully transition to home. Problem At a community hospital in Maryland a lack of a standardized discharge process contributed to increased discharge times and lengthy delays for NICU infants. If NICU infants were not discharged once medically stable, then the length of stay increased causing additional costs to the unit and hospital. Planning for discharge and after care of the infants is a key part of an effective process. This hospital had a significant need for a standardized discharge process, starting at admission and continuing through discharge. Interventions There are national recommendations for hospitals to focus on care that is timely and efficient. The American Academy of Pediatrics (AAP), the National Association of Neonatal Nurses (NANN) and the Agency for Healthcare Research and Quality (AHRQ) provide resources, programs, and toolkits for hospitals that wish to improve care transitions, including discharging the NICU infant once medically stable. The DNP student used the approach of a quality improvement initiative (QI) that involved developing and implementing a better-quality multidisciplinary discharge checklist into the electronic health record (EHR). The EHR checklist improved communication between the NICU team members in order to assure safe and costeffective discharge of NICU patients. This change in workflow prompted staff members to address discharge planning during each shift and enhanced communication between NICU parents and staff. Results This intervention led to a post-implementation average length of stay decrease from 9.92 days to 8.97 days respectively. Also, the discharge time past three o’clock decreased from an average of 54.84% to 36.00%. The imbedded discharge checklist was utilized by 100% of NICU staff, which standardized and improved the discharge process and documentation for NICU infants less than 37 weeks gestation. NICU team members utilized the discharge checklist in their daily rounding and during shift change, which improved discharge readiness and communication. Conclusions This QI project, led by a DNP student in partnership with a community hospital in Maryland, decreased the average length of stay and discharge time post-implementation while improving communication of all team members. This was a promising tool to maximize discharge planning starting from admission to improve outcomes of NICU infants. The electronic discharge checklist has the potential to serve as an example of a standardized and effective communication tool, which optimized outcomes for NICU infants and health care teams.
    • Standardized Dextrose Gel Policy Implementation for Management of Asymptomatic Neonatal Hypoglycemia

      Gertner, Alexandra; Fitzgerald, Jennifer (2021-05)
      Problem: Asymptomatic neonatal hypoglycemia in the first 48 hours of life is a frequent challenge faced by newborns. Timely management is crucial to minimize negative impacts. Data collected from the mother/baby unit of one community hospital demonstrated that despite introduction of oral dextrose gel in 2018, neonatal intensive care unit transfers and exclusive breastfeeding in neonates with asymptomatic hypoglycemia who received gel did not improve. Purpose: The purpose of the quality improvement (QI) project was to implement and evaluate the effectiveness of a standardized policy guiding the administration of oral 40% dextrose gel in at risk neonates ≥ 35 weeks’ gestation who presented with asymptomatic hypoglycemia within the newborn nursery at a community hospital in the United States. Methods: In collaboration with nursing and medical leadership, the project lead created an evidence-based policy, updated neonatal hypoglycemic algorithms to align with the policy, and developed standardized orders for the dosing and administration of oral glucose gel. Essential to project success was the development and implementation of a plan to improve nursing knowledge and compliance through PowerPoint presentations, simulated gel administration demonstrations, as well as dissemination of the updated algorithm on the unit. Data was obtained through weekly audits and tracking outcomes such as NICU transfers and exclusive breastfeeding rates. Results: Due to unforeseen delays, including the COVID-19 pandemic, project implementation occurred in two stages. All unit nurses (n=33) were educated on administration of oral glucose gel and the updated policy and algorithm by November 1, 2020. This measure alone resulted in decreased NICU transfer rates for infants with asymptomatic neonatal hypoglycemia. The second stage, policy/algorithm implementation, went live on December 21, 2020. All of the neonates who met the inclusion criteria (n=27) received intervention(s) consistent with the policy. Though NICU admission rates related to asymptomatic hypoglycemia remained low, exclusive breastfeeding rates did not increase. Conclusions: Future QI cycles should include further data collection to observe outcomes consistent with literature evidence. Potential implications include a focus on maternal breastfeeding preference within the electronic health record (EHR) to determine if exclusive breastfeeding rates in those mothers who wish to do so will improve.
    • Transitioning to Electronic Safe Sleep Documentation in the Neonatal Intensive Care Unit

      Lee, Morgan N.; Wise, Barbara V. (2022-05)
      Problem: Sudden infant death syndrome (SIDS) continues to be a leading cause of infant death in the United States. Premature infants born at less than 37 weeks gestation have an increased risk of dying from SIDS. Safe sleep (SS) modeling by the care team during a hospital admission is recommended in order to increase the sleep safety once discharged home. SS modeling adherence among nurses in a level IV inner city NICU is only 21%. Despite clear recommendations that all healthcare providers should model SS this NICU has ample room for improvement. Purpose: The purpose of this quality improvement (QI) project is to implement electronic documentation of SS practices to increase adherence of SS modeling among NICU nurses. Methods: This QI project took place from September to December 2021. SS documentation was designed and introduced in the electronic health record. Nurses were educated on the new documentation. A NICU SS algorithm and crib card (SS bundle) were utilized at the patient’s bedside to indicate whether patients were practicing SS or not. Weekly observational bedside audits assessed SS modeling and crib card compliance. Electronic health record audits conducted weekly along with observational audits determined the accuracy and compliance of the documentation. Results: Bedspace audits indicated an improvement from 21% to 58% in adherence with SS practices among the nursing staff. Chart audits revealed 100% of nursing staff documenting SS in the electronic health record by week four of the implementation phase. Accuracy of documentation with sleep position averaged 78%. Conclusions: Implementation of electronic documentation combined with a SS bundle improved modeling of SS practices. Project sustainability strategies included continuing weekly SS rounds, inserting SS training materials and documenting procedures into the new employee orientation materials, annual training and finalizing a SS order set. Although the results are not generalizable, this project can be adapted to implement a SS bundle and electronic documentation in other NICUs, newborn nurseries, and infant care units.