• Early Hearing Detection: Using Pre-Discharge Education and Standardized Referrals to Reduce Lost-To-Follow-Up Rates

      Riggs, Julie; Gourley, Bridgitte; Clark, Karen, Ph.D., R.N. (2019-05)
      Background: There are lags in ensuring that infants who do not pass their hospital newborn hearing screens receive the follow-up testing they need by the recommended three-month benchmark. The purpose of this project is to address disparities in infants lost to follow-up (LTF) by implementing a program for pre-discharge education and referral plan to free follow-up care at a suburban hospital in a mid-Atlantic state. Intervention: A partnership between the state department of health and a local university audiology program provided education and free follow-up testing of infants who did not pass the newborn hearing screen. Audiology technicians provided a screening result card to families, which also included hearing developmental milestones. Families received brief verbal education about the test result and the urgent need for a retest for those who did not pass. Infants requiring follow-up received appointments with the partner audiology clinic for a free evaluation. Results: 216 infants were born at the site and 214 babies received the in-hospital hearing screens. All 214 babies passed the in-hospital screens and did not require referral. An additional three babies were referred to the university clinic from other sites. Conclusion: This project did not yield opportunities for evaluation of LTF due to low birth volume during the short data collection period. However, this project indicated future potential for positive change. Families responded well to the cards and engaged with the education. This partnership provided opportunities for follow-up of at-risk infants in the region and is likely a model worth continuing and expanding.
    • Implementation of a Standardized Gastrostomy Tube Discharge Bundle for Neonates

      Keffer, Lauren E.; McComiskey, Carmel A. (2021-05)
      Problem: Surgical placement of a gastrostomy tube (g-tube) is indicated in pediatric patients who are unable to obtain nutrition by mouth. While a g-tube is an accepted method of long-term enteral nutrition support, post-operative complications occur. A 52-bed level IV NICU cared for 79 infants requiring surgical g-tube placement. Over the same year, 35% of those patients (n=28) visited the Emergency Department (ED) for g-tube complications (dislodgment, irritation dermatitis and leaking), and 15% (n=12) scheduled unplanned outpatient clinic appointments. There is currently a lack of standardized g-tube education accompanied by a nursing knowledge deficit for appropriate caregiver education. Purpose: The purpose of this quality improvement project is to implement and evaluate the effectiveness of a standardized g-tube discharge bundle and electronic health record education title in the Neonatal ICU to prevent unnecessary ED and/or outpatient clinic appointments for g-tube complications. Methods: Staff nurses were trained and knowledge, skills and attitudes were assessed at the conclusion of each educational session. The G-tube Discharge Bundle resided at the bedside of all g-tube patients and the accompanying educational checklist was completed in its entirety by bedside nurses prior to discharge or transfer. Caregiver knowledge was assessed with return demonstration and/or verbalization of understanding. Results: The project revealed that no participant presented in the ED with a g-tube complication within the first two months post-discharge and no scheduled or unplanned outpatient clinic appointments. Conclusions: Caregiver preparation for patients with gastrostomy supports successful discharge and transition to home. The standardized evidencebased g-tube discharge bundle addresses the importance of family-centered care while improving satisfaction among caregivers and health care providers.
    • 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.
    • Increasing Early Skin-to-Skin for Newborns of Uncomplicated Cesarean Birth

      Showunmi, Harsana; Hoffman, Ann G. (2019-05)
      Background: Following a cesarean birth (CB), newborns can be separated from the mother for up to 3 hours, delaying skin-to-skin contact (SSC). Immediate or early SSC is recommended as a standard of care to prevent hypothermia, hypoglycemia, tachypnea in newborns and to increase bonding, yet few newborns of CB engage in this practice. When mothers are unable to engage in SSC, fathers/support persons are viable options to facilitate early SSC in newborns. Local Problem: The proposed clinical site houses a small labor and delivery unit where it was not standard practice for newborns of cesarean births to engage in SSC within 1 hour following delivery. The purpose of this quality improvement (QI) project is to implement early SSC between fathers/support persons and stable, full-term newborns of uncomplicated cesarean births when the mother is unable to provide SSC. For this QI project, early SSC was considered to be SSC within 1 hour of birth Interventions: A process change was introduced to allow fathers/support persons perform SSC soon after CB. Nurses learned how to identify eligible participants and a checklist was used to serve as a reminder for when and how to execute the new process. Once identified, families were educated on SSC, then the mother appointed an alternative SSC provider. Unit practice was changed to allow fathers/support persons to follow the newborn and the nurse to the nursery after an uncomplicated CB for an opportunity to perform early SSC. If newborns were determined to be stable, SSC was initiated. During the course of the project, goals, information and results were disseminated on the unit via presentations, discussions, posters and handouts. Results: There was a total of 21 CBs during the implementation timeline; nine ineligible cases and twelve eligible cases. Out of the 12 eligible cases, 5 newborns received SSC in less than 1 hour, 5 newborns received SSC more than 1 hour but less than 2 hours and 2 newborns did not receive SSC in the required time frame. The nurses also engaged mothers in early SSC with their newborns. As a result, outcomes included 6 mothers who performed SSC with their newborns within 2 hours of birth. Conclusions: Creating an environment that incorporates early SSC as a standard of care, regardless of method of delivery, is important to improving newborn and family outcomes. In situations where mothers are not available to perform SSC, it is feasible for fathers/support persons to act as alternative SSC provider. This process change allows the newborns of uncomplicated CB to safely enjoy the same benefits as newborns of vaginal deliveries, who routinely perform immediate or early SSC. During this QI project, the checklist made it easier for the nurses to facilitate early SSC. Although adoption to utilize the checklist was slow, when used, it served to streamline the process change. By the end of implementation there was an increased awareness of fathers/support persons as alternative SSC providers and increased action to initiate SSC earlier for newborns of uncomplicated CB on the unit.
    • 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.
    • Prevention of Newborn Hypoglycemia Algorithm

      Parajon, Cecilia M.; Hoffman, Ann G. (2019-05)
      Background: Newborns at a higher risk for developing hypoglycemia are defined as newborns born small or large for gestational age, late-preterm (34-36 and 6/7 weeks gestation), those born to mothers with diabetes and any newborn exhibiting clinical signs of hypoglycemia. Identified newborns are monitored and often fed formula to stabilize their blood glucose level. Many mothers plan to breastfeed exclusively, but when formula is fed to their newborns exclusive and long-term breastfeeding is decreased. Applying the Baby-Friendly Hospital Initiative interventions like skin to skin care, frequent breastfeeding and feeding hand expressed colostrum to the at-risk newborns may prevent hypoglycemia, stabilize the glucose levels, lessen formula supplementation, and increase exclusive breastfeeding rate. The Prevention of Newborn Hypoglycemia Algorithm supports the AAP Screening and Management of Postnatal Glucose Homeostasis Algorithm, the Academy of Breastfeeding Medicine and the Baby Friendly guidelines to prevent and reduce newborn hypoglycemia and related formula use, increase breastfeeding rates and thereby improve delivery of care. Local Problem: The community hospital was initiating the process of becoming a Baby Friendly Hospital and recognized that their use of formula to manage hypoglycemia in at-risk newborns was very high and sought to decrease its use and consequently increase breastfeeding rates. The hospital currently uses an algorithm based on the AAP Hypoglycemia Algorithm that does not incorporate some of the Baby Friendly interventions. There are inconsistencies of the management in the care of the at-risk newborns. Interventions: The purpose of this quality improvement project was to implement and evaluate the effectiveness of the Prevention of Hypoglycemia Algorithm for the at-risk newborns in a community hospital. The implementation included instruction and guidance of the nursing staff in the components and the use of the algorithm. The use of the algorithm was assessed in the overall and the at-risk number of newborns that were ever and exclusively breastfed during the intervention period. At the end of the implementation, the nurses evaluated the usability of the algorithm with the Algorithm Usability Questionnaire. Results: Overall the ever-breastfeeding rate increased slightly but the exclusive breastfeeding rate dropped. During the intervention, all of the at-risk newborns were managed with parts of the algorithm and 100% breastfed some of the feedings. The exclusively breastfeeding rate was 67% in the first month and 20% the second month. There was a 70% staff approval for ease of use of the algorithm. Conclusions: All at-risk newborns breastfed for some of the feedings in the hospital during the intervention. There was an increase in the awareness of at-risk newborn hypoglycemia prevention and the use of the algorithm recommendations for all newborns. The algorithm served as a prompt to apply the Baby Friendly interventions while preventing hypoglycemia, managing the blood glucose levels, lessen formula supplementation and preserving the newborns breastfeeding abilities. The Algorithm remained posted on the nursing unit to assist this practice change to manage the at-risk newborns and help the hospital become a Baby-Friendly designated facility.
    • Reduction of Cardiopulmonary Monitor Alarms in the Special Care Nursery

      Barefoot, Leah (2015)
      Background: Health care technology has added benefits for monitoring patients, but many of these devices are associated with alarms and alerts to notify staff when a patient’s physiological limits fall outside of set parameters or when there is a machine malfunction. Alarm fatigue occurs when a person is exposed to so many clinical alarms, they eventually become immune to the sound, thus having no or slow responses to alarms. In addition to desensitization, staff exposed to these repetitive sounds may react by silencing alarms, turning them off or changing the parameters to unsafe ranges. These actions, and staff missing clinically relevant alarms, have resulted in adverse patient events and deaths in hospitals nationwide. While the issues surrounding alarm safety are multifaceted, many experts focus on strategies to decrease false or non-actionable alarms. False or non-actionable alarms are alarms that do not require any clinical intervention by staff. Evidence suggests that by changing alarm parameters to fit patient needs, false alarms are minimized, therefore decreasing alarm fatigue. Purpose: The purpose of this project is to decrease alarm fatigue in the Special Care Nursery, a step-down nursery, at a large academic medical center. In order to achieve this goal, the project aimed to decrease the number of cardiopulmonary alarms that sound throughout the unit by individualizing each patient’s alarms to their personal baseline. Methods: A quality improvement project was completed in the Special Care Nursery in which nurses were instructed on how to change alarm parameters to fit their patient’s baseline cardiopulmonary needs. Oxygen saturation was excluded from the project due to the narrow margin of acceptability for a neonate’s oxygenation status. During the one week intervention, staff were reminded of the importance of alarm parameter changes and the impact of alarm fatigue twice daily before starting their shift. In accordance with current hospital standards, prior to alarm parameter changes, a physician order was required. A job aid on how to change alarm parameters was provided to staff and available on the unit at all times. Results: Utilizing the Mann Whitney U for analysis, there was no statistically significant difference in the number of alarms that sounded prior to the intervention and following the intervention. No orders were placed for alarm parameter changes following the intervention period. Discussion: Although the intervention in this project did not result in a statistically significant change (p value=0.974) in cardiopulmonary alarms, the project brought to the forefront the discussion of alarm fatigue within the unit. Further focused work on this unit should involve analysis of current baseline settings to determine if changes can result in decreased nuisance cardiopulmonary alarms. Additional work should focus on achieving support from the front line staff on the criticality of alarm fatigue on patient safety and the role of the nursing staff in decreasing false alarms and alarm fatigue.