• 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.
    • 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.
    • 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.
    • 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.
    • Use of Cord Blood for Admission Lab Testing in High Risk Neonates

      George, Ronie; Bode, Claire (2019-05)
      Background: As part of their care in the neonatal intensive care unit (NICU) most neonates require routine admission labs, which could equal up to 10% of their total blood volume. This, and the subsequent lab draws while in the NICU can predispose them to anemia and hypovolemia with the possibility of needing blood transfusions. Local Problem: This QI project is being done in a twenty four bed level three NICU and in a twelve bed labor and delivery (L & D) unit in a major urban medical center in the Mid –Atlantic region. The current practice is to draw admission labs directly from the baby which is not only invasive but also traumatic and expensive considering the supplies used. Participants include registered nurses, neonatal nurse practitioners, neonatologists, laboratory personnel, and information technology staff. Aim: To implement the feasibility of drawing admission labs from the cord blood as an alternative to the current practice of neonatal phlebotomy. The data collected will be the number of staff who are trained to the number of staff working in the L&D and NICU and the number of samples collected from the cord blood to the number of NICU admissions during this timeframe. Interventions: The theoretical framework used here was the Plan Do Study Act. All nurses working in the labor and delivery and NICU and all high risk infants between 22 and 42 weeks who were admitted to the NICU were eligible to participate. An evidence based literature review guided improvement of current practice. Unit based practice guideline, power point presentation, competency checklist and data collection tools were prepared for education, training and data collection. Champions were selected and individual and group training sessions were done. Select cord samples were collected and sent to lab. Results: Education was completed by 80% L & D nurses, and 80% NICU nurses. Samples were collected on 64.47% neonates admitted to the NICU. Based on the posttest administered after the education, 98% agreed that using cord blood for admission labs is safe and reliable and helps prevent pain and other complications. Conclusion: The procedure has a high degree of usability and staff are continuing to collect samples from cord blood. In this present era where our focus is on quality improvement initiatives, making a wise use of available resources like umbilical cord blood will bring about a better outcome for the sick neonate and cost containment for the patients and their family as well as for the organization where it is implemented. In conclusion, cord sampling as an alternative to neonatal phlebotomy is an easily accessible procedure with the potential to improve the outcome of the sick neonates.