Implementing a Neuro-Bundle in a Level III Neonatal Intensive Care Unit

Abstract

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.