- Email: [email protected]
Use of evidence-based practice in the neonatal intensive care unit
Crit Care Nurs Clin N Am 16 (2004) 243 – 248
Use of evidence-based practice in the neonatal intensive care unit Trudy R. Pollock, RNC, CNNP, MSN*, Carol Franklin, RNC, BSN Hemby Intensive Care Nursery, Presbyterian Hospital, 200 Hawthorne Lane, Charlotte, NC 28204, USA
Neonatology is a relatively young field. Neonatal intensive care, as we know it today, is less than 40 years old [1]. Practitioners in the field, in as few as 15 years, have seen dramatic changes. Changes in science and technology have resulted in an increase in survival rates and decrease in morbidity of premature infants. The rate of survival of the extremely low birth weight (ELBW) infant has increased significantly. ELBW infants are defined as infants born at less than 1000 g and usually less than 27 weeks’ gestation. Statistically, this group of infants has by far the highest morbidity and mortality of all premature births [2]. The goal of neonatal care providers is to give the best care possible, while minimizing harm and maximizing function. In an attempt to accomplish this goal, an evidence-based practice (EBP) committee was formed in the Hemby Intensive Care Nursery (HICN). The purpose of the EBP committee is to allow nurses to combine clinical experience with available reliable research to develop or update practice guidelines. The HICN EBP committee chose the FOCUS – PDCA model for process improvement to guide their project. FOCUS is a mnemonic, representing find, organize, clarify, understand, and select. PDCA stands for plan, do, check results, and act [3].
Find a process to improve The HICN is a 24-bed, level-III neonatal intensive care unit located at Presbyterian Hospital in Charlotte, North Carolina. The average number of admissions is approximately 400 per year, with 7% to 8% of * Corresponding author. E-mail address: [email protected] (T.R. Pollock).
those admissions considered ELBW. Recognizing that these infants are at greatest risk for mortality and morbidity, the EBP committee chose to examine delivery room management of the 23- to 26-weeks’ gestation newborn. The 23 to 26 weeks’ gestation was selected to encompass most infants of ELBW.
Organize the team The hallmark of an EBP endeavor is to examine current practice thoroughly, compare it with what current research recommends, and change practice as indicated [4]. A multidisciplinary committee was formed comprised of volunteers who expressed an interest in the chosen topic. As consistency was important, members committed to the entire length of the project. The EBP committee consisted of neonatal nurse practitioners (NNPs), neonatal nurses, a neonatologist, respiratory therapists, and an outcomes management registered nurse (RN). The committee met weekly, for an 8-week period, with meetings limited to 1 hour. The initial meeting was for organizational purposes. Members were asked to perform a literature search for relevant, reliable research on the chosen topic and bring the articles back to the committee. Specific aims were identified and topics were subdivided. The subtopics were assigned to individual members and research articles were distributed for evaluation and summarization. The subtopics included thermoregulation, developmental care, and respiratory management. The specific aims for the project were: To evaluate and develop protocol for preventing
heat loss and maintaining a normal core/skin temperature in the delivery room.
0899-5885/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2004.02.006
244
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248 To understand and establish guidelines for de-
velopmentally sensitive care in the delivery room To understand gentle ventilation and make recommendations regarding respiratory management in the delivery room
C larify current knowledge and practice An outline of practice in the delivery room at the time of review is as follows : Infant is received in a prewarmed blanket. Infant is placed on a prewarmed radiant warmer. Infant is dried with blanket and a hat placed on
the infant’s head. Bag-mask ventilation (BMV) and intubations
are administered as indicated. Neonatal resuscitation program guidelines are followed. Respiratory therapist and neonatologist or NNP provide airway management and ventilator support in delivery room and during transport to the HICN. Hand ventilation is provided with a self-inflating resuscitation bag during transport. Infant is transported to the HICN in a prewarmed transport isolette. On admission to the HICN, the infant is weighed on a preheated scale and placed in a radiant warmer or in a Giraffe incubator (Ohmeda Medical, Laurel, Maryland). Bed choice is either by staff preference or current availability. The infant is then placed on ventilator support, either high-frequency oscillatory ventilation or conventional ventilation. Surfactant is given within 1 hour of arrival in the HICN. Umbilical lines are placed and radiographs performed within the first hour of admission. Infants admitted to radiant warmers are moved within 2 hours to a humidified isolette.
Understand causes of process variations and Select the process for improvement
oxygen requirements. ELBW infants do not have the ability to maintain temperature control because of the absence of brown fat, an immature neuromuscular system, and the inability to respond by thermogenesis. Research supports the use of high humidity environments for the ELBW infant to decrease insensible water loss, improve hypothermia, and maintain balance of serum electrolytes [5,6]. Thermoregulation is challenging in the delivery room setting because of high evaporative losses from the delivery process. A retrospective review of 17 infants between 23 and 26 weeks’ gestation found the mean axillary infant temperature was 95.65°F on admission to the HICN. After review of current research, it was clear the temperature for this population was suboptimal. After this review, the committee made the following recommendations: 1. Delivery room will be warmed to 78°F to 80°F before delivery. 2. Everything in contact with the infant will be preheated for a minimum of 20 minutes before delivery. 3. Staff will receive infant into a single ply towel, drying infant quickly and gently under a radiant warmer. Warmed hat will be placed on head. 4. Infant will be placed immediately into a developmental pack after thorough drying. This pack consists of a SnuggleUp and a Bendy Bumper (Children’s Medical Ventures, Norwell, Massachusetts), a waterproof pad, plastic film, and a blanket (Figs. 1 and 2). 5. All infants will be admitted into the preheated Giraffe incubator, with maximum humidity. 6. If Giraffe incubator is unavailable, infants will be admitted to a radiant warmer and transferred to a humidified isolette within 1 hour of admission. 7. Minimal handling of infant will occur until axillary temperature is greater than 97.6°F. 8. Placement of lines will occur after infant’s temperature is stabilized, with minimal draping with prewarmed sterile towels. 9. Infant will remain in the developmental pack.
Thermoregulation
Respiratory management
ELBW infants are at particular risk for hypothermia, insensible water loss, and skin breakdown. The specific aim of thermoregulation is the prevention of hypothermia. Hypothermia causes myriad detrimental consequences in the ELBW infant, including metabolic acidosis, intravascular volume shifts, and increase in
ELBW infants are at extreme risk for lung injury because of their fragile, underdeveloped air sacs and lack of surfactant production. The primary cause of bronchopulmonary dysplasia in the ELBW is the initiation of mechanical ventilation [7,8]. Although ventilation may be unavoidable for the ELBW, under-
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
245
b. PEEP of 5 cm H2O. c. Ventilator rate of 40 breaths per minute. d. FIO2 initial setting at 0.6 L per minute. e. Pulse oximeter: wean ventilator settings to maintain SaO2 85% – 92%. Developmental care
Fig. 1. Developmental pack.
standing the deleterious effects of ventilation is required. Research supports volutrauma, surfactant deficiency, and oxygen toxicity as the principle causes of lung injury in the premature infant [7]. Shearing of the lung tissue as a result of substantial opening pressures required to inflate the ELBW lungs creates an inflammatory process from the first breath [7]. Literature review supports early administration of exogenous surfactant to infants at high risk for respiratory distress syndrome. Early administration (rescue therapy) is defined as less than 2 hours of age, with preference and benefits clearly exhibited when surfactant is given as soon as possible after birth [8 – 11] Practice at the time of review is summarized as follows: Self-inflating resuscitation bags with 100% FIO2
used in the delivery room for resuscitation either by BMV or via endotracheal tube as indicated. Current bags did not have positive endexpiratory pressure (PEEP) valves or pressure manometers. Infants were transported to the HICN in a transport isolette while receiving hand ventilation. Surfactant administration given within 1 hour of birth.
ELBW infants have extremely immature autonomic, motor, and state organizational responses to stimuli [12]. This population is susceptible to adverse effects as a result of sudden movements, loud noises, and excessive handling. Research consistently reveals that supporting the ELBW behavioral organization efforts from the initial contact may produce calmer infants with fewer cerebral blood flow velocity changes and fewer intraventricular hemorrhages (IVH) [12]. After review of the literature, the committee made the following recommendations: 1. Admit infant directly into preweighed, prewarmed developmental pack in a developmentally appropriate position, flexed, nested, and supine with head in midline position. 2. Intubations done with infant in pack. Clinician may adjust Bendy Bumper around head to facilitate intubations as needed. 3. Infant transferred into transport isolette, swaddled in developmental pack. 4. Infant weighed and subsequently placed in Giraffe incubator tightly swaddled in pack. 5. Minimal handling during this immediate newborn period. 6. All lines placed with infant maintained in pack. (See Figs. 1 and 2.)
After review of the literature, the committee made the following recommendations: 1. Resuscitation bags in the delivery room will have PEEP valves and pressure manometers. 2. Ventilator support via a transport isolette will begin in the delivery room with defined parameters: a. Peak inspiratory pressure of 16 cm H2O with continuous observation of chest rise.
Fig. 2. Doll in developmental pack.
246
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
P lan and Do
C heck results
At the final EBP committee meeting, all the recommendations were summarized and agreed on by the multidisciplinary group. A protocol was developed based on the recommendations and approved by the medical director of the HICN. Staff education was planned, including didactic in-services and demonstration to all staff, including RNs, respiratory therapists, NNPs, and neonatologists. As this process also affected the delivery room staff, changes were communicated at staff meetings and by fliers to the labor and delivery staff. An educational board was placed in the common area that outlined the new protocol. The new protocol went into effect October 28, 2002. The first patient treated with the new protocol in effect arrived on November 7, 2002.
A data tool was created with input from the outcomes management RN and collection was begun. Retrospective review of 17 infants in the 10 months before start of the protocol was done to obtain baseline data. To date, there are only 7 infants included in the postprocedure data collection. The two areas the committee has reviewed are thermoregulation and developmental care.
Thermoregulation results Of the 17 infants studied under the old process, 15 infants had an axillary temperature recorded. One infant’s data was unavailable and the other infant’s
Fig. 3. Axillary temperature in degrees Fahrenheit. x - Before process change. n - After process change.
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
temperature was too low to register on the digital thermometer (<90°F). The range of temperatures was from 92.2°F to 98.1°F. The mean admission axillary temperature was 95.65°F (Fig. 3). Of the seven infants studied in the postprocess change group, the mean axillary temperature was 97.59°F. The range of temperatures in this group was narrower, from 95.6°F to 99.4°F (see Fig. 3). The difference in temperature, although seemingly significant, represents a small sample size. Data collection is ongoing to validate this finding further.
247
Summary The process change described is an ongoing project in the HICN. Through this process we found that developmentally sensitive care can be accomplished as early as the time of birth by minimizing trauma to ELBW infants, keeping them nested with minimal handling. This also supports the goal for this population of minimizing cold stress and its effects. Gentle ventilation can be achieved in the delivery room by understanding physiology and the effects of ventilation on the ELBW lung tissue.
Developmental results The committee collected data on the grade of IVH present in both the pre- and postgroup. The data included the highest grade IVH sustained by the infant during hospitalization. The data was gathered from the cranial ultrasound report dictated by the radiologist. Cranial ultrasounds are done routinely within the first 3 days of life for these infants. Of the 17 infants in the group before the process change, 7 had no IVH, 1 had a germinal matrix hemorrhage, 1 had periventricular leukomalacia, 2 had a grade I IVH, 1 had a grade II IVH, and 2 had a grade III IVH. There were no infants in this group who had a confirmed grade IV IVH. There were 3 infants who expired before the ultrasound was done. One of these was listed as ‘‘suspected IVH’’ and the other listed as ‘‘suspected grade IV IVH.’’ The third was not listed. Of the 7 infants studied in the postprocess group, 3 had no IVH, 2 had a grade I IVH, and 1 had a leftsided infarction. One infant died before the ultrasound was done and was not listed. There was no confirmed grade II, III, or IV IVH in this group. Although there appears to be a downward trend in the severity of IVH, no conclusions can be drawn from this data. First, the data size is small. Second, there are other factors that have an impact on the development of IVH in the ELBW infants and could not be taken into account in this current study. Data collection is ongoing to identify any continuing trends in decreasing the severity of IVH.
Act The committee continues to collect data until a significant sample size is reached. This data will be reviewed and the committee will reconvene to evaluate significant findings and make adjustments to the process change.
References [1] Department of Health and Human Services, Public Health Service, National Institutes of Health. Neonatal intensive care: a history of excellence. A symposium commemorating Child Health Day. Originally presented October 7, 1985. NIH publication no. 92 – 2786 1992. Available at: www.nichd.nih.gov/ publications/pubs/neonatal/nic.htm. Accessed August 17, 2003. [2] York J, DeVoe M. Health issues in survivors of prematurity. South Med J [serial online] 2002;95:969 – 76. Available at:.http://www.sma.org/smj2002/septsmj02/ pdf/york.pdf. Accessed August 17, 2003. [3] Bader MK, Palmer S, Stalcup C, Sharver T. Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: process and outcomes. Online J Knowl Synth Nurs 2002;9:4C. Accessed August 17, 2003. [4] University of Minnesota. Evidence based nursing. Available at: http://evidence.ahc.umn.edu/ebn.htm. Accessed February 5, 2002. [5] Furdon SA, Lapitsky J, Diven S, Horgan MJ. Effect of standardized approach to the care of the extremely low birth weight infant. J Nurs Care Qual 1997;11(6): 42 – 52. [6] Lund J, Kuller A, Lane J, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. J Obstet Gynecol Neonatal Nurs 1999;23:241 – 54. [7] Clark R, Grestman D, Jobe A, Moffitt S, Slutsky A, Yoder B. Lung injury in neonates: causes, strategies for prevention, and long term consequences. J Pediatr 2001;139:478 – 86. [8] Soll RF. Cochrane review. Synthetic surfactant for respiratory distress syndrome in preterm infants. The Cochrane Library, issue 4, 2001. Available at: http:// www.Cochrane.org/cochrane/revabstr/ab001149.htm. Accessed November 27, 2001. [9] Haliday H. Surfactant therapy: questions and answers. J Neonatal Nurs 1997;3:28 – 36. [10] Kendig J, Noller R, Cox C, et al. A comparison of surfactant as immediate prophylaxis and as rescue ther-
248
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
apy in newborns of less than 30 weeks gestation. N Engl J Med 1991;324:865 – 71. [11] Osiris Collaborative Group. Early versus delayed neonatal administration of a synthetic surfactant—the judgement of OSIRIS. Lancet 1992;340:8832.
[12] Als H, Lawhon G, Duffy FH, McAnulty GB, GibesGrossman R, Blickman JG. Individualized developmental care for the very low-birthweight preterm infant: medical and neurofunctional effects. JAMA 1994;272:853 – 6.
Use of evidence-based practice in the neonatal intensive care unit Trudy R. Pollock, RNC, CNNP, MSN*, Carol Franklin, RNC, BSN Hemby Intensive Care Nursery, Presbyterian Hospital, 200 Hawthorne Lane, Charlotte, NC 28204, USA
Neonatology is a relatively young field. Neonatal intensive care, as we know it today, is less than 40 years old [1]. Practitioners in the field, in as few as 15 years, have seen dramatic changes. Changes in science and technology have resulted in an increase in survival rates and decrease in morbidity of premature infants. The rate of survival of the extremely low birth weight (ELBW) infant has increased significantly. ELBW infants are defined as infants born at less than 1000 g and usually less than 27 weeks’ gestation. Statistically, this group of infants has by far the highest morbidity and mortality of all premature births [2]. The goal of neonatal care providers is to give the best care possible, while minimizing harm and maximizing function. In an attempt to accomplish this goal, an evidence-based practice (EBP) committee was formed in the Hemby Intensive Care Nursery (HICN). The purpose of the EBP committee is to allow nurses to combine clinical experience with available reliable research to develop or update practice guidelines. The HICN EBP committee chose the FOCUS – PDCA model for process improvement to guide their project. FOCUS is a mnemonic, representing find, organize, clarify, understand, and select. PDCA stands for plan, do, check results, and act [3].
Find a process to improve The HICN is a 24-bed, level-III neonatal intensive care unit located at Presbyterian Hospital in Charlotte, North Carolina. The average number of admissions is approximately 400 per year, with 7% to 8% of * Corresponding author. E-mail address: [email protected] (T.R. Pollock).
those admissions considered ELBW. Recognizing that these infants are at greatest risk for mortality and morbidity, the EBP committee chose to examine delivery room management of the 23- to 26-weeks’ gestation newborn. The 23 to 26 weeks’ gestation was selected to encompass most infants of ELBW.
Organize the team The hallmark of an EBP endeavor is to examine current practice thoroughly, compare it with what current research recommends, and change practice as indicated [4]. A multidisciplinary committee was formed comprised of volunteers who expressed an interest in the chosen topic. As consistency was important, members committed to the entire length of the project. The EBP committee consisted of neonatal nurse practitioners (NNPs), neonatal nurses, a neonatologist, respiratory therapists, and an outcomes management registered nurse (RN). The committee met weekly, for an 8-week period, with meetings limited to 1 hour. The initial meeting was for organizational purposes. Members were asked to perform a literature search for relevant, reliable research on the chosen topic and bring the articles back to the committee. Specific aims were identified and topics were subdivided. The subtopics were assigned to individual members and research articles were distributed for evaluation and summarization. The subtopics included thermoregulation, developmental care, and respiratory management. The specific aims for the project were: To evaluate and develop protocol for preventing
heat loss and maintaining a normal core/skin temperature in the delivery room.
0899-5885/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2004.02.006
244
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248 To understand and establish guidelines for de-
velopmentally sensitive care in the delivery room To understand gentle ventilation and make recommendations regarding respiratory management in the delivery room
C larify current knowledge and practice An outline of practice in the delivery room at the time of review is as follows : Infant is received in a prewarmed blanket. Infant is placed on a prewarmed radiant warmer. Infant is dried with blanket and a hat placed on
the infant’s head. Bag-mask ventilation (BMV) and intubations
are administered as indicated. Neonatal resuscitation program guidelines are followed. Respiratory therapist and neonatologist or NNP provide airway management and ventilator support in delivery room and during transport to the HICN. Hand ventilation is provided with a self-inflating resuscitation bag during transport. Infant is transported to the HICN in a prewarmed transport isolette. On admission to the HICN, the infant is weighed on a preheated scale and placed in a radiant warmer or in a Giraffe incubator (Ohmeda Medical, Laurel, Maryland). Bed choice is either by staff preference or current availability. The infant is then placed on ventilator support, either high-frequency oscillatory ventilation or conventional ventilation. Surfactant is given within 1 hour of arrival in the HICN. Umbilical lines are placed and radiographs performed within the first hour of admission. Infants admitted to radiant warmers are moved within 2 hours to a humidified isolette.
Understand causes of process variations and Select the process for improvement
oxygen requirements. ELBW infants do not have the ability to maintain temperature control because of the absence of brown fat, an immature neuromuscular system, and the inability to respond by thermogenesis. Research supports the use of high humidity environments for the ELBW infant to decrease insensible water loss, improve hypothermia, and maintain balance of serum electrolytes [5,6]. Thermoregulation is challenging in the delivery room setting because of high evaporative losses from the delivery process. A retrospective review of 17 infants between 23 and 26 weeks’ gestation found the mean axillary infant temperature was 95.65°F on admission to the HICN. After review of current research, it was clear the temperature for this population was suboptimal. After this review, the committee made the following recommendations: 1. Delivery room will be warmed to 78°F to 80°F before delivery. 2. Everything in contact with the infant will be preheated for a minimum of 20 minutes before delivery. 3. Staff will receive infant into a single ply towel, drying infant quickly and gently under a radiant warmer. Warmed hat will be placed on head. 4. Infant will be placed immediately into a developmental pack after thorough drying. This pack consists of a SnuggleUp and a Bendy Bumper (Children’s Medical Ventures, Norwell, Massachusetts), a waterproof pad, plastic film, and a blanket (Figs. 1 and 2). 5. All infants will be admitted into the preheated Giraffe incubator, with maximum humidity. 6. If Giraffe incubator is unavailable, infants will be admitted to a radiant warmer and transferred to a humidified isolette within 1 hour of admission. 7. Minimal handling of infant will occur until axillary temperature is greater than 97.6°F. 8. Placement of lines will occur after infant’s temperature is stabilized, with minimal draping with prewarmed sterile towels. 9. Infant will remain in the developmental pack.
Thermoregulation
Respiratory management
ELBW infants are at particular risk for hypothermia, insensible water loss, and skin breakdown. The specific aim of thermoregulation is the prevention of hypothermia. Hypothermia causes myriad detrimental consequences in the ELBW infant, including metabolic acidosis, intravascular volume shifts, and increase in
ELBW infants are at extreme risk for lung injury because of their fragile, underdeveloped air sacs and lack of surfactant production. The primary cause of bronchopulmonary dysplasia in the ELBW is the initiation of mechanical ventilation [7,8]. Although ventilation may be unavoidable for the ELBW, under-
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
245
b. PEEP of 5 cm H2O. c. Ventilator rate of 40 breaths per minute. d. FIO2 initial setting at 0.6 L per minute. e. Pulse oximeter: wean ventilator settings to maintain SaO2 85% – 92%. Developmental care
Fig. 1. Developmental pack.
standing the deleterious effects of ventilation is required. Research supports volutrauma, surfactant deficiency, and oxygen toxicity as the principle causes of lung injury in the premature infant [7]. Shearing of the lung tissue as a result of substantial opening pressures required to inflate the ELBW lungs creates an inflammatory process from the first breath [7]. Literature review supports early administration of exogenous surfactant to infants at high risk for respiratory distress syndrome. Early administration (rescue therapy) is defined as less than 2 hours of age, with preference and benefits clearly exhibited when surfactant is given as soon as possible after birth [8 – 11] Practice at the time of review is summarized as follows: Self-inflating resuscitation bags with 100% FIO2
used in the delivery room for resuscitation either by BMV or via endotracheal tube as indicated. Current bags did not have positive endexpiratory pressure (PEEP) valves or pressure manometers. Infants were transported to the HICN in a transport isolette while receiving hand ventilation. Surfactant administration given within 1 hour of birth.
ELBW infants have extremely immature autonomic, motor, and state organizational responses to stimuli [12]. This population is susceptible to adverse effects as a result of sudden movements, loud noises, and excessive handling. Research consistently reveals that supporting the ELBW behavioral organization efforts from the initial contact may produce calmer infants with fewer cerebral blood flow velocity changes and fewer intraventricular hemorrhages (IVH) [12]. After review of the literature, the committee made the following recommendations: 1. Admit infant directly into preweighed, prewarmed developmental pack in a developmentally appropriate position, flexed, nested, and supine with head in midline position. 2. Intubations done with infant in pack. Clinician may adjust Bendy Bumper around head to facilitate intubations as needed. 3. Infant transferred into transport isolette, swaddled in developmental pack. 4. Infant weighed and subsequently placed in Giraffe incubator tightly swaddled in pack. 5. Minimal handling during this immediate newborn period. 6. All lines placed with infant maintained in pack. (See Figs. 1 and 2.)
After review of the literature, the committee made the following recommendations: 1. Resuscitation bags in the delivery room will have PEEP valves and pressure manometers. 2. Ventilator support via a transport isolette will begin in the delivery room with defined parameters: a. Peak inspiratory pressure of 16 cm H2O with continuous observation of chest rise.
Fig. 2. Doll in developmental pack.
246
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
P lan and Do
C heck results
At the final EBP committee meeting, all the recommendations were summarized and agreed on by the multidisciplinary group. A protocol was developed based on the recommendations and approved by the medical director of the HICN. Staff education was planned, including didactic in-services and demonstration to all staff, including RNs, respiratory therapists, NNPs, and neonatologists. As this process also affected the delivery room staff, changes were communicated at staff meetings and by fliers to the labor and delivery staff. An educational board was placed in the common area that outlined the new protocol. The new protocol went into effect October 28, 2002. The first patient treated with the new protocol in effect arrived on November 7, 2002.
A data tool was created with input from the outcomes management RN and collection was begun. Retrospective review of 17 infants in the 10 months before start of the protocol was done to obtain baseline data. To date, there are only 7 infants included in the postprocedure data collection. The two areas the committee has reviewed are thermoregulation and developmental care.
Thermoregulation results Of the 17 infants studied under the old process, 15 infants had an axillary temperature recorded. One infant’s data was unavailable and the other infant’s
Fig. 3. Axillary temperature in degrees Fahrenheit. x - Before process change. n - After process change.
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
temperature was too low to register on the digital thermometer (<90°F). The range of temperatures was from 92.2°F to 98.1°F. The mean admission axillary temperature was 95.65°F (Fig. 3). Of the seven infants studied in the postprocess change group, the mean axillary temperature was 97.59°F. The range of temperatures in this group was narrower, from 95.6°F to 99.4°F (see Fig. 3). The difference in temperature, although seemingly significant, represents a small sample size. Data collection is ongoing to validate this finding further.
247
Summary The process change described is an ongoing project in the HICN. Through this process we found that developmentally sensitive care can be accomplished as early as the time of birth by minimizing trauma to ELBW infants, keeping them nested with minimal handling. This also supports the goal for this population of minimizing cold stress and its effects. Gentle ventilation can be achieved in the delivery room by understanding physiology and the effects of ventilation on the ELBW lung tissue.
Developmental results The committee collected data on the grade of IVH present in both the pre- and postgroup. The data included the highest grade IVH sustained by the infant during hospitalization. The data was gathered from the cranial ultrasound report dictated by the radiologist. Cranial ultrasounds are done routinely within the first 3 days of life for these infants. Of the 17 infants in the group before the process change, 7 had no IVH, 1 had a germinal matrix hemorrhage, 1 had periventricular leukomalacia, 2 had a grade I IVH, 1 had a grade II IVH, and 2 had a grade III IVH. There were no infants in this group who had a confirmed grade IV IVH. There were 3 infants who expired before the ultrasound was done. One of these was listed as ‘‘suspected IVH’’ and the other listed as ‘‘suspected grade IV IVH.’’ The third was not listed. Of the 7 infants studied in the postprocess group, 3 had no IVH, 2 had a grade I IVH, and 1 had a leftsided infarction. One infant died before the ultrasound was done and was not listed. There was no confirmed grade II, III, or IV IVH in this group. Although there appears to be a downward trend in the severity of IVH, no conclusions can be drawn from this data. First, the data size is small. Second, there are other factors that have an impact on the development of IVH in the ELBW infants and could not be taken into account in this current study. Data collection is ongoing to identify any continuing trends in decreasing the severity of IVH.
Act The committee continues to collect data until a significant sample size is reached. This data will be reviewed and the committee will reconvene to evaluate significant findings and make adjustments to the process change.
References [1] Department of Health and Human Services, Public Health Service, National Institutes of Health. Neonatal intensive care: a history of excellence. A symposium commemorating Child Health Day. Originally presented October 7, 1985. NIH publication no. 92 – 2786 1992. Available at: www.nichd.nih.gov/ publications/pubs/neonatal/nic.htm. Accessed August 17, 2003. [2] York J, DeVoe M. Health issues in survivors of prematurity. South Med J [serial online] 2002;95:969 – 76. Available at:.http://www.sma.org/smj2002/septsmj02/ pdf/york.pdf. Accessed August 17, 2003. [3] Bader MK, Palmer S, Stalcup C, Sharver T. Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: process and outcomes. Online J Knowl Synth Nurs 2002;9:4C. Accessed August 17, 2003. [4] University of Minnesota. Evidence based nursing. Available at: http://evidence.ahc.umn.edu/ebn.htm. Accessed February 5, 2002. [5] Furdon SA, Lapitsky J, Diven S, Horgan MJ. Effect of standardized approach to the care of the extremely low birth weight infant. J Nurs Care Qual 1997;11(6): 42 – 52. [6] Lund J, Kuller A, Lane J, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. J Obstet Gynecol Neonatal Nurs 1999;23:241 – 54. [7] Clark R, Grestman D, Jobe A, Moffitt S, Slutsky A, Yoder B. Lung injury in neonates: causes, strategies for prevention, and long term consequences. J Pediatr 2001;139:478 – 86. [8] Soll RF. Cochrane review. Synthetic surfactant for respiratory distress syndrome in preterm infants. The Cochrane Library, issue 4, 2001. Available at: http:// www.Cochrane.org/cochrane/revabstr/ab001149.htm. Accessed November 27, 2001. [9] Haliday H. Surfactant therapy: questions and answers. J Neonatal Nurs 1997;3:28 – 36. [10] Kendig J, Noller R, Cox C, et al. A comparison of surfactant as immediate prophylaxis and as rescue ther-
248
T.R. Pollock, C. Franklin / Crit Care Nurs Clin N Am 16 (2004) 243–248
apy in newborns of less than 30 weeks gestation. N Engl J Med 1991;324:865 – 71. [11] Osiris Collaborative Group. Early versus delayed neonatal administration of a synthetic surfactant—the judgement of OSIRIS. Lancet 1992;340:8832.
[12] Als H, Lawhon G, Duffy FH, McAnulty GB, GibesGrossman R, Blickman JG. Individualized developmental care for the very low-birthweight preterm infant: medical and neurofunctional effects. JAMA 1994;272:853 – 6.