- Email: [email protected]
Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport
28 Days
Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport SANDRA BELLINI
I
Photo © Andrei Malov / thinkstockphotos.com
In the United States, the systematic practice of regionalization for perinatal care was designed to provide appropriate levels of care to women and their newborns and to improve health outcomes (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal
Medicine, 2015; Kaneko et al., 2015; Lorch, Baiocchi, Ahlberg, & Small, 2012; Staebler, 2011). Reviewed and reaffirmed on a regular basis, the system, briefly described, strives to identify women with high-risk pregnancies for referral to care centers designed to manage high-risk pregnancies. Regionalization practices have resulted in
Abstract The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (<1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. This column provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport stabilization for compromised newborns. DOI: 10.1111/j.1751-486X.12248 Keywords neonatal postresuscitation care | neonatal resuscitation | neonatal stabilization | neonatal transport | STABLE Program
http://nwh.awhonn.org
© 2015, AWHONN
533
28 Days
lower neonatal mortality and morbidity rates (Laswell, Barfield, Rochat, & Blackmon, 2010). Experts in both maternal-fetal medicine and in neonatology typically staff these perinatal centers, making appropriate care readily available for high-risk births. Centers designated as low-risk manage the vast majority of births on an annual basis, as most pregnancies are normal childbearing events, yet each low-risk center is affiliated with at least one high-risk center for referrals and neonatal transport should the need arise. Despite the best of intentions, however, emergencies still occur outside high-risk perinatal
The STABLE Program is an educational outreach program focused specifically on the postresuscitation/ pretransport stabilization and care of compromised neonates
Sandra Bellini, DNP, APRN, NNP-BC, CNE, is associate clinical professor in the School of Nursing at the University of Connecticut in Storrs, CT. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
534
centers. For example, even uncomplicated pregnancies can have unforeseen complications requiring newborn resuscitation. Every birth in the United States must be attended by someone certified by the neonatal resuscitation provider program (NRP) to resuscitate a newborn in need per standards of care (American Academy of Pediatrics and American Heart Association, 2011). For these newborns, subsequent immediate transfer to a neonatal intensive care unit (NICU) is often necessary, thereby requiring neonatal transport. For non-NICU staff, the immediate postresuscitation/pretransport stabilization and care of a compromised newborn can be stressful. These clinicians are often faced with providing levels of care that are not usual or comfortable for them. While transport teams from NICUs make every effort to facilitate timely transfers of care for these newborns, the time that elapses between resuscitation in the birthing room and subsequent neonatal transport can feel like an eternity. What are the things clinicians should be doing to ensure optimization of care for an acutely ill newborn while waiting for a NICU transport team to arrive? Knowing what to do, when to do it and why can be found within the principles of a well-known national program endorsed by the American Academy of Pediatrics. It’s called the STABLE Program.
Nursing for Women’s Health
Principles of STABLE Transport Founded by Dr. Kristine Karlsen, the STABLE Program is an educational outreach program focused specifically on the postresuscitation/ pretransport stabilization and care of compromised neonates. Designed to literally pick up where the recommendations from NRP leave off in terms of spectrum of care, STABLE is a mnemonic that provides a conceptual framework for caregivers during the postresuscitation/ pretransport period. The use of a mnemonic to represent focus areas for care assists in memory recall of critical content. The overarching goals of the program are to improve safety by focusing on teamwork, identifying areas where errors occur frequently to promote safe practices and to standardize processes of care (Karlsen, 2013). Since its inception in 1996, the STABLE Program has grown and is now available in 45 countries worldwide (Karlsen, 2013). The salient concepts included within the modules of the STABLE Program are described below.
Sugar and Safe Care The first letter in the STABLE mnemonic captures two important areas of care—sugar and safe care. This module is designed to provide learners with didactic content on all aspects of glucose management in newborns requiring transport to a tertiary center. As sugar is the primary substrate for carbohydrate nutrition in newborns, the module provides important information related to identifying newborns at risk of hypoglycemia, providing appropriate intravenous glucose and knowing how frequently blood sugar should be monitored. It also provides recommendations for correcting hypoglycemia should it occur. Additionally, this module includes safety considerations including safe placement and use of umbilical catheters.
Temperature The “T” in the STABLE mnemonic represents temperature management in newborns. Concepts discussed include a neutral thermal environment, mechanisms of heat loss in newborns, complications of hypo- and hyperthermia, physiology of cold stress, aerobic and anaerobic metabolism and corrective actions for deviations from optimal ranges in temperature should they be necessary. Additional discussion focuses on
Volume 19
Issue 6
should be obtained as routine evaluation for sepsis for infants at risk (blood cultures, complete blood count [CBC] with discussion on interpretation and Creactive protein) and the initiation of appropriate therapeutic medications, such as ampicillin and gentamicin.
Emotional Support
therapeutic hypothermia for infants who meet the inclusion criteria for that specific patient population.
Photo © iStock Collection / thinkstockphotos.com
Airway “A” represents airway, and this is arguably the most comprehensive module in the program. Content covers a wide range of topics including physical examination findings and differential diagnosis of respiratory distress, X-ray interpretation, blood gas interpretation and management of abnormal blood gas values. Additional material is presented focusing on presentation and management of pneumothoraces, as well as pain management strategies for infants undergoing painful therapeutic procedures. An overview of ventilator modes of support and initiation management guidelines is also included.
Blood Pressure “B” represents blood pressure. The content and focus of this module is geared
December 2015 | January 2016
toward identification, differentiation and management of different types of shock. A refresher on basic cardiac physiology in relation to principles such as cardiac output, preload and afterload is provided and presented in a conceptual manner related to the development of shock and physical assessment findings consistent with shock. Replacement fluids and the use of dopamine to manage hypotension are included, as is a discussion of the physiologic consequences of inadequately or poorly treated shock symptoms.
Laboratory Studies The “L” in the STABLE mnemonic pertains to what laboratory studies should be drawn for a sick newborn prior to transport and why. Topics include evaluating maternal and neonatal history for risk factors, physical examination findings suggestive of infection, commonly seen pathogens in the newborn period, recommended laboratory tests that
The final module of content in the STABLE program focuses on emotional support of families in crisis. Anyone who has ever been involved in neonatal transport knows what a traumatic event that can be for a family; the fear of the unknown in relation to the newborn’s illness and prognosis, the stress of separation between parents and their newborn and the loss of the “idealized” childbirth experience—a scenario in which a transport was unlikely envisioned. Within the content of this module, clinicians will find many helpful pieces of advice regarding how to effectively and compassionately provide family-centered care for families facing an unanticipated neonatal transport event (Karlsen, 2013; Mullaney, Edwards, & DeGrazia, 2014).
Quality Improvement and Teamwork The final section of the STABLE program is actually geared more toward teamwork and collaboration among care providers than toward patient care, per se. Consistent with the emphasis on these areas also presented in NRP, health outcomes are directly related to the knowledge and function of team members, both individually and as a group. This section provides advice for successful team building, such as training with high-fidelity simulation, which has been demonstrated as a safe but effective way to educate health care teams (American Academy of Pediatrics and American Heart Association, 2011; Cross & Wilson, 2009). Featured at the conclusion of course content, the quality improvement and team focus of this section bring a sense of closure for a
Nursing for Women’s Health
535
program opened with similar concepts surrounding safe patient care.
Practical Implications for Clinicians Of the many beneficial aspects of the STABLE Program, the mnemonic framework provides those who don’t regularly care for compromised newborns with a comprehensive overview of the principles of exactly what is involved in postresuscitation, pretransport care. The program is designed to be accessible and to provide guidelines for care, both general and specific. Additionally, the organization of content and revisitation of concepts throughout the program, such as the physiology of aerobic/anaerobic metabolism and ventilation/perfusion mismatch issues, for example, enhances learners’ ability to integrate physiology with patient-specific information and apply it toward care management. Additionally, consistent inclusion of patient history
and clinical presentation, physical examination findings and recommended laboratory studies for varying diagnosis confirmation provides a comprehensive reference for neonatal care parameters. In short, the STABLE Program provides accessible, useful, helpful information to clinicians faced with postresuscitation/ pretransport care of a newborn.
Conclusion The STABLE Program is user-friendly and seeks to make the unfamiliar and intimidating more familiar and less daunting. The program provides a conceptual approach to physiology, frequently altered and maintains an important focus on identifying and correcting underlying etiology. Case studies are provided in each module that can assist the learner in application of didactic content. Patient safety, teamwork and family-centered care are integral and apparent themes throughout the program, which contribute to the
Patient safety, teamwork and family-centered care are integral and apparent themes throughout the program
overarching theme of STABLE transport as a mechanism to improve neonatal health outcomes. NWH
References American Academy of Pediatrics and American Heart Association. (2011). Neonatal resuscitation textbook (6th ed.). Elk Grove Village, IL: Author. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. (2015). Levels of maternal care. American Journal of Obstetrics and Gynecology, 212(3), 259–271. doi:dx.doi.org/10.1016/j. ajog.2014.12.030 Cross, B., & Wilson, D. (2009). Highfidelity simulation for transport team training and competency evaluation. Newborn and Infant Nursing Reviews, 9(4), 200–206. doi:dx.doi.org/10.1053/j. nainr.2009.09.005 Kaneko, M., Yamashita, R., Kai, K., Yamada, N., Sameshima, H., & Ikenoue, T. (2015). Perinatal morbidity and mortality for extremely low-birth-weight infants: A population-based study of regionalized maternal and neonatal transport. Journal of Obstetrics and Gynaecology Research, 41(7),1056–1066. doi:10.1111/jog.12686 Karlsen, K. (2013). Instructor manual, the STABLE Program (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Lorch, S., Baiocchi, M., Ahlberg, C., & Small, D. (2012). The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics, 130, 270–278. doi:10.1542/peds.2011-2820. Mullaney, D., Edwards, W., & DeGrazia, M. (2014). Family-centered care during acute neonatal transport. Advances in Neonatal Care, 14(5S), S16–S23. doi:10.1097/ANC.0000000000000119 Staebler, S. (2011). Regionalized systems of perinatal care: Health policy considerations. Advances in Neonatal Care, 11(1), 37–42. doi:10.1097/ ANC.0b013e318206fd5a
536
Nursing for Women’s Health
Volume 19
Issue 6
Photo © Rachel Donahue / thinkstockphotos.com
Laswell, S., Barfield, W., Rochat, R., & Blackmon, L. (2010). Perinatal regionalization for very low-birth-weight and very preterm infants: A meta-analysis. Journal of the American Medical Association, 304(9), 992–1000. doi:10.1001/ jama.2010.1226
Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport SANDRA BELLINI
I
Photo © Andrei Malov / thinkstockphotos.com
In the United States, the systematic practice of regionalization for perinatal care was designed to provide appropriate levels of care to women and their newborns and to improve health outcomes (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal
Medicine, 2015; Kaneko et al., 2015; Lorch, Baiocchi, Ahlberg, & Small, 2012; Staebler, 2011). Reviewed and reaffirmed on a regular basis, the system, briefly described, strives to identify women with high-risk pregnancies for referral to care centers designed to manage high-risk pregnancies. Regionalization practices have resulted in
Abstract The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (<1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. This column provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport stabilization for compromised newborns. DOI: 10.1111/j.1751-486X.12248 Keywords neonatal postresuscitation care | neonatal resuscitation | neonatal stabilization | neonatal transport | STABLE Program
http://nwh.awhonn.org
© 2015, AWHONN
533
28 Days
lower neonatal mortality and morbidity rates (Laswell, Barfield, Rochat, & Blackmon, 2010). Experts in both maternal-fetal medicine and in neonatology typically staff these perinatal centers, making appropriate care readily available for high-risk births. Centers designated as low-risk manage the vast majority of births on an annual basis, as most pregnancies are normal childbearing events, yet each low-risk center is affiliated with at least one high-risk center for referrals and neonatal transport should the need arise. Despite the best of intentions, however, emergencies still occur outside high-risk perinatal
The STABLE Program is an educational outreach program focused specifically on the postresuscitation/ pretransport stabilization and care of compromised neonates
Sandra Bellini, DNP, APRN, NNP-BC, CNE, is associate clinical professor in the School of Nursing at the University of Connecticut in Storrs, CT. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
534
centers. For example, even uncomplicated pregnancies can have unforeseen complications requiring newborn resuscitation. Every birth in the United States must be attended by someone certified by the neonatal resuscitation provider program (NRP) to resuscitate a newborn in need per standards of care (American Academy of Pediatrics and American Heart Association, 2011). For these newborns, subsequent immediate transfer to a neonatal intensive care unit (NICU) is often necessary, thereby requiring neonatal transport. For non-NICU staff, the immediate postresuscitation/pretransport stabilization and care of a compromised newborn can be stressful. These clinicians are often faced with providing levels of care that are not usual or comfortable for them. While transport teams from NICUs make every effort to facilitate timely transfers of care for these newborns, the time that elapses between resuscitation in the birthing room and subsequent neonatal transport can feel like an eternity. What are the things clinicians should be doing to ensure optimization of care for an acutely ill newborn while waiting for a NICU transport team to arrive? Knowing what to do, when to do it and why can be found within the principles of a well-known national program endorsed by the American Academy of Pediatrics. It’s called the STABLE Program.
Nursing for Women’s Health
Principles of STABLE Transport Founded by Dr. Kristine Karlsen, the STABLE Program is an educational outreach program focused specifically on the postresuscitation/ pretransport stabilization and care of compromised neonates. Designed to literally pick up where the recommendations from NRP leave off in terms of spectrum of care, STABLE is a mnemonic that provides a conceptual framework for caregivers during the postresuscitation/ pretransport period. The use of a mnemonic to represent focus areas for care assists in memory recall of critical content. The overarching goals of the program are to improve safety by focusing on teamwork, identifying areas where errors occur frequently to promote safe practices and to standardize processes of care (Karlsen, 2013). Since its inception in 1996, the STABLE Program has grown and is now available in 45 countries worldwide (Karlsen, 2013). The salient concepts included within the modules of the STABLE Program are described below.
Sugar and Safe Care The first letter in the STABLE mnemonic captures two important areas of care—sugar and safe care. This module is designed to provide learners with didactic content on all aspects of glucose management in newborns requiring transport to a tertiary center. As sugar is the primary substrate for carbohydrate nutrition in newborns, the module provides important information related to identifying newborns at risk of hypoglycemia, providing appropriate intravenous glucose and knowing how frequently blood sugar should be monitored. It also provides recommendations for correcting hypoglycemia should it occur. Additionally, this module includes safety considerations including safe placement and use of umbilical catheters.
Temperature The “T” in the STABLE mnemonic represents temperature management in newborns. Concepts discussed include a neutral thermal environment, mechanisms of heat loss in newborns, complications of hypo- and hyperthermia, physiology of cold stress, aerobic and anaerobic metabolism and corrective actions for deviations from optimal ranges in temperature should they be necessary. Additional discussion focuses on
Volume 19
Issue 6
should be obtained as routine evaluation for sepsis for infants at risk (blood cultures, complete blood count [CBC] with discussion on interpretation and Creactive protein) and the initiation of appropriate therapeutic medications, such as ampicillin and gentamicin.
Emotional Support
therapeutic hypothermia for infants who meet the inclusion criteria for that specific patient population.
Photo © iStock Collection / thinkstockphotos.com
Airway “A” represents airway, and this is arguably the most comprehensive module in the program. Content covers a wide range of topics including physical examination findings and differential diagnosis of respiratory distress, X-ray interpretation, blood gas interpretation and management of abnormal blood gas values. Additional material is presented focusing on presentation and management of pneumothoraces, as well as pain management strategies for infants undergoing painful therapeutic procedures. An overview of ventilator modes of support and initiation management guidelines is also included.
Blood Pressure “B” represents blood pressure. The content and focus of this module is geared
December 2015 | January 2016
toward identification, differentiation and management of different types of shock. A refresher on basic cardiac physiology in relation to principles such as cardiac output, preload and afterload is provided and presented in a conceptual manner related to the development of shock and physical assessment findings consistent with shock. Replacement fluids and the use of dopamine to manage hypotension are included, as is a discussion of the physiologic consequences of inadequately or poorly treated shock symptoms.
Laboratory Studies The “L” in the STABLE mnemonic pertains to what laboratory studies should be drawn for a sick newborn prior to transport and why. Topics include evaluating maternal and neonatal history for risk factors, physical examination findings suggestive of infection, commonly seen pathogens in the newborn period, recommended laboratory tests that
The final module of content in the STABLE program focuses on emotional support of families in crisis. Anyone who has ever been involved in neonatal transport knows what a traumatic event that can be for a family; the fear of the unknown in relation to the newborn’s illness and prognosis, the stress of separation between parents and their newborn and the loss of the “idealized” childbirth experience—a scenario in which a transport was unlikely envisioned. Within the content of this module, clinicians will find many helpful pieces of advice regarding how to effectively and compassionately provide family-centered care for families facing an unanticipated neonatal transport event (Karlsen, 2013; Mullaney, Edwards, & DeGrazia, 2014).
Quality Improvement and Teamwork The final section of the STABLE program is actually geared more toward teamwork and collaboration among care providers than toward patient care, per se. Consistent with the emphasis on these areas also presented in NRP, health outcomes are directly related to the knowledge and function of team members, both individually and as a group. This section provides advice for successful team building, such as training with high-fidelity simulation, which has been demonstrated as a safe but effective way to educate health care teams (American Academy of Pediatrics and American Heart Association, 2011; Cross & Wilson, 2009). Featured at the conclusion of course content, the quality improvement and team focus of this section bring a sense of closure for a
Nursing for Women’s Health
535
program opened with similar concepts surrounding safe patient care.
Practical Implications for Clinicians Of the many beneficial aspects of the STABLE Program, the mnemonic framework provides those who don’t regularly care for compromised newborns with a comprehensive overview of the principles of exactly what is involved in postresuscitation, pretransport care. The program is designed to be accessible and to provide guidelines for care, both general and specific. Additionally, the organization of content and revisitation of concepts throughout the program, such as the physiology of aerobic/anaerobic metabolism and ventilation/perfusion mismatch issues, for example, enhances learners’ ability to integrate physiology with patient-specific information and apply it toward care management. Additionally, consistent inclusion of patient history
and clinical presentation, physical examination findings and recommended laboratory studies for varying diagnosis confirmation provides a comprehensive reference for neonatal care parameters. In short, the STABLE Program provides accessible, useful, helpful information to clinicians faced with postresuscitation/ pretransport care of a newborn.
Conclusion The STABLE Program is user-friendly and seeks to make the unfamiliar and intimidating more familiar and less daunting. The program provides a conceptual approach to physiology, frequently altered and maintains an important focus on identifying and correcting underlying etiology. Case studies are provided in each module that can assist the learner in application of didactic content. Patient safety, teamwork and family-centered care are integral and apparent themes throughout the program, which contribute to the
Patient safety, teamwork and family-centered care are integral and apparent themes throughout the program
overarching theme of STABLE transport as a mechanism to improve neonatal health outcomes. NWH
References American Academy of Pediatrics and American Heart Association. (2011). Neonatal resuscitation textbook (6th ed.). Elk Grove Village, IL: Author. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. (2015). Levels of maternal care. American Journal of Obstetrics and Gynecology, 212(3), 259–271. doi:dx.doi.org/10.1016/j. ajog.2014.12.030 Cross, B., & Wilson, D. (2009). Highfidelity simulation for transport team training and competency evaluation. Newborn and Infant Nursing Reviews, 9(4), 200–206. doi:dx.doi.org/10.1053/j. nainr.2009.09.005 Kaneko, M., Yamashita, R., Kai, K., Yamada, N., Sameshima, H., & Ikenoue, T. (2015). Perinatal morbidity and mortality for extremely low-birth-weight infants: A population-based study of regionalized maternal and neonatal transport. Journal of Obstetrics and Gynaecology Research, 41(7),1056–1066. doi:10.1111/jog.12686 Karlsen, K. (2013). Instructor manual, the STABLE Program (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Lorch, S., Baiocchi, M., Ahlberg, C., & Small, D. (2012). The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics, 130, 270–278. doi:10.1542/peds.2011-2820. Mullaney, D., Edwards, W., & DeGrazia, M. (2014). Family-centered care during acute neonatal transport. Advances in Neonatal Care, 14(5S), S16–S23. doi:10.1097/ANC.0000000000000119 Staebler, S. (2011). Regionalized systems of perinatal care: Health policy considerations. Advances in Neonatal Care, 11(1), 37–42. doi:10.1097/ ANC.0b013e318206fd5a
536
Nursing for Women’s Health
Volume 19
Issue 6
Photo © Rachel Donahue / thinkstockphotos.com
Laswell, S., Barfield, W., Rochat, R., & Blackmon, L. (2010). Perinatal regionalization for very low-birth-weight and very preterm infants: A meta-analysis. Journal of the American Medical Association, 304(9), 992–1000. doi:10.1001/ jama.2010.1226