acade mNyews Contributing Editors: Curtis D. Caldwell, PhD, RNC, NNP-BC (not pictured); Debbie Fraser, MN, RNC-NIC; Heather Goodall, MSN, RNC-NIC, IBCLC; Arlene Lovejoy-Bluem, DNP, RNP, CNS, RNCNIC, C-NPT, RRT; Jody Ridky, RN, MA; Kathryn Rudd, RNC-NIC, C-NPT, MSN; Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC
Code of Ethics for Neonatal Nurses Arlene Lovejoy-Bluem, DNP, RNP, CNS, RNC-NIC, C-NPT, RRT Margarite is a 24-year-old G5 P3 mother. Despite good prenatal care, her 29-week pregnancy ended 10 days ago with the premature birth of her son Daniel. Margarite lives with her husband Joseph and her children, 4-year-old Janene, and 2-½ year-old David. When she can arrange for child care with her extended family, she visits the NICU during the day. When her husband gets off work at night, they often visit together, bringing the older children with them; they alternate visiting Daniel in the NICU while the other parent stays with Janene and David in the NICU waiting room. Andrea is the NICU RN assigned to Daniel tonight. Her assignment also includes Aimee, a 5-day-old term newborn experiencing withdrawals from opioid exposure in utero, and Carlos, a 21-day-old growing preemie with the corrected gestational age of 33 2/7 weeks. Andrea is beginning a four-day stretch of 12-hour night shifts. The new edition of the Code of Ethics for Nurses (CEN) with Interpretive Statements from the American Nurses Association just came out this year. Can it apply to the intensive care environment of newborns/infants and the skilled RNs who have chosen to work in NICUs? How might it fit with the story of Margarite and Andrea in the NICU with Daniel? Neonatal nursing carries the moral responsibility of generating and sustaining relationshipbased care partnerships1 with the parents of their patients each shift and each day (or night).
The CEN is organized under nine provisions in total, which are subdivided into three subgroups: I. Fundamental values and commitments II. Boundaries of duty and loyalty III. Duties beyond individual patient encounters NICU RNs could apply the provisions in the following ways: 1. The neonatal nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. a. Respect for human dignity b. Relationship with patients c. The nature of health d. The right to self-determination e. Relationships with colleagues and others Just before Andrea’s break time, Barbara, the break relief RN, approaches her for a report. Barbara comments on Aimee’s case, “Why do we let these poor babies go home with the drug-seeking mothers who gave birth to them? We taxpayers are stuck with paying for these long hospital stays to wean these kids off the drugs that they are born addicted to.”2 Andrea makes no further comment
Disclosure The views and opinions expressed in the News of the Academy of Neonatal Nursing are those of the contributing editors and do not necessarily reflect those of the Academy of Neonatal Nursing. The Academy of Neonatal Nursing is not responsible for products, programs, or links mentioned in these pages. They are provided as a convenience and should not be viewed, in any way, as an endorsement of any particular website, company, product, or service.
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but finds Barbara’s conversation disturbing. What specifics of moral anguish is Andrea experiencing? 2. The neonatal nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. a. Primacy of the patient’s interests b. Conflict of interest for nurses c. Collaboration d. Professional boundaries Just prior to visiting the NICU each evening, a father of twins telephones to take Starbucks orders from all staff on duty that night. He plans to provide coffee drinks for each bedside caregiver on duty at his own expense. Does this cross professional boundaries? When the Synagis representative provides an educational offering each fall complete with deli sandwiches and soft drinks, does this present an ethical conflict of interest for the NICU nurses? 3. The neonatal nurse promotes, advocates for, and protects the rights, health, and safety of the patient. a. Protection of the rights of privacy and confidentiality b. Protection of human participants in research c. Performance standards and review mechanisms d. Professional responsibility in promoting a culture of safety e. Protection of patient health and safety by acting on questionable practice f. Patient protection and impaired practice Paul, the respiratory therapist (RT) on duty in the NICU, accompanies the medical director on sign-off rounds in the unit. The medical director asks Paul and the fellow on service for the night to change the ventilator that Daniel is using. The director wants to trial a modified ventilator that is pending approval by the Food and Drug Administration (FDA). Andrea listens to the discussion and the explanation given to Margarite to obtain her “informed consent.” Andrea notices that the physicians neglect to tell Margarite that FDA approval has not been secured. Andrea is troubled by this omission. Should she be? Why or why not? 4. The neonatal nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. a. Authority, accountability, and responsibility b. Accountability for nursing judgments, decisions, and actions c. Responsibility for nursing judgments, decisions, and actions d. Assignment and delegation of nursing activities or tasks The NICU manager announced in the staff meeting three days ago that the hospital is piloting a new role for ancillary staff as “care technicians” in the NICU when the
census is skewed toward growers and feeders. The census in the NICU that night meets the criteria for the pilot to begin, and one RT could be sent home because of the decreased demands for RT care that night. Andrea is given the task of “supervising” the extra RT who will assume the care as the piloted technician of the three grower/feeders in the room for bottle feedings. As oral meds are unit doses from the pharmacy, the RT will show Andrea the medications before administering them in the first mLs of the bottle feedings. The charge nurse assures Andrea that he will also be available to supervise the RT; the charge nurse is preparing for an imminent delivery of 24-week twins. Andrea feels pressured into taking on this supervising role. What are the pros and cons ethically for taking on this responsibility? 5. The neonatal nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. a. Duties to self and others b. Promotion of personal health, safety, and well-being c. Preservation of integrity d. Maintenance of competence and continuation of professional growth e. Continuation of personal growth Margarite comes to visit with her family on this night shift. Even though Andrea is extremely busy with her assignment, she tries to make Margarite feel welcome and assists her in placing Daniel in kangaroo care. Andrea asks whether Margarite would like something to drink. Margaret asks if she could also get some drinks for her older children and her husband in the waiting room. The hospital has set up a small budget from donor funds to supply the breastfeeding mothers in the NICU with free drinks. These drinks are designated for mothers only. Andrea is torn about offering some of the drinks to the father and siblings in the waiting room. What could she do? Should she restate the “rules” set by the hospital? Why or why not? What response might she expect from management? 6. The neonatal nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. a. The environment and moral value b. The environment and ethical obligation c. Responsibility for the health care environment Most bedside NICU RNs are not aware of the integral contribution of their care to their NICU’s data collection on care strategies, outcome statistics, and case reviews for the larger neonatal community of care.3 In order to receive government funding and to meet professional requirements for quality improvement activities, every
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NICU must submit data from every case to national and state collaboratives. These collaboratives construct larger pools of data to determine the merit of current standards of care. Generally, physicians and members of the highrisk follow-up team comprise the more active professionals in this data collection and research. How could nurses become more aware of these activities? How could nurses become more active in these collaborative programs? Is there a disconnect between this quality improvement research and the bedside RN? Why or why not? 7. The neonatal nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. a. Contributions through research and scholarly inquiry b. Contributions through developing, maintaining, and implementing professional practice standards c. Contributions through nursing and health policy development In the shift huddle that night, the charge nurse shared with the staff that the surgical room where the 24-week twins will be delivered is now equipped with the video camera on the warmer for recording the resuscitation. Improving the performance of resuscitation is a key tenet for all tertiary NICUs.4 This new policy of staff training and review will facilitate debriefing after the resuscitation. Would this new training standard meet provision 7 of the CEN? Why or why not? 8. The neonatal nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. a. Health is a universal right b. Collaboration for health, human rights, and health diplomacy c. Obligation to advance health and human rights and reduce disparities d. Collaboration for human rights in complex, extreme, or extraordinary practice settings That night just after midnight, the 24-week twins are born. The charge nurse and the resuscitation team are in attendance at the delivery. The NICU has been preparing for this high-risk delivery for six days. The report from the obstetric team includes a suspicion that one of the twins has a very complex heart anomaly and may even be a trisomy. From the prenatal consult with the neonatologist, the NICU team learns that despite the high risk of severe comorbidities, the parents want everything done based on their religious beliefs.5–7 Which roles could the NICU RN assume to fulfill this provision? Does your NICU include a neonatal RN in the prenatal consult with the neonatologist? Why or why not?
9. The profession of neonatal nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. a. Articulation and assertion of values b. Integrity of the profession c. Integrating social justice d. Social justice in nursing and health policy Andrea is a member of the Academy of Neonatal Nursing and has volunteered to cofacilitate a journal club in the NICU, which will take place on those rare nights when the census is down. She uses the most current Neonatal Network as the major source of her journal article selections. Andrea has family commitments of her own, which limits her time and funds to go to a national conference. The journal club is her attempt to stay current in NICU care. How does this meet the ninth provision in CEN? If not, how could she better expand her activities to meet this provision? 1. Felgen J, Wright D, Manthey M, Person C, Dingman S. Relationshipbased care: a model for transforming practice. Minnetonka, MN: Creative Health Care Management; 2004.
2. Maguire D, Webb M, Passmore D, Cline G. NICU nurses’ lived experience: caring for infants with neonatal abstinence syndrome. Adv Neonatal Care. 2012;12(5):281-285. http://dx.doi.org/10.1097/ ANC.0b013e3182677bc1 3. Hall E, Brinchmann B, Aagaard H. The challenge of integrating justice and care in neonatal nursing. Nurs Ethics. 2012;19(1): 80-90. http:// dx.doi.org/10.1177/096973301 4. Gelbart B, Barfield C, Watkins A. Ethical and legal considerations in video recording neonatal resuscitations. J Med Ethics. 2009;35: 120-124. http://dx.doi.org/10.1136/jme.2008.024612 5. Douglas S, Dahnke, M. Creating an ethical environment for parents and health providers dealing with the treatment dilemmas of neonates at the edge of viability. J Neonatal Nurs. 2013;19:33-37. http:// dx.doi.org/10.1016/j.jnn.2012.03.012 6. Fanaroff J, Hascoet J, Hansen T, et al. The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective. Acta Paediatrica. 2014;103:701-708. http://dx.doi .org/10.1111/apa.12633 7. Boss R, Holmes K, Althaus J, Rushton C, McNee H, McNee T. Trisomy 18 and complex congenital heart disease: seeking the threshold benefit. Pediatrics. 2013;132:161-165. http://dx.doi.org/10.1542/peds .2012-3643. Doi: 10.1542/peds.2012-3643
Practice Questions for Certification Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC In keeping with ANN’s mission to advance the knowledge and education of neonatal nurses, we would like to challenge and prepare you for your certification exam with Practice Questions for Cer tification.
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If you have study topics or questions you would like to contribute, please contact Ute Berman at uberman@academy ofneonatalnursing.org. The answers to these questions are on page 206. 1. Which type of heat gain occurs when neonates are exposed to surfaces warmer than their body? a. conduction b. convection c. radiation 2. Which mechanism of heat loss is reduced by using a double-walled incubator, prewarming an incubator, and clothing the neonate? a. conduction b. convection c. radiation 3. A parent voices concern that her premature infant has developed multiple raised, red, circumscribed, compressible lesions all over the body in the past few weeks. Which of the following is a correct response to the parent’s concern? a. Most involute spontaneously and do not require treatment. b. Presence on the face may be associated with Sturge-Weber syndrome. c. S i x o r m o r e m a y b e d i a g n o s t i c f o r neurofibromatosis. 4. An acute drop in which electrolyte can cause apnea, irritability, twitching, or seizures? a. calcium b. magnesium c. sodium 5. With which of the following ECG findings can severe hypocalcemia occur? a. presence of U waves b. prolonged QT interval c. widened QRS complex
News from the Executive Committee Sean Smith, BSN, RN, Paramedic, NREMT-P, FP-C, C-NPT, CCRN-CMC, CFRN, CEN, CPEN I have been asked to introduce myself as a new Executive Committee member. I am ver y humbled and honored to be asked to serve on ANN’s Executive Committee. I may have met some of you in either Las Vegas or New Orleans, or perhaps you know me through Facebook, Baby ANN, and Smith’s Ps. The Academy has been incredibly supportive of my work to improve neonatal outcomes in Haiti. Haiti has one of the highest rates of neonatal morbidity and mortality in the world. ANN has helped me by both donating vital educational materials, and by providing a platform for advocacy for this critically underserved and at-risk population. With regard to myself,
I have practiced and taught critical care, prehospital, and emergency medicine for more than 13 years. My career highlights include research in molecular neuroendocrinology, serving in the U.S. Navy, a wide variety of ICUs, flight nursing, medical missions (Dominican Republic, Honduras, Morocco, Nepal, and Haiti, is an ongoing, more or less monthly mission for the past two years, as well as providing medical support to NASA on an as-needed basis). Aside from medical missions, I often lecture nationally (and occasionally internationally) and have multiple text review/exam writing/contributing author credits. I am currently forming a nonprofit with an emphasis on providing critical-care and emergency clinical education in medically underserved areas and underdeveloped countries. Most recently, I have spent the last several months in West Africa as part of the Ebola Emergency Response, where I worked with the World Health Organization as a facilitator for Ebola Phase III “Hot” Training. In addition to providing comprehensive direct patient care for confirmed Ebola patients, this also involved providing didactic and clinical education for multinational Ebola health care workers. I am looking forward to returning to Haiti this summer, where I have several months’ worth of projects scheduled. These include rural health care clinics, teaching resuscitation at multiple facilities, a trial effort to introduce neonatal mechanical ventilation, and serving as part of an educational/clinical team to provide the very first comprehensive pediatric open-heart surgeries in the country. As ANN members, we are blessed not only with an incredible variety of educational opportunities and clinical resources but also with the wealth of experience and knowledge shared amongst our colleagues. I very much welcome your assistance and perspective with both my work in Haiti as well with our Academy. In addition, I hope you will visit Baby ANN on Facebook and use our case studies as a teaching and study tool (https://www. facebook.com/learnwithbabyann). It is truly an incredible pleasure and privilege for me to give something back and serve you. Please do not hesitate to reach out to me at [email protected] if I can help you in any way (or if you have any suggestions for Haiti, ANN, or Baby ANN).
Nurse-Reported Missed Care in NICUs Curtis D. Caldwell, PhD, RNC, NNP-BC Tubbs-Cooley and colleagues conducted a descriptive study of NICU nurses’ self-reports of missed care using a Web-based survey.1 The goals of that study were to describe the frequency of nurse-reported missed care in NICUs and factors contributing to missed care. Participants in the study were a convenience sample of 1,850 nurses whose names were obtained through the
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purchase of a database of certified NICU nurses from the American Nurses Credentialing Center with participants from California, Florida, Washington, Iowa, Texas, New York, and Illinois. The tool for their survey was an adaptation of the MISSCARE Survey by Kalisch & Williams for NICU use.2 A total of 402 surveys were completed for a response rate of 22 percent. The respondents were predominantly female and white with years of NICU experience ranging from 3 to 44 years. Approximately 69 percent held a bachelor’s or master’s degree. Over 90 percent cared for two or more infants, and approximately 6 percent cared for four or more infants. Most of the respondents worked in highacuity NICUs with varying layouts (private rooms, open wards, and pods). Over 87 percent documented their care in an electronic or hybrid paper/electronic format, and approximately half of the respondents worked in a Magnet hospital. Results: The survey showed that 120 (52 percent) reported missing at least one of the 35 items on the care list during their last shift. The total number of missed items ranged from 1 to 35 with a median of 5 items missed. Of note, among the “never missed” items, 90.5 percent reported never missing verification of highrisk medications, 89.4 percent reported never missing
comprehensive patient assessment, and 82.7 percent never missed reassessment according to an infant’s condition. Care reported as missed was usually missed rarely or occasionally. The most frequently missed activities were attendance of daily rounds (43.9 percent), oral care for ventilated babies (41.3 percent), routine bathing (40.4 percent), parent involvement in care (39.1 percent), and parent education (37.6 percent). Reasons for Missed Care: The three most common reasons for missed care were frequent interruptions (73.6 percent overall), urgent patient situations (66 percent), and an unexpected rise in patient volume and/or acuity (61.4 percent). Approximately half of the respondents cited inadequate staffing and missing equipment or supplies as reasons for missed care. Additional conditions of missing care were heavy admission or discharge activity, lack of protected time to complete lengthy care, inadequate handoff time from previous shift or transferring unit, tension or communication breakdown, other department not providing needed care, and poor communication with unlicensed assistive personnel. Reasons not reported for missed care included lack of familiarity with equipment, procedures, or policies and the belief that the care was not needed. Authors’ Conclusions: The authors note that NICU nurses report missing necessary care and that the
Abdominal Wall Defects—Word Search Kathryn Rudd, RNC-NIC, C-NPT, MSN A
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Directions: Here are 12 words that relate to the topic of Abdominal Wall Defects. See if you can find them all. Words may appear horizontally, vertically, and even backwards. The solution to this word search puzzle will be published in the July/ Aug 2015 News of the Academy.
alphafetoprotein cloacal cryptorchidism exstrophy gastroschisis hernia macrosomia omphalocele polyhydramnios silastic silo urachus
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“work systems factors” contribute to missed care. They made no claim of understanding the context of, contributors to, and effects of these missed care items and state that more research is needed to determine the effects of missed care. They also make the important proclamation that “missed care may not necessarily be an indicator of poor quality nursing care but rather a by-product of rational nurse decision-making in the midst of competing priorities.”
1. HL Tubbs-Cooley HL, Pickler RH, Younger JB, Mark BA. A descriptive study of nurse-reported missed care in neonatal intensive care units. J Adv Nurs. 2015;71(4):83-84. http://dx.doi. org/10.1111/jan.12578 2. Kalisch B, Williams, RA. Development and psychometric testing of a tool to measure missed nursing care. J of Nurs Admin. 2009;39, 211-215.
Nationwide Children’s Hospital Small Baby Program and Small Baby Unit Guest Authors: Leslie D. Thomas, MSN, APRN, NNP-BC Elizabeth Bailey Martin, MSN, RNC Erin L. Keels, MS, APRN, NNP-BC Infants who are born near the lower limits of viability (22 to 26 weeks gestation), present complex and unique medical, social, and ethical problems. Although this population represents a relatively small number of births, survival of these infants has increased over the last two decades and is likely to continue to improve,1–3 further challenging caregivers, families, and the health care system to continuously improve care. Since the implementation of the Nationwide Children’s Hospital (NCH) Small Baby Program in 2004, outcomes for this population have improved: survival has increased from 70 percent
in 2005 to 90 percent today, the length of hospital stay has decreased, ventilator days have decreased, and the rates of severe intraventricular hemorrhage have decreased (Figure 1). Furthermore, neurodevelopmental testing at 18 months rival that of babies born at delivery hospitals in Sweden.4 Eighty-two percent of “Small Babies” born between 2005 and 2011 survived to discharge. To optimize the likelihood of an intact survival, the interprofessional care of any given infant born at the lower limits of viability must be as uniform as possible. Quality improvement science holds that decreasing variability increases reliability, which in turn can improve outcomes.5 It is important that the health care professionals involved in the care of these highly vulnerable infants are also aware of both local and national (i.e., National Institute of Child Health and Human Development [www.nichd.nih.gov]) data in order to develop evidencebased strategies for care, while tailoring these to meet the individual patient and microsystem. Most importantly, the health care team must engage in a meaningful relationship with the family and remember that the primary focus should be in the delivery of family-centered care. The NICU at Nationwide Children’s Hospital in Columbus, Ohio, is an all-referral, level IIIC unit with patients cared for by three distinct neonatology practices as well as a surgical team. Prior to the development of this quality improvement initiative, it was noticed that the attitudes and care of the staff for the infant born at the lower limits of viability was highly variable. In order to improve outcomes, the neonatal team identified that a practical, evidence-based, and reliable approach to the clinical and family-centered care of this population was needed. In order to address this critical need, an interdisciplinary
FIGURE 1 n Nationwide Children’s Hospital Small Baby outcomes.
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committee, called the Small Baby Committee, was developed. This team included physicians, neonatal nurse practitioners, nurses, respiratory therapists, nutritionists, pharmacists, occupational and physical therapists, social workers, discharge planners, and lactation specialists. The goal of this team was to develop guidelines to direct the routine daily care of neonates born prior to 27 weeks gestation and their families. The Small Baby Committee was charged with developing evidence-based and family-centered clinical guidelines starting on day of life (DOL) 1 through hospital discharge. These guidelines were developed and rolled out in stages. Small Baby Guidelines, Part I, addresses the care and needs of the patient and family between DOL 1 and 7. Small Baby Guidelines, Part II, covers DOL 8 through 28; and Small Baby Guidelines, Part III, covers DOL 29 through discharge. The guidelines provide direction on the following topics: respiratory management; skin care; developmental support; cardiovascular system management including patent ductus arteriosus; fluid, electrolyte, and nutritional management; management of pain and sedation; laboratory studies; infection control; and family care. Strong emphasis is placed on developmental care, which includes the frequency of skin-to-skin care, weekly head of bed rotations, cycled lighting, pacifier dips in breast milk, hand containment, enhancing and optimizing sleep, and increasing family involvement. Once the guidelines were developed, barriers were experienced during the implementation, which included difficulties in obtaining a consensus regarding clinical care decisions within and between the four attending physician groups, negative reactions to change from staff, and non-compliance with the guidelines by providers and staff. To overcome these barriers, interventions such as cohorting the patient population, introducing dedicated weekly rounds, and performing regular audits were employed. To cohort this population, a dedicated space of ten beds in an open pod within the NICU was utilized. This pod is closed off to the rest of the NICU by glass doors, in order to decrease noise. After a unit renovation in 2013, acutely ill Small Babies are now placed in private rooms, and the more stable Small Babies are placed in this open pod. The dedicated spaces allow for greater control over environmental stimuli including noise and lighting. Staff caring for this population, including a dedicated group of nurses (called Small Baby Nurses) along with respiratory therapists, physicians, neonatal nurse practitioners, social workers, and the NICU chaplains, undergo extensive education and training around the clinical care guidelines. Charge nurses refer to a Small Baby Nurse list when making patient assignments to assure consistency of care for this population. Small Baby Nurses and other
interested staff attend quarterly meetings, where case studies are presented, evidence-based practice is reviewed and discussed, and education is shared. To improve compliance with the clinical care guidelines and to provide teaching, multidisciplinary Small Baby Rounds are held once per week and are attended by neonatologists, OTs/PTs, respiratory therapists, RNs, NNPs, lactation specialists, nutritionists, and social services. These rounds differ from routine daily rounds because the focus is placed on adherence to or deviation from the Small Baby Guidelines, reviewing the patient’s progress from the last week and setting goals for the coming weeks, and sharing clinical data and teaching. Using this approach, we have made improvements in outcomes for this population (see Figure 1). We have found that the dedicated physical space helps provide identity for the Small Baby Program, improved adherence to the overall program goals, and improved staff attitudes. We have much to celebrate. At the same time, we face new challenges. Sustaining these gains requires diligent observation, auditing, feedback, and education; updates and reinforcement must continually be offered, all of which involves time and resources. In conclusion, the Small Baby Program provides highly reliable care of extremely premature patients and their families as demonstrated by outstanding outcomes. Upon discharge, these infants and families continue to face challenges and are offered continued care and support through our outpatient follow-up program. Editorial Board Note: If you would like to learn more about the Small Baby Program at Nationwide Children’s Hospital, authors Leslie Thomas, Elizabeth Martin, and Erin Keels will be presenting a day-long preconference session at ANN’s 15th National Neonatal Nurses Conference, September 16–19, 2015, in Orlando, Florida. They will explain how they put the entire program together, from developing guidelines and order sets to accomplishments and challenges. 1. MacDonald HG, the Committee on the Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics. 2002;110:1024-1027. 2. Vollmer B, Roth S, Baudin J, Stewart AL, Neville BGR, Wyatt JS. Predictors of long-term outcome in very preterm term infants: gestational age versus neonatal cranial ultrasound. Pediatrics. 2003;112:1108-1112. 3. Hoekstra RE, Ferrara TB, Couser RJ, Payne NR, Connett JE. Survival and long-term neurodevelopmental outcome of extremely premature infants born at 23-26 weeks gestational age at a tertiary care center. Pediatrics. 2004;113:e1-e6. 4. EXPRESS Group, Fellman V, Hellström-Westas L, Norman M, et al. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA. 2009;301:2225-2233. 5. Montgomery D. Introduction to statistical quality control. 7th ed. Hoboken, NJ: J. Wiley & Sons; 2013:3-8.
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Book/Website Review
About the Authors
Leslie D. Thomas, MSN, APRN, NNP-BC, has worked in the NICU at Nationwide Children’s Hospital for almost 31 years. During that time, she has held many different positions, including her present position of clinical leader for the neonatal nurse practitioner program. Besides the Small Baby Program which she has been involved with since its inception in 2004, Leslie’s other special interest includes palliative/end-of-life care. Elizabeth Bailey Martin, MSN, RNC, has been employed at Nationwide Children’s Hospital since 1996 and has been involved with the Small Baby Program since 2004. Over the years, she helped to develop and roll out three Small Baby guidelines and has presented at conferences and published multiple journal articles. As the program progressed, she has seen improvement in infant outcomes, staff outlooks regarding extreme preemies, and parental involvement. Elizabeth feels privileged to assist in leading this group. Erin Keels, MS, APRN, NNP-BC, received her BSN from Ohio State University in 1988, and an MS in Nursing in 2003. Erin has been a neonatal nurse since 1988, an NNP since 1993, and is the manager and now director of the Nationwide Children’s Hospital NNP Program since 2003. Erin’s interests include care of the surgical neonate, pain management, neonatal abstinence, and advanced practice leadership. For further information, please contact: [email protected] [email protected] [email protected]
Neonatal Skincare (from News of the Academy – Mar/Apr 2015 Issue)
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NICU Tools: Paediatric Calculators Jody Ridky, RN, MA Go to mobile.nicutools.org and download an app with references and calculators for use in the NICU. The app will continue to be available when your device is off line, making it helpful in the field as well as in the unit. Developed and maintained by brothers Michael (consultant neonatologist at Wellington Hospital) and Paul (Web developer) Hewson of Wellington, New Zealand, it is available free of charge to everyone. The cost of updating and maintaining the website is fully paid by the Hewsons; they do not host or receive any funding from advertising; there is no commercial content on the site. Currently, the app has 15 topics and two links to other tools. Among the newest additions is a calculator for insertion length of ETTs (ET tubes) and umbilical catheters. There is a calculator for determining MAP (mean airway pressure) and BE (base excess) as well as one for the preparation of varying dextrose solutions. Glucose delivery, hourly fluid rates, INO (inhaled nitric oxide) delivery, partial exchanges, BSA (body surface area), altitude physiology, and low-flow O2 calculators are also included. Links to bilitool.org and an EOS (early-onset sepsis) risk calculator and treatment matrix are also on the app. Additional tools will be added as they are developed; sign up for e-mail notifications when they are added to the site. Download this to your electronic device and try it out. You will find it comes in handy.
Answers to Practice Questions for Certification 1. Answer is A. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:113. 2. Answer is C. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:116. 3. Answer is A. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders: 2010;135-136. 4. Answer is C. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:162. 5. Answer is B. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:166.
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34 years within the realm of newborn intensive care. As a Master NIDCAP Trainer she has consulted in hundreds of neonatal units throughout the country and abroad on how best to integrate developmentally supportive familycentered care. Don’t miss this presentation from a neonatal pioneer.
Join Us In Orlando September 16–19!
2nd ANNual Symposium for Nurse Leaders
It’s time to put something on your calendar that you can actually look forward to! How about something that will unite you with neonatal nursing colleagues, arm you with fresh ideas and cutting-edge strategies, and offer you practical solutions that you can take back to your unit? You’ll find it all at the ANN National Conference in Orlando. Consider bringing your family or friends to enjoy this world class resort and take advantage of one of the most popular vacation destinations in the world. This year our featured keynote speaker is Gretchen Lawhon, RN, PhD, FAAP. Gretchen is cofounder and vice president of the NIDCAP Federation. She has 38 years of experience in family-centered care, with
This symposium includes one and a half days of management/leadership content available for 8.75 CNE credits. The first day (September 16), attend an afternoon workshop with the dynamic Laura Mahlmeister, RN, PhD, presenting New Strategies for Successful Leadership. The second day (September 17), join us for the keynote speakers at the National Neonatal Nurses Conference in the morning, then reconvene in the afternoon with your colleagues for this leadership track. Special pricing is available for this symposium. You can also choose to stay for the rest of the conference. For more information, and to register for the can’t-miss event of the year, visit academyonline.org./conferences.
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Code of Ethics for Neonatal Nurses Arlene Lovejoy-Bluem, DNP, RNP, CNS, RNC-NIC, C-NPT, RRT Margarite is a 24-year-old G5 P3 mother. Despite good prenatal care, her 29-week pregnancy ended 10 days ago with the premature birth of her son Daniel. Margarite lives with her husband Joseph and her children, 4-year-old Janene, and 2-½ year-old David. When she can arrange for child care with her extended family, she visits the NICU during the day. When her husband gets off work at night, they often visit together, bringing the older children with them; they alternate visiting Daniel in the NICU while the other parent stays with Janene and David in the NICU waiting room. Andrea is the NICU RN assigned to Daniel tonight. Her assignment also includes Aimee, a 5-day-old term newborn experiencing withdrawals from opioid exposure in utero, and Carlos, a 21-day-old growing preemie with the corrected gestational age of 33 2/7 weeks. Andrea is beginning a four-day stretch of 12-hour night shifts. The new edition of the Code of Ethics for Nurses (CEN) with Interpretive Statements from the American Nurses Association just came out this year. Can it apply to the intensive care environment of newborns/infants and the skilled RNs who have chosen to work in NICUs? How might it fit with the story of Margarite and Andrea in the NICU with Daniel? Neonatal nursing carries the moral responsibility of generating and sustaining relationshipbased care partnerships1 with the parents of their patients each shift and each day (or night).
The CEN is organized under nine provisions in total, which are subdivided into three subgroups: I. Fundamental values and commitments II. Boundaries of duty and loyalty III. Duties beyond individual patient encounters NICU RNs could apply the provisions in the following ways: 1. The neonatal nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. a. Respect for human dignity b. Relationship with patients c. The nature of health d. The right to self-determination e. Relationships with colleagues and others Just before Andrea’s break time, Barbara, the break relief RN, approaches her for a report. Barbara comments on Aimee’s case, “Why do we let these poor babies go home with the drug-seeking mothers who gave birth to them? We taxpayers are stuck with paying for these long hospital stays to wean these kids off the drugs that they are born addicted to.”2 Andrea makes no further comment
Disclosure The views and opinions expressed in the News of the Academy of Neonatal Nursing are those of the contributing editors and do not necessarily reflect those of the Academy of Neonatal Nursing. The Academy of Neonatal Nursing is not responsible for products, programs, or links mentioned in these pages. They are provided as a convenience and should not be viewed, in any way, as an endorsement of any particular website, company, product, or service.
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but finds Barbara’s conversation disturbing. What specifics of moral anguish is Andrea experiencing? 2. The neonatal nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. a. Primacy of the patient’s interests b. Conflict of interest for nurses c. Collaboration d. Professional boundaries Just prior to visiting the NICU each evening, a father of twins telephones to take Starbucks orders from all staff on duty that night. He plans to provide coffee drinks for each bedside caregiver on duty at his own expense. Does this cross professional boundaries? When the Synagis representative provides an educational offering each fall complete with deli sandwiches and soft drinks, does this present an ethical conflict of interest for the NICU nurses? 3. The neonatal nurse promotes, advocates for, and protects the rights, health, and safety of the patient. a. Protection of the rights of privacy and confidentiality b. Protection of human participants in research c. Performance standards and review mechanisms d. Professional responsibility in promoting a culture of safety e. Protection of patient health and safety by acting on questionable practice f. Patient protection and impaired practice Paul, the respiratory therapist (RT) on duty in the NICU, accompanies the medical director on sign-off rounds in the unit. The medical director asks Paul and the fellow on service for the night to change the ventilator that Daniel is using. The director wants to trial a modified ventilator that is pending approval by the Food and Drug Administration (FDA). Andrea listens to the discussion and the explanation given to Margarite to obtain her “informed consent.” Andrea notices that the physicians neglect to tell Margarite that FDA approval has not been secured. Andrea is troubled by this omission. Should she be? Why or why not? 4. The neonatal nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. a. Authority, accountability, and responsibility b. Accountability for nursing judgments, decisions, and actions c. Responsibility for nursing judgments, decisions, and actions d. Assignment and delegation of nursing activities or tasks The NICU manager announced in the staff meeting three days ago that the hospital is piloting a new role for ancillary staff as “care technicians” in the NICU when the
census is skewed toward growers and feeders. The census in the NICU that night meets the criteria for the pilot to begin, and one RT could be sent home because of the decreased demands for RT care that night. Andrea is given the task of “supervising” the extra RT who will assume the care as the piloted technician of the three grower/feeders in the room for bottle feedings. As oral meds are unit doses from the pharmacy, the RT will show Andrea the medications before administering them in the first mLs of the bottle feedings. The charge nurse assures Andrea that he will also be available to supervise the RT; the charge nurse is preparing for an imminent delivery of 24-week twins. Andrea feels pressured into taking on this supervising role. What are the pros and cons ethically for taking on this responsibility? 5. The neonatal nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. a. Duties to self and others b. Promotion of personal health, safety, and well-being c. Preservation of integrity d. Maintenance of competence and continuation of professional growth e. Continuation of personal growth Margarite comes to visit with her family on this night shift. Even though Andrea is extremely busy with her assignment, she tries to make Margarite feel welcome and assists her in placing Daniel in kangaroo care. Andrea asks whether Margarite would like something to drink. Margaret asks if she could also get some drinks for her older children and her husband in the waiting room. The hospital has set up a small budget from donor funds to supply the breastfeeding mothers in the NICU with free drinks. These drinks are designated for mothers only. Andrea is torn about offering some of the drinks to the father and siblings in the waiting room. What could she do? Should she restate the “rules” set by the hospital? Why or why not? What response might she expect from management? 6. The neonatal nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. a. The environment and moral value b. The environment and ethical obligation c. Responsibility for the health care environment Most bedside NICU RNs are not aware of the integral contribution of their care to their NICU’s data collection on care strategies, outcome statistics, and case reviews for the larger neonatal community of care.3 In order to receive government funding and to meet professional requirements for quality improvement activities, every
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NICU must submit data from every case to national and state collaboratives. These collaboratives construct larger pools of data to determine the merit of current standards of care. Generally, physicians and members of the highrisk follow-up team comprise the more active professionals in this data collection and research. How could nurses become more aware of these activities? How could nurses become more active in these collaborative programs? Is there a disconnect between this quality improvement research and the bedside RN? Why or why not? 7. The neonatal nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. a. Contributions through research and scholarly inquiry b. Contributions through developing, maintaining, and implementing professional practice standards c. Contributions through nursing and health policy development In the shift huddle that night, the charge nurse shared with the staff that the surgical room where the 24-week twins will be delivered is now equipped with the video camera on the warmer for recording the resuscitation. Improving the performance of resuscitation is a key tenet for all tertiary NICUs.4 This new policy of staff training and review will facilitate debriefing after the resuscitation. Would this new training standard meet provision 7 of the CEN? Why or why not? 8. The neonatal nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. a. Health is a universal right b. Collaboration for health, human rights, and health diplomacy c. Obligation to advance health and human rights and reduce disparities d. Collaboration for human rights in complex, extreme, or extraordinary practice settings That night just after midnight, the 24-week twins are born. The charge nurse and the resuscitation team are in attendance at the delivery. The NICU has been preparing for this high-risk delivery for six days. The report from the obstetric team includes a suspicion that one of the twins has a very complex heart anomaly and may even be a trisomy. From the prenatal consult with the neonatologist, the NICU team learns that despite the high risk of severe comorbidities, the parents want everything done based on their religious beliefs.5–7 Which roles could the NICU RN assume to fulfill this provision? Does your NICU include a neonatal RN in the prenatal consult with the neonatologist? Why or why not?
9. The profession of neonatal nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. a. Articulation and assertion of values b. Integrity of the profession c. Integrating social justice d. Social justice in nursing and health policy Andrea is a member of the Academy of Neonatal Nursing and has volunteered to cofacilitate a journal club in the NICU, which will take place on those rare nights when the census is down. She uses the most current Neonatal Network as the major source of her journal article selections. Andrea has family commitments of her own, which limits her time and funds to go to a national conference. The journal club is her attempt to stay current in NICU care. How does this meet the ninth provision in CEN? If not, how could she better expand her activities to meet this provision? 1. Felgen J, Wright D, Manthey M, Person C, Dingman S. Relationshipbased care: a model for transforming practice. Minnetonka, MN: Creative Health Care Management; 2004.
2. Maguire D, Webb M, Passmore D, Cline G. NICU nurses’ lived experience: caring for infants with neonatal abstinence syndrome. Adv Neonatal Care. 2012;12(5):281-285. http://dx.doi.org/10.1097/ ANC.0b013e3182677bc1 3. Hall E, Brinchmann B, Aagaard H. The challenge of integrating justice and care in neonatal nursing. Nurs Ethics. 2012;19(1): 80-90. http:// dx.doi.org/10.1177/096973301 4. Gelbart B, Barfield C, Watkins A. Ethical and legal considerations in video recording neonatal resuscitations. J Med Ethics. 2009;35: 120-124. http://dx.doi.org/10.1136/jme.2008.024612 5. Douglas S, Dahnke, M. Creating an ethical environment for parents and health providers dealing with the treatment dilemmas of neonates at the edge of viability. J Neonatal Nurs. 2013;19:33-37. http:// dx.doi.org/10.1016/j.jnn.2012.03.012 6. Fanaroff J, Hascoet J, Hansen T, et al. The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective. Acta Paediatrica. 2014;103:701-708. http://dx.doi .org/10.1111/apa.12633 7. Boss R, Holmes K, Althaus J, Rushton C, McNee H, McNee T. Trisomy 18 and complex congenital heart disease: seeking the threshold benefit. Pediatrics. 2013;132:161-165. http://dx.doi.org/10.1542/peds .2012-3643. Doi: 10.1542/peds.2012-3643
Practice Questions for Certification Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC In keeping with ANN’s mission to advance the knowledge and education of neonatal nurses, we would like to challenge and prepare you for your certification exam with Practice Questions for Cer tification.
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If you have study topics or questions you would like to contribute, please contact Ute Berman at uberman@academy ofneonatalnursing.org. The answers to these questions are on page 206. 1. Which type of heat gain occurs when neonates are exposed to surfaces warmer than their body? a. conduction b. convection c. radiation 2. Which mechanism of heat loss is reduced by using a double-walled incubator, prewarming an incubator, and clothing the neonate? a. conduction b. convection c. radiation 3. A parent voices concern that her premature infant has developed multiple raised, red, circumscribed, compressible lesions all over the body in the past few weeks. Which of the following is a correct response to the parent’s concern? a. Most involute spontaneously and do not require treatment. b. Presence on the face may be associated with Sturge-Weber syndrome. c. S i x o r m o r e m a y b e d i a g n o s t i c f o r neurofibromatosis. 4. An acute drop in which electrolyte can cause apnea, irritability, twitching, or seizures? a. calcium b. magnesium c. sodium 5. With which of the following ECG findings can severe hypocalcemia occur? a. presence of U waves b. prolonged QT interval c. widened QRS complex
News from the Executive Committee Sean Smith, BSN, RN, Paramedic, NREMT-P, FP-C, C-NPT, CCRN-CMC, CFRN, CEN, CPEN I have been asked to introduce myself as a new Executive Committee member. I am ver y humbled and honored to be asked to serve on ANN’s Executive Committee. I may have met some of you in either Las Vegas or New Orleans, or perhaps you know me through Facebook, Baby ANN, and Smith’s Ps. The Academy has been incredibly supportive of my work to improve neonatal outcomes in Haiti. Haiti has one of the highest rates of neonatal morbidity and mortality in the world. ANN has helped me by both donating vital educational materials, and by providing a platform for advocacy for this critically underserved and at-risk population. With regard to myself,
I have practiced and taught critical care, prehospital, and emergency medicine for more than 13 years. My career highlights include research in molecular neuroendocrinology, serving in the U.S. Navy, a wide variety of ICUs, flight nursing, medical missions (Dominican Republic, Honduras, Morocco, Nepal, and Haiti, is an ongoing, more or less monthly mission for the past two years, as well as providing medical support to NASA on an as-needed basis). Aside from medical missions, I often lecture nationally (and occasionally internationally) and have multiple text review/exam writing/contributing author credits. I am currently forming a nonprofit with an emphasis on providing critical-care and emergency clinical education in medically underserved areas and underdeveloped countries. Most recently, I have spent the last several months in West Africa as part of the Ebola Emergency Response, where I worked with the World Health Organization as a facilitator for Ebola Phase III “Hot” Training. In addition to providing comprehensive direct patient care for confirmed Ebola patients, this also involved providing didactic and clinical education for multinational Ebola health care workers. I am looking forward to returning to Haiti this summer, where I have several months’ worth of projects scheduled. These include rural health care clinics, teaching resuscitation at multiple facilities, a trial effort to introduce neonatal mechanical ventilation, and serving as part of an educational/clinical team to provide the very first comprehensive pediatric open-heart surgeries in the country. As ANN members, we are blessed not only with an incredible variety of educational opportunities and clinical resources but also with the wealth of experience and knowledge shared amongst our colleagues. I very much welcome your assistance and perspective with both my work in Haiti as well with our Academy. In addition, I hope you will visit Baby ANN on Facebook and use our case studies as a teaching and study tool (https://www. facebook.com/learnwithbabyann). It is truly an incredible pleasure and privilege for me to give something back and serve you. Please do not hesitate to reach out to me at [email protected] if I can help you in any way (or if you have any suggestions for Haiti, ANN, or Baby ANN).
Nurse-Reported Missed Care in NICUs Curtis D. Caldwell, PhD, RNC, NNP-BC Tubbs-Cooley and colleagues conducted a descriptive study of NICU nurses’ self-reports of missed care using a Web-based survey.1 The goals of that study were to describe the frequency of nurse-reported missed care in NICUs and factors contributing to missed care. Participants in the study were a convenience sample of 1,850 nurses whose names were obtained through the
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purchase of a database of certified NICU nurses from the American Nurses Credentialing Center with participants from California, Florida, Washington, Iowa, Texas, New York, and Illinois. The tool for their survey was an adaptation of the MISSCARE Survey by Kalisch & Williams for NICU use.2 A total of 402 surveys were completed for a response rate of 22 percent. The respondents were predominantly female and white with years of NICU experience ranging from 3 to 44 years. Approximately 69 percent held a bachelor’s or master’s degree. Over 90 percent cared for two or more infants, and approximately 6 percent cared for four or more infants. Most of the respondents worked in highacuity NICUs with varying layouts (private rooms, open wards, and pods). Over 87 percent documented their care in an electronic or hybrid paper/electronic format, and approximately half of the respondents worked in a Magnet hospital. Results: The survey showed that 120 (52 percent) reported missing at least one of the 35 items on the care list during their last shift. The total number of missed items ranged from 1 to 35 with a median of 5 items missed. Of note, among the “never missed” items, 90.5 percent reported never missing verification of highrisk medications, 89.4 percent reported never missing
comprehensive patient assessment, and 82.7 percent never missed reassessment according to an infant’s condition. Care reported as missed was usually missed rarely or occasionally. The most frequently missed activities were attendance of daily rounds (43.9 percent), oral care for ventilated babies (41.3 percent), routine bathing (40.4 percent), parent involvement in care (39.1 percent), and parent education (37.6 percent). Reasons for Missed Care: The three most common reasons for missed care were frequent interruptions (73.6 percent overall), urgent patient situations (66 percent), and an unexpected rise in patient volume and/or acuity (61.4 percent). Approximately half of the respondents cited inadequate staffing and missing equipment or supplies as reasons for missed care. Additional conditions of missing care were heavy admission or discharge activity, lack of protected time to complete lengthy care, inadequate handoff time from previous shift or transferring unit, tension or communication breakdown, other department not providing needed care, and poor communication with unlicensed assistive personnel. Reasons not reported for missed care included lack of familiarity with equipment, procedures, or policies and the belief that the care was not needed. Authors’ Conclusions: The authors note that NICU nurses report missing necessary care and that the
Abdominal Wall Defects—Word Search Kathryn Rudd, RNC-NIC, C-NPT, MSN A
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Directions: Here are 12 words that relate to the topic of Abdominal Wall Defects. See if you can find them all. Words may appear horizontally, vertically, and even backwards. The solution to this word search puzzle will be published in the July/ Aug 2015 News of the Academy.
alphafetoprotein cloacal cryptorchidism exstrophy gastroschisis hernia macrosomia omphalocele polyhydramnios silastic silo urachus
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“work systems factors” contribute to missed care. They made no claim of understanding the context of, contributors to, and effects of these missed care items and state that more research is needed to determine the effects of missed care. They also make the important proclamation that “missed care may not necessarily be an indicator of poor quality nursing care but rather a by-product of rational nurse decision-making in the midst of competing priorities.”
1. HL Tubbs-Cooley HL, Pickler RH, Younger JB, Mark BA. A descriptive study of nurse-reported missed care in neonatal intensive care units. J Adv Nurs. 2015;71(4):83-84. http://dx.doi. org/10.1111/jan.12578 2. Kalisch B, Williams, RA. Development and psychometric testing of a tool to measure missed nursing care. J of Nurs Admin. 2009;39, 211-215.
Nationwide Children’s Hospital Small Baby Program and Small Baby Unit Guest Authors: Leslie D. Thomas, MSN, APRN, NNP-BC Elizabeth Bailey Martin, MSN, RNC Erin L. Keels, MS, APRN, NNP-BC Infants who are born near the lower limits of viability (22 to 26 weeks gestation), present complex and unique medical, social, and ethical problems. Although this population represents a relatively small number of births, survival of these infants has increased over the last two decades and is likely to continue to improve,1–3 further challenging caregivers, families, and the health care system to continuously improve care. Since the implementation of the Nationwide Children’s Hospital (NCH) Small Baby Program in 2004, outcomes for this population have improved: survival has increased from 70 percent
in 2005 to 90 percent today, the length of hospital stay has decreased, ventilator days have decreased, and the rates of severe intraventricular hemorrhage have decreased (Figure 1). Furthermore, neurodevelopmental testing at 18 months rival that of babies born at delivery hospitals in Sweden.4 Eighty-two percent of “Small Babies” born between 2005 and 2011 survived to discharge. To optimize the likelihood of an intact survival, the interprofessional care of any given infant born at the lower limits of viability must be as uniform as possible. Quality improvement science holds that decreasing variability increases reliability, which in turn can improve outcomes.5 It is important that the health care professionals involved in the care of these highly vulnerable infants are also aware of both local and national (i.e., National Institute of Child Health and Human Development [www.nichd.nih.gov]) data in order to develop evidencebased strategies for care, while tailoring these to meet the individual patient and microsystem. Most importantly, the health care team must engage in a meaningful relationship with the family and remember that the primary focus should be in the delivery of family-centered care. The NICU at Nationwide Children’s Hospital in Columbus, Ohio, is an all-referral, level IIIC unit with patients cared for by three distinct neonatology practices as well as a surgical team. Prior to the development of this quality improvement initiative, it was noticed that the attitudes and care of the staff for the infant born at the lower limits of viability was highly variable. In order to improve outcomes, the neonatal team identified that a practical, evidence-based, and reliable approach to the clinical and family-centered care of this population was needed. In order to address this critical need, an interdisciplinary
FIGURE 1 n Nationwide Children’s Hospital Small Baby outcomes.
NCH Small Baby Outcomes 80
Days
60 40 20
89.0% 74.3% 51.4
79.1% 53.0
76.0% 51.9
50.0
81.3%
85.8% 49.0
48.0 40.9
15.0%
15.0%
17.0%
89.1%
76.0%
42.0% 23.0%
86.8%
16.9%
100% 80%
42.0
16.5%
38.8 23.0%
6.8%
0
60% 40% 20% 0%
2005 2006 2007 2008 2009 2010 2011 2012 2013 IPPV Days
Survival - Overall
IVH (Gr III & IV)
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committee, called the Small Baby Committee, was developed. This team included physicians, neonatal nurse practitioners, nurses, respiratory therapists, nutritionists, pharmacists, occupational and physical therapists, social workers, discharge planners, and lactation specialists. The goal of this team was to develop guidelines to direct the routine daily care of neonates born prior to 27 weeks gestation and their families. The Small Baby Committee was charged with developing evidence-based and family-centered clinical guidelines starting on day of life (DOL) 1 through hospital discharge. These guidelines were developed and rolled out in stages. Small Baby Guidelines, Part I, addresses the care and needs of the patient and family between DOL 1 and 7. Small Baby Guidelines, Part II, covers DOL 8 through 28; and Small Baby Guidelines, Part III, covers DOL 29 through discharge. The guidelines provide direction on the following topics: respiratory management; skin care; developmental support; cardiovascular system management including patent ductus arteriosus; fluid, electrolyte, and nutritional management; management of pain and sedation; laboratory studies; infection control; and family care. Strong emphasis is placed on developmental care, which includes the frequency of skin-to-skin care, weekly head of bed rotations, cycled lighting, pacifier dips in breast milk, hand containment, enhancing and optimizing sleep, and increasing family involvement. Once the guidelines were developed, barriers were experienced during the implementation, which included difficulties in obtaining a consensus regarding clinical care decisions within and between the four attending physician groups, negative reactions to change from staff, and non-compliance with the guidelines by providers and staff. To overcome these barriers, interventions such as cohorting the patient population, introducing dedicated weekly rounds, and performing regular audits were employed. To cohort this population, a dedicated space of ten beds in an open pod within the NICU was utilized. This pod is closed off to the rest of the NICU by glass doors, in order to decrease noise. After a unit renovation in 2013, acutely ill Small Babies are now placed in private rooms, and the more stable Small Babies are placed in this open pod. The dedicated spaces allow for greater control over environmental stimuli including noise and lighting. Staff caring for this population, including a dedicated group of nurses (called Small Baby Nurses) along with respiratory therapists, physicians, neonatal nurse practitioners, social workers, and the NICU chaplains, undergo extensive education and training around the clinical care guidelines. Charge nurses refer to a Small Baby Nurse list when making patient assignments to assure consistency of care for this population. Small Baby Nurses and other
interested staff attend quarterly meetings, where case studies are presented, evidence-based practice is reviewed and discussed, and education is shared. To improve compliance with the clinical care guidelines and to provide teaching, multidisciplinary Small Baby Rounds are held once per week and are attended by neonatologists, OTs/PTs, respiratory therapists, RNs, NNPs, lactation specialists, nutritionists, and social services. These rounds differ from routine daily rounds because the focus is placed on adherence to or deviation from the Small Baby Guidelines, reviewing the patient’s progress from the last week and setting goals for the coming weeks, and sharing clinical data and teaching. Using this approach, we have made improvements in outcomes for this population (see Figure 1). We have found that the dedicated physical space helps provide identity for the Small Baby Program, improved adherence to the overall program goals, and improved staff attitudes. We have much to celebrate. At the same time, we face new challenges. Sustaining these gains requires diligent observation, auditing, feedback, and education; updates and reinforcement must continually be offered, all of which involves time and resources. In conclusion, the Small Baby Program provides highly reliable care of extremely premature patients and their families as demonstrated by outstanding outcomes. Upon discharge, these infants and families continue to face challenges and are offered continued care and support through our outpatient follow-up program. Editorial Board Note: If you would like to learn more about the Small Baby Program at Nationwide Children’s Hospital, authors Leslie Thomas, Elizabeth Martin, and Erin Keels will be presenting a day-long preconference session at ANN’s 15th National Neonatal Nurses Conference, September 16–19, 2015, in Orlando, Florida. They will explain how they put the entire program together, from developing guidelines and order sets to accomplishments and challenges. 1. MacDonald HG, the Committee on the Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics. 2002;110:1024-1027. 2. Vollmer B, Roth S, Baudin J, Stewart AL, Neville BGR, Wyatt JS. Predictors of long-term outcome in very preterm term infants: gestational age versus neonatal cranial ultrasound. Pediatrics. 2003;112:1108-1112. 3. Hoekstra RE, Ferrara TB, Couser RJ, Payne NR, Connett JE. Survival and long-term neurodevelopmental outcome of extremely premature infants born at 23-26 weeks gestational age at a tertiary care center. Pediatrics. 2004;113:e1-e6. 4. EXPRESS Group, Fellman V, Hellström-Westas L, Norman M, et al. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA. 2009;301:2225-2233. 5. Montgomery D. Introduction to statistical quality control. 7th ed. Hoboken, NJ: J. Wiley & Sons; 2013:3-8.
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Book/Website Review
About the Authors
Leslie D. Thomas, MSN, APRN, NNP-BC, has worked in the NICU at Nationwide Children’s Hospital for almost 31 years. During that time, she has held many different positions, including her present position of clinical leader for the neonatal nurse practitioner program. Besides the Small Baby Program which she has been involved with since its inception in 2004, Leslie’s other special interest includes palliative/end-of-life care. Elizabeth Bailey Martin, MSN, RNC, has been employed at Nationwide Children’s Hospital since 1996 and has been involved with the Small Baby Program since 2004. Over the years, she helped to develop and roll out three Small Baby guidelines and has presented at conferences and published multiple journal articles. As the program progressed, she has seen improvement in infant outcomes, staff outlooks regarding extreme preemies, and parental involvement. Elizabeth feels privileged to assist in leading this group. Erin Keels, MS, APRN, NNP-BC, received her BSN from Ohio State University in 1988, and an MS in Nursing in 2003. Erin has been a neonatal nurse since 1988, an NNP since 1993, and is the manager and now director of the Nationwide Children’s Hospital NNP Program since 2003. Erin’s interests include care of the surgical neonate, pain management, neonatal abstinence, and advanced practice leadership. For further information, please contact: [email protected] [email protected] [email protected]
Neonatal Skincare (from News of the Academy – Mar/Apr 2015 Issue)
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NICU Tools: Paediatric Calculators Jody Ridky, RN, MA Go to mobile.nicutools.org and download an app with references and calculators for use in the NICU. The app will continue to be available when your device is off line, making it helpful in the field as well as in the unit. Developed and maintained by brothers Michael (consultant neonatologist at Wellington Hospital) and Paul (Web developer) Hewson of Wellington, New Zealand, it is available free of charge to everyone. The cost of updating and maintaining the website is fully paid by the Hewsons; they do not host or receive any funding from advertising; there is no commercial content on the site. Currently, the app has 15 topics and two links to other tools. Among the newest additions is a calculator for insertion length of ETTs (ET tubes) and umbilical catheters. There is a calculator for determining MAP (mean airway pressure) and BE (base excess) as well as one for the preparation of varying dextrose solutions. Glucose delivery, hourly fluid rates, INO (inhaled nitric oxide) delivery, partial exchanges, BSA (body surface area), altitude physiology, and low-flow O2 calculators are also included. Links to bilitool.org and an EOS (early-onset sepsis) risk calculator and treatment matrix are also on the app. Additional tools will be added as they are developed; sign up for e-mail notifications when they are added to the site. Download this to your electronic device and try it out. You will find it comes in handy.
Answers to Practice Questions for Certification 1. Answer is A. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:113. 2. Answer is C. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:116. 3. Answer is A. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders: 2010;135-136. 4. Answer is C. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:162. 5. Answer is B. Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Saunders; 2010:166.
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34 years within the realm of newborn intensive care. As a Master NIDCAP Trainer she has consulted in hundreds of neonatal units throughout the country and abroad on how best to integrate developmentally supportive familycentered care. Don’t miss this presentation from a neonatal pioneer.
Join Us In Orlando September 16–19!
2nd ANNual Symposium for Nurse Leaders
It’s time to put something on your calendar that you can actually look forward to! How about something that will unite you with neonatal nursing colleagues, arm you with fresh ideas and cutting-edge strategies, and offer you practical solutions that you can take back to your unit? You’ll find it all at the ANN National Conference in Orlando. Consider bringing your family or friends to enjoy this world class resort and take advantage of one of the most popular vacation destinations in the world. This year our featured keynote speaker is Gretchen Lawhon, RN, PhD, FAAP. Gretchen is cofounder and vice president of the NIDCAP Federation. She has 38 years of experience in family-centered care, with
This symposium includes one and a half days of management/leadership content available for 8.75 CNE credits. The first day (September 16), attend an afternoon workshop with the dynamic Laura Mahlmeister, RN, PhD, presenting New Strategies for Successful Leadership. The second day (September 17), join us for the keynote speakers at the National Neonatal Nurses Conference in the morning, then reconvene in the afternoon with your colleagues for this leadership track. Special pricing is available for this symposium. You can also choose to stay for the rest of the conference. For more information, and to register for the can’t-miss event of the year, visit academyonline.org./conferences.
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