Advances in Neonatal Care

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ZAP-VAP: A Quality Improvement Initiative to Decrease Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit, 2012-2016 Background: Ventilator-associated pneumonia (VAP) is the second most frequent hospital-acquired infection in neonatal intensive care units (NICUs) and significantly affects neonatal morbidity and mortality. The population most at risk for VAP are extremely preterm infants. Purpose: The objectives of this quality improvement project were to create and evaluate the effectiveness of a VAP prevention bundle ("ZAP-VAP") in reducing VAP. Methods: The development of the ZAP-VAP bundle and creation of audit tools were documented. A targeted gestational age less than 29 weeks was selected for this study. Electronic medical record review was used to determine the preintervention baseline for patient outcomes. Patient medical record data were analyzed retrospectively to measure patient outcomes preimplementation. VAP rates (number of VAP cases per 1000 ventilator days) were calculated pre- and postintervention. After implementation, data were analyzed prospectively to measure patient outcomes between neonates who developed VAP and those who did not. Results: The VAP rate significantly decreased from 8.5 (2010-2011) to 2.5 (P= .0004) postintervention (2016). Median mechanical ventilation days decreased among VAP cases (47 vs 33 days) and slightly increased among non-VAP cases (19 vs 24 days) during the intervention period. Median length of stay decreased for VAP cases (136 vs 100 days) but remained unchanged for non-VAP cases (85 vs 84 days). Implications for Practice: The intervention was implemented from 2012 to 2016. The protocol was readily accepted by our neonatal intensive care unit (NICU) team through education and practice changes. ZAP-VAP is an effective and straightforward protocol that improved VAP outcomes in our level IIIB NICU. An interdisciplinary team successfully implemented this intervention for mechanically ventilated infants of all gestational ages in our unit and has been a model for these practice changes in other units and other hospitals. Implications for Research: Future studies should focus on how to create sustainable interventions to decrease VAP in NICUs and to expand the approaches to other units in our hospital and other hospitals in our city among patients at risk for VAP.

Successful Reduction in Electrode-Related Pressure Ulcers During EEG Monitoring in Critically Ill Neonates Background: Neonates are at a high risk for pressure ulcers (PU) due to skin immaturity and exposure to various medical devices. The prevalence of PU in the neonatal intensive care unit is estimated to be 23%, with 80% of those being related to medical devices, including electroencephalographic (EEG) electrodes. Proposed mechanisms involve prolonged pressure to the electrodes and chemical reactions to conductive agents. Purpose: The object of this quality improvement project was to reduce PU in neonates during continuous EEG (cEEG) monitoring by 50% within 12 months and 75% within 18 months. A secondary objective was to eliminate electrode-related infections by 12 months. Balancing measures included gestational age at the time of monitoring, integrity of the EEG setup, and cost effectiveness. The process measure was adherence to the skin-monitoring tool kit. Methods: A multiple Plan-Do-Study-Act cycle method was used. All neonates monitored with cEEG were included. The monitoring tool kit was used to document the condition of scalp and EEG electrodes before, during, and after cEEG. Results: In the preproject period, 8.5% (9/106) of monitored patients developed PU, and 22.2% (2/9) of those developed infections. During the project period, 3.5% (7/198) of monitored patients developed PU and no infections were observed. During monitoring, 21 patients showed skin irritation, and timely intervention resulted in resolution in more than 90% of the cases and prevented progression into PU. Silver/silver chloride–plated electrodes, when exposed to external heat sources, can cause burns, resembling PU. Implications for Practice: Intervention at the electrode level together with skin inspection successfully reduces PU in neonates. Silver/silver chloride–plated electrodes should be avoided in neonates. Implications for Research: Further research is needed to identify the optimal electrode for neonatal EEG.

Outcomes of Neonates With Complex Medical Needs Background: Children with complex medical needs (CMN) are high healthcare resource utilizers, have varying underlying diagnoses, and experience repeated hospitalizations. Outcomes on neonatal intensive care (NICU) patients with CMN are unknown. Purpose: The primary aim is to describe the clinical profile, resource use, prevalence, and both in-hospital and postdischarge outcomes of neonates with CMN. The secondary aim is to assess the feasibility of sustaining the use of the neonatal complex care team (NCCT). Methods: A retrospective cohort study was conducted after implementing a new model of care for neonates with CMN in the NICU. All neonates born between January 2013 and December 2016 and who met the criteria for CMN and were cared for by the NCCT were included. Results: One hundred forty-seven neonates with a mean (standard deviation) gestational age of 34 (5) weeks were included. The major underlying diagnoses were genetic/chromosomal abnormalities (48%), extreme prematurity (26%), neurological abnormality (12%), and congenital anomalies (11%). Interventions received included mechanical ventilation (69%), parenteral nutrition (68%), and technology dependency at discharge (91%). Mortality was 3% before discharge and 17% after discharge. Postdischarge hospital attendances included emergency department visits (44%) and inpatient admissions (58%), which involved pediatric intensive care unit admissions (26%). Implications for Practice: Neonates with CMN have multiple comorbidities, high resource needs, significant postdischarge mortality, and rehospitalization rates. These cohorts of NICU patients can be identified early during their NICU course and serve as targets for implementing innovative care models to meet their unique needs. Implications for Research: Future studies should explore the feasibility of implementing innovative care models and their potential impact on patient outcomes and cost-effectiveness.

Evaluating Teamwork in the Neonatal Intensive Care Unit: A Survey of Providers and Parents Background: A unified vision of team mission, psychologically safe practice environment, effective communication, and respect among team members are key characteristics of an effective interdisciplinary neonatal intensive care unit (NICU) team. Purpose: A quality improvement team in a quaternary NICU surveyed parents, physicians, and nurses on perceptions of teamwork to identify opportunities for improvement. Design/Methods: Parents and healthcare staff (n = 113) completed an anonymous survey from May to July of 2014 to assess team roles and membership, team qualities, shared mission, psychological safety, hierarchy, communications, and conflict awareness. An expert panel assigned questions into one or more characteristics of team intelligence. Results: Physicians, nurses, and parents perceive their roles and the composition of the healthcare team differently. Most providers reported a shared mission and having a cooperative spirit as their teams' best attributes. While most nurses chose safety as most important, the majority of doctors chose treatment plan. Parents consider tenderness toward their infant, providing medical care and answers to their questions important. All expressed varying concerns about psychological safety, conflict resolution, and miscommunications. Implications for Practice: This survey identifies strengths and gaps of teamwork in our NICU and provides insight on necessary changes that need to be made to improve collaboration among the interdisciplinary care team including parents. Implications for Research: This quality improvement report identifies aspects of team care delivery in NICUs that require further study. The concept of team intelligence and its impact on team effectiveness invites in-depth exploration.

What Are the Effects of the Maternal Voice on Preterm Infants in the NICU? Background/Significance: Premature infants often experience extended stays in the neonatal intensive care unit (NICU) as opposed to home with parents. This prolonged separation creates a strain for both parents and infants, decreasing attachment and parental caregiving. One strategy to combat this shared stress is increasing parental participation, particularly through the use of their voices whether parents are present or not. Purpose: This Evidence-Based Practice Brief column explores the connection between mother and child, specifically the effects of maternal voice on infant autonomic stability, weight gain, and behavioral states. Methods: A systematic search of CINAHL, PubMed, and PsycInfo was used to identify studies involving the use of maternal voice intervention with preterm infants in the NICU. Results: Fifteen studies were identified. Three intervention categories emerged: (1) live maternal speech, (2) recorded maternal speech (subcategories included whether intervention content was prescribed or not), and (3) recorded maternal speech that was combined with biological maternal sounds (heart rate). Within each category, studies were organized chronologically to reflect how knowledge has changed overtime. Implications for Practice: Maternal voice has physiological as well as behavioral and emotional effect on preterm infants. Several studies found that maternal voice increased autonomic stability improving (heart rate and respirations) as well as weight gain. No negative effects were identified. Given these findings, incorporating different types of maternal voice into routine care by the bedside nurse can assist the mother in feeling more involved in her infant's care without seemingly being a distraction or obstacle to providers. Implications for Research: A major limitation for generalizability was sample size; more research is needed with larger sample sizes replicating interventions types to discern best outcomes. Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=31&autoPlay=true.

A Community Hospital NICU Developmental Care Partner Program: Feasibility and Association With Decreased Nurse Burnout Without Increased Infant Infection Rates Background: Volunteers can provide staff-directed sensory inputs to infants hospitalized in the NICU, but research on volunteer programs is limited. Purpose: To evaluate the feasibility of a developmental care partner (DCP) program in a level III NICU and determine its relationship with provider burnout and infant infection rates. Methods: DCPs were trained to provide sensory input to infants, based on the behavioral cues observed by the occupational therapists and nursing staff, in medically stable infants. Feasibility was assessed by documenting the process of training and utilizing volunteers, as well as tracking duration and frequency of DCP visits. Staff burnout measures were assessed using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) before and after implementation. Infant infection rates before and after the introduction of volunteers were compared. Results: Seventy-two volunteers were interested, and 25 (35%) completed the DCP competencies and provided sensory exposures to 54 neonates, who were visited an average of 8 times (range 1-15). Twelve (48%) DCPs did once-per-week visits, and 9 (36%) did at least 50 contact hours. MBI-HSS scores for staff emotional exhaustion (P < .001) and depersonalization (P < .006) were lower after DCP implementation. There were no differences in infant infection rates before and after DCP implementation (Fisher exact P = 1.000). Implications for Practice: Volunteer-based DCP programs may be feasible to implement in community hospitals and could help reduce staff emotional exhaustion and depersonalization without increasing the incidence of infant infections. Implications for Research: Future research on NICU volunteer programs with larger sample sizes and different infant populations is warranted.

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units Background: Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%. Purpose: This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC. Methods: A descriptive cross-sectional correlational study was completed among US quality improvement–focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs. Results: NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = −0.26, P = .049), as was colostrum for oral care (Rho = −0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003). Implications for Practice: Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount. Implications for Research: Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com