1. Section Editor(s): Dowling, Donna

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Heparinized Versus Normal Saline for Maintenance of IV Access in Neonates: An Evidence-Based Practice Change

Linda L. Cook, DNP, NNP-BC, APRN


PURPOSE: To design, implement, and evaluate an evidence-based practice change regarding the use of heparin in intravenous (IV) locks to improve patient safety. Phase I of the project examined dwell time, hours of patency, etc, for IV access devices prior to and following the practice change from heparinized saline (HS) to normal saline (NS) flush. Phase II of the project compared staff knowledge scores before and after an educational offering surrounding the practice change.


SUBJECTS: The setting was an 18-bed level III NICU located in the northeastern United States. A sample of 70 IV locks was included in the study, HS (n = 34) and NS (n = 36) respectively. Professional NICU staff (n = 40) were recruited for the educational offering.


DESIGN: A comparative descriptive design was utilized.


METHODS: The project compared the outcomes of neonates with IV locks flushed with HS and NS flush and evaluated the outcomes. A pretest/posttest design was used to analyze the change of the NICU staff's knowledge concerning heparin flush before and after an educational offering.


MAIN OUTCOME MEASURES: IV access device patency after practice change to NS flush and the change of the NICU staff's knowledge concerning heparin flush after an educational offering.


PRINCIPAL RESULTS: There was a statistically significant difference in IV catheter patency with NS flushed catheters averaging 13 hours longer than HS flushed catheters (P = .02). Also a statistically significant increase in mean scores was noted on the NICU staff posttest after the educational offering (P = .0001). There was a 20% increase in knowledge scores.


CONCLUSIONS: Findings from this project support the current literature base suggesting that the use of heparin is unnecessary for the maintenance of IV access devices. Unnecessary exposure of neonates to heparin increases risk to patient safety and should therefore be avoided. Future research should examine the use of heparin in central lines in neonates. Findings additionally support educating staff prior to practice changes.


KEY WORDS: heparin, normal saline, IV access, IV lock, neonate


Correspondence: Linda L. Cook, DNP, NNP-BC, APRN, 56 Rucuum Rd Ext, Woodbury, CT 06798 (


Author Affiliation: Danbury Hospital, Danbury, Connecticut.


Mothers' Experiences Expressing Breast Milk for Their Preterm Infants

Mary Ann Blatz, MSN, RNC-NIC, IBCLC


INTRODUCTION: Extensive research supports benefits of breast milk for hospitalized infants. It is essential issues related to milk expression be explored to develop interventions that will promote provision of breast milk. Neonatal intensive care units have begun to change from multibed rooms to single-patient rooms.




1. Examine differences in outcomes of provision of mothers' milk before and after conversion to a single-patient room NICU.


2. Describe issues related to long-term milk expression.



SUBJECTS: Forty-three mothers, who met inclusion criteria (age > 18 years of age, read and write English, initiated milk expression), provided data. Mean maternal age was 26.5 years (range, 18-39). Infant inclusion criteria included >= 24 weeks' gestational age; have expected duration of hospitalization >= 1 week; and no condition incompatible with feeding. Infant gestational age was 32.1 weeks (range, 23-40).




DESIGN: descriptive comparative.


Group 1: recruited for 3 months before opening a single-bed NICU


Group 2: recruited for 3 months afterward


Setting: level IV NICU.




1. What issues related to milk expression are identified by mothers of hospitalized infants before and after conversion?


2. What are differences in frequency of milk expression sessions by mothers of hospitalized infants before and after conversion?



PRINCIPAL RESULTS: Issues related to milk expression were: privacy was the most important factor in determining pumping location preference; determination to do what was "best for baby" was a key motivator; and the theme identified by mothers as for what made pumping routinely difficult was "time constraints." There were no significant differences found in duration of provision of breast milk (M = 28.1 and 21.7 days, respectively; t = 0.857, P = .397) between two groups. There were no significant differences in percent of infants receiving only breast milk at discharge (75% and 60.9%, respectively; [chi]2 = 2.49, P = .287). An independent samples' t test found no significant differences in frequency of milk expression sessions during first week (pumpings per week) (M = 32.1 and 35.8, respectively; t = -0.678, P = .504) and second week (pumpings per week) (M = 43.5 and 40.8, respectively; t = 0.322, P = .751).


CONCLUSIONS: The small sample size may explain nonsignificant findings. Mothers' perceptions of "privacy" were not as expected. More research is needed to examine mothers' ideas on how to address their needs.


KEY WORDS: milk, human, infant, newborn, NICU


Correspondence: Mary Ann Blatz, MSN, RNc-NIC, IBCLC, Neonatal Intensive Care Unit, University Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106 (


Author Affiliation: Neonatal Intensive Care Unit, University Hospitals Case Medical Center.


Examining the Relationship Between Positioning Postextubation and Rate of Reintubation in VLBW Infants: A Retrospective Chart Review

Laura Hehemann, BSN, RN


BACKGROUND: Body positioning of very low-birth-weight (VLBW: BW < 1500 g) infants postextubation can significantly affect their pulmonary function and oxygenation and may increase their risk for reintubation. Optimal positioning strategies by NICU nurses may promote a successful extubation; however, the best position postextubation is unknown.


PURPOSE: To determine whether prone positioning postextubation was associated with extubation success, and whether a "successful" extubation was associated with more time in prone position.


SUBJECTS: Fifty VLBW infants admitted to the NICU from October 1, 2006, through January 1, 2007, who required mechanical ventilation.


DESIGN: A retrospective study approved by the NorthShore University Health System institutional review board.


METHODS: Electronic medical records of subjects were reviewed regarding body positioning during the immediate 48-hour period following extubation. Statistical methods included Wilcoxon 2-sample test, exact Mantel-Haenszel test, and Fisher exact test.


MAIN OUTCOME MEASURES: We defined outcome measures as "success" if the baby was still extubated at 48 hours, and "failure" if the baby was reintubated before 48 hours. Demographic characteristics, type of oxygen therapy postextubation, and use of caffeine preextubation were also collected.


PRINCIPAL RESULTS: Ninety-two percent of infants (46/50) remained extubated (success) during the 48-hour postextubation period, while 8% (4/50) failed. Successful infants had nonsignificant shorter median time (hour) in supine position (17.5 vs 24) but longer in left (12 vs 7.15) and right (15.5 vs 8.13) positions. None of the failed infants had prone position. If defining time in position prone ("P") as 0 versus less than 50% versus 50% or more of total time, it is marginally associated with success (P = .073). When P was defined as never, versus any, the association was significant (P = .046). No association between preextubation caffeine use and outcome was found. The majority of infants (32/50, 65%) was placed on Nasal Continous Positive Airway Pressure (NCPAP) immediately after extubation and also had umbilical lines in place (umbilical arterial catheter 64.6% and umbilical venous catheter 70.8%).


CONCLUSIONS: The failed rate (at 48 hr postextubation) for this cohort of VLBW infants was less than 10%. Any time in prone position was associated with a "successful" extubation. All failed infants were never placed in prone, with nonsignificant longer time in position "S" but shorter time in positions "L" and "R." Limitations include the fact that the observation period was limited to the immediate 48 hour-postextubation period, the inability to detect further association or confounding due to only 4 failed babies. Despite limitations, this study provides information for future prospective trials.


KEY WORDS: neonate, NICU, reintubation, VLBW


Correspondence: Laura Hehemann, BSN, RN, Infant Special Care Unit NorthShore University Health System, Evanston Hospital, 2650 Ridge Ave, Evanston, IL 60201 (


Author Affiliation: Infant Special Care Unit, NorthShore University Health System, Evanston Hospital, Evanston, Illinois.


Near Infrared Spectroscopy Measure of Brain Activation in Premature Infants in an Incubator and During Kangaroo Care

Jackie B. Martin, DNP, RN, NNP-BC, CCNS


Susan M. Ludington-Hoe, PhD, RN, CNM, FAAN


PURPOSE: Because premature infants are highly susceptible to cerebral lesions due to cerebrovascular immaturity, knowing the effects of maternal-infant separation (infant in an incubator) and nonseparation (infant in kangaroo care [KC]) on cerebral hemodynamics is important. Cerebral hemodynamics are reflected in cerebral oxygenation (rSO2) values. The purposes were to describe and compare cerebral oxygenation as measured by near-infrared spectroscopy during incubator and KC periods.


SUBJECTS: Ten premature infants, 5 male and 5 female, mean birth weight of 1487.5 g (range, 1076-2218), mean gestational age of 304/7 weeks (range, 275/7-331/7), mean entry weight of 1764.9 g (range, 1380-2341), and mean postconceptional age of 334/7 weeks (range, 311/7-346/7) participated when oxygen support was off.


DESIGN: A within-subject controlled descriptive comparative study using a crossover design.


METHODS: Randomization was by Zellen Sealed Envelope Technique. After vital signs and feeding, the near-infrared spectroscopy sensor (Somanetics, Inc, Troy, Michigan) was placed on the left forehead and a pulse oximeter (Nellcor Boulder, Colorado) on the left foot. The infant was placed prone in KC or in the incubator for the first data collection episode of 90 minutes. Infants remained in KC or incubator until the next vital signs and feeding were completed. Then the infant was placed in the opposite condition. Data were again collected for 90 minutes and monitoring equipment was removed.


OUTCOME MEASURES: Heart rate, respiratory rate, oxygen saturation, regional cerebral oxygenation, infant behavioral state (Brazelton NBAS scale), and presence/absence of environmental noise data were collected each minute throughout both 90-minute periods in a multibed NICU in which only a fabric screen separated the infant from the NICU.


RESULTS: During KC, as compared with incubator care, respiratory rate, regional cerebral oxygenation, and percentage of time in "quiet sleep" decreased. Percentage of time in "agitation" increased, as did the number of times loud noises were present. No changes were noted in heart rate nor oxygen saturation between sequences and periods. No residual or crossover effects of KC on rSO2 were present, and rSO2 remained within clinically acceptable range at all times.


CONCLUSION: Lower regional cerebral oxygenation during KC indicates a calming brain deactivation effect, even in the presence of increased behavioral agitation that was most likely due to extreme environmental noise frequency. When KC ended, the increase in rSO2 signaled an increase in sympathetic control of cerebral hemodynamics.


KEY WORDS: cerebral oxygenation, kangaroo care, near- infrared spectroscopy


Correspondence: Jackie B. Martin, DNP, RN, NNP-BC, CCNS, Carilion Clinic, NICU-14 South, 1906 Belleview Ave, Roanoke, VA 24014 (


Author Affiliations: NICU, Carilion Clinic, Roanoke, Virginia (Dr Martin) and Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Ludington-Hoe)


Funding: Supported in part by a Carilion Research Acceleration Program (RAP) Grant


Compensatory Strategies Reported to Increase Sleep in Parents of Twins

Jurarat Mesukko, MNS,; Elizabeth Damato, PhD, RN, CPNP; Jennifer Brubaker, MSN, RN, FNP-BC; Lauren Flaherty, BSN, RN; Srimana Niyomkar, MNS


PURPOSE: To identify strategies parents found to be effective in increasing their sleep during the early postpartum period and to examine the relationships between commonly reported strategies and total sleep time. Parents are at risk for sleep deprivation while attempting to meet the childrearing needs of 2 newborn infants. Consumer publications directed toward multiple-birth families offer several approaches to increase sleep but none are empirically supported for their effectiveness.


SUBJECTS: A convenience sample of 49 mothers and 42 fathers of twins was recruited from 4 delivery hospitals in a Midwestern city.


DESIGN: Secondary analysis of data obtained during a larger descriptive correlational study of sleep patterns in parents of twins.


METHODS: Longitudinal data were collected 3 times in home visits during the first 12 weeks following infant hospital discharge.


MAIN OUTCOME MEASURES: Total sleep time was measured using wrist actigraphy. Interpretation of wrist actigraphy is based on fewer limb movements occurring during sleep versus wakefulness. Sleep diaries were used in editing actigraphy data. Parents' strategies to increase sleep were collected from a checklist provided in the sleep diary.


PRINCIPAL RESULTS: The twins were the only children for 40.8% of the sample. Strategies were grouped into categories of changes to parent habits, modifications of infant care routines, modifications of infant sleep environment, and cooperation with partner or other alternate caregivers. For all 3 times, parents were most likely to report that modified infant care routines were most effective in increasing their sleep. Modified infant routine care included cosleeping with one or both twins, feeding twins at the same time (one baby per breast or propping bottles), letting the babies "cry it out," keeping the babies awake in the late evening, keeping the babies on the same eating and sleeping schedule, and limiting infants' day time napping. Reported strategies did not correlate with total sleep time except at time 3 for mothers, when changing parent habits were moderately related to total sleep time (r = 0.33, P = .035). Changing parent habits included going to bed earlier, sleeping while the babies slept, and napping while someone else watched the babies and did housework.


CONCLUSIONS: The findings provide neonatal nurses with empirically based strategies to include in discharge teaching for parents of twins. Additionally, results of this analysis provide preliminary evidence for further development and testing of interventions to improve sleep in parents of twins.


KEY WORDS: infant, maternal, multiple birth offspring, parenting, postpartum, sleep, sleep deprivation, twins


Correspondence: Elizabeth G. Damato, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106 (


Author Affiliation: Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.


Funding: This project was supported by the National Institute for Nursing Research, National Institutes of Health (R15-NR009797), and the Foundation for Neonatal Research and Education, both awarded to E. Damato.


Translation and Evaluation of an Instrument to Measure Parental Satisfaction With Quality of Care in Neonatal Follow-up Programs

Michelle Butt, PhD, RN


PURPOSE: The purpose of this research was to develop and evaluate the psychometric properties of a French-Canadian language instrument to measure parental satisfaction with quality of care in Neonatal Follow-up (NFU) programs based upon the Parent Satisfaction Questionnaire for Neonatal Follow-up (PSQ-NFU; Butt et al, 2009). Specifically, the objectives were (a) to translate the English version of the PSQ-NFU to French and (b) to establish the reliability and validity of the new French-Canadian language instrument.


SUBJECTS: A purposive sample of 8 parents and a convenience sample of 52 bilingual parents from an urban NFU clinic in Quebec, Canada, participated in the study's instrument pretesting and psychometric testing phases, respectively.


DESIGN: The methodological approach for the cross-cultural translation and validation of measurement scales developed by Vallerand (1989) was utilized.


METHODS: First, the PSQ-NFU was translated to French and back-translated by professional translators, and the 2 versions were compared by 3 researchers and the translators to ensure the meaning of instrument items had not changed. The new French instrument was then pretested with parents to assess item clarity. Next, the instrument's psychometric properties were assessed by administering it to the convenience sample of parents on 2 occasions: immediately prior to their clinic appointment, and 1 week later via a mailing to their residential address. Completion of the instrument on 2 occasions allowed for assessment of its test-retest reliability. The administration of both an English and a French-Canadian version in the clinic allowed for construct validation via a comparison of the responses to the 2 versions.


MAIN EVALUATION MEASURES: Instrument clarity and its reliability and validity were assessed.


PRINCIPAL RESULTS: Parent pretesting indicated that the instrument had good comprehensibility. Test-retest reliability revealed an intraclass correlation coefficient of .71. The internal consistency of the French PSQ-NFU was high, with an overall instrument Cronbach alpha of 0.93. The Cronbach alpha for each of the instrument's 2 subscales, process and outcomes, was 0.86 and 0.87, respectively. Construct validity testing revealed, as hypothesized, a very high correlation between the French and English versions of the instrument (Pearson's r = 0.97, P < .001).


CONCLUSIONS: Initial testing of the French language PSQ-NFU indicates it has adequate psychometric properties to be utilized as a measure of parental satisfaction with quality of care in NFU. Further testing of the instrument's psychometric properties with a larger, more heterogeneous sample and using diverse approaches to construct validation are important considerations for future research.


KEY WORDS: instrument development, instrument evaluation, instrument translation, neonatal follow-up, parent satisfaction, quality of health care


Correspondence: Michelle Butt, PhD, RN, Room HSC-2J33, 1200 Main St West, Hamilton, ON L8N 3Z5, Canada (


Author Affiliation: School of Nursing, McMaster University, Ontario, Canada.


Acknowledgements: The author acknowledge the contribution of research team members Dr Janet Pinelli, Dr Noori Akhtar-Danesh, and Dr Ermelinda Pelausa; nursing research student Ms Margaret Bean; and the parents who graciously participated in the study. This research was funded by a McMaster University School of Nursing Pilot Project Grant.


Preschool Children's Reactions to the Birth of a Preterm Sibling

Joanne J. Casatelli, DNP; Donna A. Dowling, PhD; Marjorie M. Heinzer, PhD; Barbara Morrison, PhD; Valerie A.B. Toly, PhD


The birth of a preterm baby is a crisis experience for all family members, yet the reactions of the infants' siblings have not been extensively explored. Understanding of their reactions is necessary before interventions can be developed.


PURPOSE: The purpose of this study was to investigate children's reactions to a preterm sibling's birth as depicted in their artwork and narratives.


RESEARCH QUESTION: The research question was: What are the reactions of preschool children to the birth of a preterm sibling as expressed by Kinetic Family Drawings (KFD)?


DESIGN: A descriptive, exploratory design was employed.


SUBJECTS: A purposive sample (n = 7) of preschool children subjects, 3 to 6 years old, was recruited from families with an infant hospitalized in a tertiary level NICU.


METHODS: After written informed consent was obtained from a participating parent, the children were asked to draw a picture of their family and then asked to describe it and identify family members. The research session was audiotaped and transcribed. Parents completed the Family Information Survey (FIS), which collected data on demographics, the child's previous exposure to stress, and situational factors that could impact the experience.


Analysis: The children's drawings were analyzed by the PI, an art therapist, and a child psychologist using the KFD Rating Scale. Results were derived from analysis of the children's artwork, the narratives, and data from the FIS. In their artwork, the children showed evidence of regression and stress. This regression was demonstrated by the immaturity of the figures, lack of extremities, and minimal detail. The small size of the "self" figure and its positioning within the group may reflect the subject's poor self-esteem or invisibility within the family. Omission of the baby in many of the KFDs could represent a lack of sibling bonding or that the baby was not yet incorporated into the family. The subject's choice of color was often purposeful and favorite colors were integrated in a meaningful way in the drawings.


CONCLUSIONS: With the focus of nursing practice on holistic family-centered care, the needs of all family members must be addressed. Further research is warranted to explore, identify, and explain these phenomena so appropriate nursing strategies to help siblings and their families can be formulated.


KEY WORDS: family, infant, sibling children preschool, premature


Correspondence: Joanne J. Casatelli, DNP, North Shore University Hospital, 300 Community Drive, Manhasset, NY (


Author Affiliations: North Shore University Hospital, Manhasset, New York (Dr Casatelli); and Case Western Reserve University, Cleveland, Ohio (Drs Dowling, Heinzer, Morrison, and Toly).


Oxygen With Love: Reducing the Need for Laser Surgery With Oxygen Saturation Targeting

Marianne F. Chybik, MSN, RNC-NIC, APN/CNS


Barbara Hering, MSN, RNC-NIC, APN/CNS


Lisa Festle, MSN, RNC-NIC, APN/CNS


INTRODUCTION: A complication associated with oxygen delivery is Retinopathy of Prematurity (ROP), affecting the retinal blood vessels of premature infants. In these patients, retinal blood vessels develop abnormally when exposed to oxygen. The most advanced form of ROP leads to retinal detachment and blindness, affecting approximately 500 infants yearly in the United States. Recent research demonstrates that maintaining SaO2 levels within physiologic limits reduces complications associated with oxygen delivery. Research indicates great variability in the rate of ROP at different NICUs, suggesting that individual centers are monitoring and controlling SaO2 levels differently. A 50-bed level III NICU at an academic medical center compared its rates of severe ROP and laser surgery to data from the Vermont Oxford Network (VON) and noted that the center's rates were within the upper limits (75th quartile) of VON data. A task force was formed to review current research in order to develop a best practice guideline. Following implementation of the guideline, a direct effect on patient outcomes was noted.


METHODS: Because of growing awareness that clinical practice change was necessary to decrease the incidence of ROP, a team of nurses reviewed current research and adapted practice guidelines by Dr Jay Goldsmith (2004). An education program was developed for the NICU staff. Included was the seminal research by Dr Lily Chow (2003), suggesting that clinical practices could decrease the incidence of severe ROP in very low-birth-weight (VLBW) infants. Following staff education, the multidisciplinary team agreed to set specific SaO2 ranges and alarm limits for patients based on gestational age. In order to educate staff and families, the acronym OWL (Oxygen With Love) was implemented to serve as a reminder of appropriate SaO2 parameters.


RESULTS: The severity of ROP and the incidence of laser surgery rate in the NICU are now below the 25th quartile of VON data. Benefits to the patients include decreased length of stay, no surgery, and in the long term, better eyesight.


CONCLUSIONS: Since implementation of the SaO2 guidelines, nurses have provided suggestions to improve compliance, and the guidelines have been adjusted based on that input, assuring ownership of the protocol. Following the dramatic decrease in the rate of ROP and laser surgery in the NICU, the team plans to continue intermittent compliance audits. The laser surgery rate is monitored, and cases are reviewed for opportunities for improvement. Benchmarking data is used to ensure assess further opportunities for improvement.


KEY WORDS: neonatal oxygen saturation, retinopathy of prematurity, very low-birth-weight infant


Correspondence: Marianne F. Chybik, MSN, RNC-NIC, APN/CNS, Loyola University Medical Center, Ronald McDonald Children's Hospital, Neonatal Intensive Care Unit, Bldg 107, Room 5822, 2160 S. First Ave, Maywood, IL 60153 (


Author Affiliations: Loyola University Medical Center, Ronald McDonald Children's Hospital, Maywood, Illinois.


Implementing Kangaroo Care: Creating Evidence-Based Practice

Barbara Morrison, PhD, RN, CNM, FNP


INTRODUCTION: "Place the newborns skin-to-skin with their mothers immediately after birth (birth kangaroo care [BKC]) allowing enough uninterrupted time for mother and baby to start breastfeeding well." Forty years of research has provided significant evidence for the efficacy of BKC, the new national and international standard of care. For newborns, BKC quickens stabilization, enhances attachment and bonding, improves sleep, and hastens self-regulation. For mothers, BKC decreases bleeding, increases maternal self-confidence and sense of mothering, and improves mutual regulation. Meeting Healthy People 2020 breastfeeding objectives can be accomplished only by providing BKC and continuing KC through the postpartum. Powerful research evidence documents how BKC with or without breastfeeding significantly improves breastfeeding initiation, exclusivity and duration. However, implementing KC means dramatic changes to current practices and to the paradigm of mother-newborn care. Therefore, the purpose of the practice change was to implement BKC as routine care for all newborns.


METHODS: A committee including staff nurses, clinical educator, unit managers, nursing administration, chiefs of obstetrics, and pediatrics, and 3 faculty members from a local university (KC and breastfeeding experts) joined together to envision a model of immediate postbirth care emphasizing nonseparation of mother and newborn. Using principles of quality improvement, the committee explored the evidence related to KC, detailed current practice, dreamed of ideal practice, established benchmarks for assessing practice change, discussed measures for overcoming potential and real barriers, planned and implemented KC training sessions for all nurses, and crafted KC policy.


RESULTS: Fifteen months after the KC Task Force was created the first group of trained nurses began implementing BKC in September 2008. Between April 2008 and April 2009 there was a 5-fold increase in the number of dyads doing some BCK (P = .000). Significantly more mothers declared an intent to breastfeed (P = .02) and more dyads were discharged breastfeeding (54.2% to 60.5%). Parental responses were unanimously positive. Nurses are still learning to trust the BKC and to assess newborns and mothers while in KC. Physicians, having seen parent's reactions, are requesting KC be implemented throughout hospitalization.


CONCLUSIONS: Implementing BKC may seem intuitive, but successfully changing practice is a very complex process. After 3 years the journey to full implementation is far from complete. Implementing BCK in other birthing centers will be similar, but each institution will have unique challenges, barriers, and accomplishments. Nurses have the ability and power to make the necessary practice and culture changes to implement evidence-based care.


KEY WORDS: breastfeeding, birth evidence-based practice, kangaroo care, implementation


Correspondence: Barbara Morrison, PhD, RN, CNM, FNP, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106 (


Author Affiliation: Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.