Evidence-Based Development and Implementation of Postoperative Pain Management Guidelines in the NICU
Denise Holida, MA, ARNP, PNP-PC, NNP-BC
INTRODUCTION: The Unit-Based Quality Assurance Committee identified inconsistencies within the NNP team, pediatric residents, and among the neonatal staff with regard to individual perception of postoperative pain exhibited in the neonate and in the treatment management of postoperative pain in the NICU. In addition, postoperative pain medications were being ordered based strictly on provider preference. The purpose of the practice change was to develop an evidenced-based standardized postoperative pain management guideline for the NICU to be used by all providers.
METHODS: A review of the literature was completed on postoperative pain management for neonates, and morphine was identified as the drug of choice for postoperative pain management. Benchmarking was completed with 3 children's hospitals to evaluate their postoperative pain guidelines. A pain management survey was developed and sent to each NNP, neonatal fellows, and the neonatologists to obtain their baseline perception of recognizing postoperative pain in neonates and their management practices for postoperative with both intubated and nonintubated neonates. Thirty questionnaires were distributed, with a 40% return rate. The Postoperative Pain Management Guidelines for the NICU was developed. Implementation of the guidelines included staff education, posting of the guidelines in team workroom for quick reference, and posting on the neonatology Web site. An automated order set for the guidelines was built in EPIC (Epic Software Company, Verona, Wisconsin).
The evaluation process included pre- and postchart audits, a process evaluation tool completed by the NNP team, and follow-up interviews with the nursing staff.
RESULTS: Postimplementation chart audits demonstrate an increase in PRN morphine and around-the-clock Acetaminophen orders being written when compared with preimplementation chart audits. Results from the process evaluation tool indicate that NNPs feel that they have the knowledge to carry out the guidelines and that postoperative pain is being managed better on the unit as a result of implementing the guidelines. Follow-up interviews with the Unit-Based Quality Assurance Committee members indicate that the nursing staff feels that pain is being managed more consistently with the guidelines.
CONCLUSIONS: The evidence-based postoperative pain management guidelines do benefit the neonates in postoperative pain management in the NICU as the medical team and nursing staff have a standardized clinical practice guideline to utilize.
KEY WORDS: guidelines, neonate, pain, pain management, postoperative
Author Affiliation:Neonatal Intensive Care Unit, University of Iowa Children's Hospital, Iowa City, Iowa.
Correspondence: Denise Holida, MA, ARNP, PNP-PC, NNP-BC, Neonatal Intensive Care Unit, University of Iowa Children's Hospital, 200 Hawkins Drive, Iowa City, Iowa 52242 ().
The Process of Developing an Evidence-based Algorithm for the Prevention and Treatment of Diaper Dermatitis-Safe for Neonates of All Gestations, and the Evidence
Victoria Beall, BSN, RN, CWOCN
INTRODUCTION: An evaluation of the skin-care practices for neonates revealed that nurses were utilizing methods and products with varying effectiveness and appropriateness, to prevent and treat diaper dermatitis. Many of the products and methods were unit "traditions" and not evidence based. Developing an evidence-based algorithm would standardize skin-care products and methods and be safe for neonates of all gestations.
METHODS: A multidisciplinary taskforce was formed to review evidence-based resources specific to the neonate. Once the evidence was compiled, the taskforce evaluated skin-care products until products that satisfactorily met the evidenced-criteria were identified.
RESULTS: Products not included in the algorithm were products containing vitamin A, perfume, dyes, preservative, excessive ingredients comparatively, and powders. Barriers to implementation were nurses' resistance to change, as well as some taskforce-members lacked an understanding of evidence-based practice and how to obtain evidence-based resources. The director of research was brought to the taskforce as a guest speaker to update the taskforce regarding evidence and rating the quality of evidence. In addition, several taskforce members' became impatient with the process and wanted to put into place a nursing policy before trialing or in-servicing staff on the algorithm.
CONCLUSION: The taskforce reviewed evidence-based neonatal resources and developed an algorithm that utilized products and methodology that would be safe and effective and standardize nursing care for the prevention and treatment of diaper dermatitis for neonates of all gestations. As a result, the algorithm is now in each patient's bedside chart for staff to utilize, and appropriate products are now accessible to the staff.
KEY WORDS: algorithms, diaper rash, evidence-based nursing
Author Affiliation:Diamond Children's at University Medical Center, Tucson, Arizona.
Correspondence: Victoria Beall, BSN, RN, CWOCN, Diamond Children's at University Medical Center, Tucson, AZ 245116, and 1501 N Campbell Ave, Tucson, AZ 85724 ().
NICU Nurses as NICU Parents
Renee Fishering, MSN, CPNP-PC, NNP-BC
PURPOSE: To examine what was challenging and meaningful for NICU nurses who have also been NICU mothers, how they negotiated and coped with their roles as professional and as parent, and how their response differed from the responses of NICU mothers without professional NICU experience.
SUBJECTS: The NICU mothers who were also NICU nurses at the time their infants were admitted to the NICU were included. The NICU mothers who became NICU nurses after their NICU experience were excluded. Six nurses/nurse practitioners participated in this study.
DESIGN AND METHODS: This study utilized a narrative qualitative design to examine the lived experiences of these professional nurses who have had infants admitted to the NICU. Face-to-face taped interviews were conducted by using a semistructured interview format. The scheme for analysis was structural analysis. The responses were transcribed and analyzed by using both computer-assisted data analysis and manual analysis based on reading and rereading data both in complete transcripts and after preliminary analysis, in sections, by structural elements.
OUTCOME MEASURES: The model "Mothering in the NICU" developed by Heermann et al (2005) was used to organize themes under categories of focus, ownership, caregiving, and voice. This model describes the path that a mother takes from NICU outsider to engaged parent and serves as a framework for comparing the responses of NICU nurses and mothers without professional NICU experience.
CONCLUSIONS/IMPLICATIONS FOR PRACTICE AND RESEARCH: Examining these unique experiences gave us insight into how we can facilitate the transition from outsider to engaged parent. Mothers in this study went through the steps described in Heermann et al. However, they transitioned more quickly through the step of "Focus," and their experience of the technological aspects of the unit was less stressful. Also, all found their "Voice" and were advocates for their babies. Heermann et al described mothers who did not find their "Voice" and remained spectators to their infant's care.
Exploring the nurses' specific experiences also helped us understand how they influenced their current clinical practice. These nurses described a change in their perception and increased their empathy with NICU families.
The relationship between the staff and the mothers varied. Communication was dependent on both the nurses' and mothers' need for control over the situation. These personal and professional issues of control need to be closely examined to assess their impact on mothers finding their voice and becoming engaged partners in their infants' care.
KEY WORDS: attitude of health personnel, bonding, child advocacy, connection, infant/newborn, intensive care units, internal/external control, mothering, neonatal, NICU, nurses as parents, object attachment, parents, power (psychology, parenting/psychology)
Author Affiliation:St. Louis Children's Hospital, St. Louis, Missouri.
Correspondence: Renee Fishering, MSN, CPNP-PC, NNP-BC, St. Louis Children's Hospital, 1 Children's Place, NICU, 5th Floor, Neonatal Nurse Practitioner Office, St. Louis, MO 63110 ().
Hyaluronidase for the Treatment of Extravasations in Neonates
Kirsten Hanrahan, DNP, ARNP
INTRODUCTION: Extravasation or infiltration, the inadvertent administration of an agent into the tissue causing damage, is a recognized complication of intravenous (IV) therapy. The incidence of IV extravasations in neonates is 23% or greater, and consequences range from short-term inflammation to severe tissue necrosis. Hyaluronidase is a safe and effective treatment for neonates; however, there is no consensus regarding the specifics of treatment, resulting in regional and unit-based protocols, which vary greatly. The purpose of this project is to develop an evidence-based guideline, Hyaluronidase for Treatment of Extravasations, and implement it in a neonatal intensive care unit.
METHODS: Standardized methods were used to review evidence and develop a practice guideline. Strategies for implementing the guideline include tailoring the guideline to the population, multidisciplinary involvement and education, revised policies and procedures, a clinical algorithm and quick reference cards, automated computerized documentation and order sets, activation of clinical expertise to the bedside, and administration kits. Pre- and postimplementation data were collected from knowledge surveys, event reports, electronic medication administration records, and process evaluations. Descriptive statistics and control charts were used for analyses.
RESULTS: An online survey was used to test hyaluronidase knowledge. A total of 175 pediatric staff members participated in the baseline survey compared with 100 in the 6-month evaluation. Performance improved or remained more than 90% on 10 of the 10 knowledge questions, and areas in the need of continued improvement were identified. Practice patterns showed increased use of evidence-based interventions for extravasations. The number of reported extravasations that were treated with hyaluronidase increased from 20% (4 of 20) to 100% (7of 7). Medication administration records 6 months pre- and postimplementation showed that the administration of hyaluronidase for the treatment of an extravasation in the NICU increased from 5 to 14 events and time to treatment decreased from an average of 153 to 62 minutes. Control charts demonstrated a stable process, with special cause variation attributed to implementation of the guideline. Point-of-care providers who completed event reports were invited to complete process evaluations, averaged scores were 33.7 (range, 27-36; 9-36 possible; n = 11), indicating that they are well equipped to implement the guideline.
CONCLUSIONS: Hyaluronidase for the treatment of IV extravasations should be administered according to the best evidence. Neonates and health care providers and institutions benefit from decreased adverse outcomes. Further research about implementation, translation, and long-term outcomes in larger samples is needed.
KEY WORDS: extravasation of diagnostic and therapeutic materials, hyaluronidase, infusions, intravenous, neonate
Author Affiliation:University of Iowa Children's Hospital, Nursing Research and Evidence-Based Practice, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Correspondence: Kirsten Hanrahan, DNP, ARNP, University of Iowa Children's Hospital, Nursing Research and Evidence-Based Practice, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242 ().
Evaluating Differences in Light, Sound, and Perceptions in an Open-Bay Versus Single Family Room Design
Melissa Ohnich, BSN, RN, Jennifer Heatherly, BSN, RN, Shannon Graham, DNP, RN, AOCN, CNS
PURPOSE: To evaluate light and sound differences between an open-bay NICU and a single family room design (SFRD) unit, as well as evaluate the parents' perceptions of light, sound, and environmental stimuli between the 2 different style units.
SUBJECTS: Quantitative data were collected from 1 urban, level III NICU. Qualitative data were collected from the surveys of parents with infants in the same study by NICU.
DESIGN: This study used a pre- and postmethodology with a mixed-method approach. Quantitative data were collected by measuring light and sound levels in a level III NICU. Qualitative data were collected by having parents in the same NICU complete a survey looking at their perceptions of light, sound, and environmental stimuli.
METHODS: Light and sound measurements were taken at set intervals and predetermined locations for a period of 6 weeks in the open-bay NICU. Simultaneously, parents of NICU patients were asked to complete a "perception of light and sound" survey. After the move to the new SFRD unit, measurements were taken for 6 weeks and parents were asked to complete the same "perception of light and sound" survey.
RESULTS: After comparing data collected from both unit designs, it was determined that there is a statistically significant difference in light and sound measurements between an open-bay NICU and a SFRD unit. The parents' perception survey showed that the SFRD facility is viewed by parents to be quieter and less stimulating than the open-bay NICU.
CONCLUSIONS: Architectural design of the NICU can have an effect on light and sound as well as parents' perception of light, sound, and environmental stimuli. Moving to a SFRD unit can positively affect these extraneous factors, although even in an SFRD, the sound levels were found to be above the American Academy of Pediatrics recommended levels of less than 50 dB.
KEY WORDS: environmental stimulation, light, neonatal intensive care units, single family room design (SFRD), sound
Author Affiliation:Regional Neonatal Intensive Care Unit (RNICU) (Mss Ohnich and Heatherly), the University of Alabama (Dr Graham), Birmingham.
Correspondence: Melissa Ohnich, BSN, RN, Regional Neonatal Intensive Care Unit (RNICU), the University of Alabama, 1700 6th Ave South, Birmingham, Alabama 35249 ().
Is Milk Being Delivered at the Right Temperature? Nurses' Perception Compared to Actual Practice in the NICU
Jennifer Perkins, MS, RNC-NIC, NICU; Phyllis Lawlor-Klean, MS, RNC, APN/CNS; Jeanne Wiesbrock, BSN, RN, IBCLC
BACKGROUND: Evidence suggests that milk may be tolerated better when fed at body temperature (BT), yet there have been no studies reporting actual milk temperature at the time of delivery.
PURPOSE: To examine nurses' perception of milk temperature fed to NICU infants.
RESEARCH QUESTIONS: Is there a difference between nurses' perception and actual temperature of warmed milk?
METHODS: A descriptive study with convenience sample of nurses from 3 level III NICUs was performed. The Feeding Practices and Temperature Survey measured nurses' perception of feeding temperature by using a 6-point scale. Actual temperature tested by using an infrared thermometer was recorded along with the type of milk, method, nurses' stated milk temperature, and actual temperature.
MAIN OUTCOME MEASURES: Ideal temperature was reported as a range of 35.5[degrees]C to 37.2[degrees]C and more than 50% of respondents reported feeding temperature as clinically very significant (N = 141). Analysis of 419 temperatures showed syringes (M = 30.4[degrees]C +/- 2.6) were significantly different from bottles (M = 31[degrees]C +/- 3.1). The actual temperature and the nurse-reported perceived temperature were lower than BT (P = .000) and higher than room temperature (P = .000). Temperature at delivery ranged from 22 to 46.4[degrees]C.
PRINCIPAL RESULTS: Using the current methods of warming milk and formula in the NICU, nurses were not able to provide feedings to infants at a consistent temperature.
CONCLUSIONS: Current warming methods yield wide variation in milk temperature. Nurses' responses of ideal temperature are not consistent with actual temperature at milk delivery. Nurses play an integral role in maintaining consistency for infant feeding.
OBJECTIVES:
* To discuss the evidence to support-feeding milk at body temperature.
* To describe findings of study testing nurse perception and actual milk temperature at the time of delivery.
* To discuss practice implications involved in milk delivery.
KEY WORDS: bottle feeding, breast feeding, enteral nutrition, feeding methods, intensive care, neonatal
Author Affiliations:Advocate Good Samaritan Hospital, Downers Grove, Illinois (Dr Perkins); Advocate Christ Medical Center/Hope Children's Hospital, Oak Lawn, Illinois (Dr Lawlor-Klean); and Advocate Lutheran General Hospital, Park Ridge, Illinois (Ms Wiesbrock).
Correspondence: Jennifer Perkins, MS, RNC-NIC, NICU, Advocate Good Samaritan Hospital, 3815 Highland Ave, Downers Grove, IL 60515 ().
An Evidence-Based Approach to Improving Breastfeeding Outcomes in the NICU
Shakira Lita Ismay Henderson, MS, MPH, BSN, RNC-NIC, IBCLC
INTRODUCTION: A mother's success with breastfeeding is dependent on accurate lactation information, support from family, the health care system, and even society. The national goal set by Healthy People 2010 is aimed at breastfeeding initiation rates of 75%. However, breastfeeding initiation rates fall below national goals in infants admitted to the neonatal intensive care unit (NICU). It is estimated to be about 40%.The special lactation needs of this neonatal population, coupled with the lack of lactation knowledge and expertise of the health care team, create barriers to successful breastfeeding initiation rates in the NICU.
The NICU admission should not deter mothers from pursing their decision to breastfeed. The aims of this project were (i) to raise patient satisfaction scores with regard to nursing support of breastfeeding in our NICU, (ii) to improve the breastfeeding knowledge base of the nursing staff, and (iii) to create a culture of breastfeeding in our unit through active staff involvement.
METHODS: Six NICU nurses became certified as breastfeeding counselors. These nurses offered 1-to-1 lactation consults on night and day shifts to NICU mothers. The mothers were either referred by NICU nurses or self-referred by signing up on a sign sheet on the parent services bulletin board. Staff breastfeeding education was given in 10 minute in services at monthly staff meetings. A staff newsletter titled, Tips from the Breastaurant, was distributed monthly. Parent posters were made monthly and hung in the pumping room. Staff referrals of mothers were tracked monthly, and monthly staff referral champions were announced by e-mail and on unit banners.
One of the breastfeeding counselors served as coordinator and data collector for the project. Data were collected monthly on patient satisfaction, percentage of mothers who breastfed after consultation, percentage of mothers who pumped, and number of staff referrals.
RESULTS: Patient satisfaction rose from the 70th percentile to consistently 85th percentile and greater. An increase had not been seen beyond the 70th percentile for 6 years. Staff referrals were more than 20 per month. Breastfeeding initiation rates were 50% or more each month. The percentage of mothers who pumped breast milk for their infant was more than 50% each month.
CONCLUSION: This design can be easily implemented in any NICU. However, further research is needed to explore the impact of NICU nurse counselors on breastfeeding outcomes.
KEY WORDS: Breastfeeding, breastfeeding counselor, breastfeeding outcomes, evidence-based practice, neonatal intensive care unit, neonatal intensive care nurse, NICU, nurse counselor, patient satisfaction, staff referrals
Author Affiliation:Neonatal Intensive Care Unit, Miami Hospital-Baptist Health, Miami, South Florida.
Correspondence: Shakira Lita Ismay Henderson, Neonatal Intensive Care Unit, Miami Hospital-Baptist Health, 6200 SW 73rd St, Miami, FL 33143 (; ).
Reducing Unplanned Extubations in the NICU: A Planned Experimentation Study
Rachel Wiener, BAN, RNC-NIC; Lauren Heimall, MSN, RNC-NIC, PCNS-BC; John Chuo, MD, MS
BACKGROUND: In 2007, the rate of unplanned extubations (UE) in our NICU was documented as high as 23 per 1000 ventilator days. These events pose risk and morbidity to our neonatal patients. Many factors contributing to UE can be controlled, including how well the tape is secured onto the infant's face. A best-practice technique for securing an endotracheal (ET) tube does not currently exist, leading to practice variation associated with UE. A multidisciplinary team was formed to study the problem and explore solutions.
PURPOSE: To define a best practice for securing ET tubes by comparing different methods of ET tube securement in an attempt to reduce the incidence of UE in the NICU.
SUBJECTS: Thirty-eight patients admitted to the NICU between August 2009 and October 2009 who required oral intubation. A total of 154 taping events were studied.
DESIGN: We used a randomized, nonblinded planned experimentation study.
METHODS: We studied 4 combinations of taping methods by using 2 tape configurations and 2 combinations of a hydrocolloid barrier (duoderm). We used a YYY configuration and YHY configuration of tape and used a duoderm mustache or no-duoderm mustache. The combinations were printed on a data collection form and placed at the bedside. Each retaping event used the next combination specified on the form.
MAIN OUTCOME MEASURES: The amount of retaping time in minutes between each retaping event was measured.
PRINCIPLE RESULTS: The study did not demonstrate a significant difference between methods to secure an ET tube. There was no difference in retaping time found between the YYY method and the YHY method. A duoderm mustache was also not a factor in increasing retaping times. Therefore, a decision was made by our team to standardize to the hospital's policy of securing an ET tube with the YYY method of tape and no-duoderm mustache.
CONCLUSIONS: We found that the strategy for closing the practice gap is process standardization. Before the study, a staff survey found that more than 50% of staff preferred to use the YHY method, which resulted in low compliance by staff to the hospital standard of the YYY method. After the study, we successfully increased compliance with the YYY method to 100%. We found that continued staff education and reinforcement was needed to maintain that level of compliance.
KEY WORDS: endotracheal intubation, endotracheal tube securement, neonate, unplanned extubation
Author Affiliation:Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
The authors thank the members of the Unplanned Extubation Quality Improvement Team in the N/IICU at the Children's Hospital of Philadelphia.
Correspondence: Rachel Wiener, BAN, RNC-NIC, N/IICU, Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 ().
Job Satisfaction of Neonatal Intensive Care Unit Nurses
Kathleen McDonald, MSN, APRN, RN, C-CNS; Katie McDonald, BSN, RN; Lorraine Rubarth, PhD, APRN, NNP-BC; Linda Miers, PhD, APRN
PURPOSE: The purpose of this study is to describe the job satisfaction of neonatal intensive care unit (NICU) nurses.
SUBJECTS: Subjects studied were NICU nurses in attendance at an annual, regional NICU conference. All participants were women and worked in a hospital setting.
DESIGN: A descriptive, correlational design was used to study job satisfaction among NICU nurses recruited at the conference. A researcher-developed Likert-type questionnaire was used to collect data.
METHODS: The job satisfaction questionnaires were distributed at the conference, and consent was implied if the questionnaire was completed and returned the same day at the conference. No identifying information was collected. One hundred nine nurses responded to the questionnaire. The questionnaire format consisted of a researcher-developed survey consisting of 17 questions in a Likert-type response rating 1 to 5 and 1 question that allowed a written response. All submitted questionnaires were deemed usable. Descriptive statistics such as frequencies and correlations were used to analyze the resulting data.
PRINCIPAL RESULTS: The majority of participants were moderately satisfied overall in their current position and workplace (mean = 4.07).
MAIN OUTCOME MEASURES: Satisfaction was most affected by organizational support (t = 0.53), team spirit (t = 0.53), work environment (t = 0.50), and staffing levels (t = 0.46). Neonatal intensive care unit nurses are most satisfied with level of autonomy (mean = 4.17), communication between physicians and staff nurses (mean = 4.10), and with interdisciplinary communication (mean = 3.96). (Correlation is significant at the 0.01 level [2-tailed].)
CONCLUSIONS/SIGNIFICANCE: Job satisfaction and factors affecting satisfaction have been researched. Insight in to the job satisfaction of a group of NICU nurses has been obtained as intended. The majority of those surveyed were moderately satisfied. Factors most affecting job satisfaction included organizational support, team spirit, work environment, and staffing levels. The factors NICU nurses were most satisfied with included autonomy and communication. The small sample size (n = 109) of Midwest NICU nurses proved to be a limitation for application. Additional research is needed to evaluate nursing role, educational level, and job satisfaction in other parts of the United States.
KEY WORDS: job satisfaction, neonatal intensive care nurse, nursing job satisfaction, nurse satisfaction
Author Affiliation:Alegent Health Bergan, Mercy Medical Center, Neonatal Intensive Care Unit, Omaha, Nebraska.
Correspondence: Kathleen McDonald, MSN, APRN, RN, C-CNS, Alegent Health Bergan, Mercy Medical Center, Neonatal Intensive Care Unit, 7500 Mercy Rd, Omaha, NE 68124 ().