Neonatal Intensive Care Unit Team Research Articles

Perceptions of the Neonatal Intensive Care Unit team and the nursery about newborn pain

Perceptions of the Neonatal Intensive Care Unit team and the nursery about newborn pain

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project.

Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes. An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM. Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM. Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

Parent Preferences and Experiences in Advance Care Planning in the Neonatal Intensive Care Unit.

Our objective was to evaluate the preferences and experiences of bereaved parents around advance care planning (ACP) in the neonatal intensive care unit (NICU). Single-center cross-sectional survey of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021 was carried out. Chi-square, Fisher's exact, Fisher Freeman Halton, and Wilcoxin rank sum tests were used to evaluate differences between parents who did and did not receive ACP. Out of eligible parents, 40 out of 146 (27%) responded to our survey. Most parents (31 out of 33, 94%) rated ACP as being very important and 27 out of 33 (82%) reported having ACP discussions during their child's admission. Parents preferred initial ACP discussions to occur early in their child's illness trajectory with members of the primary NICU team, with most parents' experiences aligning with these preferences. Parents value ACP discussions suggesting a further role for ACP in the NICU. · NICU parents value and participate in advance care planning discussions. · Parents prefer advance care planning with members of the primary NICU, specialty, and palliative care teams. · Parents prefer advance care planning early in their child's illness trajectory.

Experiences of healthcare personnel with death in the neonatal intensive care unit: a systematic review of qualitative studies

ObjectiveTo synthesise evidence from qualitative studies on the experiences of healthcare personnel (HCP) in the neonatal intensive care unit (NICU) caring for dying neonates.MethodsWe conducted a systematic search, in accordance...

Assessing HeartSong as a Neonatal Music Therapy Intervention: A Qualitative Study on Personal and Professional Caregivers' Perspectives.

The music therapy HeartSong intervention pairs newborn infant heartbeats with parents' Song of Kin. Formal evidence on professional and personal caregiver perspectives of this intervention is lacking. This survey study evaluates the HeartSong music therapy intervention from parent and staff perspectives. A qualitative study assessing inclusion of HeartSong for family neonatal intensive care unit (NICU) care surveyed 10 professional caregivers comprising medical and psychosocial NICU teams anonymously reflecting their impressions of the intervention. Digital survey of parents/guardians contacted through semistructured phone interviews relayed impressions of recordings: subsequent setup, Song of Kin selection, and use of HeartSong, including thoughts/feelings about it as an intervention. Professional and personal caregivers valued the HeartSong intervention for bereavement support, family support, including parental, extended family/infant support, and to enhance bonding. Emergent themes: memory-making, connectedness/closeness, support of parent role, processing mental health needs of stressful NICU days, and subsequent plans for lifelong HeartSong use. Therapeutic experience was named as a crucial intervention aspect and participants recommended the HeartSong as a viable, accessible NICU intervention. HeartSong's use showed efficacy as a clinical NICU music therapy intervention for families of critically ill and extremely preterm infants, when provided by trained, specialized, board-certified music therapists. Future research focusing on HeartSong in other NICU populations might benefit infants with cardiac disease, parental stress, and anxiety attending to parent-infant bonding. Costs and time benefits related to investment are needed before implementation is considered.

Rudeness and civility in health care

Rudeness and civility in health care

The Use of Telehealth to Improve Handoffs Between Neonatologists and Primary Care Providers for Medically Complex Infants.

As part of the Supporting Pediatric Research Outcomes Utilizing Telehealth (SPROUT) collaboration, three institutions (University of California, Davis, Children's Hospital Colorado, and Children's Hospital of Philadelphia) sought to improve communication with primary care providers (PCPs) using telehealth. This project connected families of neonatal intensive care unit (NICU) patients, their PCPs, and their NICU team through telehealth to provide an enhanced hospital handoff. This case series reports four cases that exemplify the benefits of these enhanced hospital handoffs: Case 1: assisting with changing care plans after NICU discharge, Case 2: demonstrating physical findings, Case 3: incorporation of additional subspecialties through telehealth, Case 4: arranging care for remote patients. Although these cases demonstrate some of the potential benefits of these handoffs, further study is needed to determine acceptability of these handoffs and to see whether they impact patient outcomes.

The effect of sensory stimulation on apnea of prematurity

ObjectivesThe study aims to assess the effect of sensory stimulation on apnoea among premature newborns. MethodsThirty preterm newborns that were diagnosed with apnoea of prematurity, had a gestational age between 32 and 34 weeks, had low birth weight, and were appropriate for gestational age from 1200 to 2000 g were included in this prospective randomized study. Subjects were divided into two equivalent groups: a control group that received the standard care including nasal oxygen (one litre per minute) and caffeine citrate, and a study group that received the same care plus sensory stimulation (tactile, proprioceptive, and kinaesthetic). Participants’ heart rate, oxygen saturation, and apnoea frequency were measured by the neonatal intensive care unit team using a pulse-oximeter. The sensory stimulation sessions were 10 min, 3 times per day, totalling 30 min over a 7 day period. ResultsThere was a significant decrease in heart rate within both groups after receiving treatment from before treatment (p < 0.05), with no significant differences between the two groups. Furthermore, there was no significant difference in oxygen saturation within the groups after treatment compared with the levels before treatment, with no significant differences between the two groups (p > 0.05). Before treatment, there was a non-significant difference in the apnoea rate between both groups (p = 0.464), whereas there was a significant decrease in the apnoea rate of the study group after treatment compared with the control group (p = 0.031). ConclusionSensory stimulation applied with standard respiratory care can decrease the frequency of apnoea of prematurity.

Parents' Views to Strengthen Partnerships in Newborn Intensive Care.

Background: Parental involvement in their newborn's neonatal intensive care reduces stress and helps with the parent-child attachment, transition to home, and future development. However, parents' perspectives are not often sought or considered when adapting family-centered care in neonatal intensive care units (NICUs).Aim: To identify what parents believe helps or hinders their involvement in their newborn's care when admitted to our Level 3B NICU.Methods: Between August and October 2018, nine mothers and one father were interviewed during three 60- to 90-min audiotaped focus groups using a semi-structured interview tool. From the content analysis of the verbatims, three reviewers identified key themes that affected how involved parents could be in their newborn's care.Results: Parents provided examples of factors that facilitated or restricted their involvement. The analysis identified themes: (1) parent-staff interactions, (2) supportive/trustworthy healthcare professionals, (3) consistency in care and caring staff, (4) family, couple, and peer support, (5) newborn status, (6) resources and education for parents, (7) the NICU environment, and (8) academic and research participation.Conclusion: We identified a conceptual framework to allow our NICU team to prioritize working strategies to strengthen parental involvement in newborn care. In addition to implementing ways to involve parents, we need to address parents' satisfaction with their participation. These findings may help other investigators explore parents' expectations toward their NICU experience.

Being the Father of a Preterm-Born Child: Contemporary Research and Recommendations for NICU Staff.

Background: Most studies on parental reactions to a preterm birth and to hospitalization of the newborn in Neonatal Intensive Care Units (NICUs) have involved mothers. However, emotional responses and behaviors of fathers are equally important. Usually, the father is the first to meet the preterm newborn, to find out information about baby's condition and to communicate to the mother and other family members. In this context he is often left alone and can show psychological difficulties including affective disorders such as depression or anxiety. This paper describes the role of fathers in the NICU, the best practices to support fathers, and to explain the role of a psychologist in the NICU staff. Considerations and suggestions are provided on the difficulties encountered to support parents, with a focus on the role of fathers during the COVID-19 pandemic.Methods and Discussion: Considering contemporary research data and following an attachment perspective, we analyze the role of the father of a preterm-born child in the relation with the partner and in newborn caring. Research has shown that involving fathers in newborn care in NICU and at home is essential not only because it promotes the father/son attachment relationship and has positive effects on the psychological and somatic development of the newborn, but also for the health of the mother and whole family.Conclusion: Recommendations are provided to enhance the functions of fathers in the NICU, promote their involvement in the care of their infant, and interventions to prevent the manifestation of psychological suffering and/or perinatal affective disorders. The commitments of a psychologist in a NICU team are presented and require not only clinical skills, but also the ability to manage the emotional and relational difficulties of fathers, family and NICU staff. Considerations and suggestions are provided on the difficulties encountered by parents in the NICU during the COVID-19 pandemic.

Parental and staff experiences of restricted parental presence on a Neonatal Intensive Care Unit during COVID-19.

AimThe COVID‐19 pandemic had a significant impact on parental presence in the Neonatal Intensive Care Unit (NICU) during the first wave. The NICU team at the Rosie Hospital, Cambridge, endeavoured to explore the impact on parent and staff experiences of supporting parents throughout the period when visiting was restricted, between 13th August and 11th September 2020.MethodsBespoke surveys were designed following the first lockdown to gather information on the impact on staff and parents. The questions were developed in the context of initial observations and conversations with staff and parents.ResultsThe findings of this study have illustrated the extent of the restrictions on parental wellbeing and mood, with the restrictions having had an adverse effect on these. In addition, the findings illustrate the adverse effect that the parents reported due to the restricted presence in terms of their babies’ wellbeing, parent‐infant bonding, partners’ wellbeing, parental confidence, the ability to breastfeed confidently and parents’ access to the medical teams.ConclusionThe findings of this study have a number of clinical implications for parents and staff. Namely, the data supported the decision not to close NICU again during the second and third waves.

Neonates with Maternal Colonization of Carbapenemase-Producing, Carbapenem-Resistant Enterobacteriaceae: A Mini-Review and a Suggested Guide for Preventing Neonatal Infection.

Carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) are highly drug-resistant Gram-negative bacteria. They include New Delhi metallo-ß-lactamase (NDM)-producing carbapenemase (50.4% of all species in Ontario). Antibiotic challenges for resistant bacteria in neonates pose challenges of unknown dosing and side effects. We report two antenatally diagnosed CP-CRE colonization scenarios with the NDM 1 gene. The case involves extreme preterm twins who had worsening respiratory distress at birth requiring ventilator support, with the first twin also having cardiovascular instability. They were screened for CP-CRE, and a polymyxin antibiotic commenced. In the delivery room, neonatal intensive care unit (NICU) and the follow-up clinic, in collaboration with the interdisciplinary group, contact precautions and isolation procedures were instituted. None of the infants exhibited infection with CP-CRE. Consolidating knowledge with regard to CP-CRE and modifying human behavior associated with its spread can mitigate potential negative consequences. This relates to now and later, when travel and prolific human to human contact resumes, from endemic countries, after the current COVID-19 pandemic. Standardized efforts to curb the acquisition of this infection would be judicious given the challenges of treatment and continued emerging antibiotic resistance. Simple infection control measures involving contact precautions, staff education and parental cohorting can be useful and cost-effective in preventing transmission. Attention to NICU specific measures, including screening of at-risk mothers (invitro fertilization conception) and their probands, careful handling of breastmilk, judicious antibiotic choice and duration of treatment, is warranted. What does this study add? CP-CRE is a nosocomial infection with increasing incidence globally, and a serious threat to public health, making it likely that these cases will present with greater frequency to the NICU team. Only a few similar cases have been reported in the neonatal literature. Current published guidelines provide a framework for general hospital management. Still, they are not specific to the NICU experience and the need to manage the parents’ exposure and the infants. This article provides a holistic framework for managing confirmed or suspected cases of CP-CRE from the antenatal care through the NICU and into the follow-up clinic targeted at preventing or containing the spread of CP-CRE.

Incremental Improvements Can Reduce Alarm Fatigue in the Neonatal Intensive Care Unit.

Incremental Improvements Can Reduce Alarm Fatigue in the Neonatal Intensive Care Unit.

Parental perception of neonatal retro-transfers from level 3 to level 2 neonatal intensive care units

Objective The primary objective of this study was to determine the overall parental satisfaction with retro-transfers from a level 3 to a level 2 Neonatal Intensive Care Unit (NICU). The secondary objectives were to explore factors that caused parental satisfaction associated with retro-transfer and investigate the factors that could be modified to improve the retro-transfer process. Methods This is a retrospective cross-sectional study. Questionnaires were mailed to all parents of infants transferred from level 3 to level 2 NICUs from 2016 to 2017. Independent samples t-tests, Spearman’s rank correlations, and multiple logistic regression analyses were conducted to identify factors associated with parental retro-transfer satisfaction. Results Our response rate was 39.1% (n = 140). Of all parents, 64.29% parents were extremely satisfied with the overall retro-transfer process. In our bivariate analyses, multiple factors were found to be strongly associated with parental retro-transfer satisfaction, including parental level of education, the amount of notice and rationale given for the retro-transfer and the level of parental communication and engagement with their infant’s healthcare team before and after transfer. Multiple logistic regression analyses revealed that when questions regarding the retro-transfer were answered and the level 2 NICU team demonstrated a concrete understanding of the infant’s medical issues and history, parental satisfaction increased. Conclusion Majority of parents were satisfied with the retro-transfer process. However, close collaboration and ongoing and open lines of communication between parents and the level 3 NICU healthcare teams will increase parental retro-transfer satisfaction rates.

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care.

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

Attitudes and concerns of neonatologists and nurses to family-integrated-care in neonatal intensive care units in China.

BackgroundParents in China are denied visitation of their newborns in neonatal intensive care unit (NICU), leading to a prolonged period of parent-infant separation. The family-integrated care (FICare) model, which supports the integration of parents into the NICU team, is gradually being introduced in China. Considering resistance to the implementation of FICare, this study aimed to assess the attitudes and concerns of neonatologists and nurses towards FICare in China.MethodsUsing a before and after study design, a qualitative analysis was conducted to determine the perceptions and attitudes of medical professionals towards FICare in China. A total of 34 neonatologists and 94 nurses from 5 tertiary NICUs in China were enrolled. A self-developed questionnaire was used. The study steps included reading session and then survey for the first time (survey 1), a FICare getting buy-in education session (4 hours), a group discussion session, and finally repeat the questionnaire (survey 2). The surveys were completed by trained researchers regarding willingness, acceptance and concerns of implementing FICare in NICUs in China. Differences in attitudes towards FICare were compared between groups (Chi-square/correction for continuity).ResultsThere are positive responses in neonatologists and nurses regarding the necessity (Survey 1: 58.8% and 57.4%; Survey 2: 88.2% and 67.0%), feasibility (Survey 1: 17.6% and 19.1%; Survey 2: 32.3% and 34.0%), and interest in joining FICare (Survey 1: 82.4% and 83.0%; Survey 2: 97.1% and 85.1%). A higher proportion of neonatologists indicated that FICare could promote breastfeeding in the NICU comparing to nurses (Survey 1: 47.1% vs. 19.1%; Survey 2: 61.8% and 46.8% respectively). Most of the neonatologists and nurses are not sure whether FICare can shorten the hospital stay (Survey 1: 82.3% and 68.1%; Survey 2: 85.3% and 60.6%) or improve the doctor-patient relationship (Survey 1: 58.8% and 68.1%; Survey 2: 73.5% and 69.1%). Challenges concerning the implementation of FICare were identified as inadequate ward space, lack of human resources, and potential increases in nosocomial infection.ConclusionsThe getting buy-in education program in introducing new paradigms of neonatal care may help on how to design and implement more effective educational tools for FICare.

45 Helping the Helpers: Peer Critical Incident Stress Management for NICU Health Care Providers to Improve Resilience, Burnout and Patient Safety

Abstract Introduction/Background Health care providers in neonatal intensive care units (NICU) experience critical or distressing events that can overwhelm their usual coping skills and lead to significant stress. Ineffective support for health care providers dealing with critical incidents can lead to poor unit resilience, staff burnout and compromised patient care behaviours. A formalized peer program and process to address critical workplace incidents and support care providers, “Critical Incident Stress Management (CISM)” is used in many first responder professions. While there is growing interest in implementing peer CISM teams in critical care units, there is a lack of research describing the impact of CISM in NICU. Objectives This study examined the effect of implementing a multidisciplinary NICU health care provider peer CISM team on resilience, burnout, and team/safety culture in a tertiary NICU. Design/Methods Multidisciplinary team members were peer selected and formally CISM trained. Change management strategies were employed to introduce CISM to the NICU. All health care providers were invited to complete an anonymous online or paper survey before and 1 year after NICU CISM team implementation. The survey contained validated measures of resilience, burnout, and team/safety culture that were analyzed pre and post intervention. Results The response rate pre-intervention was 66% (114/172 staff) and 32% post (60/186 staff). Stress recognition significantly improved as fewer staff reported being less effective at work when feeling stressed post incident (74% vs 61%, pre and post CISM respectively, p&amp;lt;0.05) (Table 1). Fewer staff reported feeling burned out from their work (41% vs 31%, p=0.4), trending towards improved resilience (Table 1). Communication in the NICU significantly improved as staff indicated debriefing methods met their needs (38% vs 57%, p&amp;lt;0.05) and felt comfortable speaking up about safety concerns (66% vs 78%) (Table 1). Post-intervention, despite feelings of increased workload indicated by a significant decrease in agreement that “NICU staff levels were sufficient for patient load” (54% vs 33%, p&amp;lt;0.001), a majority of staff reported a supportive environment in the NICU (59% vs 77%, p=0.08) (Table 1). Work culture significantly improved as staff felt rewarded and recognized for improving quality (13% vs 31%, p&amp;lt;0.05) (Table 1). Conclusion Implementation of a peer CISM team led to improved NICU care provider resilience, stress recognition, and team culture, all of which can mitigate the effects of increased patient load. Findings from this research and knowledge gained from the CISM implementation process should be shared with other health care environments.

Preliminary Adaptation, Development, and Testing of a Team Sports Model to Improve Briefing and Debriefing in Neonatal Resuscitation.

We aimed to determine the effect of a team sports briefing model on the neonatal resuscitation team. Method: We adapted and redesigned a team sports briefing and debriefing model and related protocol and tested them with a neonatal resuscitation team in a U.K. university teaching hospital. The team's confidence and perceptions around these 2 aspects of resuscitation were studied along with frequency of task execution before and after a teaching intervention about the sports teams' approach to briefing and the introduction of a 7-point checklist. In 20 preintervention observations of 13 key tasks, areas for improvement in how neonatal intensive care unit (NICU) staff prepared for deliveries and potential resuscitations were found such as in "discussing potential deliveries that day" (n = 10, 50%), "identifying roles within the resus team that shift" (n = 5, 20%), and announcing when and where a debrief would occur (n = 0, 0%). Postintervention, the NICU team's mean task completion increased significantly from 9.23 (SD = 6.34) to 18.0 (SD = 1.83), a statistically meaningful difference of 8.77 (95% CI, 4.99-12.55; P < 0.001). Together with increased levels of confidence and efficiency reported postintervention, this provides some evidence that a brief-debrief process based on how sports team's approach pregame situations could be potentially transferable and beneficial to NICU team performance.

Decreasing radiographs in neonates through targeted quality improvement interventions.

ObjectiveOur aim was to decrease radiograph use for monitoring placement of peripherally inserted central catheters (PICC) and endotracheal tubes (ETT) in neonates admitted to the neonatal intensive care unit (NICU) by 20% from November 2017 to November 2018.Study designWe carried out three Plan-Do-Study-Act (PDSA) cycles: (1) implementation of a radiograph protocol emphasizing ideal patient positioning, standard radiograph views and frequency, (2) standardizing ETT depth using the NRP guidelines, and (3) implementation of an institution specific ETT depth guideline.ResultsThe pre-intervention radiographs per PICC day was 0.86 versus a post-intervention value of 0.46 (P = 0.004). The pre-intervention radiographs per ETT day was 1.45 versus a post-intervention value of 1.07 (P = 0.002).ConclusionsOur multidisciplinary NICU team performed a QI project, which resulted in more than a 20% decrease in the number of radiographs used for monitoring placement of PICCs and ETTs.

Shifting focus toward healthcare-associated bloodstream infections: The need for neonatal intensive care unit-specific NHSN definitions.

Healthcare-associated bloodstream infections (HABSIs) are a significant cause of mortality and morbidity in the neonatal intensive care unit (NICU) population. Our objectives were to review the epidemiology of HABSIs in our NICU and to examine the applicability of National Healthcare Safety Network (NHSN) definitions to the NICU population. We performed a retrospective review of all neonates admitted to the 54-bed, level IV NICU at Yale-New Haven Children's Hospital with a HABSI between January 1, 2013, and December 31, 2018. Clinical definitions per NICU team and NHSN site-specific definitions used for source identification were compared using the McNemar χ2 test. We identified 86 HABSIs with an incidence rate of 0.80 per 1,000 patient days. Only 13% of these were CLABSIs. Both CLABSIs and non-catheter-related bloodstream infections occurred primarily in preterm neonates, but the latter were associated with a significantly higher incidence of comorbidities and the need for respiratory support. The NHSN definitions were less likely to identify a source compared to the clinical definitions agreed upon by our NICU treating team (P < .001). Furthermore, 50% of patients without an identified source of infection by NHSN definitions were bacteremic with a mucosal barrier injury organism, likely from gut translocation. HABSIs occur primarily in premature infants with comorbidities, and CLABSIs account for a small proportion of these infections. With the increasing focus on HABSI prevention, there is a need for better NHSN site-specific definitions for the NICU population to prevent misclassification and direct prevention efforts.