Implementing SBIRT to Address Maternal Marijuana Use.

A quality improvement project conducted at 3 Texas hospitals to implement a new systematic process to address maternal marijuana use among breastfeeding mothers. The new process was created using the evidence-based Screening, Brief Intervention, Referral to Treatment (SBIRT) model to address maternal marijuana use. Nurses screened all postpartum mothers for marijuana use at each of the 3 hospitals. Mothers who reported ever using marijuana were advised to abstain while breastfeeding and given educational materials and a treatment referral card. Among all 3 hospitals, the mean nurses' adherence to the SBIRT process was 69 percent, exceeding the project aim of 50 percent adherence. SBIRT, which has been used extensively with other populations and settings, was easily translated into practice for use with postpartum mothers who reported using marijuana. A systematic process using SBIRT may help mitigate the risk of harm for infants of mothers who use marijuana.

Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries.

BACKGROUND: Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use. PURPOSE: To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time. METHODS: An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months. RESULTS: The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time. IMPLICATIONS FOR PRACTICE: A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse. IMPLICATIONS FOR RESEARCH: Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Implementing a QAPI framework for improvement in an academic setting: A roadmap to success.

Designation as an accredited school of nursing (SON) requires "…. a comprehensive framework for ensuring quality in nursing education programs" (NLN CNEA, 2016). Although standards for accreditation of baccalaureate and graduate nursing programs are defined by agencies such as the Commission on Collegiate Nursing Education (CCNE, 2018) and the National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) (NLN CNEA, 2016), methods for collecting, analyzing, or reporting data are not prescribed, resulting in wide variation in quality management processes among schools. The lack of a standardized approach can lead to inefficiencies, invalid or misleading data, and unnecessary stress for all involved in the quality management process (Hanna, Duvall, Turpin, Pendleton-Romig, & Parker, 2016). In contrast, hospitals and nursing homes frequently implement a quality assurance and performance improvement (QAPI) program, a well-defined, methodical approach to quality management. The QAPI model offers healthcare organizations a systematic, comprehensive, and data-driven strategy for maximizing outcomes (Centers for Medicare & Medicaid Services (CMS), 2016). Recognizing the need to improve and standardize the processes for data collection, analysis, and reporting, this paper describes how leaders at one accredited SON collaborated to translate CMS's QAPI model into the academic setting, establishing the foundation and mechanism to ensure the quality and integrity of the SON's outcomes.

Implementing a clinical protocol using breastfeeding to mitigate vaccination pain in infants.

BACKGROUND: Although an effective public health intervention and a routine pediatric practice, vaccines are a common source of iatrogenic pain in childhood. Techniques, such as exam table restraint may cause infants to struggle and heighten distress, but studies demonstrate that breastfeeding and lap holding are effective strategies to reduce injection pain during vaccination. LOCAL PROBLEM: Adoption of pain-relieving techniques into clinical practice is often underutilized. In a pediatric clinical practice in southern Connecticut, there were no guidelines for providing pain mitigation strategies, including breastfeeding, during infant vaccination. METHODS AND INTERVENTIONS: The Plan-Do-Study-Act (PDSA) cycle was used for the improvement process. A clinical protocol introduced breastfeeding as a pain-relieving strategy during vaccination; lap holding was a second option. All clinical staff were educated on the infant pain experience, and nurses were further trained on vaccine administration techniques during breastfeeding. RESULTS: A total number of 354 infants were seen for vaccination during the 12-week project: 168 were breastfed infants, of which 53% were breastfed during vaccination; 234 were placed on the parent/caregiver's lap during vaccination; and only 13 infants were restrained on the exam table. There was no documentation of position for 18 infants. CONCLUSIONS: A clinical protocol was an effective tool to guide nurses on pain-relieving options, such as breastfeeding and lap holding, during vaccine administration. Positive experiences during vaccination administration have the potential for short-term and long-term benefits including, compliance with routine care and adherence to vaccination schedules.

Intrauterine Tobacco Smoke Exposure and Congenital Heart Defects.

Tobacco use and second-hand smoke exposure during pregnancy are linked to a host of deleterious effects on the pregnancy, fetus, and infant. Health outcomes improve when women quit smoking at any time during the pregnancy. However, the developing heart is vulnerable to noxious stimuli in the early weeks of fetal development, a time when many women are not aware of being pregnant. Congenital heart defects are the most common birth defects. Research shows an association between maternal tobacco exposure, both active and passive, and congenital heart defects. This article presents recent evidence supporting the association between intrauterine cigarette smoke exposure in the periconceptional period and congenital heart defects and discusses clinical implications for practice for perinatal and neonatal nurses.

Postnatal steroids for the treatment of bronchopulmonary dysplasia: a complex case presentation.

Postnatal steroids are a controversial intervention for the prevention and treatment of bronchopulmonary dysplasia in preterm infants. Studies demonstrating a potential for steroid-related adverse effects, including growth and neurodevelopmental impairment, have significantly changed clinical practice over the past decade. There are circumstances in which the potential benefits may outweigh the risks associated with postnatal steroids. This case presentation details the hospital course and treatment plan for an extremely low-birth-weight infant who remained ventilator dependent at the age of 3 weeks. Evidence-based research, American Academy of Pediatric recommendations, and collaboration with the family helped guide the plan of care. Following a short course of low-dose dexamethasone, the infant was successfully extubated. The case highlights the importance of using clinical judgment based on research and family preferences to benefit the patient.

Controversy and evidence about nicotine replacement therapy in pregnancy.

Nicotine replacement therapy (NRT) is effective for smoking cessation, but much controversy surrounds its use during pregnancy. The importance of finding ways to help pregnant smokers quit is undisputed, since smoking during pregnancy causes harm to the mother and the fetus, with effects of smoke exposure extending into childhood. Researchers and providers are divided, however, with respect to opinions of safety and efficacy of NRT use in pregnant smokers. The research-based evidence on the topic is limited, but there are studies examining the efficacy of NRT in pregnancy. This article presents the evidence for this smoking cessation methodology in pregnancy.

Preventing postpartum smoking relapse: an opportunity for neonatal nurses.

Smoking during pregnancy and exposure to environmental tobacco smoke have harmful and sometimes devastating effects on the health of the newborn. Although interventions for smoking cessation during pregnancy demonstrate effectiveness for increasing smoking abstinence, the majority of women relapse in the postpartum period. However, modifying contributing factors for relapse may improve the success of sustained abstinence. Many parents are eager to quit smoking and willing to participate in smoking cessation interventions. Through a population-based approach to healthcare, neonatal nurses are in an ideal position to prevent relapse and to promote smoking abstinence; they can coordinate and lead efforts for establishing smoking cessation strategies that integrate obstetric, newborn, and pediatric services.