Influences of a remote monitoring program of home nasogastric tube feeds on transition from NICU to home.

OBJECTIVE: The transition from the neonatal intensive care unit (NICU) to the home is complex and multifaceted for families and infants, particularly those with ongoing medical needs. Our hospital utilizes a remote monitoring program called Growing @ Home (G@H) to support discharge from the NICU with continued nasogastric tube feeds. We aim to describe the experience of the transition from NICU to home for families enrolled in G@H. STUDY DESIGN: Using a semi-structured interviewing technique, parents of infants discharged on G@H were interviewed at NICU discharge, at 1-month, and at 6-months after NICU discharge. Interviews were recorded and transcribed into data analysis software. Conventional content analysis was used to analyze qualitative data. Codes were assigned to describe key elements of the interviews and used to identify major themes. RESULTS: Parents (n=11) identified three major themes when discussing the effect of G@H on the transition to home. The program provided a means of escape from the NICU, allowing families to stop living split lives between their homes and the NICU. It acted as a middle ground between the restrictive yet supportive NICU environment, and the normal yet isolated home environment. G@H served as a safety net for families, providing the continued connection to the NICU for their still fragile infants. CONCLUSION: G@H utilizes telehealth to positively support the complex transition from NICU to home for families and infants discharged with nasogastric tube feeds.

Exploring Parent Experiences With Early Palliative Care Practices in the NICU.

BACKGROUND: The anxiety and uncertain outcome of an admission of a seriously ill infant to the neonatal intensive care unit (NICU) can cause great stress for parents and contribute to poor mental health outcomes. Early implementation of family-centered palliative care (PC) may provide support for NICU parents. Key concepts of early PC in the NICU include shared decision-making, care planning, and support for coping with distress. PURPOSE: The purpose of this study was to explore parent experiences during their child's NICU admission with the early PC practices of shared decision-making, care planning, and coping with distress. METHODS: Qualitative descriptive methodology was used. Strategies of reflexive journaling, peer debriefing, and data audits were used to enhance trustworthiness. Parents (N = 16) were interviewed, and data were analyzed by conventional content analysis. Targeted recruitment of fathers occurred to ensure they comprised 25% of sample. RESULTS: Parents' descriptions of decision-making were contextualized in gathering information to make a decision, the emotional impact of the decision, and influences on their decision-making. In experiences with care planning, parents described learning to advocate, having a spectator versus participant role, and experiencing care planning as communication. Key themes expressed regarding parental coping were exposure to trauma, survival mode, and a changing support network. IMPLICATIONS FOR PRACTICE AND RESEARCH: These findings highlight key areas for practice improvement: providing more support and collaboration in decision-making, true engagement of parents in care planning, and encouraging peer support and interaction in the NICU and in online communities.

Exploring Infant Feeding Experiences and Maternity Care Practices in Appalachia.

OBJECTIVES: Our aim was to explore postpartum individuals' experiences and perceptions of breastfeeding and International Board Certified Lactation Consultants' (IBCLC) knowledge and perceptions of maternity care practices and perceived barriers to breastfeeding among their patient populations in Appalachia. METHODS: Semistructured interviews were conducted with seven IBCLCs and seven postpartum individuals. Interviews were recorded and transcribed. Thematic analysis was conducted to determine emergent themes and subthemes related to knowledge/perceptions, experiences, and barriers to breastfeeding among postpartum individuals, as well as emergent themes associated with the knowledge and perceptions of maternity care practices, easy-/difficult-to-implement Baby-Friendly Hospital Initiative maternity care practices, and perceived barriers to breastfeeding among IBCLCs. RESULTS: Postpartum individuals recruited from an Appalachian obstetrics/gynecology clinic were aware of the benefits of breastfeeding, but their infant feeding journeys were more stressful than they expected, and they had limited access to lactation support and breastfeeding education/information. IBCLCs identified the benefits of the Baby-Friendly maternity care practices but mentioned some risks, especially when there is a lack of communication and coordination among providers. Environmental and informational barriers were identified by both postpartum individuals and IBCLCs as breastfeeding challenges potentially amenable to change. CONCLUSIONS: To support postpartum mothers in the Appalachian region, environmental barriers (eg, lack of lactation support) and informational barriers (eg, lack of prenatal education) need to be addressed.

Current state of home health in children with medical complexity.

BACKGROUND: Home health services are a right for children in the US, but higher survival rates of extremely preterm infants have led to an increase in children with medical complexity (CMC) and therefore an increased demand for home health services. Unfortunately, an adequately trained and compensated workforce to support medially complex children at home does not exist. METHODS: After identifying the existing research, common themes were identified. This article was written to give an overview of these themes and highlight specific supporting data. RESULTS: A lack of resources in the home health arena and the financial barriers that accompany them, as well as the clear impact this issue has on the health and well-being of families and caregivers, were frequently present in the literature. CONCLUSIONS: Reasonable next steps for research and advocacy include a focus on recruitment and retention of home health nurses, as well as training specific to the level of skill required to adequately care for CMC. Further research is needed, as in our search we found several unexplored, unassessed avenues that could help health care professionals understand the problem more fully. These steps are necessary if we want CMC to live the healthiest life available to them.

Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis.

BACKGROUND: Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment. PURPOSE: This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU). METHODS: Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes. RESULTS: There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support. IMPLICATIONS FOR PRACTICE AND RESEARCH: NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.

Neonatal Intensive Care Workflow Analysis Informing NEC-Zero Clinical Decision Support Design.

Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.

Motivational interviewing to improve self-management in youth with type 1 diabetes: A randomized clinical trial.

PURPOSE: Effective interventions are needed to help adolescents with T1D develop independent self-management skills to prevent commonly observed deterioration of disease self-management resulting in poor health outcomes. Using a prospective RCT design, we assessed the impact of a nurse-led education program based on motivational interviewing (MI) in youth with Type 1 diabetes (T1D). DESIGN AND METHODS: After parental consent and youth assent, we prospectively randomized 66 adolescents 13-18 years old with T1D to either usual care (every 3 months visit with pediatric endocrinologist) or usual care supplemented by 2 in-person and 4 follow-up phone calls with a nurse educator in a pediatric endocrinology clinic of the University Hospital Farhat Hached, Sousse, Tunisia. We used MI sessions to support youth general and disease specific self-management skills. Outcomes were change, between baseline and 6 months, in TRAQ (a validated measure of youth self-management) scores and HbA1c values. RESULTS: Mean TRAQ scores (based on a 5-point Likert scale) increased by 1.44 points (s.d. = 0.56) in the Intervention Group versus 0.26 points (s.d. = 0.34) in the control group (p < 0.001). The mean HbA1C value decreased in the intervention group by 0.95 units versus a decrease of 0.12 units in the control group (p = 0.047). CONCLUSION: We found that a brief, nurse-led MI-based educational intervention, integrated into specialty pediatric care, resulted in a significant improvement in both self-reported self-management skills and in HbA1c values. TRIAL REGISTRATION: Registered in ClinicalTrials.gov Identifier: NCT04798937.

Haemodynamics and cerebral oxygenation of neonatal piglets in the immediate ex utero period supported by mechanical ventilation or ex utero oxygenator.

KEY POINTS: The margin of human viability has extended to the extremes of gestational age (<24 weeks) when the lungs are immature and ventilator-induced lung injury is common. Artificial placenta technology aims to extend gestation ex utero in order to allow the lungs additional time to develop prior to entering an air-breathing environment. We compared the haemodynamics and cerebral oxygenation of piglets in the immediate period post-oxygenator (OXY) transition against both paired in utero measures and uniquely against piglets transitioned onto mechanical ventilation (VENT). Post-transition, OXY piglets became hypotensive with reduced carotid blood flow in comparison with both paired in utero measures and VENT piglets. The addition of a pump to the oxygenator circuit may be required to ensure haemodynamic stability in the immediate post-transition period. ABSTRACT: Gestational age at birth is a major predictor of wellbeing; the lower the gestational age, the greater the risk of mortality and morbidity. At the margins of human viability (<24 weeks gestation) immature lungs combined with the need for early ventilatory support means lung injury and respiratory morbidity is common. The abrupt haemodynamic changes consequent on birth may also contribute to preterm-associated brain injury, including intraventricular haemorrhage. Artificial placenta technology aims to support oxygenation, haemodynamic stability and ongoing fetal development ex utero until mature enough to safely transition to a true ex utero environment. We aimed to characterize the impact of birth transition onto either an oxygenator circuit or positive pressure ventilation on haemodynamic and cerebral oxygenation of the neonatal piglet. At 112 days gestation (term = 115 days), fetal pigs underwent instrumentation surgery and transitioned onto either an oxygenator (OXY, n = 5) or ventilatory support (VENT, n = 8). Blood pressure (BP), carotid blood flow and cerebral oxygenation in VENT piglets rose from in utero levels to be significantly higher than OXY piglets post-transition. OXY piglet BP, carotid blood flow and carotid oxygen delivery (DO2 ) decreased from in utero levels post-transition; however, cerebral regional oxygen saturation (rSO2 ) was maintained at fetal-like levels. OXY piglets became hypoxaemic and retained CO2 . Whether OXY piglets are able to maintain cerebral rSO2 under these conditions for a prolonged period is yet to be determined. Improvements to OXY piglet oxygenation may lie in maintaining piglet BP at in utero levels and enhancing oxygenator circuit flow.

The role of transport and telecommunications technology in the development of the Scottish Highlands and Islands Medical Service: a historical perspective.

The Highlands and Islands Medical Service (HIMS) was introduced across the Scottish Highlands and Islands region after the publication of the Dewar Report in 1913. It was the first state-funded medical service in the UK and one of the first in the world. The Dewar Committee recommended the establishment of HIMS following research into healthcare provision in the region, concluding that there was insufficient provision. Among Dewar's major findings were the lack of sufficient transport infrastructure, high transport costs and low availability, and the lack of telecommunication services. This historical study with current relevance has addressed the contribution of transport and telecommunication technologies to the overall success of the Highland and Islands Medical Service. We have considered the crucial role of developments in the transport and telecommunications industries in overcoming contemporaneous healthcare problems. Through the study of contemporary letters, newspaper articles and government reports, this study assesses whether the views expressed at the time agree with the central contention that automobiles and telecommunication services were essential to the success of HIMS. This study also assesses the parallels drawn between the problems faced by HIMS in the 1900s and modern-day rural healthcare providers. Automobile use allowed those in the Highlands and Islands to commute with far greater ease, indirectly allowing doctors and members of the healthcare team to travel to see patients further afield and in greater numbers due to reduced travelling time. Additionally, funds provided by other government departments as well as HIMS allowed telecommunication technology to develop in the region, resulting in improved communication between widely dispersed healthcare workers, thereby improving healthcare provision. Prior to the formation of HIMS, the Highlands and Islands region in Scotland struggled to provide sufficient health care to its residents. The formation of HIMS resulted in improved health care in the region while simultaneous developments in the transport and telecommunication industries occurred. Past scholars have established links between the transport and telecommunication industries and healthcare provision in several countries. This study has contributed to existing literature by providing an insight into the relationship between such services in the Highlands and Islands region as well as rural life in the early 1900s. To conclude, the development of the transport and telecommunications industries acted synergistically with HIMS to lead to success in provision of good health care in the region.

Smokefree home rules and cigarette smoking intensity among smokers in different stages of smoking cessation from 20 low-and-middle income countries.

Smokefree environment created by smokefree policies is associated with smoking reduction; however, there is paucity of literature on the relationship between smokefree home rules and smoking intensity in low-and-middle income countries (LMICs), and how smokefree policy affects smoking behavior of smokers at different stages of smoking cessation. This study examined the relationship between smokefree home rules and average number of cigarettes smoked per day (CPD) among daily smokers at different stages of the transtheoretical model (TTM) of change. Data from 18,718 current daily cigarette smokers from the Global Adult Tobacco Survey (GATS) conducted from 2011 to 2017 in 20 LMICs were analyzed. Weighted multivariable linear regression analyses were conducted using the log of CPD as the outcome variable with smokefree home rules as the exposure variable, controlling for selected covariates. Approximately 15% of the participants were in precontemplation, 5% were in preparation, 15% lived in partial smokefree homes, and 30% lived in complete smokefree homes. The average number of CPD was 12.3, 12.0, and 10.6 among participants living in homes where smoking was allowed, partial smokefree homes, and complete smokefree homes, respectively. Compared to living in homes where smoking was allowed, living in complete smokefree homes were associated with 22.5% (95%CI = 18.4%-26.5%), 17.9% (95%CI = 8.4%-27.3%), and 29.3% (95% CI = 17.1%-41.5%) fewer CPD among participants in precontemplation, contemplation, and preparation stages, respectively. These findings suggest that complete smokefree home policy will benefit smokers in LMICs irrespective of their intention to quit smoking in addition to protecting non-smokers from secondhand smoke exposure.

Is the positive association between middle-income and rich household wealth and adult sub-Saharan African women's overweight status modified by the level of education attainment? A cross-sectional study of 22 countries.

BACKGROUND: Previous studies show a positive association between household wealth and overweight in sub-Saharan African (SSA) countries; however, the manner in which this relationship differs in the presence of educational attainment has not been well-established. This study examined the multiplicative effect modification of educational attainment on the association between middle-income and rich household wealth and overweight status among adult females in 22 SSA countries. We hypothesized that household wealth was associated with a greater likelihood of being overweight among middle income and rich women with lower levels of educational attainment compared to those with higher levels of educational attainment. METHODS: Demographic and Health Survey (DHS) data from 2006 to 2016 for women aged 18-49 years in SSA countries were used for the study. Overweight was defined as a body mass index (BMI) ≥ 25 kg/m2. Household wealth index tertile was the exposure and educational attainment, the effect modifier. Potential confounders included age, ethnicity, place of residence, and parity. Descriptive analysis was conducted, and separate logistic regression models were fitted for each of the 22 SSA countries to compute measures of effect modification and 95% confidence intervals. Analysis of credibility (AnCred) methods were applied to assess the intrinsic credibility of the study findings and guide statistical inference. RESULTS: The prevalence of overweight ranged from 12.6% in Chad to 56.6% in Swaziland. Eighteen of the 22 SSA countries had measures of effect modification below one in at least one wealth tertile. This included eight of the 12 low-income countries and all 10 middle income countries. This implied that the odds of overweight were greater among middle-income and rich women with lower levels of educational attainment than those with higher educational attainment. On the basis of the AnCred analysis, it was found that the majority of the study findings across the region provided some support for the study hypothesis. CONCLUSIONS: Women in higher wealth strata and with lower levels of educational attainment appear to be more vulnerable to overweight compared to those in the same wealth strata but with higher levels of educational attainment in most low- and middle- income SSA countries.

NICU Parent Preferences for Stakeholder Engagement in Research.

BACKGROUND: Engagement of parents as stakeholders in the research process can help ensure that interventions are aligned with their needs and experiences, but little is known about their preferences for research collaboration. PURPOSE: The purpose of this qualitative, exploratory study was to explore former neonatal intensive care unit (NICU) parents' attitudes toward engagement as parent collaborators and identify potential barriers and facilitators to parent collaboration in research. METHODS: Three focus groups and 3 interviews were conducted. Participants completed a demographic survey including information about their child's hospitalization. Parents were asked to discuss their NICU story, involvement in the parent community, experience with research, and factors influencing their decision to collaborate on a research study. RESULTS: Nine parents completed the study. Participation was motivated by a desire to help other families. Recruitment suggestions included using parent organizations, social media networks, and advertising in the NICU. Facilitators to research engagement were passion about research topic, distance participation, affecting change, helping other parents, and compensation. Barriers included time constraints and unresolved trauma. IMPLICATIONS FOR PRACTICE: NICU nurses can leverage their relationships with parents to act as liaisons between research teams and parents, helping recruit and encouraging them to form research partnerships. IMPLICATIONS FOR RESEARCH: Parents are interested in collaborating with neonatal research teams when they can improve experiences for other families and can see or help implement change. Researchers should be conscious of constraints on parents' ability to meet frequently or in person and offer accommodations such as conference calls and online training.

Early for Everyone: Reconceptualizing Palliative Care in the Neonatal Intensive Care Unit.

BACKGROUND: Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE: To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY: Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS: Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE: Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH: As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.

Development of the NEC-Zero Toolkit: Supporting Reliable Implementation of Necrotizing Enterocolitis Prevention and Recognition.

The goal of the NEC-Zero project is to reduce the burden of necrotizing enterocolitis (NEC) by increasing access to evidence-based tools to help clinicians and parents integrate evidence into daily care. It involves (a) human milk feeding with prioritized mother's own milk; (b) use of a unit-adopted standardized feeding protocol; (c) a unit-adopted strategy for timely recognition that integrates risk awareness and a structured communication tool when symptoms develop; and (d) stewardship of empiric antibiotics and avoidance of antacids. A toolkit for caregivers and parents was developed to make implementation consistent. For clinicians the toolkit includes: the GutCheckNEC risk score, a structured communication tool, the "Avoiding NEC" checklist, and the NEC-Zero website. For parents, NEC-Zero tools include the website, three educational brochures in English and Spanish, and a collaborative care video produced with the NEC Society. This article describes the toolkit and how it has been accessed and used.

Health Care Provider Intervention and Utilization of Cessation Assistance in 12 Low- and Middle-Income Countries.

Background and Aim: There is a need to improve utilization of cessation assistance in low- and middle-income countries (LMICs), and tobacco cessation research has been identified as priority in LMICs. This study evaluates the relationship between health care provider intervention and cessation assistance utilization in LMICs. Methods: Data from 13 967 participants (aged ≥15 years, 90.3% males) of the Global Adults Tobacco Survey conducted in 12 LMICs (74.3%-97.3% response rates) were analyzed with utilization of counseling/cessation clinic, WHO-recommended medications, and quitline as outcome variables. Health care provider intervention ("no intervention," only "tobacco screening," "quit advice") was the exposure variable. Weighted multiple logistic regression models were used to examine the relationship between each outcome variable and the exposure variable, adjusting for other covariates. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported. Results: Approximately 52%, 8%, and 40% of participants received no intervention, only tobacco screening, and advice to quit, respectively. Overall, 0.4%, 1.9%, 3.0%, and 4.5% used quitline, WHO-recommended medications, counseling/cessation clinic, and any cessation assistance, respectively. Compared with no intervention, quit advice was associated with increased utilization of quitline (OR = 2.24, 95% CI = 1.2 to 4.4), WHO-recommended medications (OR = 1.67, 95% CI = 1.2 to 2.3), counseling/cessation clinic (OR = 4.41, 95% CI = 3.2 to 6.1), and any assistance (any of the three types) (OR = 2.80, 95% CI = 2.2 to 3.6). Conclusion: The findings of this study suggest that the incorporation of quit advice by health care providers in tobacco control programs and health care systems in LMICs could potentially improve utilization of cessation assistance to improve smoking cessation in LMICs. Implications: This first study of association between health care provider intervention and the utilization of cessation assistance in LMICs reports that there was a missed opportunity to provide quit advice to about 60% of smokers who visited a health care provider in the past year. The odds of utilization of counseling/cessation clinic, WHO-recommended medications, and quitline were significantly increased in participants who were advised to quit smoking. The results suggest that effective integration and implementation of advice to quit in tobacco control programs and the national health care systems may increase the use of cessation assistance to quit smoking.

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units.

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

Roles and Experiences of Parents in Necrotizing Enterocolitis: An International Survey of Parental Perspectives of Communication in the NICU.

BACKGROUND: Although partnering with parents is important to improving neonatal outcomes, no studies have investigated what parents are taught, remember, or experience when their child is afflicted with necrotizing enterocolitis (NEC). PURPOSE: To characterize parental perceptions of communication and support they were given about NEC. METHODS: An online survey was developed, reviewed for face validity, and then administered to parents whose child had experienced NEC. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using a qualitative descriptive approach. FINDINGS: Parents (N = 110) wanted to know the risk factors and warning signs for NEC and wanted to be told as soon as their child was admitted to the neonatal intensive care unit (NICU). Information provided before diagnosis was felt to be poor by the majority of families, with only 32% feeling satisfied or very satisfied. No parent wrote that they were "scared" by information provided to them about NEC; in fact, parents were dissatisfied when they received "sugar-coated" information. Engaged parents were significantly more satisfied than those who were not informed, had their concerns and suggestions dismissed, or who had to advocate for their baby against clinician opposition (eg, activating the chain of command). IMPLICATIONS FOR PRACTICE: Areas for quality improvement include better communication and collaboration with parents through early engagement in NEC prevention using modalities beyond verbal instruction. IMPLICATIONS FOR RESEARCH: More research is needed on how best to engage parents, especially to engage in prevention, and how doing so affects satisfaction and outcomes.

Evidence for Implementation Strategies to Provide Palliative Care in the Neonatal Intensive Care Unit.

BACKGROUND: Palliative care is a holistic framework that is designed to improve quality of life by identifying and treating distressing symptoms of life-threatening or complex conditions. Neonatal palliative care (NPC) has potential benefits for parents, staff, and patients, yet evidence suggests that implementation and utilization of organized NPC services are low. PURPOSE: The purpose of this study is to answer the clinical question: In neonatal intensive care, what evidence can be used to guide implementation of palliative care protocols? SEARCH STRATEGY: A literature search was conducted using CINAHL (Cumulative Index of Nursing and Allied Health Literature), PubMed, and the Cochrane Library databases. Publications with a focus on neonates, neonatal intensive care unit, and implementation or evaluation of a palliative care protocol, team, or educational intervention were retained. RESULTS: The search yielded 17 articles that fit with the following themes: NPC protocols or teams (n = 8), healthcare team needs (n = 3), and barriers to implementation (n = 6). Approaches to NPC implementation were varied, and outcome data were inconsistently reported. Healthcare team members cited a need for education and consistent, ethical delivery of NPC. Common barriers were identified as lack of NPC education, poor communication, and lack of adequate resources such as staff and space. IMPLICATIONS FOR PRACTICE AND RESEARCH: Successful team approaches included standardized order sets to initiate NPC, NPC education for staff, and references to NPC guidelines or protocols. Barriers such as lack of interdisciplinary cooperation, lack of appropriate physical space, and lack of education should be addressed during program development. Further research priorities for NPC include seeking parent perceptions, shifting focus from mostly end-of-life to an integrated model, and collecting outcome data with rigor and consistency.

What factors are associated with anaemia in pregnancy among Nigerian women? Evidence from a national survey.

Background: Anaemia in pregnancy remains a severe public health problem in sub-Saharan African countries including Nigeria. Objectives: To assess factors associated with anaemia in pregnancy among Nigerian women. Methods: A secondary analysis of the 2018 Nigeria demographic health survey was conducted to determine the predictors of anaemia among Nigerian pregnant women (N=1522). SAS 9.4 was used for the analysis. Results: The prevalence of anaemia in pregnancy was 61.1%. On multivariable logistic regression analysis, women in the North-central (AOR=2.52, CI=1.46-4.35) and South-south (AOR=2.21, CI=1.06-4.59) had increased odds of anaemia in pregnancy, compared to those in the Northwest. Women with no education (AOR=2.38, CI=1.28-4.44), primary education (AOR=3.06, CI=1.58-5.96) and secondary education (AOR=1.75, CI=1.04-2.94) had increased odds of anaemia in pregnancy compared to women with teriary education. Also, women not in marital union had increased odds of anaemia in pregnancy compared to women in a union (AOR=2.56, CI=1.15-5.72). Women in the second (AOR=2.42, CI=1.79-3.29) and third trimesters of pregnancy (AOR=2.83, CI=2.07-3.89) had increased odds of anaemia. Conclusion: These findings are important for the control of anemia among pregnant Nigerian women. Women in the Northcentral and Southsouth zones are particularly at risk for anaemia in pregnancy and should receive special attention during antenatal care.