Oxytocin Guidelines Associated with Compliance to National Standards.

OBJECTIVE: Develop a multidisciplinary, consensus-driven, evidence-based approach to oxytocin use, while adhering to national guidelines. DESIGN: This was a quality improvement project that used the Plan Do Study Act method to create cycles of change over several years. To initiate discussion, a survey was administered at a social event for providers from divergent community practices that addressed the controversial aspects of oxytocin use. Graphic feedback was provided showing divergences between answers and the evidence. The perinatal team directed design and implementation of this project with specific involvement of a nurse quality improvement coordinator and nurse educator. MEASURES: Process, outcome, and balancing measures were used to evaluate the program. Process measure: use of a standardized order-set. OUTCOME MEASURE: rate of adherence to the resultant protocol. Balancing measures: 1) maximum oxytocin dose, 2) time from oxytocin initiation to birth, 3) cesarean birth rates, and 4) Apgar scores. RESULTS: An initial increase in adherence to the protocol decreased with the loss of the "paper" order-set. Adherence improved when computerized physician order entry was adjusted: 2006: 73%, 2007: 95%; 2011: 57%, 2013: 100% (p = 0.007, 2006 vs. 2007) (p < 0.001, 2006 vs. 2013). Compliance with the protocol was associated with a decrease in maximum oxytocin dose and in time between oxytocin initiation and birth (p < 0.001). CONCLUSION: Consistency and safety in patient care can be accomplished using literature-based evidence and active consensus building among members of the perinatal team. A standardization process must be integrated into the electronic medical record to become a sustained part of a practice culture.

Implementing Standardized Feeding Guidelines, Challenges, and Results.

PURPOSE: The purpose of this article was to develop standardized nutritional guidelines that would promote increased growth velocity (GV) in premature infants. DESIGN: Evidence-based standardized nutritional guidelines were developed. Guidelines included total parenteral nutrition advancement; enteral feeding advancement; and a bedside nurse gastric residual management algorithm. Staff education was given. Guideline compliance was measured. Nutritional intake and daily weights were recorded. SAMPLE: Infants of birth weight <1,500 grams who were admitted to the NICU before day of life four. MAIN OUTCOME VARIABLE: Increase in GV from 12 to 15 g/kg/d. RESULTS: Growth velocity was unchanged. Compliance to the nutritional guidelines was 70 percent. No difference was seen in length of stay. Rate of necrotizing enterocolitis was decreased.

Improving pain assessment in the NICU: a quality improvement project.

Pain assessment documentation was inadequate because of the use of a subjective pain assessment strategy in a tertiary level IV neonatal intensive care unit (NICU). The aim of this study was to improve consistency of pain assessment documentation through implementation of a multidimensional neonatal pain and sedation assessment tool. The study was set in a 60-bed level IV NICU within an urban children's hospital. Participants included NICU staff, including registered nurses, neonatal nurse practitioners, clinical nurse specialists, pharmacists, neonatal fellows, and neonatologists. The Plan Do Study Act method of quality improvement was used for this project. Baseline assessment included review of patient medical records 6 months before the intervention. Documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment were reviewed. Literature review and listserv query were conducted to identify neonatal pain tools. Survey of staff was conducted to evaluate knowledge of neonatal pain and also to determine current healthcare providers' practice as related to identification and treatment of neonatal pain. A multidimensional neonatal pain tool, the Neonatal Pain, Agitation, and Sedation Scale (N-PASS), was chosen by the staff for implementation. Six months and 2 years following education on the use of the N-PASS and implementation in the NICU, a chart review of all hospitalized patients was conducted to evaluate documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment in the medical progress note. Documentation of pain scores improved from 60% to 100% at 6 months and remained at 99% 2 years following implementation of the N-PASS. Pain score documentation with ongoing nursing assessment improved from 55% to greater than 90% at 6 months and 2 years following the intervention. Pain assessment documentation following intervention of an elevated pain score was 0% before implementation of the N-PASS and improved slightly to 30% 6 months and 47% 2 years following implementation. Identification and implementation of a multidimensional neonatal pain assessment tool, the N-PASS, improved documentation of pain in our unit. Although improvement in all quality improvement monitors was noted, additional work is needed in several key areas, specifically documentation of reassessment of pain following an intervention for an elevated pain score.

Optimizing therapeutic hypothermia for neonatal encephalopathy.

OBJECTIVE: Therapeutic hypothermia (TH) for neonatal encephalopathy is becoming widely available in clinical practice. The goal of this collaborative was to create and implement an evidence-based standard-of-care approach to neonatal encephalopathy, deliver consistent care, and optimize outcomes. METHODS: The quality improvement process identified and used the Model for Improvement as a framework for improvement efforts. This was a Vermont Oxford Network Collaborative focused on optimizing TH in the treatment of neonatal encephalopathy. By using an evidence-based approach, Potentially Better Practices were developed by the topic expert, modified by the collaborative, and implemented at each hospital. These included the following: timely identification of at-risk infants, coordination with referring hospitals to ensure TH was available within 6 hours after birth, staff education for both local and referring hospitals, nonsedated MRI, incorporating amplitude-integrated EEG into a TH protocol, and ensuring standard neurodevelopmental follow-up of infants. Each center used these practices to develop a matrix for implementation. RESULTS: Local self-assessments directed the implementation and adaptation of the Potentially Better Practices at each center. Resources, based on common identified barriers, were developed and shared among the group. CONCLUSIONS: The implementation of a TH program to improve the consistency of care for patients in NICUs is feasible using standard-quality improvement methodology. The successful introduction of new interventions such as TH to the NICU culture requires a collaborative multidisciplinary team, use of a systematic quality improvement process, and perseverance.

Magnetic resonance imaging studies without sedation in the neonatal intensive care unit: safe and efficient.

Use of magnetic resonance imaging (MRI) in the neonatal intensive care unit has been increasing over the past several years because of improved MRI technology and increased clinical awareness of the prognostic and diagnostic information available. Historically, the use of sedation has been the standard for achieving quality imaging without motion artifact, but it exposed the patient to risks associated with sedation medications. In an effort to obtain MRI studies with elimination of risks associated with sedation, a quality improvement project was initiated. Implementing a standardized approach utilizing a vacuum immobilizer has led to successful neonatal MRI completion without the need for sedation in 94% of study attempts. Acceptable or excellent image quality was achieved in more than 97% of attempts. Time away from the neonatal intensive care unit significantly decreased with this approach, with the mean duration of time away decreasing from 60 to 48 minutes (P < .0001). Obtaining MRI studies without sedation can be successfully implemented in a neonatal intensive care unit, nearly eliminating patient risks associated with sedation while improving utilization of hospital resources and maintaining adequate quality imaging.

Overcoming barriers to oxygen saturation targeting.

OBJECTIVE: To reduce hyperoxia in very low birth weight infants who receive supplemental oxygen, the Children's Mercy Hospital neonatal respiratory quality improvement committee introduced the potentially better practice of oxygen saturation targeting and identified strategies to overcome barriers to implementation of this practice. METHODS: Using rapid-cycle quality improvement projects, this center adapted an oxygen saturation targeting protocol and tracked hourly oxygen saturation as measured by pulse oximetry in very low birth weight infants who received supplemental oxygen. RESULTS: The percentage of time in the range of 90% to 94% of oxygen saturation as measured by pulse oximetry increased from 20% to an average of 35% after implementation of the protocol. The percentage of time with oxygen saturation as measured by pulse oximetry >98% dropped from 30% to an average of 5% to 10%. CONCLUSIONS: A well-planned strategy for implementing oxygen saturation targeting can result in a sustained change in clinical practice as well as change in the culture of the NICU regarding the use of oxygen.

Standardizing nasal cannula oxygen administration in the neonatal intensive care unit.

OBJECTIVE: A multicycle, quality improvement method was used to standardize nasal cannula O2 administration and weaning in the NICU. METHODS: A 2-armed nasal cannula standardized order form (nasal cannula for stable O2 arm and nasal cannula for stable flow arm) was developed after review of the literature, surveying of the practice of NICU physicians and nurse practitioners, and development of consensus among these providers. Outcomes were measured by tracking the distribution of protocol arm chosen, days on O2, weeks on nasal cannula, and disposition of infants who were supported by nasal cannula. Data were collected in an SPSS statistical data set. RESULTS: Of the 90 infants evaluated, 12 were supported on the stable O2 arm and 53 on the stable flow arm for their entire nasal cannula course. Twenty-five infants switched between arms of support. Patients who were on the stable flow arm of the standard order set for their entire nasal cannula course experienced fewer O2 days but more days on nasal cannula. A subpopulation of infants were supported on nasal cannula flow 0.5 to 1.0 L, with fraction of inspired O2 of 21%. When data from the first 10 weeks of observation were compared with that of the second 10 weeks, the rate of discharge on O2 had decreased from 13 (30%) of 44 to 3 (7%) of 39. CONCLUSIONS: The multiple steps of literature review, practice surveys, and consensus-building resulted in enthusiastic reception of the nasal cannula standardized order form. The 2-armed nasal cannula protocol forced caregivers to consider which method of support was most beneficial for each infant who was on nasal cannula and allowed a subpopulation of NICU patients to be supported with a lower fraction of inspired O2 than previously used in the NICU.