Quality Improvement Study on New Endotracheal Tube Securing Device (Neobar) in Neonates.

OBJECTIVES: To examine the rate of unplanned extubation (UE) after the introduction of NeoBar (endotracheal tube stabilization device) compared to the previous tapping method and to analyze the factors associated with UE in the neonatal intensive care unit (NICU). METHODS: A quality improvement study was conducted in a tertiary NICU between October 2011 and December 2013. In October 2012, after many educational sessions NeoBar was introduced as a tool for securing endotracheal tube. The UE rate was compared one year before and one year after the introduction of NeoBar. The UE rate was reported as UE per 100 intubation days. Statistical process control charts were used for understanding the special cause variation. The authors used Standards for Quality Improvement Reporting Excellence (SQUIRE) method of reporting for this project. RESULTS: The UE rate decreased from 1.47 per 100 intubation days to 1.17 per 100 intubation days following the introduction of NeoBar (p=0.91). The UE rate was consistently below/at the mean, showing a stable change following the introduction of NeoBar, despite no statistically significant difference in UE rate. The common factors associated with UE were retaping/adjustment of endotracheal tube, infant agitation and performance of other procedures in both time periods. CONCLUSIONS: Use of NeoBar as endotracheal tube securing device was associated with similar UE rates compared to taping method. Large prospective studies are required to assess whether NeoBar reduces the UE rate.

Eating in "SINC": Safe Individualized Nipple-Feeding Competence, a Quality Improvement Project to Explore Infant-Driven Oral Feeding for Very Premature Infants Requiring Noninvasive Respiratory Support.

Oral feeding is a developmental task for all premature infants. often, independent nipple feeding is the last barrier to discharge home from the NICU. A relationship exists between consistent, infant-driven feeding management practices and improved feeding performance. Conversely, a random approach to feeding may contribute to poor short-term and long-term clinical outcomes. We report a quality improvement project that was undertaken across five NICUs in an urban setting. our aim was to safely initiate and advance nipple feeding for very preterm neonates (born at <32 weeks gestation) who had a respiratory morbidity requiring nasal continuous positive airway pressure therapy. A novel algorithm entitled "eating in SINC: Safe individualized nipple-Feeding Competence" was developed. Safe individualized nipple-feeding competence involves the baby, the parents, and the health care team by using infant-driven strategies, common language, and developmentally appropriate goals while supporting fragile neonates to be skilled feeders.

Special Considerations in Neonatal Mechanical Ventilation.

Care of infants supported with mechanical ventilation is complex, time intensive, and requires constant vigilance by an expertly prepared health care team. Current evidence must guide nursing practice regarding ventilated neonates. This article highlights the importance of common language to establish a shared mental model and enhance clear communication among the interprofessional team. Knowledge regarding the underpinnings of an open lung strategy and the interplay between the pathophysiology and individual infant's response to a specific ventilator strategy is most likely to result in a positive clinical outcome.

Effect of a Quality Improvement Project to Use Exclusive Mother's Own Milk on Rate of Necrotizing Enterocolitis in Preterm Infants.

OBJECTIVE: Mother's own milk (MOM) remains the key strategy to prevent necrotizing enterocolitis (NEC) in preterm infants. We developed and implemented quality improvement (QI) initiatives to improve rate of using MOM in preterm infants of <32 weeks of gestation. The objective was to evaluate the impact of this QI project on NEC incidence in this population. STUDY DESIGN: In November 2009, we established a QI multidisciplinary team that reviewed literature and practices of other institutions to promote exclusive use of MOM in preterm infants of <32 weeks of gestation. The team developed practice changes that were implemented in February 2010. We tracked use of MOM and occurrence of NEC stage ≥ 2 from January 2009 until March 2012 when donor human milk was introduced. The subjects were divided into three groups: baseline (year 2009; n = 189), intervention phase (year 2010; n = 202), and sustain phase (January 2011-March 2012; n = 254). Clinical outcomes of the baseline and sustain phases were compared. RESULTS: Exclusive use of MOM improved significantly from 60.8% to 73.6% at time of first feed (p = 0.004) without any delay in feed introduction (median [interquartile range], 40 [26, 75.5] hours versus 43.5 [24, 69] hours; p = 0.96). There was a nonsignificant increase in exclusive use of MOM at time of full feed (from 79.5% to 85.2%; p = 0.11); however; use of any MOM increased significantly from 80.4% to 91.3% (p < 0.001) at discharge. Time to reach full feed and length of stay remained similar between the baseline and sustain periods. On regression analysis, risk of NEC decreased significantly in the sustain period (odds ratio = 0.32; 95% confidence interval, 0.11-0.93). CONCLUSIONS: QI initiatives were effective in increasing use of exclusive MOM at time of first feed and of any MOM at time of discharge and in reducing NEC incidence in our neonatal intensive care unit.