Arcus Experience: Bridging the Data Science Gap for Nurse Researchers.

BACKGROUND: For years, nurse researchers have been called upon to engage with "big data" in the electronic health record (EHR) by leading studies focusing on nurse-centric patient outcomes and providing clinical analysis of potential outcome indicators. However, the current gap in nurses' data science education and training pose a significant barrier. OBJECTIVES: We aimed to evaluate the viability of conducting nurse-led, big-data research projects within a custom-designed computational lab and examine the support required by a team of researchers with little to no big-data experience. METHODS: Four nurse-led research teams developed a research question reliant on existing EHR data. Each team was given its own virtual computational lab populated with raw data. A data science education team provided instruction in coding languages-primarily structured query language and R-and data science techniques to organize and analyze the data. RESULTS: Three research teams have completed studies, resulting in one manuscript currently undergoing peer-review and two manuscripts in progress. The final team is performing data analysis. Four barriers and four facilitators to big-data projects were identified. DISCUSSION: As the data-science learning curve is steep, organizations need to help bridge the gap between what is currently taught in doctoral nursing programs and what is required of clinical nurse researchers to successfully engage in big-data methods. Additionally, clinical nurse researchers require protected research time and a data science infrastructure that supports novice efforts with education, mentorship, and computational lab resources.

National collaborative maximizes pediatric hospital-based nurse scientist impact and resources through strategic networking.

This paper describes how a national collaborative of pediatric nurse scientists has leveraged the expertise of their membership and strategic networking to guide the development of the evolving hospital-based nurse scientist role and influence centers of nursing research. Members' narratives illustrate how their networking across the collaborative has resulted in increased clarity and understanding of the hospital-based nurse scientist role, consistency in job responsibilities and expectations, title changes that more accurately reflect the nature of the role, establishment or expansion of centers of nursing research, success in talent recruitment, diversification of center team members, reporting structure alterations, and dedicated nursing research funding mechanisms. These tangible outcomes enable pediatric nurse scientists to become more effective in their roles and transform the care of pediatric patients and their families.

Clinician Perspectives on Specifications for Metrics to Inform Pediatric Alarm Management.

Background: Ongoing management of monitor alarms is important for reducing alarm fatigue among clinicians (e.g., nurses, physicians). Strategies to enhance clinician engagement in active alarm management in pediatric acute care have not been well explored. Access to alarm summary metrics may enhance clinician engagement. Objective: To lay the foundation for intervention development, we sought to identify functional specifications for formulating, packaging, and delivering alarm metrics to clinicians. Methods: Our team of clinician scientists and human factors engineers conducted focus groups with clinicians from medical-surgical inpatient units in a children's hospital. We inductively coded transcripts, developed codes into themes, and grouped themes into "current state" and "future state." Results: We conducted five focus groups with 13 clinicians (eight registered nurses and five doctors of medicine). In the current state, information exchanged among team members about alarm burden is initiated by nurses on an ad hoc basis. For a future state, clinicians identified ways in which alarm metrics could help them manage alarms and described specific information, such as alarm trends, benchmarks, and contextual data, that would support decision-making. Conclusion: We developed four recommendations for future strategies to enhance clinicians' active management of patient alarms: (1) formulate alarm metrics for clinicians by categorizing alarm rates by type and summarizing alarm trends over time, (2) package alarm metrics with contextual patient data to facilitate clinicians' sensemaking, (3) deliver alarm metrics in a forum that facilitates interprofessional discussion, and (4) provide clinician education to establish a shared mental model about alarm fatigue and evidence-based alarm-reduction strategies.

Advancing Opportunities for Clinical Inquiry and Professional Development During a Pandemic.

A notable challenge faced by pediatric hospitals during the COVID-19 pandemic included the need to decrease inpatient census and socially distant non-clinical hospital employees to alternative work arrangements. In doing so, nurses and other clinical care services employees were reassigned to new roles, while others continue to work from home. This paper aims to describe how during the COVID-19 pandemic, a pediatric hospital-based center for nursing research and evidence-based practice used this opportunity to virtually engage staff across the department in topics of clinical inquiry through education sessions, office hours, and individualized/team consultation. Therefore, elevating and increasing the presence of nursing research and evidence-based practice while providing opportunities for the continued professional development of nurses, respiratory therapists, clinical dietitians, child life specialists and employees in neurodiagnostics.

Evidence in Hand: Optimizing the Unique Skill Set of a Hospital-Based Center for Nursing Research and Evidence-Based Practice.

This paper describes how, as the COVID-19 pandemic emerged, one hospital-based center for nursing research and evidence-based practice capitalized on its unique skill mix to quickly pivot to provide hospital administrators and staff with timely, relevant evidence regarding the care of patients and families, as well as the protection of direct care providers and all support staff. The products produced by this center, both proactive and in direct response, contributed to clinical operations decision-making and thus, tangibly impacted practice. The positive outcomes described speak not only to the clinical environment, but also to the presence and specialized contributions of a multiprofessional center for nursing research and evidence-based practice in such a way that was not possible prior to COVID-19.

Human Milk and Breastfeeding Outcomes in Infants With Myelomeningocele.

BACKGROUND: In 2015, the study setting instituted an enteral feeding pathway, "PO Ad Lib Feeding to Support Breastfeeding." Many infants admitted to the study setting's newborn/infant intensive care unit with a primary diagnosis of myelomeningocele fall within the setting's enteral feeding pathway's inclusion criteria. PURPOSE: The primary objective of this study is to describe the enteral feeding exposure and trends, by type and method, among infants with myelomeningocele. METHODS: Retrospective descriptive cohort design. Participants were infants with a primary diagnosis of myelomeningocele between 2013 and 2016. The electronic health record was used to collect descriptive data (demographics and daily enteral feeding exposure). Data were analyzed using descriptive statistics. FINDINGS/RESULTS: More than 80% (n = 148, 81.3%) of the participants' mothers had a personalized prenatal nutrition consultation and the majority of those mothers (n = 102/118, 86.4%) had a goal to breastfeed for more than 6 months. The majority (n = 144/182, 79.1%) of the study cohort was exposed to mothers' own human milk as their first feed. It is also notable that 80.8% (n = 147) fed at least once directly at the breast; however, infants were also fed by bottle or by feeding tube. IMPLICATIONS FOR PRACTICE: It demonstrates that with appropriate evidence-based breastfeeding interventions, mothers having infants with myelomeningocele can expect to feed their infants human milk as well as direct breastfeed. IMPLICATIONS FOR RESEARCH: Future research should focus on human milk/breastfeeding outcomes of infants with myelomeningocele post-hospital discharge. Long-term breastfeeding may have an important role in the development of infants with myelomeningocele.

NICU Nurses and Lactation-Based Support and Care.

BACKGROUND: The provision of human milk and breastfeeding is essential in the neonatal intensive care unit (NICU) population. However, recent national research has demonstrated very low percentages of NICU nurses providing lactation-based support and care to patients and families, and less than half of all NICUs have an International Board Certified Lactation Consultant (IBCLC) on staff. PURPOSE: The purpose of this study was to describe how NICU bedside nurses are providing lactation-based support and care during their shifts and the frequency of that support. The secondary aim was to gain an understanding of the NICU nurses' attitudes toward human milk and breastfeeding. METHODS: Through a prospective descriptive cohort design, the authors of this study created and disseminated a web-based survey (SurveyMonkey) of 21 questions including the Iowa Infant Feeding Attitude Scale (IIFAS) to a Northeastern urban hospital staff of bedside nurses. RESULTS: A total of 140 of the 389 eligible NICU bedside nurses responded to the survey. Between 50.7% and 72.9% of nurses reported to providing lactation-based support and care during the previous shift worked and during the previous week worked, respectively. The participants' responses to the IIFAS resulted in an overall score of 69.1, indicating an attitude of "positive to breastfeeding." IMPLICATIONS FOR PRACTICE: The study demonstrates that the majority provide lactation-based support and care on every shift and hold very positive attitudes toward the provision of human milk and breastfeeding. Hospitals should be encouraged to promote educational and training programs in their respective institutions. IMPLICATIONS FOR RESEARCH: Researchers should examine NICU nurses' attitudes and beliefs about human milk and breastfeeding on a national scale.

Creation of a Regional Human Milk Assembly: A Model to Influence Practice and Policy Change in the NICU.

BACKGROUND: The 2011 Surgeon General's Call to Action to Support Breastfeeding highlights a need for optimizing lactation-based education for all health professionals; however, few schools of nursing and medicine offer lactation-based curriculum. In an effort to address these gaps in education and care, the director of the lactation program at a large urban children's hospital developed and instituted the annual regional Human Milk Assembly (HMA), a half-day collaborative meeting of the hospital's regional and referral hospitals' neonatal intensive care unit (NICU) nursing staff, to address lactation-based educational and training needs of all participating institutions. PURPOSE: The purpose of this study was to determine whether and how participating HMA hospitals implemented the best practices surrounding human milk and breastfeeding shared by the host institution during a 10-year span of the HMA. METHODS: A prospective descriptive study was designed using an electronic web-based survey (SurveyMonkey.com) to elicit participant data. Quantitative data were analyzed using descriptive statistics whereas qualitative data were analyzed for themes via content analysis. RESULTS: Thirty-one of the 50 hospitals surveyed responded to the electronic survey for a total of 34 individual participants. Seventeen of the 22 (77%) of best practices were implemented at rates of over 50%. IMPLICATIONS FOR PRACTICE: By enabling a culture of transparency and sharing, hospital staff can be encouraged to implement best practices across a network of regional care centers. IMPLICATIONS FOR RESEARCH: This annual regional HMA could be a model for other areas and research should be conducted to evaluate such programs nationwide.

Human milk and breastfeeding: An intervention to mitigate toxic stress.

The American Academy of Nursing has identified toxic stress in childhood as a health policy concern of high priority. Adult diseases (e.g., obesity, diabetes, hypertension and cardiovascular disease) should be viewed as developmental disorders that begin early in life that could be reduced with the alleviation of toxic stress in childhood. The provision of human milk/breastfeeding is an evidence-based intervention that may hold the greatest potential to mitigate the effects of toxic stress from the moment of birth. Assisting families to make an informed choice to initiate and continue breastfeeding from birth has the potential to address both the disparity in the quality of nutrition provided infants and the economic stress experienced by families who purchase formula. The Expert Panel on Breastfeeding endorses initiatives to improve the initiation, duration, and exclusivity of breastfeeding to mitigate the effects of toxic stress in this call to action for research to build the evidence to support these critical relationships.

The use of technologies to support human milk & breastfeeding.

The application of lactation technologies is not limited to the NICU or the hospital setting. These technologies can be implemented within the home or hospital setting to promote the use of human milk and protect the breastfeeding relationship. Through the use of breast pumps, scales, and nipple shields, women can be supported to achieve their personal breastfeeding and lactation goals.

An ethical case for the provision of human milk in the NICU.

Despite recommendations from the World Health Organization, the United Nations Children's Fund, the American Academy of Pediatrics Section on Breastfeeding, and others, only a small percentage of infants in the United States receive exclusive human milk for the first 6 months of life. In the United States, decisions related to infant feeding are determined by surrogate or proxy in place of the neonatal voice, using the "best interest principle" as the guiding ethical focus. Given the established research on the benefits of an exclusive human milk diet compared with artificial nutrition (infant formula), infant feeding decisions made for the critically ill neonate should rest entirely in the infant's best interest, not solely in parental authority. If the mother's own milk is not available or its use is contraindicated, the American Academy of Pediatrics recommends donor human milk. However, the preverbal voice of the neonate makes it difficult to isolate the best interest of the infant separated from the family unit. Using a case exemplar, it is proposed that the means in which infant feeding decisions are made for the critically ill infant should rest entirely in the infant's best interest, not parental authority, during the course of care in the hospital setting. The best interest principle, surrogate decision making, parental authority, and proxy consent are reviewed. Furthermore, a case for the best interest principle to further illustrate the importance of the infant's voice in relationship to enteral feeding decisions is provided. Finally, implications for clinical practice are offered.

Associated morbidities to congenital diaphragmatic hernia and a relationship to human milk.

The majority of what is known in the recent literature regarding human milk studies in the neonatal intensive care setting is specific to term and/or preterm infants (including very-low-birth-weight preterm infants). However, there is a lack of human milk and breastfeeding literature concerning infants with congenital anomalies, specifically infants diagnosed with congenital diaphragmatic hernia (CDH). By applying human milk research conducted among other populations of infants, this article highlights how human milk may have a significant impact on infants with CDH. Recent human milk studies are reviewed and then applied to the CDH population in regard to respiratory and gastrointestinal morbidities, as well as infection and length of stay. In addition, clinical implications of these relationships are discussed and suggestions for future research are presented.

Breastfeeding the infant with congenital diaphragmatic hernia post extracorporeal membrane oxygenation.

Infants born with congenital diaphragmatic hernia (CDH) often require extracorporeal membrane oxygenation (ECMO). Infants on ECMO may experience a long period of being nothing by mouth (NPO) while receiving parenteral nutrition. Once the infant with CDH is repaired and off ECMO, human milk should be used to initiate enteral feedings. Human milk provides immunologic, developmental, and nutritional protection for these highrisk infants and may be crucial in decreasing morbidities commonly associated with post-ECMO survivors. These mother-infant dyads require extensive lactation support to ensure maintenance of milk supply and successful transition to direct breastfeeding. Three case studies are presented as exemplars to demonstrate how breastfeeding success can be achieved even in the most vulnerable infants.

Lactation Outcomes After Participation in a Tailored Prenatal Nutrition Consultation Among Women With Infants With Congenital Anomalies.

OBJECTIVE: To describe lactation outcomes among of a cohort of mother-infant dyads in which the women had an individualized prenatal nutrition consultation intervention. DESIGN: Descriptive cohort study. SETTING: A free-standing children's hospital with a center for fetal diagnosis and treatment and a specialized maternity unit. PARTICIPANTS: A total of 160 women who had prenatal nutrition consultations in 2014 to 2017 and gave birth to infants with known congenital anomalies and required intensive care after birth. METHODS: We surveyed women regarding their lactation outcomes after the Breastfeeding Report Card metrics of the Centers for Disease Control and Prevention and obtained permission to abstract demographic and clinical information from the setting's electronic health record. We analyzed data with standard descriptive statistics. RESULTS: Among the cohort, 86.9% (n = 139) of participants intended to provide human milk or combination feeding in the prenatal period. A total of 128 (92.1%) infants were first exposed to human milk enterally. At the time of discharge, 92.1% (n = 128) of the infants received human milk. The breastfeeding outcomes of the cohort significantly surpassed national data: initiation (98.1% vs. 84.1% national), breastfeeding at 3 months (89.4%), exclusive breastfeeding at 3 months (60% vs. 46.9% national), breastfeeding at 6 months (76.9% vs. 58.3% national), exclusive breastfeeding at 6 months (45% vs. 25.6% national), breastfeeding at 12 months (50.6% vs. 35.3% national), and breastfeeding beyond 12 months (34.4%). CONCLUSIONS: Lactation outcomes among women who had prenatal nutrition consultations far surpassed national data, and this intervention has implications for family-centered prenatal care, informed decision making, and improved breastfeeding outcomes in the hospital setting and postdischarge.

Evidence-Based Criteria Supporting Early Discharge for Pediatric Patients With Osteosarcoma Receiving High-Dose Methotrexate: A Retrospective Chart Review.

Purpose: The purpose of this study is to describe the outcomes following the implementation of an early discharge protocol for pediatric patients with osteosarcoma receiving high-dose methotrexate (MTX) to determine if the protocol safely decreased length of stay without increased toxicity. Methods: This was a retrospective descriptive cohort design. Participants included children, 5 to 25 years of age, diagnosed with osteosarcoma, who received methotrexate between December 2017 and July 2019. A total of 141 doses across fifteen individual patients were included in the cohort. Data were abstracted from the electronic health record and analyzed using descriptive statistics. Results: The majority of administrations (n = 94, 67%) met early discharge criteria without an increase in toxicity or hospital readmission. Conclusion: Pediatric patients receiving high-dose MTX for osteosarcoma can be safely discharged from the hospital when serum MTX level < 0.4 µmol/L with the implementation of education, hydration goals, frequent lab monitoring, and close follow-up. More than half of patients on this study were able to be discharged from the hospital sooner than prior protocol. More importantly, this retrospective chart review highlighted the ability to maintain safe administration without increasing toxicity.

Parental Perceptions of Adolescent Connectedness and the Role of the Primary Care Provider.

INTRODUCTION: Adolescent connectedness to adults, schools, and peers is a protective factor for development. This study aimed to describe parental perceptions of opportunities for youth connectedness and the potential role of the primary care provider in supporting these opportunities. METHOD: Eleven parents or caregivers of youth aged 11-18 years participated in semistructured interviews for a prospective qualitative descriptive study. Interview transcripts were analyzed using constant comparison and deductive and inductive coding. RESULTS: Findings suggest that parents and caregivers view adolescent participation in activities as positive, and nonparental adults play a large role in influencing adolescent involvement in activities. Parents and caregivers did not recall discussing connectedness with their adolescent's primary care provider but would find this helpful. DISCUSSION: Conversations about connectedness are missing from the well adolescent visit, and more research is needed to explore the most effective ways to have these discussions with adolescents and their parents or caregivers.

Case Report of Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk for an Infant in the NICU.

In this report, we describe a case of bilateral lactational mastitis in a primigravid, Spanish-speaking woman who exclusively pumped breast milk for a hospitalized, critically ill infant in the NICU within a free-standing children's hospital. The case follows her clinical presentation, assessments, diagnostics, and therapeutic interventions during the 45-day postpartum period. This case report highlights the situational and environmental context of the woman's experiences and emphasizes potential disconnections of care. Regarding her mastitis, the maternity care providers relied on the woman to provide all relevant information without knowledge of her hospitalized infant's health status. Traditionally during the postpartum period, infants hospitalized in the NICU and their mothers are cared for by separate provider teams. Clinicians must acknowledge that when women transition from recent patients to parent visitors after birth, they will likely have ongoing medical, obstetric, and psychosocial care needs.

The Critical Window of Opportunity: Lactation Initiation Following Cesarean Birth.

Introduction: Cesarean birth is reported to be risk factor for the delayed onset of maternal lactation. The purpose of this study was to describe the timing of lactation initiation, subsequent feeding/milk expression patterns, and daily milk volumes among women who had a cesarean birth of an infant with a known congenital anomaly during the 3-day postpartum hospital stay. Materials and Methods: Retrospective descriptive cohort study. The electronic medical records of dyads, between 2014 and 2017 at the study setting, were abstracted for demographic and clinical data. Milk expression and milk volume data were abstracted from maternal lactation logs. Data were analyzed using descriptive statistics. Results: Among the cohort (n = 468 dyads), the mean time from infant delivery by cesarean to lactation initiation was 257.5 minutes. The cohort was divided into three groups by the timing of lactation initiation: EARLY (≤60 minutes; n = 112), MID (>60 minutes to ≤360 minutes; n = 309), and LATE (>360 minutes; n = 47). Statistically significant differences are seen between groups for the daily means: number of feeds/pumps and maternal milk volumes (irrespective of the presence of lactation risk factors). Discussion: This is the first study to explore the relationship of lactation initiation among women postcesarean birth whose infants have a known congenital anomaly. The time between the infant's birth and the first feed/milk expression, and the patterns of feeding/milk expression during the postpartum hospital stay, are key drivers for maternal milk supply.