Multiple Attempts of Peripheral Intravenous Catheter Insertion in a Preterm Infant Provoke Toxic Stress: A Case Report.

Premature infants admitted to the NICU often require intravenous (IV) therapy. Peripheral intravenous catheter (PIVC) insertion is a common painful/stressful/invasive procedure. Repeated exposure to stressors produces toxic stress: a prolonged, frequent activation of the body's stress response that occurs when buffering relationships, that is, mother/supportive adult, are absent. This article presents an exemplar case study of a PIVC insertion to describe toxic stress responses a premature infant experienced during the procedure. The infant was admitted for extreme prematurity and respiratory failure. Twenty-nine days later, the infant developed possible necrotizing enterocolitis that necessitated cessation of enteral feedings, gastric decompression, IV administration of fluids, parenteral nutrients, and antibiotics. The PIVC insertion procedure was monitored and observed. The infant showed physiologic dysregulation, including bradycardia, tachycardia, oxygen desaturation, and high skin conductance responses, resulting from the stress exposure and insufficient nonpharmacologic/pharmacologic stress interventions. Education and practice change are needed to promote pain/stress management.

A National Survey of Neonatal Nurses' Knowledge, Beliefs, and Practices of Antibiotic Stewardship.

BACKGROUND: In the neonatal intensive care unit, implementation of antibiotic stewardship programs has been challenging, especially for staff nurses. PURPOSE: To identify neonatal nurses' knowledge and attitudes toward antibiotic stewardship programs in neonatal intensive care units. METHODS: This was a descriptive survey study to assess knowledge, attitudes, and beliefs of neonatal nurses related to antibiotic stewardship. The survey consisted of 23 questions, 6 of which were open-ended. The questions evaluated perceptions of general understanding of antibiotic stewardship, administration of antibiotics, information and perspective about antibiotic use, antibiotic resistance, and availability and usage of resources and education related to antibiotics. The survey was posted online for about 3 months on the Web site of a professional organization of neonatal nurses. RESULTS: Of the 78 neonatal nurses who responded to the survey, 39% were very familiar with the term antibiotic stewardship . The majority of participants did not question the treating provider about the choice, route, or dose of antibiotics. The majority also agreed that more education is needed to achieve the goal of incorporating principles of antibiotic stewardship more fully into practice in the neonatal intensive care unit. IMPLICATIONS FOR PRACTICE: Results suggest that although most nurses are familiar with the term antibiotic stewardship , they would like to have more education on the appropriate use of antibiotics. IMPLICATIONS FOR RESEARCH: Further studies are needed to identify nurse involvement in applying the principles of antibiotic stewardship programs while working with the vulnerable population of preterm infants.

Maternal Vertical Microbial Transmission During Skin-to-Skin Care.

BACKGROUND: Skin-to-skin (STS) care may contribute to mother-to-infant vertical microbial transmission by enriching the preterm infant's microbiome. PURPOSE: The purpose of this observational study was to define the impact of increased STS care duration on vertical microbial transmission and consequently modulate oral and intestinal microbial balance. METHODS: Postpartum women and their preterm infants, 31 to 34 weeks' gestation (n = 25), were recruited for this study. Using 16S rRNA sequencing, we compared α- and ß-diversity with the Shannon and Chao indexes and nonmetric multidimensional scaling, respectively, and relative abundance of microbial communities, which refers to the percentage of specific organisms in a community, from mother's chest skin, preterm infant's oral cavity, and preterm infant's stool samples. Effects of STS care on vertical transmission were determined by comparing oral and stool microbial population of preterm infants who received low exposure (<40 minutes) with that of preterm infants who received high exposure (>60 minutes). RESULTS: Microbial composition, diversity, and relative abundance were different across the 3 sites. Oral microbial richness was less and stool richness was greater among the preterm infants in the high STS care group. Oral and intestinal microbial diversity and composition were different between the groups, with the relative abundance of Gemella and Aggregatibacter genera and Lachnospiraceae family significantly greater in the stool of the high STS care group. IMPLICATIONS FOR PRACTICE: Results suggest that STS care may be an effective method to enhance microbial communities among preterm infants.

Encouraging Our NICU to "Read-a-Latte": Leveraging a Read-a-Thon to Launch a Quality Improvement Initiative.

BACKGROUND: Preterm infants have known impairments in language development relative to infants born at full term, and the language-poor environment of the neonatal intensive care unit (NICU) is a contributing factor. Adapting outpatient literacy programs for the NICU is a potential evidence-based intervention to encourage adult speech exposure to infants through reading sessions during NICU hospitalization. PURPOSE: To evaluate implementation of a 10-day NICU Read-a-Thon and potential barriers and facilitators of a year-round program aimed at increasing reading sessions for NICU patients. METHODS: We established an implementation team to execute a Read-a-Thon and evaluated its impact utilizing quantitative and qualitative approaches. Quantitative methodology was used to report number of donated books and infant reading sessions. Qualitative methodology inclusive of interviews, surveys, and source document reviews was used to evaluate the Read-a-Thon. RESULTS: We received approximately 1300 donated books and logged 663 reading sessions over the 10-day Read-a-Thon. Qualitative evaluation of the Read-a-Thon identified 6 main themes: motivation, emotional response to the program, benefits and outcomes, barriers, facilitators, and future of literacy promotion in our NICU. Our evaluation informed specific aims for improvement (eg, maintaining book accessibility) for a quality improvement initiative to sustain a year-round reading program. IMPLICATIONS FOR PRACTICE AND RESEARCH: Neonatal units can leverage Read-a-Thons as small tests of change to evaluate barriers, facilitators, and change processes needed to implement reading programs. Process maps of book inventory and conducting a 5 W's, 2 H's (who, what, when, where, why, how, how much) assessment can aid in program planning.

A clinical-academic partnership to develop a family management intervention for parents of preterm infants.

AIMS: To examine the critical role that an academic clinical partnership played in the development and refinement of a family management intervention in the Neonatal Intensive Care Unit (NICU). BACKGROUND: Clinical-academic partnerships enable earlier infusion of implementation science principles into development of evidence-based interventions, yet partners often report difficulty leveraging resources, personnel and expertise to create beneficial outcomes for all. DESIGN: Longitudinal qualitative descriptive design. METHODS: To develop and refine the intervention, designated time was taken during meetings of the NICU's Parent Partnership Council (PPC), a committee comprised of nursing, physician and allied health leadership and former NICU parents. Partnership was also achieved by having bedside clinical nurses, in addition to medical and nursing students, participate as research team members. Qualitative data were collected via email, research team and Council meetings, and informal individual chats with key stakeholders (N = 25) and NICU mothers (N = 22). Qualitative data were analysed deductively using thematic analysis based on MacPhee's partnership logic model and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) model. The consolidated criteria for reporting qualitative research checklist guided our work. RESULTS: During Council meetings, the clinical-academic nurse, Director of Family-Integrated Care and Council members identified the need for a family management intervention, and worked together to develop and refine PREEMIE PROGRESS. Mothers found the intervention had numerous strengths and perceived a benefit knowing they helped future parents. CONCLUSIONS: This work was only possible by leveraging both the university's technology/research resources and the clinical expertise of the NICU staff and PPC. Co-authored presentations, publications and grant funding continued this NICU's legacy in family-centred care and helped shape the clinical-academic nurse's career. RELEVANCE TO CLINICAL PRACTICE: Clinical-academic partnerships can promote excellence in nursing practice, research and education through swifter knowledge translation and earlier infusion of implementation science principles into the development of evidence-based nursing interventions.

Antimicrobial Stewardship Programs in Preterm Infants: Encouraging Staff Nurse Engagement.

In NICUs, antibiotics are the most frequently prescribed medications. Misuse or overuse of antibiotics may lead to resistant species and other life-threatening complications and untoward effects. Antimicrobial stewardship programs-coordinated programs that promote the appropriate use of antimicrobials (including antibiotics)-have reduced unnecessary medication administration, costs, readmissions, complications, and mortality rates related to antimicrobial agents, predominantly among adult patients in many hospitals. At the same time, however, implementation of antimicrobial stewardship programs among preterm infants has been challenging, especially for staff nurses in NICUs. This article provides an overview of the literature addressing the concept of stewardship, outlines core elements of antibiotic stewardship programs from the Centers for Disease Control and Prevention, and examines strategies for nursing implementation in NICUs focusing on preterm infants.

Influence of NICU Nurse Education on Intention to Support Lactation Using Tailored Techniques: A Pilot Study.

BACKGROUND: Preterm infants' outcomes improve when fed their mothers' milk. Low percentages of neonatal intensive care unit (NICU) nurses support mothers facing barriers to establishing and sustaining adequate milk supplies. Nurses' motivations and attitudes are instrumental, but understudied, factors in their intention to promote maternal lactation. PURPOSE: Using the Theory of Reasoned Action, this study explored (1) NICU nurses' attitudes, social pressures, feelings of preparedness, perceptions of comfort, and intention to support lactation; and (2) magnitude of relationships among these concepts before and after undertaking an educational module. METHODS: A descriptive pre-/postintervention design included a sample of 24 NICU nurses who completed a module, including general lactation and hands-on expressing information. The Nursing Support for Breastfeeding Questionnaire was administered before and after completing the module. RESULTS: Attitudes, social norms, perception of preparedness, and intention were moderate to high before and after completion of the module. Perception of comfort was moderate. When comparing pre- and postintervention, effect sizes for intention and perception of comfort were moderate. Magnitude of the relationship between attitudes and intention was strong before intervention and moderate after intervention. Subjective norms demonstrated stronger relationships with attitudes and intention after intervention. Preparedness and comfort had stronger relationships with attitudes than with intention both before and after intervention. IMPLICATIONS FOR PRACTICE: Nurses' attitudes, perception of preparedness, and comfort are modifiable considerations in developing strategies to support evidence-based lactation techniques. IMPLICATIONS FOR RESEARCH: Additional studies are needed with fully powered and stronger designs to validate findings to guide interventions for nurse support for NICU mothers to optimize lactation.

Mothers' experiences expressing breast milk for their preterm infants: does NICU design make a difference?

PURPOSE: This study examined differences in outcomes of provision of mothers' milk before and after implementation of a single-family room (SFR) neonatal intensive care unit (NICU) and described issues related to long-term milk expression. SAMPLE: The sample included 40 mothers (15 in the original NICU and 25 in the SFR NICU). DESIGN: Descriptive comparative. METHODS: Mothers were recruited 2 months before and 3 months after opening an SFR NICU. Nutritional data were collected throughout hospitalization. Mothers used a milk expression diary during hospitalization and completed a survey, "My Experiences With Milk Expression" immediately before infant discharge. RESULTS: Seventy-five percent of mothers planned to express breast milk or breastfeed before delivery. The majority of the mothers (55%) were most comfortable pumping in their own homes because of the increased privacy. There were no statistically significant differences between the 2 groups regarding the place where they were most comfortable pumping or where they usually pumped, although more mothers pumped in their babies' rooms in the SFR NICU. The majority of the mothers reported concern about their milk supply at some time during hospitalization and 47.5% reported having breast problems. At discharge, 71.8% of the total group was providing some breast milk and 44.7% of the total group was providing breast milk exclusively. There were no significant differences between the groups in outcomes concerning the provision of breast milk. CONCLUSIONS: Individual mother's needs for privacy need to be determined and interventions to support mothers' feeding plans throughout hospitalization and at discharge need to be developed.