Neonatal Nurses NICU Quality Improvement: Embracing EBP Recommendations to Provide Parent Psychosocial Support.

BACKGROUND: The neonatal intensive care unit (NICU) can be a stressful environment for infants, their families, and the healthcare team. There is an immediate need for neonatal nurses to embrace and translate the new National Perinatal Association recommendations for psychosocial support of NICU parents into clinical practice to demonstrate best practices for infants, their families, and the whole team. PURPOSE: To summarize the current evidence-based practice recommendations and to provide suggestions for team members to develop strategies to adopt and implement them through quality improvement (QI) projects. METHODS: Literature reviews were conducted by the original 6 National Perinatal Association workgroup teams and covered all levels of available evidence (eg, qualitative, quantitative, and clinical research, guidelines, and clinical and parental expertise). Evidence was synthesized to formulate this set of recommendations published in December 2015. We describe their applicability to the vital role of neonatal nurses, while elucidating QI projects that track measurements of change to translate these recommendations into practice. RESULTS: Neonatal nurses are in an ideal position to transform systems of support for NICU parents through the adoption of these recommendations at the bedside, and further to identify areas for QI to enhance implementation. IMPLICATIONS FOR PRACTICE: Neonatal nurses are integral to problem solving and identifying QI strategies for translating these recommendations into NICU clinical practice to improve parent psychosocial support. IMPLICATIONS FOR RESEARCH: This article disseminates evidence and encourages scientific investigation into various methods of supporting emotional health of NICU parents to create better health outcomes.

Evidence-Based Practice and Quality Improvement in Nursing Education.

For more than a decade, nursing education has experienced several significant changes in response to challenges faced by healthcare organizations. Accrediting organizations have called for improved quality and safety in care, and the Institute of Medicine has identified evidence-based practice and quality improvement as 2 core competencies to include in the curricula for all healthcare professionals. However, the application of these competencies reaches far beyond the classroom setting. For nurses to possess the knowledge, skills, and attitudes to apply evidence-based practice and quality improvement to the real-world setting, academic-clinical institution partnerships are vital.

Ensuring Quality in the NICU: Translating Research Into Appropriate Clinical Care.

Since the Institute of Medicine's landmark report To Err Is Human, extensive efforts to improve patient safety have been undertaken. However, wide-scale improvement has been limited, sporadic, and inconsistent. Implementation of evidence-based interventions remains a challenge, resulting in unwarranted variations in care. Three main categories of problems in healthcare delivery are defined as overuse, underuse, and misuse of medical services, resulting in inappropriate care, inefficiencies, and poor quality. Although broad acknowledgement that these categories of quality problems exist, there are limited standards for measuring their overall impact. This article aims to discuss the important role of implementation science in advancing evidence-based practice, using neonatal therapeutic hypothermia for the treatment of hypoxic-ischemic encephalopathy as an exemplar for examining appropriateness of care.

Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units.

Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations.The Children's Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the "SLUG Bug" project designed to reduce central line-associated bloodstream infections (CLABSIs).The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure.CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more ("improvement") was achieved by 94% of centers and a score 4 or more ("significant improvement") was achieved by 35%.Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases.

A randomized-controlled trial pilot study examining the neurodevelopmental effects of a 5-week M Technique intervention on very preterm infants.

PURPOSE: To systematically test the cumulative effect of the M Technique on infant neurodevelopment in hospitalized very preterm infants. DESIGN: A pilot randomized controlled trial (RCT). SUBJECTS: Twenty very preterm infants (<30 weeks gestation with average birth weights <1000 g) were randomly assigned to nontreatment or treatment groups. The study period began once the infants reached 30 weeks postmenstrual age (PMA). METHODS: Each infant received standard neonatal intensive unit (NICU) care or standard NICU care plus a 7-minute M Technique session, 6 times per week for 5 weeks. Neurobehavioral development (using the NICU Network Neurobehavioral Scale [NNNS]) and growth velocity (difference in infant weight at the beginning and end of protocol) were compared between the 2 groups. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations) and infant behavioral states were measured 5 minutes before, during, and up to 10 minutes postintervention continuously on all infants in the treatment group at 3 different gestational time points (30, 32, and 34 weeks PMA) over the 5-week period. RESULTS: Mann-Whitney U analyses revealed no differences between the 2 groups on all 12 NNNS summary score domains but a difference in growth velocity between the 2 groups (P = 0.005). Repeated-measures analysis of variance revealed significant physiologic differences of mean heart rate, respiratory rate, and SaO2 (F = 41.116, P < 0.0005) and behavioral states (F = 38.564, P < 0.0005) from baseline to 10 minutes after the M Technique intervention across all 3 time points. State scores decreased from baseline (M = 6.11) to post intervention (M = 1.4) at all 3 time points. CONCLUSIONS: This pilot RCT demonstrates the utility of the M Technique in hospitalized very preterm infants starting at 30 weeks PMA with notable evidence of positive weight, physiological, and behavioral state adaptations. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurological outcomes.

Eliminating Central Line Associated Bloodstream Infections in Pediatric Oncology Patients: A Quality Improvement Effort.

Central Line-Associated Bloodstream Infections (CLABSI) are the largest contributor to harm across the Children's Hospital's Solutions for Patient Safety network. Pediatric hematology/oncology (PHO) patients are at increased risk for CLABSI due to multiple factors. Consequently, traditional CLABSI prevention strategies are insufficient to eliminate CLABSI in this high-risk population. Methods: Our SMART aim was to reduce the CLABSI rate by 50% from a baseline of 1.89/1000 central line days to less than 0.9/1000 central line days by December 31, 2021. We created a multidisciplinary team being mindful to identify roles and responsibilities upfront. We developed a key driver diagram and designed and implemented interventions to influence our primary outcome. Results: We implemented interventions and conducted Plan-Do-Study-Act cycles concurrently. We found that performing audits by directly observing tasks rather than auditing documentation resulted in more accurate compliance assessments. As a result, our CLABSI rate improved from 1.89/1000 central line days in 2020 with 11 primary CLABSI to 0.73/1000 central line days in 2021 with four primary CLABSI. Average days between events improved from 30 days in 2020 to 73 days in 2021, and we achieved an unprecedented 542 days CLABSI-free, extending into 2022. Conclusions: Through a multimodal approach and utilizing characteristics of high-reliability organizations, we significantly reduced primary CLABSI, approaching zero in our PHO population and doubling the average days between events. Future efforts will focus on the sustained engagement of all stakeholders and improving our safety culture.

Application of the M Technique in hospitalized very preterm infants: a feasibility study.

PURPOSE: To explore the application of a novel relaxation method (the M Technique) in hospitalized very preterm infants in a level IIIC neonatal intensive care unit. DESIGN: A feasibility, observational intervention study. SUBJECTS: Ten very preterm infants were enrolled to receive the treatment intervention. Eligible infants born less than 30 weeks' gestation received the intervention at 30 weeks' postmenstrual age. METHODS: Based on infant readiness, each infant received the M Technique for 5 minutes. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations), behavioral variables (stress and relaxation cues), and infant behavioral state were measured 5 minutes before, during, and up to 10 minutes after the intervention, continuously. RESULTS: Descriptive analysis revealed that baseline physiologic, behavioral state, and behavioral cue parameters changed during and after the application of the M Technique. A decrease in heart rate and respiratory rate occurred during the M Technique (P = .006, P > .001 respectively) and a decrease in heart rate occurred at the end of the M Technique session (P = .02). In addition, an increase in SaO2 occurred during and at 5 minutes following the M Technique session (P = .04, P = .02, respectively). State scores decreased from baseline (mean = 5.1; range, 3-9) to after the intervention (mean = 2.0, range 1-4). As the intervention was delivered, more positive than negative behavioral cues were observed throughout, at the end, and after the M Technique session. CONCLUSION: In this feasibility study, the M Technique can be delivered without adverse effects to very preterm infants who are 30 weeks' postmenstrual age. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurologic outcomes.