Quality Indices and Outcomes of a Neonatology Telerounding Program in a Level II Neonatal Intensive Care Unit: Single-Center Experience during the COVID-19 Pandemic.

OBJECTIVE: The objective of this program evaluation was to describe the outcomes of daily neonatologist telerounding with the onsite advanced practice provider (APP) in a Level II neonatal intensive care unit (NICU), before and during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Bedside telerounding occurred with an onsite APP using a telehealth cart and paired Bluetooth stethoscope. Data collected by longitudinal and cross-sectional surveys and chart review before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic were analyzed using descriptive statistics and thematic analysis. RESULTS: A total of 258 patients were admitted to the Level II NICU before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic. Demographic characteristics and outcomes, including breastfeeding at discharge and length of stay were similar pre- and postonset of the COVID-19 pandemic. Postrounding surveys by 10 (response rate 83%) neonatologists indicated parents were present in 80 (77%) of rounds and video was at least somewhat helpful in 94% of cases. Cross-sectional survey responses of 23 neonatologists and APPs (response rate 62%) indicated satisfaction with the program. Common themes on qualitative analysis of open-ended survey responses were "need for goodness of fit" and "another set of eyes" and "opportunities for use." CONCLUSION: Daily telerounding with neonatologists and APPs in a Level II NICU supported neonatal care. Quality metrics and clinical outcomes are described with no differences seen before and during the COVID-19 pandemic. KEY POINTS: · Little is known about Level II NICU quality metrics and outcomes.. · Daily bedside telerounding with neonatologists and APPs is described.. · Telerounding supported neonatal care before and during the COVID-19 pandemic.. · Neonatologists found visual exam helpful in the majority of cases.. · No differences in NICU clinical outcomes were seen during the COVID-19 pandemic..

Neonatal Care Provider Tasks in the NICU and Delivery Room.

BACKGROUND: Decreased availability of pediatric residents in neonatal intensive care units (NICUs) has created demand for other neonatal medical care providers. No recent publications exist about how to approach the organization of tasks involved in that care. PURPOSE: The purpose of this article is to present a structure and resources to guide the organization of tasks in the care of sick and premature infants in the NICU. METHODS: The methods included a literature review to develop evidenced-based practice resources. The literature was reviewed regarding the relevant history and resources to support task organization during patient rounds and care in the NICU, and for delivery attendance by skilled providers. The goal, to establish a reference to support education about these approaches, is based upon evidence, which appears to be rooted in tradition. FINDINGS: Evidence-based resources include documentation templates, problem list in order of systems, and provider tasks for NICU and delivery attendance. IMPLICATION FOR RESEARCH: Future studies can measure mentor or learner perceptions of the value of these resources, critical thinking improvement, safety, and clinical outcomes. IMPLICATION FOR PRACTICE: These resources may provide structure for learners and providers who have studied the physiology, pathophysiology, and problem management concepts, but need to learn how to execute their responsibilities in these busy environments.

Growing Neonatal Advanced Practice Providers via Mentorship Can Fill the Need: Program Description and Tool Kit.

BACKGROUND: The need for neonatal advanced practice providers (APPs) has been described. Hospital training programs for neonatal physician assistants (PAs) have been developed by physicians. No publications exist about programs administered by neonatal APPs for both new graduate neonatal nurse practitioners (NNPs) and neonatal PAs. PURPOSE: The purpose of this work was to mentor, train, and hire neonatal APPs in a program administered by neonatal APPs. METHODS: We developed a 2-pronged approach to attract PAs and new graduate NNPs. Marketing strategies included receptions, information, and mentorship. A 12-month neonatal PA fellowship program included clinical mentorship and weekly didactics. Case-based presentations were provided by neonatal APPs, neonatologists, and allied professionals. The new graduate NNP program included clinical mentorship and monthly meetings with peer support, lectures, and case presentations. Neonatal APPs were clinical mentors. Team-building activities supported mentorship and collaboration among all care providers. FINDINGS: In less than 5 years, 10 PAs and 11 new graduate NNPs have been trained and hired, as well as experienced neonatal APPs hired for this regional neonatology program. For the first time in years, locum tenens neonatal APPs are not required. We have developed a "tool kit" of content, activities, exercises, and evaluations to support successful attainment of expected competencies. IMPLICATION FOR RESEARCH: Future studies can measure retention, satisfaction, and clinical outcomes. IMPLICATION FOR PRACTICE: A successful training program has been implemented to meet the growing demand. We support the values of integrity, collaboration, and equity to facilitate this successful paradigm shift among all neonatal professional team members.

Neonatal Care Provider Tasks for Hospitalized Well Newborns.

BACKGROUND: Changes in the pediatrician's practice model have created demand for other medical care providers for hospitalized well newborns. Well newborn care may be the responsibility of those who work in any level I-IV neonatal intensive care units, whether in a primary or secondary role. No recent publications exist about how to approach the organization of tasks. PURPOSE: The purpose of this article is to present a structure and resources to guide the organization of tasks in the care of hospitalized well newborns for learners or occasional care providers. METHODS: The methods used in this project included literature review to develop evidence-based practice resources. The literature was reviewed regarding the relevant history and resources to support task organization of well newborn care provided by skilled providers in the hospital. The goal is to establish a reference to support education about these approaches, which appear to be rooted in tradition. FINDINGS: Evidence-based resources include an overview of provider tasks and responsibilities for well newborn care for each hospital day and per shift. IMPLICATION FOR RESEARCH: Future studies can measure mentor or learner perceptions of the value of these resources, critical thinking improvement, safety, and clinical outcomes. IMPLICATION FOR PRACTICE: These resources may provide structure for learners or occasional providers who have studied the physiology, pathophysiology, and problem management concepts but need to learn how to execute their responsibilities in these busy environments.

Do We Nurture Our Young? Qualitative Conceptual Analysis of Worst and Best Mentorship Experiences Among Neonatal Advanced Practice Providers.

BACKGROUND: There is increasing demand for neonatal advanced practice providers (APPs) and a shortage of neonatal nurse practitioners (NNPs). In many neonatal intensive care units, neonatal physician assistants are trained and hired, as well as new graduate NNPs. Neonatal APPs are utilized as mentors in a regional neonatology program in the Pacific Northwest. As part of a long-term goal to develop an educational program for neonatal APP mentors, an initial survey was administered. PURPOSE: The purpose of this survey was to raise personal insight and identify themes about 51 neonatal APP mentors' recollections of one's own worst and best mentorship experiences. METHODS: The design used in this content analysis of survey responses included a phenomenological, qualitative approach. The participants received an online survey consisting of 2 questions asking them to describe their worst and best mentorship experiences. The blinded results were analyzed via content analysis by 2 coinvestigators. RESULTS: Consistent themes about worst experiences include "Eat our young," "I am better than you," "Thrown under bus," and "Unwanted." Consistent themes about best experiences include "Validation," "Empowerment," "Positivity," and "Inclusion." IMPLICATIONS FOR PRACTICE: Recommendations for successful neonatal APP mentorship based upon the recurrent themes include use of consistent, engaged, trained, and supported mentors, provision of on-time constructive feedback, avoidance of public criticism, private and public praise, focus on the learner, preparation for tasks, and semiautonomy, with adequate support. IMPLICATIONS FOR RESEARCH: Absenteeism, recruitment, retention, and satisfaction data may be measured to determine whether structured mentorship programs are beneficial.

Development of an Alarm Algorithm, With Nanotechnology Multimodal Sensor, to Predict Impending Infusion Failure and Improve Safety of Peripheral Intravenous Catheters in Neonates.

BACKGROUND: Peripheral intravenous catheters connected to an infusion pump are necessary for the delivery of fluids, nutrition, and medications to hospitalized neonates but are not without complications. These adverse events contribute to hospital-acquired patient harm. An artificial intelligence theory called fuzzy logic may allow the use of appropriate variables to predict infusion failure. PURPOSE: This innovative study aimed to develop an intravenous infusion nanotechnology monitoring system that would alert the nurse to impending peripheral intravenous infusion failure. METHODS: An intravenous infusion nanotechnology monitoring system, using predictor variables of pressure, pH, and oxygen saturation used in a fuzzy logic alarm algorithm was developed to alert the nurse to impending peripheral intravenous infusion failure. FINDINGS: The developed intravenous infusion nanotechnology monitoring system is composed of a peripheral intravenous catheter with nanotechnology multimodal sensor, an intravenous pump, a fuzzy logic algorithm, and alarm. For example, using this system, an elevated in-line pressure, a low pH, and a low venous oxygen level would generate an alarm for possible impending infusion failure. IMPLICATIONS FOR PRACTICE: With further development, this technology may help nurses predict and prevent adverse outcomes from intravenous infusions. This work shows how nurses can be content experts and innovators of technology that they use to make clinical decisions. IMPLICATIONS FOR RESEARCH: After regulatory approval, a randomized controlled trial may be performed to investigate whether interventions at the time of an alarm would result in fewer adverse outcomes and improve safety.

Use of Potassium Hydroxide (KOH) Test Reduces Antifungal Medication Prescription for Suspected Monilial Diaper Dermatitis in the Neonatal Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Despite availability of rapid fungal potassium hydroxide (KOH) tests, many care providers rely on visual assessment to determine the diagnosis of monilial diaper dermatitis (MDD). PURPOSE: To determine whether a KOH test, when MDD is suspected, would result in more accurate diagnoses, with decreased antifungal medication prescription and exposure. METHODS: Quality improvement project from 2016 through 2017 with protocol implemented in 2017 for treatment of MDD after positive KOH testing. If monilial rash suspected, after 2 negative KOH tests, then antifungal ordered (considered false negative). χ testing and cost determination were performed. SAMPLE: Neonates in 2 level III neonatal intensive care units. OUTCOME VARIABLES: KOH test results, use of antifungal medication, and cost. RESULTS: The patient census included 1051 and 1015 patients in the year before and after the protocol initiation. The medical orders for antifungal medication decreased from 143 to 36 (P < .001; 95% odds ratio confidence interval, 2.24-4.38). There was a 75% reduction in both use and cost, as charged, of antifungal agents. Overall charges, including KOH test costs, decreased by 12%. Three infants received multiple negative KOH tests, then a positive one. These met the definition of false-negative tests, per protocol. There were no cases of fungal sepsis. IMPLICATIONS FOR PRACTICE: Use of a quality improvement protocol, in which the use of KOH testing is required, before antifungal agents are prescribed, results in decreased exposure and costs. IMPLICATIONS FOR RESEARCH: To test the feasibility of bedside "point-of-care" KOH testing, and whether KOH testing and reduced antifungal medication use affects antimicrobial resistance or invasive fungal sepsis.

Collaboration, not competition: cost analysis of neonatal nurse practitioner plus neonatologist versus neonatologist-only care models.

BACKGROUND: Although advanced practice in neonatal nursing is accepted and supported by the American Academy of Pediatrics and National Association of Neonatal Nurse Practitioners, less than one-half of all states allow independent prescriptive authority by advanced practice nurse practitioners. PURPOSE: The purpose of this study was to compare costs of a collaborative practice model that includes neonatal nurse practitioner (NNP) plus neonatologist (Neo) versus a neonatologist only (Neo-Only) practice in Washington state. Published Internet median salary figures from 3 sources were averaged to produce mean ± SD provider salaries, and costs for each care model were calculated in this descriptive, comparative study. FINDINGS/RESULTS: Median NNP versus Neo salaries were $99,773 ± $5206 versus $228,871 ± $9654, respectively (P < .0001). The NNP + Neo (5 NNP/3 Neo full-time equivalents [FTEs]) cost $1,185,475 versus Neo-Only (8 Neo FTEs) cost $1,830,960. The NNP + Neo practice model with 8 FTEs suggests a cost savings, with assumed equivalent reimbursement, of $645,485/year. IMPLICATIONS FOR PRACTICE: These results may provide the impetus for more states to adopt broader scope of practice licensure for NNPs. IMPLICATIONS FOR RESEARCH: These data may provide rationale for analysis of actual costs and outcomes of collaborative practice.

Toward salience: an application of integrative, case-based, nursing education for neonatal advanced practice.

The purpose of this article was to present a new, integrative, case-based educational approach for neonatal advanced practice nursing students in a hybirdized long-distance program at the University of Washington. The theoretical background is based on a holistic, systems-based, and case-based approach to learning. A guideline for instructors will be included, emphasizing recommendations of Benner et al for teaching a sense of salience, integration, critical reasoning, and role formation. Such a holistic approach to neonatal advanced practice nursing education may maximize the unification of knowledge with practice and improve learning, at a time when resources are few.

A model of collaboration and efficiency between neonatal nurse practitioner and neonatologist: application of collaboration theory.

A model of clinical practice involving neonatal nurse practitioners (NNP) and neonatologists is presented through the application of collaboration theory. This strategy has been used in business and other applications. In this article, the terms and principles of the model will be explained. The relevant features will be identified, including interdependence, communication, strategic negotiation, independent billing, NNP licensure support, semiformal systems, and radical tailorability. Recommendations for structure and components to ensure safe practice involving the unique contributions of the NNP will be highlighted. An example of such a successful practice will be described.

Complex case study: nursing care of an infant with restrictive dermopathy.

This article is a complex case study of an infant, born at 33 2/7 weeks' gestation, with restrictive dermopathy, who died at 5 weeks of age. The review of perinatal and postnatal courses, as well as the rare disorder of restrictive dermopathy, a lethal genodermatosis laminopathy, is presented. Neonatal problems are identified. These include problems of prematurity, including need for a neutral thermal environment, nutritional support, and sepsis evaluation. Problems related to the diagnosis of restrictive dermopathy include skin abnormalities of mild hydropic appearance and ichthyosis-like exanthem, thrombocytophilia, pain, and respiratory insufficiency that led to death. The specific social issues of a non-English-speaking family from Russia faced with a lethal diagnosis for their infant are discussed. This infant was born in a community hospital with a perinatal center and tertiary-level neonatal intensive care unit and was transferred at 3 weeks of age to a regional pediatric medical center for subspecialist pulmonary, dermatologic, and genetic evaluation, where she died shortly afterward. Finally, recommendations are made for a nursing care plan related to the problems presented in this case.

Making babies real: dressing infants in the NICU.

This article presents the physiologic rationale for dressing infants in the NICU. It reports interview responses from mothers and nurses on their feelings about one infant dressing program, proposes a care plan, discusses the advantages and disadvantages of infant dressing, and suggests ideas for related research. The goals of the program described here are to provide preterm and/or sick infants with increased insulation to improve thermoregulation, personalize and normalize care, promote developmentally appropriate care, promote discharge planning, and support all families equally, regardless of socioeconomic status.