Staff Attitudes towards Patient Safety Culture and Working Conditions in an Irish Tertiary Neonatal Unit

Introduction There is little published research evaluating attitudes towards patient safety culture and working conditions in neonatal units. This study aimed to explore this within a Level III Irish neonatal unit setting. Methods This was a quantitative, cross-sectional study performed in the Rotunda Hospital, Dublin. A 30-item safety attitudes questionnaire (SAQ) was utilized to analyze staff perceptions in areas including job satisfaction, working conditions and stress recognition. Results The 'Stress Recognition' domain received the highest score (75.3) followed by 'Job Satisfaction' domain with a mean score of 74.4. The lowest mean scale score in the neonatal unit was for 'Perceptions of Management', with a mean score of 50.7. Collaboration and Communication scores were high across all disciplines. Conclusion This SAQ has highlighted a number of important areas for quality improvement and staff satisfaction in our neonatal unit.

Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.

BACKGROUND: The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics. METHODS: Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected. RESULTS: Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital. CONCLUSIONS: A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.

Recomendaciones para la identificación inequívoca del recién nacido / Recommendations for the unequivocal identification of the newborn

La identificación del recién nacido es un derecho reconocido, tanto a nivel internacional como nacional, y la correcta identificación del paciente constituye una prioridad dentro de las políticas de mejora de la seguridad de la asistencia sanitaria. En este documento el Comité de Estándares de la Sociedad Española de Neonatología recoge las recomendaciones para garantizar la identificación inequívoca del recién nacido durante su estancia hospitalaria. La combinación del codificador neonatal (pulsera de la madre y pulsera del recién nacido y pinza de cordón con un mismo número y con un código de barras idéntico y exclusivo para cada recién nacido), junto con la recogida de una muestra de sangre materna y otra de sangre del cordón umbilical (para análisis de ADN en caso exclusivamente de duda de identidad) es actualmente el método más fiable de identificación del recién nacido (AU)

Newborn identification is a legal right recognised by international and national laws. Moreover, improving the accuracy of correct patient identification is an important goal of patient safety solutions programs. In this article, the Standards Committee of the Spanish Society of Neonatology establishes recommendations to ensure correct identification of the newborn whilst in hospital. Currently, the most reliable method of identification of the newborn is the combination of identification cord clamp and bracelets (mother bracelet, newborn bracelet and cord clamp with the same number and identical and exclusive barcode system for each newborn) and the collection of maternal and umbilical cord blood samples (for DNA testing only for identification purposes) (AU)

The Perinatal-Neonatal Care Journey for Parents of Preterm Infants: What Is Working and What Can Be Improved.

Preterm birth is traumatic for parents, but there are few reports of parents' views on how the healthcare journey can be improved. This secondary thematic analysis used focus group data from parent consultation on proposed neonatal services standards for Northern Ireland to discover parents' experiences and recommendations for the perinatal, neonatal, and home care phases. Parents of preterm infants (n = 40) described their healthcare journey as positive overall and were grateful for the caring and competent care providers they encountered. However, parents described experiences that varied in quality and family centeredness across the care journey from perinatal to home care. They noted inconsistencies in healthcare team communication and provider practices and reported receiving limited emotional and practical support at all phases. In the perinatal phase, parents described difficult situations of discovering medical problems leading to preterm birth. In the neonatal intensive care unit phase, they also experienced unmet needs for involvement in decision making, financial strain, and difficulty coping with transfers and discharge. Parents experienced emotional challenges and lack of support in the home care phase. Parents identified actions that health systems can take to improve the consistency of care and communication across all phases and settings to encourage better collaboration and transitions in care.

Evaluation of the Effectiveness of Two Morphine Protocols to Treat Neonatal Abstinence Syndrome in a Level II Nursery in a Community Hospital.

The authors sought to evaluate the impact on length of hospital stay and treatment duration of morphine after implementation of a change in the institutional protocol for managing neonatal abstinence syndrome (NAS) in an effort to improve patient outcomes. A single-center, retrospective chart review was conducted at a Level II nursery in a community hospital in Kentucky. Fifty-nine neonates born between January 1, 2014, and December 31, 2015, who were diagnosed with NAS and received morphine for treatment were included. The protocol 1 group consisted of 33 neonates who received an initial dose of morphine 0.04 mg/kg/dose administered orally every 4 hours (January 1-December 31, 2014), and the protocol 2 group consisted of 26 neonates who received an initial dose of morphine 0.06 mg/kg/dose administered orally every 3 hours (January 1-November 30, 2015), after a change in the protocol for managing NAS was implemented on January 1, 2015. Data were reviewed and compared between the two protocol groups to determine the impact that the dosage change had on length of hospital stay and morphine treatment duration. The average length of stay decreased by 7 days in the protocol 2 group compared with the protocol 1 group (21 vs 28.65 days). The average duration of treatment decreased by 7 days in the protocol 2 group compared with the protocol 1 group (18.3 vs 25.4 days). These differences between groups were not statistically significant, however, because the population size was not large enough to achieve adequate power. These results indicate that protocol 2 displayed the potential to decrease length of stay and duration of treatment compared with protocol 1 at this facility; however, balancing higher starting doses with the risk of oversedation will continue to challenge the health care team. Concern for oversedation when using the higher starting dose in protocol 2 has prompted further research (e.g., protocol 3, initial morphine 0.05 mg/kg/dose every 3 hrs). Continued research is also necessary with larger patient populations to enable generalizability to other institutions.

User Evaluation of Neonatology Ward Design.

OBJECTIVE: The object of this article is to identify the set of affective and emotional factors behind users' assessments of a space in a neonatology unit and to propose design guidelines based on these. BACKGROUND: The importance of the neonatology service and the variety of users place great demands on the space at all levels. Despite the repercussions, the emotional aspects of the environment have received less attention. METHODS: To avoid incurring limitations in the user mental scheme, this study uses two complementary methodologies: focus group and semantic differential. The (qualitative) focus group methodology provides exploratory information and concepts. The (quantitative) semantic differential methodology then uses these concepts to extract the conceptual structures that users employ in their assessment of the space. Of the total 175 subjects, 31 took part in focus groups and 144 in semantic differential. RESULTS: Five independent concepts were identified: privacy, functionality and professional nature, spaciousness, lighting, and cleanliness. In relation to the importance of the overall positive assessment of the space, the perception of privacy and sensations of dominance and pleasure are fundamental. Six relevant design aspects were also identified: provide spacious surroundings, facilitate sufficient separation between the different posts or cots, use different colors from those usually found in health-care centers, as some aversion was found to white and especially green, design areas with childhood themes, use warm artificial light, and choose user-friendly equipment. CONCLUSIONS: Results provide design recommendations of interest and show the possibilities offered by combining both systems to analyze user response.

Interprofessional Education in Neonatal Care.

Interprofessional education is not a new concept. Yet, the operationalization of interprofessional education with related competencies for collaborative team-based practice in neonatal units is often difficult. Changes in healthcare with an emphasis on patient-focused care and the concern for patient safety and quality care are accelerating the need for more interprofessional education. This article briefly outlines the evolution of interprofessional education to support collaborative team-based practice and how that facilitates safety and quality care in neonatal units.

Safe Sleep for Hospitalized Infants.

BACKGROUND: The American Academy of Pediatrics (AAP) published expanded safe sleep guidelines in 2011. OBJECTIVE: The purpose of this quality improvement project was to promote the AAP safe sleep recommendations and provide appropriate role modeling of these recommendations for hemodynamically stable infants throughout their hospital stay. DESIGN AND INTERVENTION: A safe sleep educational initiative for parents and hospital staff included an observation of infant sleep practice before and after the initiative and a pre- and posteducation questionnaire of nurses' knowledge, attitudes, and opinions. SETTING AND PARTICIPANTS: A Magnet-designated urban hospital that included 72 pediatric beds, a 60-bed NICU, and 41 mother-baby beds; and 658 pediatric and obstetric nurses. RESULTS: One-hundred percent of nurses received the educational intervention. Observations noted an improvement from 70% to 90% (p< 0.01) of infants in a safe sleep position when comparing pre- and postintervention results. There were some improvements in knowledge of and agreement with the AAP guidelines after the educational intervention, but not as much as expected. CONCLUSIONS: There was inconsistency between nursing knowledge and practice about safe infant sleep. Nurses were aware of the AAP recommendations, but it took time to achieve close to full compliance in changing clinical practice. Observation was an important part of this initiative to reinforce knowledge and role model best practice for parents.

Neonatal nurses' beliefs, knowledge, and practices in relation to sudden infant death syndrome risk-reduction recommendations.

BACKGROUND: Sudden infant death syndrome (SIDS) remains the third leading cause of infant death in the United States and the leading cause of death beyond 1 month of age. In 2011, the American Academy of Pediatrics (AAP) released the newest SIDS risk-reduction recommendations, which address healthcare providers in neonatal intensive care units (NICUs). Little is known about neonatal nurses' SIDS prevention strategies since the release of these newest recommendations. PURPOSE: To assess neonatal nurses' beliefs, knowledge, and practices regarding SIDS prevention in both the NICU and step-down transitional care unit (TCU). METHODS: A prospective-descriptive design was used. The 33-item SIDS Risk-Reduction Questionnaire was distributed to a convenience sample of nurses in a level III NICU/TCU in the Midwest. RESULTS: Two hundred questionnaires were distributed; 96 (48%) were returned completed. Fifty-three percent of nurses strongly agreed that SIDS recommendations make a difference in preventing SIDS and 20% strongly believed that parents model SIDS prevention practices employed by staff. A majority of nurses correctly identified 2011 recommendations. Sixty-three percent of nurses often or always gave parents verbal information and 28% often or always gave parents written information regarding SIDS. Differences were seen between NICU and TCU nurses concerning beliefs and practices, suggesting that TCU nurses more consistently follow SIDS recommendations. IMPLICATIONS FOR PRACTICE: Increased neonatal nursing and parental education regarding SIDS prevention and updated hospital policies promoting safe sleep are paramount. IMPLICATIONS FOR RESEARCH: Larger multicenter studies in level II/III NICUs are needed to provide further data on SIDS attitudes and practices.

How differing shift lengths relate to quality outcomes in pediatrics.

OBJECTIVE: The aims of this study were to describe the shift lengths of pediatric nurses and to measure the association of shift length with nurse job outcomes, nurse-reported patient outcomes, and nurse-assessed safety and quality of care in hospitals. BACKGROUND: Long work hours have been linked with poor patient outcomes in adult patient populations, but little is known about the relationship in pediatric settings. METHODS: A secondary analysis of cross-sectional nurse survey data was conducted. Our analysis focused on 3710 registered nurses who worked in 342 acute care hospitals that treated children. RESULTS: Most pediatric nurses worked 12-hour shifts, especially in intensive care settings. Nurses who worked extended shifts of more than 13 hours reported worse job outcomes and lower quality and safety for patients compared with nurses who worked 8-hour shifts. CONCLUSIONS: Allocating resources to nursing to improve working hours may be a productive strategy for administrators to improve the health and well-being of pediatric patients and nurses.

Establishing successful breastfeeding in the newborn period.

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.

Targeted oxygen therapy in special care nurseries: is uniformity a good thing?

AIM: There is wide variation in the commencement of inspired oxygen (FiO2) and the oxygen saturation (SpO(2) ) targets set in special care nurseries (SCNs). Evidence supports minimising unnecessary oxygen exposure. Does the introduction of a protocol advocating the uniform approach of commencing FiO2 at 30% and targeting SpO2 of 94-96% for infants ≥ 33 weeks gestation with respiratory distress reduce oxygen exposure? METHODS: A 'Before After' study was undertaken in three SCNs. Data were recorded for all infants admitted to the SCNs who required oxygen over a 3-year period. Infants were analysed in gestational age groups: 33-36 weeks (late preterm) and +37 weeks (term/post-term). RESULTS: Of the 19,830 infants born, 868 (4%) were treated with oxygen. The introduction of an oxygen-targeting protocol resulted in a statistically and clinically significant reduction in the proportion of infants who were treated with any oxygen for 1 h or more, 4 h or more and in the proportion who received >30% FiO2 for 1 h or more (all P ≤ 0.01). This reduction was significant for infants of both gestational age groups. The median duration of oxygen for term/post-term infants was reduced from 12 h pre-protocol to 10 h post-protocol (P= 0.01); however, no significant difference was found for the preterm group (reduced from 11 to 8 h, P= 0.07). CONCLUSION: Introduction of a uniform oxygen protocol in SCNs for infants ≥ 33 weeks gestation with respiratory distress reduces the number of infants receiving oxygen and, in term infants, the duration of oxygen exposure.

Effect of revised nursery orders on newborn preventive services.

OBJECTIVE: Aspects of neonatal care that are the subject of evolving guidelines include hepatitis B virus (HBV) immunization; discharge follow-up recommendations; and prevention of perinatal group B streptococcal (GBS) disease. In 2007, a university hospital's standardized newborn nursery orders were changed to reflect current recommendations in these areas. The objective of the study was to determine the effect of new nursery orders on the quality of care provided to these newborns. METHODS: The study was a retrospective review of medical records, birth certificates, and a computer database of 857 infants. The nursery orders changed in the following ways: (1) physicians had to "opt out" of HBV immunization; (2) discharge follow-up recommendations were based on American Academy of Pediatrics (AAP) recommendations; and (3) AAP recommendations for GBS were followed except blood cultures were not required for certain infants. RESULTS: The percentage of infants receiving HBV immunizations increased from 74% in 2007 to 83% in 2008 (P = .0018). The percentage of infants whose mothers received antibiotics for GBS less than 4 hours before delivery and who received a complete blood count increased from 36% to 83% (P < .0001). The percentage of newborns who had discharge follow-up plans consistent with AAP recommendations did not change significantly. CONCLUSION: A simple change in nursery orders was associated with significant improvement in newborn care.

Lactation space design: supporting evidence-based practice and the baby-friendly hospital initiative.

The design of spaces where lactation occurs within a healthcare facility often lacks careful attention to the environmental requirements of breastfeeding. Although numerous studies evoke overwhelming support for lactation initiation in hospitals, few designers may understand the importance of such spaces. Furthermore, many designers may be unaware of the contributions they may make to this initiative. Countless studies that support the philosophy that breast milk is the best nutritional option for babies have been conducted. There are many health and economic advantages of breastfeeding for babies, mothers, and communities. Research suggests that exclusive breastfeeding for the first 6 months of life reduces the rate of illness throughout infancy and beyond, saves lives, and could save billions of dollars in the United States each year.The Baby Friendly Hospital Initiative is a global program established to promote within healthcare facilities the facilitation of breastfeeding infants from birth. Results of this initiative show a significant increase in breastfeeding rates in many countries. The intuitive design response to such favorable research is to enhance the lactation environment, assuming that mothers who feel comfortable in lactation spaces will use them more frequently, which promotes lactation in healthcare facilities. Considering the numerous research-supported advantages of breastfeeding, designers would be prudent to seek and apply knowledge of the environmental needs to the design of lactation spaces. This may be achieved by becoming familiar with lactation procedures to understand the circulation, adjacencies, and spatial requirements of lactation programs. Incorporating this information into the design may allow the development of ideal spaces that facilitate lactation.

Influência do local de nascimento e do transporte sobre a morbimortalidade de recém-nascidos prematuros / Effect of place of birth and transport on morbidity and mortality of preterm newborns

OBJETIVO: Verificar a influência do local de nascimento e do transporte sobre a morbimortalidade de recém-nascidos prematuros na Região Sul do Brasil. MÉTODOS: Estudo de coorte com recém-nascidos prematuros transferidos para a unidade de tratamento intensivo de referência (grupo transporte = 61), tendo sido acompanhados até a alta. Os dados sobre o atendimento no hospital de origem e transporte foram obtidos no momento da internação. Esse grupo foi comparado com neonatos da maternidade de referência, pareados por idade gestacional (grupo controle = 123), tendo como desfecho primário o óbito e desfechos secundários as alterações da glicemia, temperatura e saturação de oxigênio no momento da internação e a incidência de enterocolite necrosante, displasia broncopulmonar e sepses. Na associação entre as variáveis e o desfecho, foi utilizado o risco relativo. Foi adotado um nível de significância de α = 5 por cento e β = 90 por cento. RESULTADOS: A distância média percorrida foi de 91 km. A idade gestacional média foi de 34 semanas. Entre os recém-nascidos transferidos, 23 por cento (n = 14) não tiveram atendimento pediátrico na sala de parto. No transporte, 33 por cento dos recém-nascidos foram acompanhados por pediatra, e os equipamentos utilizados foram: incubadora (57 por cento), bomba de infusão (13 por cento), oxímetro (49 por cento) e aparelho para aferição da glicemia (21 por cento). O grupo transporte apresentou maior incidência de hiperglicemia, risco relativo (RR) = 3,2 (2,3-4,4), hipoglicemia, RR = 2,4 (1,4-4,0), hipertermia, RR = 2,5 (1,6-3,9), e hipoxemia, RR = 2,2 (1,6-3,0). Foram observados 18 por cento de óbitos no grupo dos transferidos e 8,9 por cento no grupo controle, RR = 2,0 (1,0-2,6). CONCLUSÕES: A pesquisa expõe deficiências no atendimento e transporte dos recém-nascidos, sendo necessária uma melhor organização do atendimento perinatal e do transporte na região nordeste do Rio Grande do Sul.

OBJECTIVE: To evaluate the effect of place of birth and transport on morbidity and mortality of preterm newborns in the southern region of Brazil. METHODS: This cohort study included preterm newborns transported to a reference intensive care unit (transport group = 61) and followed up until discharge. Data about care in hospital of origin and transport were obtained at admission. This group was compared with infants born in the maternity ward of the reference hospital paired according to gestational age (control group = 123). Primary outcome was death, and secondary outcomes were changes in blood glucose, temperature and oxygen saturation at admission and the incidence of necrotizing enterocolitis, bronchopulmonary dysplasia and sepsis. Relative risk (RR) was used to evaluate the association between variables and outcome. The level of significance was set at α = 5 percent and β = 90 percent. RESULTS: Mean travel distance was 91 km. Mean gestational age was 34 weeks. Of the neonates in the transport group, 23 percent (n = 14) did not receive pediatric care in the delivery room. During transportation, 33 percent of newborns were accompanied by a pediatrician, and the equipment available was: incubator (57 percent), infusion pump (13 percent), oximeter (49 percent) and device for blood glucose test (21 percent). The transport group had a greater incidence of hyperglycemia (RR = 3.2; 2.3-4.4), hypoglycemia (RR = 2.4; 1.4-4.0), hyperthermia (RR = 2.5; 1.6-3.9), and hypoxemia (RR = 2.2; 1.6-3.0). The percentage of deaths was 18 percent in the transport group and 8.9 percent in the control group (RR = 2.0; 1.0-2.6). CONCLUSIONS: This study revealed deficiencies in neonatal care and transport. Perinatal care and transport should be better organized in the northeastern region of Rio Grande do Sul, Brazil.

Effect of place of birth and transport on morbidity and mortality of preterm newborns.

OBJECTIVE: To evaluate the effect of place of birth and transport on morbidity and mortality of preterm newborns in the southern region of Brazil. METHODS: This cohort study included preterm newborns transported to a reference intensive care unit (transport group = 61) and followed up until discharge. Data about care in hospital of origin and transport were obtained at admission. This group was compared with infants born in the maternity ward of the reference hospital paired according to gestational age (control group = 123). Primary outcome was death, and secondary outcomes were changes in blood glucose, temperature and oxygen saturation at admission and the incidence of necrotizing enterocolitis, bronchopulmonary dysplasia and sepsis. Relative risk (RR) was used to evaluate the association between variables and outcome. The level of significance was set at α = 5% and ß = 90%. RESULTS: Mean travel distance was 91 km. Mean gestational age was 34 weeks. Of the neonates in the transport group, 23% (n = 14) did not receive pediatric care in the delivery room. During transportation, 33% of newborns were accompanied by a pediatrician, and the equipment available was: incubator (57%), infusion pump (13%), oximeter (49%) and device for blood glucose test (21%). The transport group had a greater incidence of hyperglycemia (RR = 3.2; 2.3-4.4), hypoglycemia (RR = 2.4; 1.4-4.0), hyperthermia (RR = 2.5; 1.6-3.9), and hypoxemia (RR = 2.2; 1.6-3.0). The percentage of deaths was 18% in the transport group and 8.9% in the control group (RR = 2.0; 1.0-2.6). CONCLUSIONS: This study revealed deficiencies in neonatal care and transport. Perinatal care and transport should be better organized in the northeastern region of Rio Grande do Sul, Brazil.

A reduction of necrotising enterocolitis at Groote Schuur Hospital nursery.

Necrotising enterocolitis (NEC) is an gastro-intestinal emergency occurring almost solely in preterm, low birth weight infants. Mortality, morbidity and the complication rate are high. An increase in NEC at the Groote Schuur Hospital nursery in 2008 prompted a change of practice, resulting in a significant decrease in the condition.