A Pilot Project to Improve Neonataal

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Klein, L. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Newborn

Care

A Pilot Project to Improve Neonatal Peripheral Intravenous

Site Assessment and Documentation

Lisa Klein, MSN, RNC-OB,

RNC-LRN, CNS, Marymount

University, Reston, VA

Keywords

neonatal

nursing

peripheral intravenousassessment

documentation

Paper Presentation

Purpose for the Program

There is currently no consistent protocol de-scribed in the literature for documentation of

the nursing assessment of neonatal peripheral in-

travenous sites. Most authors concur that hourly

assessments are the minimum frequency and in-

dicate what the assessment parameters should

be; however, they do not discuss a protocol for

documentation of the assessments. Multiple au-

thors and professional nursing groups have iden-

tified that problems exist in the care of periph-

eral intravenous sites in neonates. This project

attempted to determine if nurses in a neonatal in-

tensive care unit (NICU) could conduct and docu-

ment an hourly evidence-based focused assess-

ment of neonatal peripheral intravenous sites.

An additional purpose of the project was to obtain

input from direct care nurses before initiating a

change in practice. Critical care nurses perform

multiple hourly assessments and care interven-

tions on each patient. Additional documentation of

five measurement parameters may not be realistic

to add to the workload of the direct care nurse. By

having the nurses who participated in data collec-

tion provide feedback regarding the complexity

or simplicity of the instrument, they were able to

evaluate the potential value of the process and the

instrument to their care.

Proposed Change

Many NICUs use a system of charting by excep-tion for assessment of peripheral intravenous sites

in neonates. This project introduced a documen-

tation form that includes the five evidence-basedparameters to indicate the status of the peripheral

intravenous sites. It attempted to determine if an

instrument on which to document the assessment

was relevant to the practice of the NICU nurses

providing care. The project also determined the

time needed to perform and document the periph-

eral intravenous site assessment and if that time

was considered reasonable by the NICU nurses

providing care.

Implementation, Outcomes, and Evaluation

The documentation form was piloted in a large

suburban NICU. The short-term goal of this

pilot project was to determine if the instru-

ment on which to document the assessment

and the time to perform and document it was

deemed reasonable by the nurses providing

care. The nurses are still participating in the

pilot project. Early data suggest that the tool

may be helpful but nurses are unsure if all of

the parameters are necessary for an adequate

assessment.

Implications for Nursing Practice

It is hoped that this project will stimulate further

study of the individual assessment parameters to

determine if any or all of them in a tool format are

valid and reliable in predicting infiltrations and ex-

travasations, which would be useful in improvingpatient outcomes.

The Great Pretenders: Utilizing Evidence-Based Practice

to Optimize Clinical Outcomes for the Late Preterm Infant

Jaimi S. Hall, MSN, RNC-OB,

Peninsula Regional Medical

Center, Salisbury, MD

Angela T. Houck, DNPc,RNC-nic, RN-BC, Peninsula

Regional Medical Center,

Salisbury, MD

Keywords

late preterm infant

evidence-based practice

Newborn Care

Paper Presentation


The late preterm infant faces many challenges

associated with prematurity. In 2010, 99 late

preterminfants (approximately 5% of the total birthvolume) were born at Peninsula Regional Medi-

cal Center. Nearly 29% of these infants were ad-

mitted to the neonatal intensive care unit (NICU),

and 12.8% were readmitted to the pediatric unit

for complications associated with prematurity. The

purpose of this program wasto determine if adopt-

ing an evidence-based model of care utilizing

the Association of Womens Health, Obstetric and

Neonatal Nurses Assessment and Care of the

Late Preterm Infant Guideline will improve clinical

outcomes and reduce late preterm infant neonatal

intensive care unit admissions and readmissions

to the pediatric unit.

Proposed Change

To adopt, institute, and practice Association of

Womens Health, Obstetric and Neonatal Nurses

(AWHONN) clinical guidelines for every infant

born between 34.0 and 36.6 weeks of gestation

at Peninsula Regional Medical Center.


Data collection took place over a 6-month pe-

riod to determine baseline rates of hypothermia,

JOGNN 2012; Vol. 41, Supplement 1 S31


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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

hypoglycemia, respiratory distress, feeding dif-

ficulties, phototherapy, excessive weight loss,

neonatal intensive care unit admissions, and read-

missions to the pediatric unit. A multidisciplinary

team developed the late preterm infant initiative

utilizing AWHONNs clinical guidelines. Compo-

nents of the initiative included policy and order

set development, predelivery and predischargeeducation, and individualized feeding plans. Be-

ginning March 22, 2011, all late preterm infants

were admitted to the intermediate care nursery

and cared for with a nurse-to-patient ratio of 1:3

to 4. All aspects of the clinical guidelines were

utilized based on the individual needs of the in-

fant. Data collection on these infants began May

1, 2011.

To date, 31 late preterm infants have been cared

for under the new initiative. Eight of these infants

were subsequently admitted to the neonatal inten-

sive care unit (25.8%), and no infants were read-

mitted to the pediatric unit. The overall goal is to

improve clinical outcomes while reducing admis-sions to the neonatal intensive care unit by 10%

and readmissions to the pediatric unit by 5%, as

compared with the 2010 rates.


As the primary bedside caregiver, nurses are ex-

tremely vested in their patients outcomes. This

initiative has led to an increased staff awareness

of this population, their unique needs, and the

challenges they face. This knowledge, coupled

with the utilization of evidence-based care, trans-

lates into improved clinical outcomes for the late

preterm infant. This initiative also has improved

teamwork and communication and has fostered

relationships between nurses and other health

professionals. Family-centered care is at the core

of obstetric nursing as well as this initiative. Provid-

ing care that enhances family bonding, empow-

ers parents, and improves clinical outcomes in-

creases patient and nurse satisfaction. In this era

of rising health care costs and nonreimbursement

for preventable readmissions, it behooves nurses

to adopt practicesthat anticipate and prevent pos-sible sequelae related to late prematurity.

Tackling Newborn Hypoglycemia in the Delivery Room:

Utilizing Colostrum, Skin to Skin and State of the Art

Policies

Pamela Kinney Tozier, BSN,

RNC, CCE, IBCLC, Maine

Medical Center, Portland, ME

Keywords

hypoglycemia

diabetics

hand expression

colostrums

skin-to-skin

Newborn Care

Paper Presentation


N

ewborn hypoglycemia in the delivery room

is a widespread challenge. Most often in-

fants who are breastfed and are temporarily sep-

arated from their mothers receive formula as a

quick fix to increase blood glucose levels. This

approach not only decreases breastfeeding suc-

cess, but it also exposes the newborn to unsta-

ble levels of glucose because of the formulas

stimulation of insulin production. Too many infants

who are breastfed receive excessive amounts of

formula within the first hour of life because their

glucose values are checked before feeding, as

soon as 15 to 30 minutes after birth. After wit-

nessing a 40-minute-old newborn receive 40 ml of

formula for a glucose level of 40, then promptly

vomit, gag, and turn dusky, I decided it was

time to act on my concerns that something wasout of balance regarding the blood sugar/feeding

issue.

Proposed Change

To attain stable glucose levels in babies who are

breastfed by giving infants drops of colostrum,

feeding them before labs are checked, and keep-

ing them in continuous skin-to-skin contact. I had

recently become an international board certified

lactation consultant, and that new level of knowl-

edge, coupled with my nursing experience, pre-

pared me well for presenting my ideas to the

administration. I also proposed that we estab-

lish ways to give colostrum to babies who werenot ready to latch effectively. I wanted to rewrite

the existing breastfeeding policy, have nurses

adhere more vigilantly to our skin-to-skin policy,

write a policy on prebirth hand expression of

colostrum, and be a driving force to change many

of the parameters of the newborn hypoglycemia

algorithm.


We have successfully implemented a new hypo-

glycemia algorithm that accepts lower glucose

values initially, has the newborn feed first, andthen the first glucose level checked by 90 min-

utes of age. We have implemented widespread

hand expression of colostrum, before and after

childbirth, for all of our diabetic patients who are

breastfeeding, and we have maintained continu-

ous skin-to-skin contact as a norm. The outcomes

to date have been a decrease in separation of the

mother and baby, higher newborn glucose levels,

higher patient satisfaction, and better success of

breastfeeding.

S32 JOGNN, 41, S1-S118; 2012.DOI: 10.1111/j.1552-6909.2012.01360.x http://jognn.awhonn.org


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Lawson, T. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention


Labor and delivery nurses are the first line of de-

fense in helping stabilize newborn glucose lev-

els without the introduction of formula, thereby up-

holding the standard of best practice. It is possible

for just one nurse with a vision to apply evidence-

based practice to achieve quality outcomes.

Premature Infant Nutrition ClinicTerry Lawson, RN, IBCLC,

University of California San

Diego Medical Center, San

Diego, CA

Keywords

human milk

premature infant nutrition

lactation consultant

Newborn Care

Paper Presentation


The benefits of human breast milk for term in-

fants outweigh formula. Breast milk is an even

greater benefit to the preterm infant because it

provides infection prevention and promotes im-

proved neurodevelopment. In 2006, the University

of California San Diego MedicalCenter was desig-

nated as Baby Friendly. The Supporting Premature

Infant Nutrition program was launched in 2007.

Thegoalwas to improve the growth and nutrition of

preterm infants. It was noted that following hospi-

tal discharge, most mothers were not successfully

breastfeeding their premature infants. These in-fants continued to require fortifiers, but we did not

know how much or for how long. Mothers contin-

ued to need to pump, but supply was decreasing.

Both parents were exhausted and overwhelmed.

Proposed Change

In August 2008, the Premature Infant Nutrition

Clinic was established by a pediatrician and reg-

istered nurse. Utilizing a team approach, visits in-

cluded infants growth and development assess-

ments and discussions of the mothers concerns.

After the assessment and discussion, the regis-

tered nurse performs a lactation consult and as-

sesses the infant feeding, looking for ways to im-prove milk transfer, increase milk supply, and in-

crease breastfeeding and decrease breast pump-

ing. At the end of the 45- to 60-minute session, a

plan is developed to help the mother reach the de-

sired goal. Visits are individualized, ranging from

one-time only to severalvisits 1 to 3 weeks apart. A

follow-up letter is sent to the primary provider with

appointment highlights and recommendations.


It was noted during the first year, 97 patients/183

visits occurred; the second year, 83 new patients;

and the third year, 130 new patients/637 visits oc-

curred. During the 3 years, the gestational age

breakdown included the following: 46 newborns

less than 30 weeks of gestation, 90 newborns 30

to 33 6/7 weeks of gestation, 104 newborns 34

to 33 6/7 weeks of gestation, and 40 newbornsgreater than 37 weeks of gestation. Multiples data

included 215 singletons, 83 sets of twins, and 12

sets of triplets. Currently, the team sees 7 to 8 pa-

tients in a 4-hour session, 1 day a week. There is a

need to expand to 2 days to manage the increase

in consultations. Outcomes have improved, such

as increased breast milk for longer duration of

time, more breastfeeding, decreased/no breast

pumping, and increased exclusive breastfeeding.


Assuring best practice and performing research

is exemplified by the projects in progress, includ-

ing a Premature Infant Nutrition Clinic Quality As-

surance project, research of liquid fortification ofthe mothers milk at discharge, and an interna-

tional multicenter validation of a preterm growth

chart. Both providers and nurses are involved in

every aspect leading to increasedpatient andstaff

satisfaction.

Implementing Practice Protocols and Education to Improve

the Care of Infants with Neonatal Abstinence Syndrome

Katherine Y. Lucas, DNP,APRN, NNP-BC, Cape Fear

Valley Health System,

Fayetteville, NC

Purpose of the Program

The National Council on Alcoholism and Drug

Dependency estimates that between 1% and

11% of babies born each year are exposed to il-

licit substances in utero. The American Academy

of Pediatrics reported that 50% to 95% of infants

exposed to opioids or opioid derivatives, including

heroin and methadone, develop neonatal absti-

nence syndrome (NAS). Research that is more re-

cent describes an increasing incidence of infants

exposed to harmful substances prior to birth. Ba-bies exposed to opioids or opioid derivatives dur-

ing pregnancy are at increased risk of developing

NAS. Optimal treatment of this NAS population is

hampered by the current lack of evidence-based

standardized guidelines and protocols for phar-

macologic management and care that promote

improved outcomes for NAS patients. Care and

management of these infants can be improved

with practice guidelines and education.



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Proposed Change

To develop and implement evidence-based clin-

ical practice guidelines and an educational pro-

Keywords

NICU

FNAST

education

Newborn Care

Paper Presentation

gram on NAS and the Finnegan Neonatal Absti-

nence Scoring Tool (FNAST), to improve nursing

assessment and care of the NAS infant, and im-

prove scoring accuracy with use of the FNAST.


This study was a nonexperimental, pretest/

posttest study that evaluated change in nursing

knowledge about NAS and use of the FNAST after

the implementation of a quality improvement, ed-

ucational project. Nurses were tested before and

after participation in education about NAS. A sub-

set of 10 nurses was evaluated using the FNAST

with video of infants having NAS. Volunteer par-

ticipation in the NAS educational project occurred

in 81% of the neonatal intensive care unit nurses.

All nurses showed some improvement in scores

on the posttest, with 2% to 44% improvement. All

10 nurses who participated in the interactive video

test scored 90% or higher against the FNAST cri-

terion 1 week after participation in the educational

project.


Evidenced-based clinical practice guidelines andeducation on NAS and the FNAST equip care-

givers with the necessary tools to consistently and

accurately assess an infant with NAS when using

the FNAST. Recent research shows that provid-

ing education to nurses can result in knowledge

gained, improved professional practice, and im-

proved patient treatment goals. Education also

can equip nurses with the necessary knowledge

to care for patients with complex medical prob-

lems like NAS. Further, providing nurses with

specific information about a medical problem

is correlated with improved adherence to best

practice.

Perinatal Palliative Care: Support of Mothers,

Infants and Families

J. Frances Fusco, MHS, BSN,

RN, University Community

Hospital, Tampa, FL

Theresa Bish, RN, IBCLC,

University CommunityHospital, Tampa, FL

Keywords

perinatal palliative care

infant advanced directives

Newborn Care

Poster Presentation


To support mothers, infants, and families

through the Perinatal Palliative Care program.

Proposed Change

To enhance the existing bereavement programto include infants with low viability or no viability

through palliative care.


Implementation is in process and awaiting final

approval of pertinent policies and procedures to

supportthis program. The evaluation will be based

upon a patient satisfaction survey taken by tele-

phone follow-up of patients discharged from the

hospital.


Provide care andsupport to both infants and moth-

ers going through this experience.

Neonatal Head Trauma: Implementation of a Care Algorithm

to Improve Safety

Sandra Hoffman, MS, RN,

CNS-BC, Abbott Northwestern

Hospital, Minneapolis, MN


To create a process by which newborns with

head trauma or at risk of complications of

neonatal head trauma are identified, assessed,

and monitored differently with the goal of improv-

ing safety.

Proposed Change

To create and implement a neonatal head trauma

algorithm that is part of the newborn standing or-

ders across a large multihospital health system

to ensure that newborns who are at risk of head

trauma or who have head trauma, are evaluated

more closely to ensure their safety.



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Braithwaite, P., Donahue, N. and Bayne, L. E. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Keywords

neonatal head trauma

vacuum extraction

forceps delivery

subgaleal hemorrhage

Newborn Care

Poster Presentation


Neonatal head trauma can result in catastrophic

outcomes, and it is essential that infants at risk

of complications of a difficult or instrumented de-

livery are identified and monitored more closely.

Complications, such as subgaleal hemorrhages

may manifest at birth or may occur over many

hours, so identification of infants at risk and in-creased vigilance is important for patient safety.

After a review of the literature, a multidisciplinary

team of neonatal and birthing clinical nurse spe-

cialists, pediatricians, a neonatologist, and a

neonatal nurse practitioner created a neonatal

head trauma algorithm to become part of the new-

born standing orders. Staff and physician educa-

tion was done regarding neonatal head trauma,

and the neonatal head trauma algorithm was im-

plemented across a large multihospital health sys-

tem. The evaluation of this change is ongoing.


Nurses caring for newborns are in a key position

to identify complications of neonatal head traumathat may result from the birthing process. A stan-

dardized approach can ensure the identification

and closer monitoring of infants who may have an

injury that may not manifest for many hours after

delivery. Education about neonatal head trauma

increases awareness of the risks, promotes ap-

propriate pain management, and helps to keep

newborns safe.

Help! Im Cold! Improving the Warmth of Our Newborns

Pamela Braithwaite, BSN,RNC, Christiana Care Health

System, Bear, DE

Nicole Donahue, BSN, MSN,

RNC, Christiana Care,

Middletown, DE

Lynn E. Bayne, PhD, NNP-BC,

RN, Christiana Care Health

System, Newark, DE

Keywords

preterm

hypothermia

fishbone diagram

root-cause analysis

morbidity

mortalitypolyethylene

Newborn Care

Poster Presentation


Cozy Cuties is a multidisciplinary performance

improvement team convened to address hy-

pothermia from birth to admission to the neona-

tal intensive care unit among inborn preterm in-

fants at less than 31 weeks gestational age. Re-

view of facility data over the past 5 years showed

that the initial admission temperatures of these

infants were significantly lower than average in

our neonatal intensive care unit (NICU) than the

benchmark of 850 NICUs within the Vermont Ox-

ford Network. Across this time period, 61% of the

infants who were less than 31 weeks gestational

age had body temperatures less than 36C at ad-

mission and were classified as hypothermic using

the World Health Organization definition. Two large

studies of infants from 23 weeks to 30 completed

weeks of gestation, suggested that when infants

are admitted to the NICU with hypothermia, their

chances of survival decrease by approximately

10% for every degree below 36C, independent

of any disease conditions. In addition, late onset

sepsis is increased by 11% and odds of death are

increased by 28%.

Proposed Change

Root cause analysis using fish bone techniques

was conducted on the first five cases of ad-

mission of hypothermia for each calendar month

over the 12-month period prior to project incep-tion. Literature was reviewed to establish potential

causes. A facility tour determined how many po-

tential causes existed and coupled the potential

cause with evidence-based interventions. A ther-

mal intervention bundle was developed and im-plemented. The bundle included a timeout-style

thermal checklist, increased room temperature,

proper radiant warmer preheat and use, short-

ened infant time at point of delivery for both vagi-

nal birth and cesarean birth, change in transfer

technique of newborn to a warmer from point of

delivery, effective use of polyethylene wrap, at-

tention to application of pulse oximetry, warming

of surfactant, and warming of caregiver hands.

Aggressive clinical staff education in labor and

delivery and NICU was conducted using a vari-

ety of methods, including video and social media.

Post-implementation, infants who were less than

31 weeks gestational age were prospectively fol-

lowed and the incidence of the outcome variableswas collected.


Data were analyzed, and findings showed that our

admission hypothermia rates have been reduced

from 61% over the past 5 years to approximately

18% over the past 6 months. Ongoing monitoring

for sustained improvement is now in place.


A multidisciplinary team can be an extremely ef-

fective agent of change. It is important to bring

key stakeholders in a project to realize gains. Clin-

icians are obligated to benchmark practices thatmay contribute silently to patientillness. Body tem-

perature should never be taken for granted. The

goal shouldalwaysbe tokeepa warm infantwarm,

not to rewarm a cold infant.



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Welcome Aboard and Homeward Bound: The NICU

Familys Journey for a Safe Voyage to Discharge

Geraldine Tamborelli, MS, RN,

Maine Medical Center,Portland, ME

Keywords

discharge

satisfaction

best practice

education

family centered care

multidisciplinary

Newborn Care

Poster Presentation


Improveparent andstaffsatisfaction with the dis-charge process and complex follow-up care for

the very premature or sick infant. Involve parents

in the plan of care, the daily care of their infants,

and their personal preferences early on.

Proposed Change

To standardize teaching, timing of education, doc-

umentation, and communication of education to

better prepare parents for discharge.


Implementation using Plan-Do-Study-Act cycles,staff and patient satisfaction, as well as chart au-

dits were used for measurement and feedback.


The best practice was identified and we continue

to maintain the gains by evaluating satisfaction

levels and random chart audits.

Birthways Lactation Services: A Model

for Breastfeeding Support

Angela Carswell, RN, IBCLC,

Mary Greeley Medical Center,

Ames, IA

Keywords

lactation program

exceeding national and state

breastfeeding rates

Newborn CarePoster Presentation


The purpose of the Birthways Lactation Ser-

vices program is twofold. We want to increase

breastfeeding initiation and duration rates and

thereby improve long-term health for every infant.

We also want to increase the lactation consultants

productivity while decreasing full time equivalents

and cost. Most lactation programs have lost state

funding in recent years and are now funded by

hard-to-find grants, or as in our hospitals case, bycommunity benefit dollars.

Proposed Change

For 10 years, our program was set up to provide

home visits to our clients (within a 50 mile radius)

who either chose tohave a visit or when a visit was

physician ordered. Eight years ago, it was deter-

mined this was a costly way to deliver care even

with funds provided by a grant and some insur-

ance reimbursement. At that time we started the

clinic model and were encouraged by the pos-

itive results. Our lactation consultants cross-train

to the discharge planning position of the Birthways

Lactation Services program where they round with

the pediatricians, schedule the clinic visits at dis-charge, and provide a discharge feeding plan for

babies with feeding problems.


Three to five times per day, the coordinator of the

lactation program and her team perform checks

that include weight, jaundice, and lactation evalu-

ation.We believe ouroutcomes reflectthe success

of the program. Our breastfeeding initiation rate is

87.6% as compared with the states 73.9%. Our

6-month breastfeeding rate is 79.3% (one of the

best in the state) as compared with the national

rate of 17%. We are ahead of the Healthy People

2020 goals of an 81.9% initiation of breastfeeding

and a 6-month breastfeeding duration of 60.6%.

Our home visit model took 3.1 full time equivalents,andour clinic model takes 1.2full time equivalents,

which represents a savings of more than $140,000

in salaries and mileage reimbursement. Our lacta-

tion consultants can see five more infants per day

or 25 more per week, which makes it possible to

provide second visits for those clients who need

them.


The advantages of breastfeeding are well re-

searched and well documented. We believe our

program model is the best practice and is leading

the way in breastfeeding promotion and supportof

the American Academy of Pediatrics Policy State-

ment and theU.S. Surgeon Generals Call to Actionto Support Breastfeeding. Our service model de-

creases hospital readmission rates and promotes

exclusive breastfeeding with increased productiv-

ity and decreased cost.



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Keller, A. and Brenneman, A. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Operation Kangaroo Care

Anne Keller, MS, RNC, CNP,

OhioHealth, Columbus, OH

Alicia Brenneman, BSN, RNC,

Grant Medical CenterOhioHealth, Columbus, OH

Keywords

Kangaroo Care

cesarean birth

Newborn Care

Poster Presentation


Kangaroo care is recommended in the Guide-

lines for Perinatal Care for stable newborns.

The act of placing the infant skin-to-skin (alsocalled Kangaroo care) with the mother has been

shown to maintain skin temperature regulation

of the newborn, increase initiation of successful

breastfeeding, and ease the transition for intrauter-

ine to extrauterine life. The practice of Kangaroo

care has been well adopted in our setting. During

2010, 75% of all mothers who gave birth vaginally

participated in skin-to-skin care. The staff started

to initiate Kangaroo care in the postanesthesia

care unit to provide all the benefits to the moth-

ers who had cesarean births.

Proposed Change

Before the initiation of skin-to-skin in the postanes-thesia care unit, infants had been removed from

the warmer after being wrapped with warm blan-

kets and a hat and given to the mother to hold

or breastfeed. This process was not satisfying to

the staff. The staff stated that if the vaginal birth in-

fant could benefit from skin-to-skin, then we should

adopt the practice with the cesarean birth infant.

The process before leaving the operating room is

to now initiate skin-to-skin with the infant (who is

dressed only with a diaper and hat) and apply

warm blankets against the back of the infant whileleaving its chest exposed.


The implementation was started by staff nurses

who considered the evidence-based practice of

Kangaroo care to be best for the newborn. Staff

began by placing the infant skin-to-skin after mov-

ing the mother from the operating room table

to a hospital bed. Both are transported to the

postanesthesia care unit, initial checks are pre-

formed, and a baseline set of vitals is obtained

on the infant. The mother-infant pair is left skin-

to-skin for the next 60 to 90 minutes. Outcomes

have been measured by patient satisfaction and

stable infant temperatures during the time frame.

Patients report they would initiate Kangaroo care

with their next birth.


Empowering nurses to change practice to over-

come traditional barriers of medical care to pro-

mote the empowerment of motherhood.

Infant Feeding Plan: An Innovative Documentation Tool to

Improve Communication between Caregivers and FamiliesJennifer Peterman, RN, BSN,

IBCLC, Hospital of the

University of Pennsylvania,

Philadelphia, PA

Keywords

breastfeeding

infant feeding plan

patientfamily centered care

Newborn Care

Poster Presentation


A lack of communication was identified sur-

rounding a mothers feeding decision and

multiple health care providers. This lack of com-

munication resulted in a mothers perceived lack of

respect by providers regarding her preference for

newbornfeeding. To address this issue, an innova-

tive, crib side, infant feeding plan documentation

tool was created to identify a mothers preference

for feeding her newborn from birth through dis-

charge. Providers also noted a large variation be-

tween provider practices related to newborn feed-

ing and maternal preference.

Proposed Change

To improve communication between providers

and mothers, a crib side infant feeding plan doc-

umentation tool was implemented.


Prior to implementation, representatives from each

provider group involved in newborn care collab-

orated on the creation of the infant feeding plan

document. The development of the individualized

plan began at maternal admission, with the use of

a scripted narrative, to discuss maternal newborn

feeding preferences. Once feeding preferences

were identified, a mutually agreed upon feeding

plan was created and signed by both the mother

and the nurse. Throughout the infants stay, the

plan waslocated at the infants crib. If any changes

to the feeding plan were needed, both the nurse

and mother discussed, updated, and signed the

revised feeding plan.

Outcomes and evaluation are ongoingPrior to the implementation of the feeding plan,

breastfeeding rates were 68% and during the year

postimplementation, breastfeeding rates have

continued to increase to 74%. Anecdotally, pa-

tients report feeling that their infant feeding

choices are respected and that the use of this plan

prompts infant feeding discussions. Providers

commented that the plan is convenient and useful

in practice, and the Joint Commission recognized

it as a best practice model of care.



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This initiative provided an opportunity for nursing

to re-energize their commitments to patient com-

munication and infant feeding, especially breast-

feeding. Patientfamily centered care is based

on respect and honest communication between

providers and families. This tool gave nurses an

opportunity to dialogue with the infants mothers

regarding feeding options and changes in infant

feeding as needed. At admission, nurses were

able to review with the family the evidence asso-

ciated with optimal infant feeding. Also, the tool

served as a contract between the mother and

the providers to ensure that the mothers feeding

preference plan was implemented. The tool also

served as an easy way to communicate to anyprovider caring for the infant.

A Baby Weigh Station: Continuum of Care for Late Preterm

Breastfeeding Infants

Kathleen H. Bright, BSN,

RNC, IBCLC, Doctors

Hospital-Ohiohealth,

Columbus, OH

Joyce Sheppard, RN, IBCLC,

Womens Health Services,

Riverside Methodist Hospital,

Columbus, OH

Whitney Lenger Mirvis, BSN,

RN, IBCLC, Riverside

Methodist Hospital, Columbus,

OH

Jane Lamp, MS, RN-BC, CNS,

Riverside Methodist Hospital,

Columbus, OH

Keywords

late

preterm

breastfeeding

weigh

Newborn Care

Poster Presentation


Late preterm infants who breastfeed are the

largest segment of preterm infants. In Colum-

bus, Ohio, the incidence of late preterm infants

who breastfed was 9.1% of live births (in 2008)

and the rate at our hospital was 7.7% (of 6,456births/year in 2010). Late preterm infants often ap-

pear to be able to breastfeed successfully during

hospitalization, (hence, their nickname the great

imposter), but this may not be sustained follow-

ing discharge. As 1 of 15 sites for the Associ-

ation of Womens Health, Obstetric and Neona-

tal Nurses 2010 Late Preterm Infant Evidence-

Based Practice Guidelines research study, com-

mitment occurred in this hospitals outpatient set-

ting to measure and improve post-discharge care

of late preterm infants who breastfed.

Proposed Change

To ensure a successful continuum of care for the

postdischarge late preterm infant via a commu-nity resource where 90% of late preterm infants

will gain weight after events of lactation consulta-

tion and first weight measurement.


Utilize a baby weigh station within a user-friendly

lactation support center to offer a community ac-

cessible onsite, free service, monitored by ap-

proachable staff and expert professionals. Identify

late preterm infants who return for repeat weight

measurement, track weight gain, and generate

monthly progress reports. To estimate the total

number of late preterminfants who were consulted

and weighed on more than one visit, the followingformula was used: Numerator number of late

preterm infants who gain weight of more than 0.5

ounces at more than 5 days of age and thereafter;

Denominator total number of late preterm infants

consulted/weighed. Over 12 months, 151 individ-

ual late preterm infant weights were measured:

116 had repeated weights and 99% demonstrated

weight gain (monthly averages). Additional bene-

fits included referrals to lactation, pediatrics, pe-

diatric surgery, and behavioral services. An ac-

cessible weigh station was evaluated to be an ef-

fective pathway to ongoing care and support for

late preterm infants. Late preterm infants gained

weight appropriately and their mothers reported

sustained breastfeeding.


Accessible community service, monitored by ap-

proachable staff and expert professionals is an

effective means to continue and grow client re-

lationships. Monitor at-risk groups for anticipated

problems and provide a portal for continuing care.



9/27

Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Increasing Exclusive Breast Milk Feeding Rates at an Urban

Academic Hospital

Laurie Dohnalek, RN, MBA,

NE-BC, Georgetown UniversityHospital, Washington, DC

Cynthia Heer, RNC-OB,

RN-BC, MSN, Georgetown

University Hospital,

Washington, DC

Elizabeth Starrels, RN, BSN,

IBCLC, Georgetown University

Hospital, Washington, DC

Carol A. Ryan, MSN, RN,

IBCLC, FILCA, Georgetown


Washington, DC

Margaret Howland, RN, BSN,

RNCOB, Georgetown


Washington, DC, DC

Lauren O. Wurster, RN, MSN,

Georgetown University

Hospital, Washington, DC

Keywords

exclusive breastfeeding

exclusive breast milk feeding

breastfeeding rates

Joint Commission

perinatal core measure

Newborn Care

Poster Presentation


To increase exclusive breast milk feeding ratesat an urban academic hospital.

Proposed Change

Over an 18-month periodinterventions were imple-

mented to increase exclusive breast milk feeding

rates by at least 10%.


To implement this program, the following interven-

tions were completed:

Creation and implementation of Donor Pas-

teurized Milk Policy; all nurses attended

mandatory education session

Implementation of 24-hour rooming in (noseparation of mothersand newborns viastan-

dard nursery) Survey given to patients to identify the most

popular reasons for supplementation Journal clubs discussing breastfeeding is-

sues Consultations with lactation consultants at

other facilities Increasing rates and duration of initial skin-to-

skin contact and first breastfeeding session Daily patient rounds and assessments by in-

ternational board certified lactation consul-

tant Mandatory interdisciplinary breastfeeding

education for all nurses, obstetricians, andpediatricians

Education related to alternative breast milk

feeding methods Outside speaker (international board certi-

fied lactation consultant) that moderated dis-

cussion of obstacles to exclusive breast milk

feeding Feeding care plans (for complicated situa-

tions) developed collaboratively with nurses

and international board certified lactation

consultants Implementation of mother and newborn

quiet time

These interventions were implemented and the re-

sult was an increase in the staffs knowledge and

skills, thus changing practice and creating confi-

dence. The outcome was that our exclusive breast

milk feeding rates increased. A data collection tool

was created to monitor and track exclusive breast

milk feeding rates. We also are utilizing a patient-

based survey to evaluate the effectiveness of the

interventions.


Education is a major aspect of our initiative to in-

crease exclusive breast milk feeding rates. The

low incidence of exclusive breastfeeding is par-

tially due to a lack of breastfeeding knowledge

among health care professionals. Educational pro-

grams that increase nurses knowledge and im-

prove attitudes toward breastfeeding promote ac-

curate and reliable delivery of breastfeeding infor-

mation and skills to the mothers. These programs

also encourage positive role modeling of support-

ive breastfeeding attitudes. This may improve ex-clusive breast milk feeding rates because of the

effect that this has on patients. Many of the in-

terventions included in our program are directly

aimed at increasing breastfeeding knowledge of

our staff and patients.

Exclusive Breastfeeding: It Takes Our Village

Julie Delcasino, RNC-MNN,

BSN, Presbyterian Healthcare,

Charlotte, NC

Diane Slough, RN, BSN,

IBCLC, Presbyterian Hospital,

Charlotte, NC

Keywords

exclusive breastfeeding

Newborn Care

Poster Presentation


E

xclusive breastfeeding is best for the infant

and mother. Evidence-based practice de-

scribes this choice, but who can say their hospital

truly promotes exclusive breastfeeding? We are a

600-bed hospital with more than 7,000 births/year.

It takes our village to educate the mother, fam-

ily, and staff within womens services. It is the re-

sponsibility of us all to help mothers be successful

and promote the recommendations of the Asso-

ciation of Womens Health, Obstetric and Neona-

tal Nurses, World Health Organization, American

Academy of Pediatrics, American College of Ob-

stetricians and Gynecologists, U.S. Department of

Health and Human Services, Centers for Disease

Control and Prevention, and the Joint Commission

for exclusive breastfeeding.

Proposed Change

We want to provide best patient care. In May

2010, our exclusive breastfeeding rate was 37%.

We realized our shortfall and discussed ways to

improve our rate. Within our shared governance

structure, we have a unit research council. The

topic of change regarding exclusive breastfeed-

ing, hospital supplementation, and education for



10/27


staff was our new project. Our council consists of

staff nurses from the departments of motherbaby

and gynecology. The nurse educator and lacta-

tion consultant are also committee members. We

began with a literature search. How do you treat

a baby with low blood sugar but still exclusively

breastfeed? What do you do when a mother is

medically unable to breastfeed after birth? Whatabout mothers who want to sleep all night and

request that staff bottle feed their infants? What

about the obstetrician or pediatrician who tells the

mother, You need your sleep at night. A little for-

mula never hurt. What about labor and delivery

nurses who say, Breastfeeding is not our job, its

the lactation consultants job. Extensive educa-

tion was needed for womens services staff, physi-

cians, parents, and families.

Implementation, Outcomes and Evaluation

The nurse educator and lactation consultant de-

veloped an education program for all womens

services staff. The major health care organizations

that recommended exclusive breastfeeding were

cited. Articles from the literature search were pre-

sented. Benefits of breastfeeding for the mother,

infant, and community were discussed. Many ex-

amples of hospital practices that decrease suc-

cess of exclusive breastfeeding were recalled.

Skin-to-skin care and rooming in were discussed.

In North Carolina, we have the Perinatal Qual-

ity Collaborative of North Carolina for exclusivebreastfeeding. The Perinatal Quality Collaborative

of North Carolinas well-baby track focuses on

supporting mothers choice to provide exclusive

breastfeeding for their term infants. We became

an active member of the Perinatal Quality Col-

laborative of North Carolina project for exclusive

breastfeeding.


We want to provide thebest practice and the litera-

ture supports exclusive breastfeeding. As obstet-

ric nurses, we have power to educate andsupport

mothers and families to make informed decisions

about their individual infants care.

Now I Lay Me Back to Sleep . . . .Safely

Courtnie J. Burrell, RNC,

Henrico Doctors Hospital,

Richmond, VA

Diane Stairs, RN, Henrico

Doctors Hospital, Richmond,

VA

Keywords

SIDS

safe sleepmodel

Newborn Care

Poster Presentation


One of the Healthy People 2020 goals is to im-

prove the health and well being of women,

infants, children, and families. One way to accom-

plish this goal is by reducing the rate of fetal and

infant deaths. In Virginia, from 2003 to 2007, there

were approximately 78 infant deaths/year due to

sudden infant death syndrome (SIDS). This rate

is greater than the national average. It has beenproven that supine sleeping is the greatest fac-

tor in reducing the risk of SIDS even though many

nurses still feel more comfortable placingthe baby

prone. Hospital nurses are the first professional

role models for new parents. Modeling suggested

behaviors, such as back sleeping, can be a pow-

erful education tool as well as parental education

through verbal and written educational materials.

Proposed Change

Infants are no longer able to have stuffed animals

or extra blankets in the incubator or crib. Once

the infant is transitioned to an open crib, the infant

should be placed in a supine position unless a

physicians order indicates otherwise. Nurses are

to model safe sleep positioning at least 24 hours

prior to discharge and provide parental education

on SIDS and SIDS risk reduction. SIDS education

is also offered at infant cardiopulmonary resusci-

tation classes.


The safe sleep task force was initiated and a hos-

pital policy on safe sleep was written. The staff

received mandatory in-services regarding SIDS to

ensure consistency in parental education. One in-

service was on SIDS and SIDS risks in the term

newbornand the other addressed the needs of the

prematureinfant. Safe sleep education was added

to the March of Dimes notebook, which all parentsof infants admitted to the neonatal critical care

center receive. This is reviewed with the parents

prior to discharge. An education record is signed

at discharge acknowledging that the information

was reviewed. After discharge the charts are

retrospectively audited for safe sleep education

and supine positioning at least 24 hours prior to

discharge.


The expectation is to provide consistent safe sleep

education to the parents and to model safe sleep

positioning. Data collected will be used to validate

success of the program andto encourage the staff

continued participation and support. Integrating

evidence-based findings into practice will facili-

tate further involvement into addressing the higher

incidence of sudden infant death syndrome in the

African American population.



11/27

Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Implementing Skin-to-Skin Care in a Baby-Friendly

Community Hospital

Jennifer L. Reeg, MSN, RNC,

Health First Cape CanaveralHospital, Cocoa Beach, FL

Tracy Lott, RNC, BSN, MS,

Health First Cape Canaveral

Hospital, Cocoa Beach, FL

Keywords

breastfeeding

skin-to-skin care

kangaroo care

newborn

Newborn Care

Poster Presentation


To improve motherinfant attachment andbreastfeeding.

Proposed Change

To implement skin-to-skin care in a baby friendly

community hospital.


Health First, Inc. Cape Canaveral Hospital, a

Baby-Friendly facility since June 2000, launched a

skin-to-skin initiative in 2009. An evidence-based

practice protocol for placing newborns skin-to-

skin at birth and in the immediate postpartum pe-

riod was incorporated into our labor, delivery, re-

covery, and postpartum (LDRP) unit, and encour-

aged during the entirety of the postpartum stay.Staff nurses were educated in appropriate skin-to-

skin techniques and patient instruction, first in a

small group interactive setting and later followed

with a video and discussion format. Patient ed-

ucation pamphlets were distributed to women in

labor and Kangaroo care shirts were loaned to

new mothers during their hospital stay. Families

were encouraged to attempt to keep their new-

born skin-to-skin for up to 6 hours a day for the first

week oflife and a minimum of2 hours a day for the

second week through fourth week. Mothers were

assured that anyone, e.g., fathersand grandmoth-

ers, can engage in the skin-to-skin care with the

infant. Studies have reported benefits of skin-to-skin care of the newborn to include reduced cry-

ing, improved motherinfant interaction, warmer

babies, and greater breastfeeding success. Ad-

ditional positive effects on neonatal self-regulation

during the transition from intrauterine to extrauter-ine life include increased sleep, decreased apnea

and bradycardia, improved respiration and oxy-

gen saturation, accelerated weight gain, and, for

the mother, increased milk production. The staff at

Cape Canaveral Hospital has observed anecdotal

evidence of these benefits.

The nursing and lactation staff at Cape Canaveral

Hospital strive to achieve skin-to-skin care with ev-

ery new motherbaby couplet, making allowance

for individual circumstances and infant condition.

A chart audit was conducted from 2010 to 2011

for evidence of skin-to-skin care attempted and

encouraged immediately after birth and within the

first hour of life, and of documentation of mothereducation on benefits of skin-to-skin care. Results

show a 90% success rate, indicative of a positive

trend in the number of motherbaby couplets opt-

ing for this practice and verbalizing their intent to

continue skin-to-skin care at home. Mothers seen

one-on-one in the lactation clinic after discharge

are further encouraged to continue skin-to-skin

care in the first weeks.


The practice of skin-to-skin care as a component

of our baby friendly philosophy contributes posi-

tively to neonatal transition, enhances attachment,

and promises long-term benefit to new families.We at Cape Canaveral Hospital are committed to

continuing promotion of skin-to-skin care as part

of best practice.

Cue-Based Feeding: Implementation in an 83 Bed, Level

Three, Metropolitan Neonatal Intensive Care Unit

Lindsay Newland, RN, BSN,

IBCLC, Baylor University

Medical Center Dallas, Dallas,

TX

Keywords

cue based feeding

infant driven feeds

NICU

feeding

Newborn Care

Poster Presentation


T

he purpose of this program was to implement

cue-based feeding in our neonatal intensive

care unit (NICU).

Proposed Change

Achievement of full oral feedings is often times

the last milestone reached prior to discharge

from the NICU. Many NICUs still used a sched-

uled feeding method to initiate and progress oral

feedings. Several studies have come out to sup-

port that a cue-based feeding approach, also

known as an infant-driven approach, may help

the NICU infant achieve full oral feedings up to

6 days sooner than a scheduled feeding method.

A cue-based feeding approach tailors the pro-

gression of oral feedings for each individual, withclose attention paid to the infants developmental

cuesto decrease stress. The following outlines our

transition from scheduled feedings to cue-based

feedings.


We introduced a cue-based feeding program in

our 83-bed, level three, metropolitan NICU, which

has more than 200 nurses and staff. This was



12/27


achieved with a multidisciplinary team approach.

Staff education was given by nurses, including

one team leader and four super-trainers on each

shift. Education was given in the form of bedside

in-services, updates in the unit newsletter, a nurs-

ing policy and guideline, and a continuing educa-

tion offering. The education ranged in topics, such

as benefits of cue-based feeding, how to read in-fant cues, how to use a cue-based feeding scale

form, educating parents, and trouble shooting. Af-

ter implementation, bedside charts were audited

to assess staff adherence with cue-based feed-

ing and address issues. Concerns and common

issues were addressed in the form of bedside

in-services, questions and answers, updates in

emails and newsletters,as well as focus groups on

each shift.A multidisciplinary meeting took place 6

months after implementation to address concerns

and update the program.


Cue-based feeding has become a common lan-guage in our unit and is considered a success.

Research is currently underway in our unit to as-

sess time to full oral feedings and the effect on

direct breastfeeding rates. Future research to con-

sider is the effect that cue-based feedings has on

oral aversion after discharge.

Be Quiet! You Are Getting On My Neurons! Noise

Reduction in the Neonatal Intensive Care Unit

Jennifer L. Notestine, BSN,RNC-NIC, Mount Carmel East

Hospital, Columbus, OH

Teresa L. Rapp, RN, NNP-BC,

Mount Carmel East Hospital,

Columbus, OH

Keywords

noise

neurodevelopment

neonate

neonatal intensive care unit

Newborn Care

Poster Presentation


Multiple studies have shown that excessive

noise affects neurodevelopment in infants.

Our clinical excellence committee wanted to ex-

plore the noise levels in our neonatal intensive

care unit (NICU). Our findings were that our levels

exceeded recommended levels. Based on these

findings, we felt that changes needed to be made.

Proposed Change

We provided education on the effects of excess

noise on neonates to our NICU staff and imple-

mented noise-reduction strategies in an attempt

to decrease our overall noise level.


Our clinical excellence committee presented edu-

cation on the effects of excess noise with the sup-

portof the hospital leadership. Education includedpresentations in unit meetings as well as poster

presentations. Specific noise-reduction strategies

were proposed by the clinical excellence commit-

tee and agreed upon by the staff. Strategies were

implemented by the staff and follow-up monitoring

was completed to assess effectiveness.


Research has shown that the immediate effects

of elevated levels of sound show that environ-

mental noise can be a major source of stressful

stimulation, can cause agitation, and bring about

complications in the medical management of theneonate. Heightened awareness of the effects of

noise in the NICU promotes an optimal environ-

ment for positive developmental outcomes.

Exploring New Frontiers: Providing Skin-to-Skin Contact

for Mothers and Newborns during Cesarean Birth

Nora C. Fortin, RNC-OB, BSN,

Wentworth Douglass Hospital,

Dover, NH

Keywords

skin-to-skin

patient satisfaction

neonatal thermoregulation

Newborn Care

Poster Presentation


As cesarean birth rates increased in the United

States in response to the American Col-

lege of Obstetricians and Gynecologists state-

ment concerning vaginal birth after cesarean,

studies demonstrated higher dissatisfaction with

childbirth experiences. Women giving birth by ce-

sarean are more prone to postpartum depression,

bonding difficulties, and unsuccessful breastfeed-

ing.

Proposed Change

To increase maternal delivery satisfaction, we de-

veloped a plan to provide skin-to-skin contact

immediately after cesarean births. The proposed

change broke the barriers between the traditional

surgical environment and the delivery room and

required collaboration between the departments

of surgical services, anesthesia, pediatrics, and

obstetrics.


Informal surveys of patient satisfaction since im-

plementation have been positive. A more formal

evaluation of the process will include a review of

newborn thermoregulation in the operating room

and a postpartum survey of patient satisfaction.


This new service is an example of how nurses are

empowered to question tradition to advocate for

their patients.



13/27

Fortin, N. C. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Moms Own Milk Bundle: Increasing Supply in an 83 Bed,

Level III, Neonatal Intensive Care Unit

E. Christina Conner, BSN, RN,

IBCLC, Baylor University

Medical Center at Dallas,

Dallas, TX

Keywords

breast milk

NICU

quality initiatives

collaborative

increasing

milk supply

Newborn Care

Poster Presentation


Hospitals are encouraged to step up

evidence-based practices with various ini-

tiatives, such as The Joint Commission Perinatal

Core Measures and Baby Friendly Hospital Ini-

tiative, which both recognize the protection and

value of moms own milk. The use of human donor

milk in the neonatal intensive care unit (NICU) has

been expensive but worth the payoff with less

very low birth weight morbidity and mortality in

our large NICU. The purpose of the Moms Own

Milk (MOM) Bundle is a multidisciplinary, collabo-

rative approach to gently encourage and support

a mothers decision to provide her precious milk

for her baby in the NICU.

Proposed Change

The MOM Bundle uses quality initiatives through-

out the Women and Childrens Service line to ini-

tiate and maintain the mothers milk supply. Im-

provements are focused on the barriers mothers

face when providing milk and discovering an in-

novative game plan to reduce those barriers.


Implementation of this quality initiative focuses on

staff and family education. After looking at the

average length of stay, baseline breastfeeding

rates, number of donor milk bottles used each

day, and fiscal expenditures spent on donor milk,

our goal is projected to decrease donor milk use,

decrease medical and surgical necrotizing ente-

rocolitis rates, and decrease length of stay.


The MOM Bundle is a collaborative approach toincrease the availability and volume of mothers

milk in our Level III, 83-bed, NICU. Working to-

gether with our medical, nursing, and NICU sup-

port staff, we project an increase in moms own

milk, which benefits the mother, the infant, and the

hospital goals.

Virtual Special Care Nursery: A Cost Savings Idea

Michelle M. McFail, MSN,

RNC-OB, Baptist Health, LittleRock, AR

Keywords

special care

length of stay

late preterm infant

Newborn Care

Poster Presentation


The purpose of the virtual special care nurs-ery is to decrease the length of stay for these

patients while maintaining quality care.

Proposed Change

A majority of infants born 35 to 36 6/7 weeks of

gestation and infants born to mothers who were

diabetic and insulin-dependent were admitted to

the neonatal intensive care unit (NICU) for monitor-

ing within 24 hours of birth. The average length of

stay for the special care infant was 7 days. It was

decided that the differing needs of these infants

from full-term newborns could be provided for in

a virtual setting. Nurses would be trained follow-

ing evidence-based guidelines. The care wouldbe provided in the mothers room or the well-baby

nursery.


Over a 6-month timeframe, information was gath-

ered, equipment purchased, protocols estab-

lished, and a plan was implemented to care for

the special care infant on the postpartum unit. The

team estimated that within 24 hours after birth,

approximately 75% of late preterm infants wereadmitted to the NICU prior to the implementation

of the special care nursery. After 6 months of im-

plementation, the admissions had decreased to

9%. Each year since implementation, the number

of admissions to the NICU has decreased for this

population. The length of stay has decreased from

7 days to approximately 2 days for this group as

well.


Nursing staff in the special care nursery are

trained to evaluate and intervene quickly based

on evidence-based protocols. This allows for theinfant to remain with the family. Having the in-

fant in close proximity increases the time avail-

able for educating the mother about the unique

needs of the special care infant and allows her

to feel an increased sense of confidence when

taking the infant home. This process increases

the nursing staffs satisfaction about the care they

provide.



14/27


Two Phase Innovative Approach for Newborns at Risk

of Hyperbilirubinemia

Martha Montes, BSN, RN,

University of Illinois MedicalCenter, Chicago, IL

Lourdes Notario, BSN, RN,

University of Illinois Medical

Center, Chicago, IL

Keywords

hyperbilirubinemia

phototherapy

transcutaneous bilirubin (Tcb)

Bili clinic

Newborn Care

Poster Presentation


Each year approximately 60% of the 4 mil-lion newborns in the United States receive

a diagnosis of clinical jaundice. The American of

Academy of Pediatrics has instituted guidelines

for the assessment and management of hyper-

bilirubinemia in newborns. The purpose of this

project was to develop an innovative approach

to identify newborns at risk of hyperbilirubinemia

at delivery and at 24 hours of life and to improve

neonatal outcomes for at-risk infants with hyper-

bilirubinemia after discharge during the weekend

and holiday. Most infants with hyperbilirubinemia

who are discharged before 72 hours should be

seen within 2 days of discharge.

Proposed Change

Previously, discharged infants with hyperbiliru-

binemia who required follow-up on weekends and

holidays were seen in the emergency room, which

delayed evaluation and treatment. We sought to

identify infants at risk and streamline the evalua-

tion and treatment process by instituting a week-

end and holiday Bili Clinic on the mother-baby

unit.


To identify infants at risk, we instituted collection

of cord blood type and Coombs testing at deliv-

ery for mothers with blood type O positive or RHnegative blood types. Furthermore, all newborns

after 24 hours of life had a transcutaneous biliru-

bin test performed and if the result was greater

than 6 a serum bilirubin specimen was collected.The goal was to identify those at risk of hyper-

bilirubinemia andinitiate treatment in a timelyman-

ner. The weekend and holiday Bili Clinic opened

in April 2010. During the week, newborn health

care providers (from the departments of pediatrics

or family medicine) identified newborns requiring

outpatient follow-up on the weekend and holiday

and initiated the process for pre-admission to the

Bili Clinic, maintained a logbook, and informed

parents of required follow-up. Parents received an

information form with the follow-up appointment

to the Bili Clinic (scheduled anytime from 8:00

a.m. to 4:00 p.m.). As parents arrived for follow-

up, the staff activated the Bili Clinic process, noti-

fied the newborn health care provider of the new-

borns arrival, and initiated procedures (weight,

transcutaneous bilirubin, or serum bilirubin) as re-

quested. Based on the test results, the decision

was made to provide further patient follow-up,

discharge home, or admit the newborn for treat-

ment. This process for at-risk infants bypassed

the emergency department and facilitated prompt

treatment at the Bili Clinic.


Evaluation is ongoing based on patient comments

and efficiency of workflow for nursing staff. Infants

received phototherapy in a timelier manner and

thus increased patient and nurse satisfaction, de-creased overall costs, and promoted better out-

comes for the patient.

Operationalizing Palliative Care Processes through a

Perinatal Palliative Care Program

Becky Gams, RN, MS, CNP,

University of Minnesota

Medical Center, Fairview,

Minneapolis, MN

Keywords

comfort care

palliative

loss

newborn

life-limiting

fetal

Newborn Care

Poster Presentation


Parents who receive a life-limiting fetal diag-

nosis face many unexpected decisions: con-

tinue the pregnancy or proceed with early termi-

nation, comfort care or pursue neonatal intensive

care intervention, treatment options with second

opinions or withdrawal of life sustaining measures.

The program offers a formalized care process for

families choosing to continue the pregnancy and

utilize comfort care for their newborn at the time of

birth.

Proposed Change

The University of Minnesota Amplatz Childrens

Hospitals Perinatal Palliative Care is a family-

centered, multidisciplinary program that provides

a continuum of medical, emotional, psychosocial,

and spiritual support through diagnosis, preg-

nancy, birth, and death. Throughout this process,

parents are supported in creating a plan of care

for theirbabythatis consistent with their goalsand

wishes. The program goals address the National

Quality Forums Preferred Practices for Palliative

Care and support caregivers in meeting palliative

care outcomes.



15/27

Gams, B. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention


Historically, care for these families was heroically

pulled together by a few dedicated and passion-

ate individuals. However, as the newly established

Fetal Diagnostic and Treatment Centers patient

volume grew, the needs for families choosing to

continue pregnancy and newborn comfort care

were expected to grow as well. Steps to formalizethe program, led by the advanced practice nurse

leader, included a literature review, interviews with

leaders from established programs, development

of support from hospital administration and key

individuals willing to operationalize the program,

and creation of a multidisciplinary education pro-

cess. The palliative care approach is enhanced

by our established Pregnancy and Newborn Loss

program. Although current numbers are small, av-

eragingfourper year from 2008 to 2010, eight fam-

ilies were served in 2011 (year-to-date). Families

commented that this was the happiest and sad-

dest day of my life. Data from patient satisfaction

surveys and multidisciplinary debriefings are dis-

seminated to the health care team. Within this sup-

portive formalized structure, a broad health care

team accommodates the individual needs and cir-

cumstances of each family in the program.


The Perinatal Palliative Care program offers this

care model within an institution with an established

pregnancy and newborn loss program and a re-

cently established Fetal Diagnostic and Treatment

Center. Program scope, role definitions, respon-

sibilities for maternal and neonatal medical man-

agement, program access, and multidisciplinary

education will be described. A detailed birth plan

template, newborn comfort care orders, care con-

ference documentation, and process workflow will

be displayed.

Baby Cuddlers Make a Difference

Monica C. Kraynek, MS,

RNC-LRN, RN-BC, The

Western Pennsylvania Hospital,

Pittsburgh, PA

Mona Patterson, RN, BSN, The

Western Pennsylvania Hospital,

Pittsburgh, PA

Christina Westbrook, RN, BSN,

MSN, MBA, The WesternPennsylvania Hospital,

Pittsburgh, PA

Keywords

baby cuddler

neonatal abstinence

length of stay

Newborn Care

Poster Presentation


The number of newborn infants treated every

year at the Western Pennsylvania Hospital

for neonatal abstinence syndrome (NAS) has in-

creased more than 150% since 2004. Nurses con-

duct the Finnegan Neonatal Abstinence Scoring

Tool every 2 hours to analyze the infants with-

drawal symptoms and determine if pharmaco-

logic intervention is necessary and/or effective.Up to 30% of infants may be managed without

medication. Interventions for treatment of these

infants include medication and supportive care.

The purpose of the program, as a unit evidence-

based practice project, was to learn if the addition

of baby cuddlers as caregivers could affect the

length of stay required for treatment of these in-

fants.

Proposed Change

A baby cuddler is a trained baby holder who

can fill the gaps when parents are not able to bepresent. The cuddler provides an important com-

ponent of the developmental care for the hospi-

talized infant. The importance of human contact

and touch in the well being of all hospitalized in-

fants has been well documented. Baby cuddlers

on a daily basis held, rocked, and comforted the

infants suffering from drug withdrawal.


Seventy-five infants were admitted to the depart-

ment with the diagnosis of NAS in the 1-year study

period from May 2009 to May 2010. Length of stay

was compared from the first 6 months without the

baby cuddler program to the last 6 months after

the initiation of the program. From May 2009 to Oc-

tober 2009, the average length of stay for infants

with NAS was 26.2 days without the baby cud-dler program. From November 2009 to May 2010,

the average length of stay for infants with NAS was

22.4 days, a decrease in length of stay of 3.8 days.

After the official evidence-based project ended,

from May 2010 to April 30, 2011, the pediatric

unit cared for an additional 75 NAS patients. The

length of stay average was 23.9 days, a decrease

in length of stay of 2.3 days compared with the ini-

tial noncuddler group. Baby cuddlers completed

an orientation to their role and received education

on hand washing and Health Insurance Portability

and Accountability Act regulations. From initiation

of the project on October 1, 2009, to February

28, 2011, baby cuddlers have contributed 2,855hours of cuddling to patients suffering from NAS.


Nurses have implemented a low-cost intervention

that decreases length of stay and, thus, affects

hospital financesand provides quality patient care

to a vulnerable population.



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Normal Newborn Nursery Neonatal Intensive Care Unit:

Whats in Between?

Judith Pfeiffer, BSN, RN-C,

Lehigh Valley Health Network,Allentown, PA

Denise Keeler, BSN,

RNC-NIC, Lehigh Valley

Health Network, Allentown, PA

Keywords

transitional NICU

transitional newborn nursery

observational nursery

Newborn Care

Poster Presentation


A trend of term newborns requiring transferfrom the newborn nursery to the neonatal in-

tensive care unit (NICU) was identified in a Level

III NICU at a Magnet hospital. This offering will de-

tail the pragmatic strategies utilized to decrease

NICU admissions of high-risk transition newborns

and present specific obstetric-related diagnoses.

Proposed Change

To develop standards in clinical practice to pro-

mote newborn stabilization specific to newborns

delivered between 35 and 36 weeks of gestation,

born to mothers with chorioamnionitis or diabetes

who received intravenous (IV) insulin during la-

bor. Nurses are critical to assess, plan, act, and

evaluate care for high-risk transition newborns to

improve clinical outcomes and increase efficiency.


A collaborative team approach was taken to es-

tablish clinical criteria to identify infants at risk of

transfer to the NICU. Standards were developed

for newborns delivered between 35 and 36 weeks

gestation, born to mothers with chorioamnionitis

or diabetes who received IV insulin during labor.

These infants, high-risk transition newborns, are

admitted to the NICU for up to 6 hours of obser-

vation. Glucose management, breastfeeding, and

newborn admission policies were revised to re-

flect new processes. The criteria and interventionswere standardized and embedded into practice. A

multidisciplinary approach was utilized to assure

all care providers involved with maternalnewborncare received education, including process flow

charts, algorithms, and reference cards. The cri-

teria were communicated to the family prior to de-

livery to ensure inclusion with all aspects of care.

To foster family-centered care, families were made

aware of where their newborns would be admitted.

Since July 2008, full-term hypoglycemic newborn

transfers decreased 15% from the motherbaby

unit to the NICU, the admission of high-risk transi-

tion newborns to the NICU increased 27%, and the

transfer of all newborns back to the motherbaby

unit is about 80%.


Clinical criteria to identify newborns at risk of in-

stability during extrauterine transition of life were

standardized and embedded into practice. These

criteria provided necessary collaborative nursing

and medical management of the newborn patient

care for the newborn nursery registered nurse and

the primary care pediatrician. Clinical autonomy

was maintained for the NICU nurse who provided

care to the newborn during the transitional time

frame.Standard processes and care requirements

enabled nurses in a NICU to make prudent and

timely decisions to improve neonatal outcomes.

Improved quality outcomes for the newborn and

improved patient satisfaction are a direct result of

a standardized plan of care for high-risk transitionnewborns.

Wait for Eight: Improvement of Newborn Outcomes

by the Implementation of Newborn Bath Delay

Diana V. Lipka, RNC, BA,

Baycare/Saint Josephs

Womens Hospital, Tampa, FL

Marcia K. Schulz, RNC, MS,

Baycare/Saint Josephs

Womens Hospital, Tampa, FL

Keywords

newborn bath delay

skin-to-skin

transition

Newborn Care

Poster Presentation


To improve newborn outcomes by implement-

ing the evidence-based research to delay

bathing the newborn.

Proposed Change

To improve newborn outcomes, implementation

of evidence-based research was initiated. Imple-

mentation of bath delay showed that regardless

of gestational age, the incidence of newborns ex-

periencing hypothermia and hypoglycemia during

the transitional period was reduced by changing

the focus of unnecessary interventions.


To review the current practice and identify the pri-

oritization of the nursing task over the outcomes

of bathing, the newborn, newborn care guidelines

including revision of newborn order sets were es-

tablished. Reference to evidence-based research

and data collection post-implementation of guide-

lines were utilized. Multidisciplinary team actions

involved evidence-based practice data regarding

the effectiveness of newborn bath delay. Script-

ing to parents and families were created, which

included the development of crib cards in order

for clinical staff to facilitate the process change by

direct hands-on education.



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Lipka, D. V. and Schulz, M. K. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

The description of the process from admission to

discharge identified the value in bath delay related

to skin-to-skin research. Global hospital staff edu-

cation was initiated and staff were presented with

advice to give to parents and families during new-

born care education.The value of skin-to-skin care

with transition, bonding, and breastfeeding was

emphasized. Our efforts were validated by the im-proved outcomes of practice change of newborn

bath delay, which resulted in increasedpatient sat-

isfaction.


Historical review of newborn care delivery demon-

strated that nursing has shown to place prior-

ity on the completion of nursing tasks over the

outcomes related to the newborn transitional pe-

riod. To improve newborn outcomes, implemen-

tation of evidence-based research was initiated

to foster practice change. The research of skin-to-

skin practice directly correlated the needto review

newborn care and practices thereof. The need to

review one such practice was the newborn bath.

Recognition of the importance of an uninterruptednewborn transition resulted in positive newborn

outcomes and patient satisfaction. Implementa-

tion of bath delay showed that regardless of ges-

tational age, the incidence of newborns experi-

encing hypothermia and hypoglycemia during the

transitional period was reduced by changing the

focus of unnecessary interventions.

Buccal Care with Colostrum in the Low Birth Weight Infant

Kimberly Pinkerton, MSN, RN,

RNC-NIC, IBCLC, Mission

Hospital System, Asheville, NC

Jennifer Wilkinson, BSN,

RNC-NIC, Mission Hospital

System, Asheville, NC

Keywords

low birth weight babies

breast milk

NICU

buccal care

Newborn CarePoster Presentation


There is overwhelming evidence in the literature

that human milk is superior to any form of nu-

trition for the neonate. It contains immunological,

nutritional, and developmental properties that pre-

vent infection, provide individualized nutrition, and

optimize brain growth and visual development.

Recent studies have proven that the protective

factors in colostrum are even more concentrated

in the colostrum of women who deliver low birth

weight infants. This population of patients in the

neonatal intensive care unit (NICU) is most vulner-

able to morbidities, including necrotizing enteral

colitis and nosocomial infections. Human milk de-

creases the incidence and severity of nosocomialinfections and necrotizing enteral colitis. It also

has been proven to protect against gastrointesti-

nal and respiratory infections. Its perfect combi-

nation of protein, carbohydrates, and plasma pro-

teins improves gastric emptying, which promotes

feeding tolerance. The purpose of this project is to

promote buccal application of mothers colostrum

for low birth weight infants in the NICU.

Proposed Change

The nursing intervention of buccal application of a

mothers colostrum potentially decreases the inci-

dence of certain morbidities and decreases the

length of stay of these fragile infants. The pro-

posed change in practice is to institute a policyof buccal application of colostrum in the NICU.

The infants are being followed longitudinally for

outcomes related to this care.


A protocol for the buccal application of a mothers

colostrum as well as banked breast milk for all

low birth weight infants (weighing less than 1,500

grams) was developed and implemented in Jan-

uary 2011. Staff education was completed at staff

meetings via slide presentations. The completed

policy also includes an education sheet for par-

ents as a means of encouraging their participation

in this bedside practice.


Due to the limited availability of colostrum, moth-

ers arebeing encouraged to begin pumping within

6 hours of delivery and pump on a prescribed

schedule. We created syringe kits with detailed

instruct

A Pilot Project to Improve Neonataal

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