EPIQ Newsletter February 2016

EPIQ Evidence Based Practices for Improving Quality

“What’s with all the abdominal girths”

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Inside this issue

Page 1 Our Babies

Page 2 Brought to You by EPIQ

Page 4 Handling Audits

Page 6 EPIQ Conference

Drive to Zero… Since the implementation of the new UVC/UAC insertion practice

guidelines, there have been ZERO incidences of skin breakdown on the abdomen of infants born at less than 29 weeks gestation.

Our Babies… The EPIQ steering committee is committed to focusing on the outcomes of infants born at less than 29 weeks gestation.

Between January and December 2015 there have been 29 infants born at less than 29 weeks gestation. The following table illustrates a breakdown of their gestational ages.

Gestational Age Number of Infants Born 23+0-6 Weeks 1 24+0-6 Weeks 4 25+0-6 Weeks 2 26+0-6 Weeks 5 27+0-6 Weeks 7 28+0-6 Weeks 10 Total 29 Exclusions: Case Room deaths/Palliative Care Transfers from St. Boniface General Hospital (4) Out-born infants who died

There were no NICU deaths in this group between January and September 2015!

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EPIQ Newsletter February 2016

Brought to You By EPIQ

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Indomethacin Prophylaxis

Patent ductus arteriosus is a very significant risk factor for intraventricular hemorrhage and severe intraventricular hemorrhage. The use of prophylactic indomethacin decreases the hemodynamic instability of the infant, thereby decreasing IVH incidence and severity. The new HSC guideline for administering prophylactic indomethacin is as follows:

• For infants less than 27 weeks, administer indomethacin within 12 hours of life

• For infants between 27+0 and 27+6 weeks consider indomethacin on an individual basis. For example: infants who did not receive antenatal steroids are at a higher risk of developing IVH, and thus may benefit from receiving indomethacin prophylaxis

• 28 weeks – generally not recommended

Platelet counts and electrolytes need to be monitored, as well as fluid balance. If a cardiac anomaly is suspected, an echocardiogram must be performed prior to indomethacin usage.

Indomethacin Prophylaxis & PDA Rates

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Outcomes

The graphs below show that with the use of indomethacin in our patients fewer babies have PDAs; therefore, fewer ligations are required. The second graph depicts how infants receiving indomethacin prophylaxis are not necessarily less likely to develop IVH, but the severity of the hemorrhage is less, reducing their risk for negative long-term developmental outcomes.

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IVH   Severe  IVH  

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Indomethacin Prophylaxis & IVH Rates

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PDA   PDA  Liga3on  

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No Prophylaxis

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EPIQ Newsletter February 2016

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Antenatal Steroids

Over the last year neonatology has been working closely with obstetrics, emphasizing the benefits of ANS, particularly receipt of a complete course. As a team, neonatology and obstetrics are recommending administration of ANS to mothers at < 24 weeks gestation when there is a risk of imminent delivery and active care for the neonate is planned. In addition, a second course of ANS is recommended to mothers at <34 weeks gestation if delivery imminent and two or more weeks has elapsed since the first course. The graph below shows changes in ANS receipt since 2014.

Antenatal Steroid Receipt

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The graph shows how immediately after the practice change was implemented, the number of patients who did not receive ANS when they met eligibility criteria was lower compared to before the practice change was implemented. As expected, the number of eligible patients who received complete courses of ANS was increased. This positive change is to be expected immediately following any practice change roll-out. Great job! The next six months following the practice change, the number of patients

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July-­‐Dec  2014   Jan-­‐  June  2015   July-­‐Dec  2015  

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Complete Partial None

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receiving ANS continued to increase, albeit with somewhat decreased acceleration. The number of patients who did not receive ANS when they were otherwise eligible, seems to be on the rise. What is yet to be determined are the reasons for this change. There may be clinician, patient, and system factors all contributing to this trend. Or perhaps the trend can be attributed to natural fluctuations in statistics.

The next table shows the effect administration of ANS has had on our infants born at <29 weeks.

Composite Outcome is defined as death or any of BPD, NEC, severe IVH or ROP needing treatment

The graph illustrates how almost 90% of infants whose mothers were eligible to receive ANS were subjected to a composite outcome. In contrast only 50% – 55% of infants whose mothers actually receive a partial or complete course of ANS suffered from composite outcomes.

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Complete Partial None

Composite Outcomes vs. Antenatal Steroid Receipt

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EPIQ Newsletter February 2016

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Nine of 14 consecutive infants less than 29 weeks born between March 30th, 2015 and July 11th, 2015 were audited. The average gestational age was 25.3 weeks (±1.5 weeks). The average birth weight was 798 grams (±239 grams). These 9 infants had 2641 “discrete interventions” during the first 7 days of life. This resulted in an average of 293 (±43) interventions per child (the median was 298).

Implications

“Minimal handling and gentle care” is part of the EPIQ Intraventricular Hemorrhage Intervention Bundle; with emphasis being placed on the first few days of life where the risk of IVH is highest and the events causing PVL occurs. The evidence grade applied to this intervention is “1C” indicating that the benefits appear to outweigh the risks and burdens of the implementing the intervention, despite the supporting evidence being of low quality.

NEC Assessment

Abdominal girths - once per shift is sufficient. The inter-rater reliability of girth measurement is poor. The character of the abdomen (i.e.: soft, distended, taut, loopy, or discolored) is more important than the measurement from shift to shift.

Aspirates - a large volume of the gastric aspirate 2-3 hours post feed in the absence of other clinical signs of gastrointestinal pathology is not as clinically significant as the presence of blood or bile in the aspirate.

The most clinically significant indicator of suspect NEC is an increase in frequency and severity of apnea & bradycardia of prematurity.

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Discrete Interventions: Medical staff, nurses, respiratory therapists, and family caregivers performed the bedside interventions. The bedside nurse was responsible for recording whenever the patient was subjected to a form of handling. The handling events that were monitored were as follows:

• Vital signs • Diaper changes • Position changes • Repositioning of electrode leads • Abdominal girth measurement • nCPAP adjustments • Oral or nasal suctioning • ETT suctioning • Skin care • Heel pokes • Weighing attempts • X-rays or ultrasounds • IV attempts and venipuncture • Kangaroo care • Bed linen changes • Line insertion or repositioning • NG tube insertion • ETT re-taping/repositioning • Extubation or surfactant • Dressing changes • Wound care

Handling Audit

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EPIQ Newsletter February 2016

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Results

What we did well

Painful procedures such as IV/heel pokes, NG tube insertions, and ETT manipulations were well minimized.

Areas of Improvement

Abdominal Girths. “What’s with all the abdominal girths!?” was a comment made during the review of the audit results. Abdominal girth measurement accounted for 9.4% of the handling these infants received in the first 7 days of life. Between days 2 and 7, each infant was subjected to 4-5 girth measurements each day. Abdominal girth measurement as an assessment for necrotizing enterocolitis is not an evidence-based practice. Placing the measuring tape underneath the patient by lifting their legs increases intracranial pressure and thus increases the risk of IVH. Also, the measuring tape itself poses a paper-cut risk to the infant, increasing the risk of infection. As a result of this audit, it was proposed at the Fall Education Days to only measure abdominal girths once per shift or if there is a perceived problem.

Kangaroo Care. The handling audit revealed an average of less than 1 kangaroo care event performed per baby per day in the first 7 days of life. The benefits of kangaroo care have been well documented. Kangaroo care promotes milk production in the mother. Human milk (especially mother’s own milk) reduces the risks of necrotizing enterocolitis, protects against nosocomial

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infection and late-onset sepsis through passive immunity, and promotes brain development in the premature infant. While minimal handling is important, kangaroo care is an extremely therapeutic intervention and should be promoted and encouraged daily.

Position changes and diaper changes: The handling audit revealed that our patients undergo an average of 5 to 6 position changes and up to 7 diaper changes per day. The “micro-preemie” diapers used at HSC’s NICU are specially designed for infants with immature skin. Because of this, routine position changes and diaper changes only need to be done every six hours, rather than every three. While bedside nurses currently do well “blocking care”, a developmentally appropriate patient-driven rather than nurse-driven approach can be used. For example, if the patient is awake outside of their “scheduled touch-time”, the nurse can use the patient’s awake-time to perform assessments, diaper changes, and position changes, rather than adhering to strict nurse-driven touch-times.

↓ EPIQ Newsletter February 2016

EPIQ Conference

Each year, MiCare funds two delegates from each EPIQ site to attend the conference. This year’s delegates from HSC are Catherine Lesawich RN NNP and Kathryn Walker.

At the conference, each NICU will present a summary of their last year’s changes and outcomes. There will also be presentations titled “Breast Milk & Stem Cells; Fresh Milk”, “Demystifying Eating on CPAP”, and “Photoprotection of TPN”.

Doris Sawatzky-Dickson & Renee Freisen have been chosen as delegates to attend the FiCare Workshop where they will learn about Family Integrated Care in the NICU.

The Banff Centre, Banff, AB

FiCare Workshop February 5th – 7th 2016

EPIQ Conference

February 7th – 9th 2016

EPIQ Training Workshop & CNN Annual Meeting February 9th & 10th 2016

EPIQ Steering Committee Members

Dr. Molly Seshia MD (Chair)

Dr. John Baier MD

Nicole Sneath RN NNP

Deb MacDonald CRN

Barb Swaine CRN

Karen Bodnaryk RN

Tanya Tichon RN

Sue Roberts RN

Jennifer McCoy RN BN

Sharla Fast RD

Jeremy Amman RD

Kelli Greeley

John Minski RRT