Scoping review of systematic reviews of nursing interventions in a neonatal intensive care unit or special care nursery.

AIM(S): To identify, synthesise and map systematic reviews of the effectiveness of nursing interventions undertaken in a neonatal intensive care unit or special care nursery. DESIGN: This scoping review was conducted according to the JBI scoping review framework. METHODS: Review included systematic reviews that evaluated any nurse-initiated interventions that were undertaken in an NICU or SCN setting. Studies that reported one or more positive outcomes related to the nursing interventions were only considered for this review. Each outcome for nursing interventions was rated a 'certainty (quality) of evidence' according to the Grading of Recommendations, Assessment, Development and Evaluations criteria. DATA SOURCES: Systematic reviews were sourced from the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis for reviews published until February 2023. RESULTS: A total of 428 articles were identified; following screening, 81 reviews underwent full-text screening, and 34 articles met the inclusion criteria and were included in this review. Multiple nursing interventions reporting positive outcomes were identified and were grouped into seven categories. Respiratory 7/34 (20%) and Nutrition 8/34 (23%) outcomes were the most reported categories. Developmental care was the next most reported category 5/34 (15%) followed by Thermoregulation, 5/34 (15%) Jaundice 4/34 (12%), Pain 4/34 (12%) and Infection 1/34 (3%). CONCLUSIONS: This review has identified nursing interventions that have a direct positive impact on neonatal outcomes. However, further applied research is needed to transfer this empirical knowledge into clinical practice. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Implementing up-to-date evidence on effective nursing interventions has the potential to significantly improving neonatal outcomes. PATIENT OR PUBLIC CONTRIBUTION: No patient or public involvement in this scoping review.

Heatwaves and wildfires suffocate our healthy start to life: time to assess impact and take action.

Adverse environmental exposures in utero and early childhood are known to programme long-term health. Climate change, by contributing to severe heatwaves, wildfires, and other natural disasters, is plausibly associated with adverse pregnancy outcomes and an increase in the future burden of chronic diseases in both mothers and their babies. In this Personal View, we highlight the limitations of existing evidence, specifically on the effects of severe heatwave and wildfire events, and compounding syndemic events such as the COVID-19 pandemic, on the short-term and long-term physical and mental health of pregnant women and their babies, taking into account the interactions with individual and community vulnerabilities. We highlight a need for an international, interdisciplinary collaborative effort to systematically study the effects of severe climate-related environmental crises on maternal and child health. This will enable informed changes to public health policy and clinical practice necessary to safeguard the health and wellbeing of current and future generations.

Normative values of renin and aldosterone in clinically stable preterm neonates.

BACKGROUND: There is a paucity of literature on the normative levels of plasma renin concentration (PRC) and serum aldosterone (SA) in premature neonates. This study aims to provide normative data on PRC and SA levels in preterm neonates in the first 2 weeks after birth and explore associations with maternal, perinatal, or postnatal factors. METHODS: Neonates born at 26- to 34-week gestation were recruited from two neonatal intensive care units in Canada and Australia. The direct renin assay PRC and SA were analyzed on day 1 and days 14-21 after birth to compare across categorical variables and to produce normative values. RESULTS: A total of 262 subjects were enrolled from the Canadian (29%) and Australian (71%) sites. The mean gestational age was 30 weeks, with a mean birth weight of 1457 g. The normative values of PRC and SA for neonates born between 26 + 0 and 29 + 6 weeks and 30 + 0 and 34 + 0 weeks of gestation were produced for day 1 and day 14-21 after birth. Both PRC and SA increased from day 1 to day 14-21. The more premature neonates reached a higher PRC on days 14-21 after birth but exhibited lower SA levels on day 1 after birth. When comparing gender, birth weight, and maternal risk factor categories, no statistical differences in PRC or SA were found. A small but significant decrease in PRC, but not SA, was noted for neonates with placental pathology. CONCLUSIONS: This study produced normative values of PRA and SA in clinically stable preterm neonates that can be referenced for use in clinical practice. A higher resolution version of the Graphical abstract is available as Supplementary information.

Bushfires and Mothers' Mental Health in Pregnancy and Recent Post-Partum.

BACKGROUND: The compounding effects of climate change catastrophes such as bushfires and pandemics impose significant burden on individuals, societies, and their economies. The enduring effects of such syndemics on mental health remain poorly understood, particularly for at-risk populations (e.g., pregnant women and newborns). The aim of this study was to investigate the impact of direct and indirect exposure to the 2019/20 Australian Capital Territory and South-Eastern New South Wales bushfires followed by COVID-19 on the mental health and wellbeing of pregnant women and mothers with newborn babies. METHODS: All women who were pregnant, had given birth, or were within three months of conceiving during the 2019/2020 bushfires, lived within the catchment area, and provided consent were invited to participate. Those who consented were asked to complete three online surveys. Mental health was assessed with the DASS-21 and the WHO-5. Bushfire, smoke, and COVID-19 exposures were assessed by self-report. Cross-sectional associations between exposures and mental health measures were tested with hierarchical regression models. RESULTS: Of the women who participated, and had minimum data (n = 919), most (>75%) reported at least one acute bushfire exposure and 63% reported severe smoke exposure. Compared to Australian norms, participants had higher depression (+12%), anxiety (+35%), and stress (+43%) scores. Women with greater exposure to bushfires/smoke but not COVID-19 had poorer scores on all mental health measures. CONCLUSIONS: These findings provide novel evidence that the mental health of pregnant women and mothers of newborn babies is vulnerable to major climate catastrophes such as bushfires.

Parental perceptions on the impact of visiting restrictions during COVID-19 in a tertiary neonatal intensive care unit.

AIM: During the first wave of coronavirus disease 2019 (COVID-19), visiting guidelines in neonatal units changed to maintain the health and safety of staff, neonates, and families. In the neonatal intensive care unit/special care nursery (NICU/SCN), restrictions were placed on parental contact and extended family excluded. Our team was interested in evaluating the effect of these restrictions on parental stress and discharge confidence. METHODS: A prospective descriptive study utilising survey methodology was undertaken. The survey was developed and previously used by the NICU research group to evaluate parental knowledge and understanding, parental role, communication, and parental stress (admission/discharge). We have also included a section regarding COVID19 visiting restrictions (ETH.2020.LRE.00124). The survey used a five-level Likert scale. Statistical analysis was completed using SPSS version 21. RESULTS: Notably, 33 surveys were returned. Results showed visiting restrictions reduced social contact between partners 26/33 (84%), with their other children 14/16 (87.5%) and extended family 28/33 (84.8%). Parents indicated that they had high levels of confidence in understanding their babies' medical needs (78-93%) and gaining hands-on experience caring for their baby (87-100%). However, 11/33 (33%) of parents reported concerns with discharge processes and gaining consistent information as challenges during their baby's admission. Notably, 17/33 (51.5) stated their NICU/SCN experience had been very to extremely stressful. Parents openly described how the restrictions had affected their mental/emotional health identifying the need to treat parents as one unit, and a gap in the psychological support available for families. CONCLUSION: Support services and consistency of communication with NICU/SCN families need to be enhanced and prioritised during periods of restrictions, especially peri-discharge.

Clinical signs and symptoms of diaper dermatitis in newborns, infants, and young children: A scoping review.

RATIONALE: Diaper dermatitis (DD) is a significant problem in the care of newborns, infants, and young children and good recognition of signs and symptoms optimises timely treatment. There is also a need for a standardised set of related descriptors to enable communication between health care providers about diagnosis and treatment. OBJECTIVE: The study aimed to review the literature for descriptive words to define the clinical signs, symptoms, and characteristics, including anatomical locations and assessment scales or tools, in the newborn, infants and young children population who have been diagnosed with DD. METHODS: A systematic review process utilising PRISMA guidelines [1] was conducted using advanced search techniques to analyse the terms from the database thesauri and keywords. Data bases including Ovid MEDLINE® and Epub Ahead of Print, in-Process & Other Non-Indexed Citations, Daily and Versions® were searched from 1946 to March 18, 2021. Cochrane Handbook Searching for and selecting studies were used as a guide and as best practice to conduct the search. RESULTS: Of the 551 publications originally identified, 55 full text publications were examined and 21 met the inclusion criteria. The wide range of descriptors used in the literature for DD supports the need for a clearer approach to report the signs and symptoms, and the severity, of DD. CONCLUSIONS: These findings point to gaps in the literature, both in recording signs and symptoms of DD and features such as wetness, infection, anatomical location, severity and pain in newborns, infants, and young children. There is a need to develop a robust methodological tool to bridge the gap and link a common terminology on signs and symptoms to support diagnosis of the severity of DD.

Impact of introducing a lactation consultant into a neonatal unit.

AIM: Benefits of mothers' own milk (MOM) for premature and sick neonates are well documented. To increase access, many neonatal units have a lactation consultant (LC) on staff. This study aimed to assess the impact of a permanent LC on (i) maternal access to LC support; (ii) staff confidence in providing Breast Feeding (BF) education and (iii) provision of MOM. METHODS: Study included a staff survey and chart audit. Questions provided feedback on access to lactation support and meeting maternal needs. Audit data included: gestational age, birthweight, intention to breastfeed, documentation of LC appointment, provision of MOM at 12 hours, days 3, 7, 28 and discharge. Student's t-tests were used for numerical data and chi-squared tests for categorical variables. RESULTS: Ninety-one staff surveys were returned, (pre 35/75 (47%), post 56/85 (66%) with staff reporting organising an LC appointment was significantly easier (P < 0.0001). Staff perceived maternal lactation needs and confidence to breastfeed post-discharge had significantly improved post-LC. The chart audit showed a significant increase in maternal access to LC appointments (15% vs. 80%; P < 0.01), breast pump education by day 3 (65% vs. 81%; P < 0.01), and an increase in MOM provision by 12 h (46% vs. 61%; P < 0.01) post-LC but not at days 7, 28 or discharge. CONCLUSION: A dedicated LC increases staff and maternal access to lactation education and support, improving provision of early MOM. Further research is required to assess the effect of LCs in improving breastfeeding rates in neonatal units.

Incidence and prevalence of acute stress disorder and post-traumatic stress disorder in parents of children hospitalized in intensive care units: a systematic review protocol.

OBJECTIVE: The objective of this review is to determine the incidence and prevalence of acute stress disorder and post-traumatic stress disorder in parents who have a child hospitalized in an intensive care unit. INTRODUCTION: Having a child admitted to an intensive care unit is known to be challenging and stressful for parents. This stress may lead to clinical stress disorders that may be improved through interventions. However, there is insufficient clarity around the incidence and prevalence of these disorders. INCLUSION CRITERIA: This review will consider studies of parents who have had a child admitted to a neonatal or pediatric intensive care unit and who have developed associated acute stress disorder or post-traumatic stress disorder related to their child's hospitalization. METHODS: The proposed review will follow JBI methodology for systematic reviews of prevalence and incidence. A strategic search for eligible studies will include multiple database sources and unpublished literature. Studies will be assessed for inclusion by two independent reviewers based initially on study titles and abstracts, and subsequently on full text. Methodological quality will be assessed by two independent reviewers, with inclusion criteria focusing on sampling and statistical analysis. Data extraction will be completed, and data synthesis will pool data where possible. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020190875).

Health professionals' experiences of grief associated with the death of pediatric patients: a systematic review.

OBJECTIVE: The objective of this review was to synthesize the experiences of health professionals who have experienced grief as a result of a pediatric patient dying. INTRODUCTION: There has been some research into health professionals' grief experiences associated with the death of pediatric patients, but there has not been a review that synthesizes the findings of these experiences. Other related reviews have focused on prenatal, perinatal or adult deaths or the coping strategies employed by health professionals. This review highlights the complexities of experiences faced by pediatric health professionals. INCLUSION CRITERIA: Qualitative studies involving pediatric health professionals working in any healthcare setting who had experienced grief from the death of a patient were considered for inclusion. Studies were conducted in any country, at any time and published in English. METHODS: The search was conducted in PubMed, CINAHL, Embase, PsycINFO, Scopus and ProQuest Dissertations and Theses. The search was completed in January 2019. The review followed principles of meta-aggregation in line with the JBI approach. Methodological quality assessment was based on representation of participants' voices and congruence between research methodology and both research question and analysis of data. RESULTS: Meta-aggregation led to three synthesized findings from 12 qualitative studies that met the inclusion and methodological quality criteria. Studies predominantly included nurses working in a hospital, with sample sizes ranging from six to 25 participants. The synthesized findings were physical, behavioral, psychological or spiritual symptoms; compounding grief; and alleviating grief. Physical, behavioral, psychological, or spiritual symptoms highlighted the various characteristics of grief experiences by health professionals. Compounding grief was the largest synthesized finding and incorporated the various factors that contributed to a poorer experience of grief. Alleviating grief showed the limited identified factors that improved the experience of grief. Methodological quality led to synthesized findings receiving a ConQual rating of low or moderate. CONCLUSIONS: The synthesized findings from this review highlight the varied reported experiences of grief in health professionals. The methodological quality and reporting of studies, however, led to decreased confidence in the synthesized findings and recommendations arising from this review. Healthcare professionals should be aware of the potential for experiencing grief when a patient dies and the compounding and alleviating factors associated with this. Further research could expand participant and language limitations, and improve methodological quality and reporting.

A pilot randomised clinical trial of 670 nm red light for reducing retinopathy of prematurity.

BACKGROUND: Photobiomodulation by 670 nm red light in animal models reduced severity of ROP and improved survival. This pilot randomised controlled trial aimed to provide data on 670 nm red light exposure for prevention of ROP and survival for a larger randomised trial. METHODS: Neonates <30 weeks gestation or <1150 g at birth were randomised to receive 670 nm for 15 min (9 J/cm2) daily until 34 weeks corrected age. DATA COLLECTED: placental pathology, growth, days of respiratory support and oxygen, bronchopulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, sepsis, worst stage of ROP, need for laser treatment, and survival. RESULTS: Eighty-six neonates enrolled-45 no red light; 41 red light. There was no difference in severity of ROP (<27 weeks-p = 0.463; ≥27 weeks-p = 0.558) or requirement for laser treatment (<27 weeks-p = 1.00; ≥27 weeks-no laser treatment in either group). Survival in 670 nm red light treatment group was 100% (41/41) vs 89% (40/45) in untreated infants (p = 0.057). CONCLUSION: Randomisation to receive 670 nm red light within 24-48 h after birth is feasible. Although no improvement in ROP or survivability was observed, further testing into the dosage and delivery for this potential therapy are required.

Predicting Neonatal Skin Injury: The First Step to Reducing Skin Injuries in Neonates.

BACKGROUND: Skin injuries remain common in neonates admitted to neonatal intensive care units. While predicting neonates at risk of skin injury may assist in reducing the incidence of injury, currently there is limited evidence on which tool may be superior. METHODS: A prospective study was completed during November-December 2016 to evaluate the predictive value of the Skin Risk Assessment and Management Tool (SRAMT). Comparisons were made between SRAMT and Neonatal/Infant Braden-Q Scale (BQS) as well as staff's capacity to predict a neonate's risk of skin injury. Data collected included gestation, weight, day of assessment, injury types, causation, medical devices in situ and risk scores. RESULTS: In total, 248 assessments were completed with 38% (93) recorded skin injuries. Median (interquartile range) gestation and weight at assessment were 36.7 (26.86-56.86) weeks and 2.44 (0.99-4.06) kg, respectively. Receiver operating characteristic curve analysis showed the SRAMT had AUC (SE) of 0.94 (0.02) compared with 0.82 (0.03) for BQS (0.011, P < .001). The SRAMT and BQS had sensitivity of [(90.0 (80.5-95.9), 72.86 (60.9-82.8)] and specificity [(88.46 (81.7-93.4), 79.23 (71.2-85.8)], respectively. CONCLUSION: In this study, the SRAMT's capacity to predict neonates at risk of injury was higher than the Neonatal BQS and staff. Predicting injuries remains complex and often multifactorial.

Exploring the Impact of a Dual Occupancy Neonatal Intensive Care Unit on Staff Workflow, Activity, and Their Perceptions.

In 2012, a tertiary neonatal intensive care unit (NICU) transitioned from an open plan (OP) to a dual occupancy (DO) NICU. The DO design aimed to provide a developmental appropriate, family-centered environment for neonates and their families. During planning, staff questioned the impact DO would have on staff workflow and activity. To explore the impact of changing from an OP to a DO NICU, a prospective longitudinal study was undertaken from 2011 to 2014, using observational, time and motion, and surveys methods. Main outcome measures included distance walked by staff, minutes of staff activity, and staff perceptions of the DO design. Results highlighted no significant difference in the distances clinical nurses walked nor time spent providing direct clinical care, whereas technical support staff walked further than other staff in both designs. Staff perceived the DO design created a developmentally appropriate, family-centered environment that facilitated communication and collaboration between staff and families. Staff described the main challenges of the DO design such as effective staff communication, gaining educational opportunities, and the isolation of staff and families compared to the OP design. Our study provides new evidence that DO provides an improved developmentally environment and has similar positive benefits to single-family room for neonates and families. Such design may reduce the larger floor plan's impact on staff walking distance and work practices. Challenges of staff transition can be minimized by planning and leadership throughout the development and move to a new design.

A pilot randomised blinded placebo-controlled trial of paracetamol for later treatment of a patent ductus arteriosus.

OBJECTIVE: To explore the efficacy and risks of oral paracetamol in later (>2 weeks old) treatment of patent ductus arteriosus (PDA). STUDY DESIGN: A multicentre double-blind placebo-controlled randomised pilot trial in three neonatal intensive care units in Australia. Infants born <33 weeks with haemodynamically significant PDA were treated with a 5-day course of oral paracetamol or placebo. Cardiac ultrasounds were used to document haemodynamic parameters. The primary outcome analysed was ductal closure by 48 h after treatment completion. Secondary outcomes included reduction in ductal diameter >25% and safety. RESULTS: Fifty-five infants were enrolled, of whom 27 received paracetamol and 28 placebo. Eighty percent had received previous non-steroidal anti-inflammatory drug. Mean postnatal age was 25 days. Four of the 27 ducts treated with paracetamol closed vs. 0/28 treated with placebo (p = 0.05). An additional 13/27 given  paracetamol vs. 7/28 given placebo showed significant constriction (p = 0.008). No adverse effects were observed . CONCLUSIONS: There was some evidence of increased closure with oral paracetamol at postnatal age >2 weeks; however, the overall efficacy was not high.

Correction: A pilot randomised blinded placebo-controlled trial of paracetamol for later treatment of a patent ductus arteriosus.

In the published version of this paper the author Yan Chen was missed out of the author list. This has now been corrected in the HTML and PDF versions of the paper.

Health professionals' experiences of grief associated with the death of pediatric patients: a qualitative systematic review protocol.

REVIEW QUESTION: What are health professionals' experiences of grief associated with the death of pediatric patients in acute or community healthcare settings?

Smoking in the family is most predictive of the development of childhood asthma in preterm babies <30 weeks gestation: Results of the Respiratory Outcomes Study 2 (RESPOS2).

OBJECTIVES: The Respiratory Outcomes Study 2 (RESPOS2) investigated the relationship between neonatal outcomes (specifically, chronic lung disease [CLD]) and environmental factors on the development of asthma and atopic outcomes at primary school age for preterm babies (PBs) <30 weeks gestational age (GA). METHODS: The study included all surviving PBs <30 weeks GA admitted to the Neonatal Intensive Care Unit at Canberra Hospital, Australian Capital Territory between 2007 and 2009. Parents were sent a questionnaire regarding asthma and atopy symptoms when the PBs were aged 5-7 years old. Data were compared based on CLD status. RESULTS: There were 103 PBs included in the study with a 68.9% response rate to the respiratory questionnaire (71/103). Of these PBs, 15/71 (21.1%) received a diagnosis of CLD. There were no significant differences with regards to asthma, hay fever or eczema in PBs either with or without CLD. The most significant predictor for the development of asthma was smoking in the family (Odds Ratio [OR]: 11.66, 95% Confidence Interval [CI]: 2.01-67.56) with a trend toward significance for family history of asthma (OR: 3.83, 95% CI: 0.85-17.25). CONCLUSION: The RESPOS2 has confirmed previous reports that CLD in PBs <30 weeks GA is not associated with the development of childhood asthma, hay fever or eczema. In our group of PBs, the strongest predictor of the development of asthma was smoking in the family.

Exploring Parental and Staff Perceptions of the Family-Integrated Care Model: A Qualitative Focus Group Study.

BACKGROUND: Family-integrated care (FICare) is an innovative model of care developed at Mount Sinai Hospital, Canada, to better integrate parents into the team caring for their infant in the neonatal intensive care unit (NICU). The effects of FICare on neonatal outcomes and parental anxiety were assessed in an international multicenter randomized trial. As an Australian regional level 3 NICU that was randomized to the intervention group, we aimed to explore parent and staff perceptions of the FICare program in our dual occupancy NICU. SUBJECTS AND DESIGN: This qualitative study took place in a level 3 NICU with 5 parent participants and 8 staff participants, using a post implementation review design. METHODS: Parents and staff perceptions of FICare were explored through focus group methodology. Thematic content analysis was done on focus group transcripts. RESULTS: Parents and staff perceived the FICare program to have had a positive impact on parental confidence and role attainment and thought that FICare improved parent-to-parent and parent-to-staff communication. Staff reported that nurses working with families in the program performed less hands-on care and spent more time educating and supporting parents. IMPLICATIONS FOR PRACTICE: FICare may change current NICU practice through integrating and accepting parents as active members of the infant's care team. In addition, nurse's roles may transition from bedside carer to care coordinator, educating and supporting parents during their journey through the NICU. IMPLICATIONS FOR RESEARCH: Further research is needed to assess the long-term impact of FICare on neonates, parents, and staff.

Increased use of heated humidified high flow nasal cannula is associated with longer oxygen requirements.

AIM: There has been an increased use of heated humidified high flow nasal canula (HFNC) in premature babies (PBs) admitted to our neonatal unit. The aim of this study is to identify clinical characteristics in PBs < 29 weeks gestational age (GA) that distinguish between those who did not or did receive HFNC. METHODS: This study compared prospectively collected data from 2010 to 2012. Comparisons were undertaken between PBs<29 weeks GA who received continuous positive airway pressure (CPAP: 44/72 (61.1%)) to those who received both CPAP and HFNC (28/72 (38.9%)). Data were analysed using general linear models. RESULTS: There were no significant differences in baseline characteristics between the groups (GA: 27.6 ± 1.1 vs. 27.5 ± 1.1 (weeks), birth weight: 1066 ± 209 vs. 1057 ± 304 (grams) respectively). When analysing outcome measures with multivariate analysis, we found the corrected GA to cease CPAP and oxygen were significantly longer in the HFNC group (31.2 ± 2.1 vs. 32.7 ± 2.0 weeks, P = 0.01 and 32.8 ± 3.5 vs. 36.5 ± 2.8 weeks, P < 0.0001 respectively). CONCLUSIONS: Increased use of HFNC has been associated with increased oxygen requirements. These findings highlight the need to review the use of HFNC in small PBs.

Transition from an open-plan to a two-cot neonatal intensive care unit: a participatory action research approach.

AIMS AND OBJECTIVES: To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. BACKGROUND: In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice. DESIGN: A participatory action research approach. METHODS: A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009-2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey. RESULTS: The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members. CONCLUSION: This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture. RELEVANCE TO CLINICAL PRACTICE: A supportive work environment for staff is critical in providing high-quality health care.

CeasIng Cpap At standarD criteriA (CICADA): Implementation improves neonatal outcomes.

BACKGROUND: A previous randomised controlled trial (RCT) in babies born < 30 weeks gestation found the so-called CICADA method (ceasing continuous positive airways pressure (CPAP) with a view to remain off rather than slow weaning) significantly reduced CPAP time. Post-RCT we introduced the CICADA method and evaluated whether the improved outcomes of the CICADA method during the RCT were replicated in clinical practice. AIM: The aim of the study is to compare cardio-respiratory outcomes in PBs < 30 weeks GA over three epochs: (i) pre RCT, (ii) during RCT and (iii) post RCT implementation. METHODS: The study used prospective data to compare baseline characteristics and cardio-respiratory outcomes over the three epochs. RESULTS: There were 270/393(69%) PBs < 30 weeks GA who fulfilled the inclusion criteria over the three epochs. No significant differences were found in GA or birthweight between the three epochs (27.9 ± 1.3, 27.7 ± 1.4, 28.0 ± 1.3 (weeks ± 1 standard deviation); and 1100 ± 252, 1086 ± 251, 1094 ± 320 (grams ± 1 standard deviation)). There were significant decreases in CPAP days and corrected GA to cease CPAP post implementation (20.5 ± 2.1, 21.1 ± 2.1, 16.5 ± 1.8 (days ± SE); P = 0.006 and 33.3 ± 0.4, 33.5 ± 0.4, 32.6 ± 0.4 (weeks ± SE); P = 0.01). Compared with the pre RCT epoch, there were significant reductions in patent ductus arteriosus (36/78 (46%), 33/87 (37%), 18/103 (17%); P < 0.001) and chronic lung disease (40/78 (51%), 19/87 (21%), 30/103 (29%); P < 0.001). CONCLUSIONS: CPAP time, corrected GA to cease CPAP, patent ductus arteriosus and chronic lung disease significantly reduced following the introduction of the CICADA method. Early cessation of CPAP expedites the transition from neonatal intensive care to special care.