Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants.

OBJECTIVE: Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC. STUDY DESIGN: An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds). RESULTS: Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score. CONCLUSIONS: Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.

A Novel Neonatal Feeding Intolerance and Necrotizing Enterocolitis Risk-Scoring Tool Is Easy to Use and Valued by Nursing Staff.

BACKGROUND: Preterm infants are at increased risk of developing feeding intolerance and necrotizing enterocolitis. Comprehensive, targeted nursing assessments can evaluate the risk for and identify early signs of these conditions in an effort to prevent their destructive sequela. PURPOSE: While the long-term goal is to develop a validated risk-scoring tool for the prediction of feeding intolerance and necrotizing enterocolitis, the objective of the preliminary phase presented here is to assess the ease of use and nurses' attitudes toward a novel feeding intolerance and necrotizing enterocolitis risk-scoring tool. METHODS: A novel risk-scoring nursing tool was implemented in a University of Illinois-affiliated 48-bed level III neonatal intensive care unit. Data were collected from the electronic medical record of all preterm infants with parental consent during the initial 6-month study period. Scoring accuracy (accuracy of selection of risk factors based on electronic medical record data), ease of use, and nurses' attitudes toward the tool were assessed at the study site and by evaluators at a national neonatal nursing conference. RESULTS: Fourteen nurses scored 166 tools on the 63 enrolled infants. Sixteen tools (9.6%) contained errors. Mean study site tool ease of use was 8.1 (SD: 2.2) on a 10-point scale. Ninety percent of conference evaluators agreed/strongly agreed that the tool addressed important knowledge gaps. IMPLICATIONS FOR PRACTICE: The tool is easy to use and valued by nurses. Following validation, widespread implementation is expected to be a clinically feasible means to improve infant clinical outcomes for minimal time and financial cost. IMPLICATIONS FOR RESEARCH: Tool validation and refinement based on nursing feedback will improve its broad applicability and predictive utility.

A 6th Vital Sign--Potential Use of Nasogastric Tube for Intra-abdominal Pressure Monitoring Method to Detect Feeding Intolerance in Very Low Birth-Weight Preterm Infants (<1500 g).

BACKGROUND: While various feeding strategies designed to optimize growth have been investigated and used in the clinical setting, the problem of not being able to recognize the warning signs of feeding intolerance early enough to prevent serious gastrointestinal complication commonly associated with very low birth-weight (VLBW) preterm infant remains. Currently, early stages of feeding intolerance are most often identified though nurse assessments. Additional methods to predict feeding intolerance in this population are needed. Currently, intra-abdominal pressure monitoring has been an effective method to predict intolerance to enteral nutrition in the adult and pediatric populations. PURPOSE: There is supportive evidence for the use of noninvasive methods, such as nasogastric tubes, to effectively monitor IAP. While this may not be the gold standard method of using Foley catheters for measurement, it could provide predictive levels that are indicative of progression toward bowel inflammation. FINDINGS: This review shows the potential for using noninvasive nasogastric tubes for monitoring intra-abdominal pressure and may provide direction for evaluating intra-abdominal pressures in VLBW preterm infants as a reliable method for early identification of feeding intolerance. IMPLICATIONS FOR PRACTICE: The use of nasogastric tubes to monitor intra-abdominal pressure may provide an effective noninvasive tool to identify VLBW preterm infants progressing toward feeding intolerance and would add to assessment data. IMPLICATIONS FOR RESEARCH: Development and testing of a reliable nasogastric tube monitoring device in the VLBW preterm infant population and identify predictive levels that indicate progression toward feeding intolerance is needed. Once IAP predictive levels are identified, provider interventions could be developed.

Educating neonatal nurses in Brazil: a before-and-after study with interrupted time series analysis.

BACKGROUND: Preterm birth contributes significantly to infant mortality and morbidity, including blindness from retinopathy of prematurity (ROP). Access to intensive neonatal care is expanding in many countries, but care is not always optimal, one factor being that nursing is often by inadequately trained nurse assistants. OBJECTIVE: The aim of this study was to evaluate whether an educational package for nurses improves a range of outcomes including survival rates and severe ROP in 5 neonatal units in Rio de Janeiro, Brazil. METHODS: The study design included an uncontrolled before-and-after study in 5 units, with interrupted time series analysis. Participatory approaches were used to develop a self-administered educational package for control of pain, oxygenation, infection, nutrition, and temperature and to improve supportive care ('POINTS of Care'). Educational materials and DVD clips were developed and training skills of nurse tutors were enhanced. There were two 1-year periods of data collection before and after a 3-month period of self-administration of the education package. RESULTS: Overall, 74% of 401 nurses and nurse assistants were trained. A total of 679 and 563 infants were included in the pre- and post-training periods, respectively. Despite improvement in knowledge and nursing practices, such as the delivery and monitoring of oxygen, there was no change in survival (pre-training 80%, post-training 78.2%), severe ROP (1.6 vs. 2.8%), sepsis (11.3 vs. 12.3 cases per 1,000 infant days) or other outcomes. Outcomes worsened over the pre-intervention period but the change to an improvement after the intervention was not statistically significant. During the study period many trained staff left the units, but few were replaced. CONCLUSIONS: Future studies need to focus on barriers to implementation, team building, leadership and governance, as well as the acquisition of knowledge and skills.

Prevention and early recognition of necrotizing enterocolitis: a tale of 2 tools--eNEC and GutCheckNEC.

BACKGROUND AND SIGNIFICANCE: Risk for neonatal necrotizing enterocolitis (NEC) is complex, reflecting its multifactorial pathogenesis. PURPOSE: To improve risk awareness and facilitate communication among neonatal caregivers, especially nurses, 2 tools were developed. DESIGN: GutCheck was derived and validated as part of a formal research study over 3 phases, evidence synthesis, expert consensus building, and statistical modeling. The Wetzel/Krisman tool, eNEC, was developed and tested as part of a quality improvement initiative in a single clinical setting using evidence synthesis, review by internal expert clinicians, and implementation and evaluation of its use by direct line neonatal staff. Refinement of both tools is under way to evaluate their effect on clinical decision making, early identification of NEC and surgical NEC. METHODS AND MAIN OUTCOMES: Clinicians can take an active role to reduce NEC in their units by focusing on modifiable risk factors such as adoption of standardized feeding protocols, preferential feeding of human milk, and antibiotic and histamine blocker stewardship. RESULTS: Feeding during transfusion remains controversial, but judicious use of transfusions, adoption of transfusion guidelines, and withholding feeding during transfusion are feasible measures with potential benefit to prevent NEC and confer little risk.

Transfusion-associated necrotizing enterocolitis: translating knowledge into nursing practice.

Necrotizing enterocolitis (NEC) is a leading cause of prolonged hospitalizations for premature infants in the United States. In a recent large retrospective study, a significant proportion of NEC cases were shown to occur within 48 hours of packed red blood cell (PRBC) transfusion, especially in growing preterm neonates of older postnatal age. A small body of evidence consistently demonstrates that 25-35 percent of NEC cases are temporally associated with PRBC transfusion and that cases of NEC associated with transfusion are generally more severe with a higher rate of surgical intervention and mortality. Awareness of this association is vital for potential prevention and early recognition of NEC. The neonatal nurse has a primary role in care strategies that may affect NEC. This review of literature was compiled to educate neonatal nurses about the existence of transfusion-associated necrotizing enterocolitis and guide the translation of knowledge into nursing practice at the bedside.

Expert consensus building using e-Delphi for necrotizing enterocolitis risk assessment.

OBJECTIVE: To confirm content validity of GutCheck(NEC) , a risk index for necrotizing enterocolitis (NEC) and to determine the level of agreement among experts about NEC risk factors in premature infants. DESIGN: Electronic Delphi method (e-Delphi). SETTING: Online electronic surveys and e-mail communication supported by an interactive study website. PARTICIPANTS: Nurses and physicians (N = 35) from four countries and across the United States who rated themselves as at least moderately expert about NEC risk. METHODS: e-Delphi involved three rounds of surveys and qualitative thematic analysis of experts' comments. Surveys continued until criteria for consensus and/or stability were met. RESULTS: Of 64 initial items, 43 were retained representing 33 risk factors (final GutCheck(NEC) Content Validity Index [CVI] = .77). Two broad themes about NEC risk emerged from 242 comments: the impact of individual physiologic vulnerability and variation in neonatal intensive care unit (NICU) clinicians' practices. Controversy arose over the impact of treatments on NEC, including probiotics, packed red blood cell (PRBC) transfusions, and patent ductus arteriosus (PDA) management using indomethacin. CONCLUSION: GutCheck(NEC) achieved borderline content validity for a new scale. The e-Delphi process yielded a broad perspective on areas in which experts share and lack consensus on NEC risk. Future testing is underway to reduce the number of risk items to the most parsimonious set for a clinically useful risk tool and test reliability.

Necrotizing fasciitis: a case report of a premature infant with necrotizing enterocolitis.

Necrotizing fasciitis (NF) is a severe infection involving the superficial fascia, subcutaneous tissue, and, occasionally, deeper tissue layers. Usual treatment is with surgical debridement in combination with antibiotics. In review of the literature there is one neonatal report of NF associated with necrotizing enterocolitis. We present a case report of a 25 week gestation infant with necrotizing fasciitis and the complexity of wound and pain management presented for the nursing staff in the neonatal intensive care unit.

Mothers' "liquid gold": a quality improvement initiative to support early colostrum delivery via oral immune therapy (OIT) to premature and critically ill newborns.

Early breast milk, known as colostrum ("liquid gold") provides immune benefits to infants, offering potential risk reduction for nosocomial infection (NI) and necrotizing enterocolitis (NEC), a serious gastrointestinal emergency. Provision of colostrum is recognized as oral immune therapy (OIT) and is valuable to all NICU infants unable to feed orally. A quality improvement project was initiated by the multidisciplinary NICU Quality Care Council at London Health Sciences Centres-Victoria (LHSC-VH) to obtain mothers' colostrum for early OIT. The initiative was driven by the Canadian EPIQ (Evidence-based Practice for Improving Quality) group as a means of reducing the rates of NEC and NI, two major morbidities in the NICU. The overall aim was to facilitate the availability of OIT to preterm and critically ill neonates as soon as possible after birth.

Thermoregulation and thermography in neonatal physiology and disease.

INTRODUCTION: Infrared thermal imaging, or thermography, is a technique used to measure body surface temperature in the study of thermoregulation. Researchers are beginning to use this novel methodology to study cancer, peripheral vascular disease, and wound management. METHODS: The authors tested the feasibility of using an FLIR SC640 uncooled, infrared camera to measure body temperature in neonates housed in heated, humid incubators. The authors examined thermograms to analyze distributions between central and peripheral body temperature in extremely low birth weight infants. The authors have also used this technology to examine the relationship between body temperature and development of necrotizing enterocolitis in premature infants. RESULTS: Handheld, uncooled, infrared cameras are easy to use and produce high-quality thermograms that can be visualized in grayscale or color palettes to enhance qualitative and quantitative analyses. CONCLUSION: Future research will benefit from the use of this noninvasive, inexpensive measurement tool. Nurse researchers can use this methodology in adult and infant populations to study temperature differentials present in pathological conditions.

Gently caring: supporting the first few critical hours of life for the extremely low birth weight infant.

Caring for the extremely low birth weight infant in the first days of life is complex and challenging, yet rewarding. It is the experienced health care provider who will be best prepared to meet the needs of these fragile infants and their concerned/frightened parents. Understanding how to minimize stress and support body functions will enable us to better care for these infants in the first few days of life. We should strive to partner with parents, even in the resuscitative and stabilization phases of care, particularly when an infant may not survive. Nursing plays an essential role in providing this minute-to-minute support. It is not always what we do, but how we do it, that may matter most.

Enteral feeding for high-risk neonates: a digest for nurses into putative risk and benefits to ensure safe and comfortable care.

Enteral feeding is considered a relatively safe method of providing nutritional support to high-risk neonates. Nonetheless, there are associated risks, which can be classified as follows: factors to consider before initiating enteral feeding; feeding tube placement; delivery of milk feedings; and gastrointestinal, environmental, and technical factors. For each classification, this article highlights adverse consequences and synthesizes the literature for evidence-based nursing practice recommendations, which are summarized in the "Conclusion" section. Many gaps are identified in the research literature, and directions for future research are described to ensure safe and comfortable care for high-risk neonates receiving enteral feedings.

Current controversies in the understanding of necrotizing enterocolitis. Part 1.

Necrotizing enterocolitis (NEC) has widespread implications for neonates. While mostly affecting preterm neonates, full-term neonates, especially those with congenital heart disease, are also at risk. Although the exact pathogenesis of NEC remains elusive, three major factors, a pathogenic organism, enteral feedings, and bowel compromise, coalesce in at-risk neonates to produce bowel injury. Initiation of the inflammatory cascade likely serves as a common pathway for the disorder. Clinical signs and symptoms range from mild feeding intolerance with abdominal distension to catastrophic disease with bowel perforation, peritonitis, and cardiovascular collapse. Vigilant assessment of at-risk neonates is crucial. When conservative medical management fails to halt injury, surgical intervention is often needed. Strategies to decrease the incidence and ultimately prevent NEC loom on the horizon, such as exclusive use of human breastmilk for enteral feedings and administration of probiotics.

A critical analysis of the routine testing of newborn stools for occult blood and reducing substances.

Stool tests for occult blood or reducing substances were introduced in the neonatal intensive care unit (NICU) as potential aids in the early recognition of necrotizing enterocolitis (NEC) in high-risk neonates, and have been recommended by some as routine nursing procedures. Neither the performance characteristics of these tests with respect to NEC, nor their indirect impact, were evaluated formally before widespread adoption into clinical care. The published evidence suggests that these tests are not useful as diagnostic or screening tools. There is no evidence that routine stool screening for occult blood or reducing substances predicts NEC or decreases the rate or severity of this disease. The direct costs of the tests are significant. A greater concern is their potential unintended consequences, which include the cost of secondary tests, restricted nutritional intake, and the accumulation of distracting, useless data. The logistics of maintaining quality control, the demands on nursing time, and the cost of testing are increasingly important considerations. This installment of Focus on the Physical diverges from a step-by-step systematic physical assessment by addressing the utility of testing neonatal stools for occult blood and reducing substances as aids in the early diagnosis or prevention of NEC. Using the information from these tests requires a framework for understanding their rationale, the test performance characteristics in the NICU setting, and the potential benefits, costs, and risks of their routine use.

Nursing the preterm surgical neonate.

The preterm neonate's response to surgery manifests in all body systems. Necrotising Enterocolitis (NEC) is an acute gastro-intestinal emergency requiring surgical intervention. Severe NEC may require the removal of infarcted bowel. Examining the response to surgery in the preterm neonate with NEC offers nurses a rationale for their post-operative care. Both physiological and psychological responses need to be understood in the light of family centred care.