Observational study using video recordings to explore the first hour after admission to a neonatal intensive care unit.

AIM: To explore the admission process to our neonatal intensive care unit. METHODS: A first phase quality improvement initiative was conducted. We utilised observational video recording of a convenience sample of inborn admissions. Two remote GoPro cameras were placed, one giving an overview of activity and the other focussed on the infant. Recordings captured the first hour after admission including transfer to the neonatal intensive care unit by the birthing team. The video footage of each case study was reviewed by a multidisciplinary panel using an agreed semi-quantitative analysis of events. RESULTS: Ten admissions to the neonatal intensive care unit were video recorded between June and October 2018. Gestational age 282 -401 . A focus on maintaining airway support was inconsistent as was the ability to provide continuous monitoring of vital signs. Overall leadership of the process was lacking and handover often appeared fragmented. Median temperature on admission was 362 (354 -373 ) °C. Vascular access and fluid management occurred at a median of 36 (13-67) minutes. CONCLUSIONS: Planning and approval for this study were protracted, particularly negotiating the use of video recording. Anecdotally, this delay is thought to have contributed to an improvement in managing admissions, particularly when maintaining airway support and monitoring. However, our baseline data have highlighted a lack of leadership, fragmented handover, low admission temperatures and broad time frames to achieve vascular access. A guideline to streamline handover and nursery transition is currently being implemented; a subsequent evaluation cycle is planned.

When can I hold my baby? An audit of time to first cuddle for preterm babies (<32 weeks) pre introduction and post introduction of a Family-Integrated Care model.

AIM: The audit examined time to first cuddle between preterm babies (born < 32 weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay. BACKGROUND: Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing. DESIGN: A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit. METHODS: A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27 + 6 weeks and 28-31 + 6 weeks. SQUIRE checklist guided reporting of the audit. RESULTS: One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27 + 6 weeks n = 39 and 28-31 + 6 weeks n = 40) and 74 from 2018 (≤27 + 6 weeks n = 35 and 28-31 + 6 weeks n = 39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27 + 6 weeks in 2018 were cuddled earlier (median = 141 h old) compared with those in 2015 (median = 157 h old). Median time to reach full feeds decreased and was significant in the ≤27 + 6-week group: 288 h (12 days) in 2015 to 207.5 h (8.6 days) in 2018. Length of stay was longer for the ≤27 + 6-week gestation 2018 group (median = 64 days) and 28-31 + 6-week gestation 2018 group (median = 22 days). CONCLUSION: Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge. RELEVANCE TO CLINICAL PRACTICE: Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.

Reporting the incidence of unplanned extubation in the neonatal intensive care unit.

AIM: The aim of this study was to highlight the incidence of unplanned extubation (UE) and identify associated factors in our neonatal population. METHODS: This study was a prospective audit. RESULTS: A specifically designed audit tool was used to capture UE events; 182 neonates required mechanical ventilation for 863 days. There were 41 episodes of UE. The UE rate was 4.75 per 100 days of ventilation. At the time of UE, median gestational age of patients was 27.3 weeks (23.4-37.6), with a corrected age median of 29.2 weeks (23.4-37.6). Re-intubation was required in two thirds of the patients for increasing apnoea and increased work of breathing. Endotracheal tubes are secured in a standardised way either using Neobar or brown tape. UE events occurred with both methods. The two most common factors associated with UE included active handling of the baby and the time of day (0700-1000 h). CONCLUSIONS: This audit has provided our neonatal intensive care unit with a benchmark for improvement. It has also created staff awareness of the risk of UE and promoted staff engagement to reduce UE. A bundle approach to reduce UE has been introduced. Future audits are planned to monitor the impact of these initiatives.

Transition from hospital to home: Parents' perception of their preparation and readiness for discharge with their preterm infant.

AIMS AND OBJECTIVES: To explore the experiences of parents with babies born between 28-32 weeks' gestation during transition through the neonatal intensive care unit and discharge to home. BACKGROUND: Following birth of a preterm baby, parents undergo a momentous journey through the neonatal intensive care unit prior to their arrival home. The complexity of the journey varies on the degree of prematurity and problems faced by each baby. The neonatal intensive care unit environment has many stressors and facilitating education to assist parents to feel ready for discharge can be challenging for all health professionals. DESIGN: Qualitative descriptive design. METHODS: The project included two phases, pre- and postdischarge, to capture the experiences of 20 couples (40 parents), whilst their baby was a neonatal intensive care unit inpatient and then after discharge. Face-to-face interviews, an online survey and telephone interviews were employed to gather parent's experiences. Constant comparative analysis was used to identify commonalities between experiences. Recruitment and data collection occurred from October 2014-February 2015. RESULTS/FINDINGS: Overlapping themes from both phases revealed three overarching concepts: effective parent staff communication; feeling informed and involved; and being prepared to go home. CONCLUSION: Our findings can be used to develop strategies to improve the neonatal intensive care unit stay and discharge experience for parents. Proposed strategies would be to improve information transfer, promote parental contact with the multidisciplinary team, encourage input from fathers to identify their needs and facilitate parental involvement according to individual needs within families. RELEVANCE TO CLINICAL PRACTICE: Providing information to parents during their time in hospital, in a consistent and timely manner is an essential component of their preparation when transitioning to home.

Empowering Parents of Australian Infants and Children in Hospital: Translation, Cultural Adaptation, and Validation of the EMpowerment of PArents in The Intensive Care-30-AUS Questionnaire.

OBJECTIVES: To translate, culturally adapt, and psychometrically test the EMpowerment of PArents in The Intensive Care-30 questionnaire in Australian pediatric critical care, neonatal, and pediatric ward settings. DESIGN: Cross-sectional, descriptive, multicenter study conducted in two phases; 1) translation and cultural adaptation and 2) validation of the EMpowerment of PArents in The Intensive Care-30 questionnaire. SETTINGS: Two Western Australian sites, the PICU and two pediatric wards of a children's hospital and the neonatal unit of a women's and newborn hospital. PARTICIPANTS: Parents whose baby or child was admitted to the participating wards or units with a length of hospital stay greater than 24 hours. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Phase 1: A structured 10-step translation process adhered to international principles of good practice for translation and cultural adaptation of patient-reported outcomes. Thirty parents participated in cognitive debriefing. Phase 2: A total of 328 parents responded to the EMpowerment of PArents in The Intensive Care-30-AUS questionnaire. Reliability was sufficient (Cronbach α at domain level 0.70 -0.82, for each clinical area 0.56-0.86). Congruent validity was adequate between the domains and three general satisfaction items (rs 0.38-0.69). Nondifferential validity showed no significant effect size between three patient or parent demographic characteristics and the domains (Cohen's d < 0.36). Between the different clinical areas, significant differences in responses were found in all domains. CONCLUSIONS: The translated and culturally adapted EMpowerment of PArents in The Intensive Care-30-AUS is a reliable and valid questionnaire to measure parent-reported outcomes in pediatric critical care, pediatric ward, and neonatal hospital settings. Using this questionnaire can provide a framework for a standardized quality improvement approach and identification of best practices across specialties, hospital services and for benchmarking similar health services worldwide.

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

AIMS AND OBJECTIVES: The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit. BACKGROUND: Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention. Minimal evidence is available around reasoning, decision making and questioning around medication administration. Therefore, this study focuses upon addressing the gap in knowledge around what nurses believe influences their decision to question. DESIGN: A critical incident design was employed where nurses were asked to describe clinical incidents around their decision to question a medication issue. Nurses were recruited from a neonatal clinical care unit and participated in an individual digitally recorded interview. RESULTS: One hundred and three nurses participated between December 2013-August 2014. Use of the constant comparative method revealed commonalities within transcripts. Thirty-six categories were grouped into three major themes: 'Working environment', 'Doing the right thing' and 'Knowledge about medications'. CONCLUSIONS: Findings highlight factors that influence nurses' decision to question issues around medication administration. Nurses feel it is their responsibility to do the right thing and speak up for their vulnerable patients to enhance patient safety. Negative dimensions within the themes will inform planning of educational strategies to improve patient safety, whereas positive dimensions must be reinforced within the multidisciplinary team. RELEVANCE TO CLINICAL PRACTICE: The working environment must support nurses to question and ultimately provide safe patient care. Clear and up to date policies, formal and informal education, role modelling by senior nurses, effective use of communication skills and a team approach can facilitate nurses to appropriately question aspects around medication administration.

Examination of the perception of communication and collaboration in a neonatal intensive care unit: a decade on, has it changed?

OBJECTIVE: The aim of this study was to ascertain the perception of communication and collaboration within and between the groups of medicine and nursing in a neonatal unit. METHODS The study used an analytical cross-sectional design involving both doctors and nursing staff in the neonatal clinical care unit (NCCU). A quantitative questionnaire using a Likert scale format, accompanied by an open-ended question, provided a snapshot of the perception of communication and collaboration within the NCCU. RESULTS Significant differences were noted between the two disciplines. Medical staff were satisfied overall with the communication. They perceived communication was more open, timely and that a mutual understanding existed. They thought teamwork was good. As time of employment in NCCU lengthened, the understanding between the groups lessened. Problems with the handover information emerged for both medical and nursing staff. Both groups felt problems were due to the hierarchical system. CONCLUSION Within the NCCU the perception of communication and collaboration is rated more highly by doctors. This has implications for the overall care of babies and for safety issues. Education is needed in the neonatal unit to identify and bridge gaps in communication and enhance teamwork.