Safe to Sleep in Tennessee: A Statewide Quality Improvement Initiative.

OBJECTIVE: Sleep-related deaths were the fourth leading cause of infant death in Tennessee between 2014 and 2018. In response, the Tennessee Initiative for Perinatal Quality Care developed a statewide quality improvement project, which focused on the demonstration and enforcement of a safe sleep environment in participating birthing hospitals to help families learn and practice the same at home. The project's aim was to improve the percent of infants audited for safe sleep practices (0-12 mo of age, cared for in participating newborn nurseries or neonatal intensive care units) that were compliant with the practices recommended by the 2016 American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome. STUDY DESIGN: Participating teams were required to develop and implement safe sleep policies in compliance with the AAP recommendations, provide safe sleep education to staff and families, and complete monthly safe sleep audits. A tool was provided to assess whether each audited infant was compliant with safe sleep recommendations and any reason(s) the infant was not compliant. Teams met virtually for monthly huddles and semiannual learning sessions to discuss the development and testing of change ideas. RESULTS: The project teams were able to improve the percent of infants audited that were compliant with safe sleep recommendations by 22% over the course of the project. Audits revealed the main reasons for noncompliance were additional objects in the crib (49%, 329/671), unsafe bedding (27%, 181/671), and head of bed elevation (24%, 164/671). CONCLUSION: This project demonstrates the positive impact that a statewide quality improvement initiative can have on identifying and addressing barriers, sharing resources and education, and monitoring local and statewide data, which led to increased compliance with safe sleep recommendations in the hospital. Safe sleep education and monitoring should be ongoing as new parents and staff always need to be educated on safe sleep principles. KEY POINTS: · In 2020, 25% of all infant deaths in Tennessee were due to an unsafe sleep environment.. · Sleep-related deaths in infants are frequently preventable.. · State quality improvement projects are effective in increasing safe sleep compliance.. · State perinatal quality collaboratives can partner with their State Department of Health, local hospitals, and providers, to increase awareness, educate parents, and model a safe sleep environment..

Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants.

BACKGROUND: We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS: The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110-130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS: Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS: A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

High-Flow Nasal Cannula Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the United States.

BACKGROUND: High-flow nasal cannula (HFNC) is widely used to treat neonatal respiratory conditions. Significant evidence emerged in recent years to guide practice, yet current practice patterns and their alignment with the evidence remain unknown. PURPOSE: To examine current HFNC practice patterns and availability of clinical practice guidelines used in neonatal intensive care units in the United States. METHODS/ANALYSIS: A nonexperimental, descriptive study was designed using a web-based survey to elicit a convenience sample of US neonatal providers. Quantitative data were analyzed using descriptive statistics, χ tests were used to test for differences among the categories, and post hoc comparisons among each combination of categories were conducted using a Bonferroni-corrected α of .05 to determine significance as appropriate. RESULTS: A total of 947 responses were analyzed (626 neonatologists and 321 neonatal nurse practitioners). Univariate analyses suggested wide variations in practice patterns. One-third of the respondents used clinical guidelines, the majority utilized HFNC devices in conjunction with nasal continuous positive airway pressure, more than two-thirds used HFNC as a primary respiratory support treatment, and among all respondents, significant differences related to HFNC device types were reported. IMPLICATIONS FOR PRACTICE: US providers revealed wide practice variations related to HFNC therapy. In addition, type of device used appears to impact practice patterns and approaches. Use of standardized guidelines was reported by one third of the respondents, and as such may be the contributing factor for wide practice variations. IMPLICATIONS FOR RESEARCH: Future Research is needed to target aspects of practice where practice variations exist, or practice is not supported by evidence. Significant practice differences related to the device types should be considered in future research design.

Interprofessional practice and education: holistic approaches to complex health care challenges.

The incidence of chronic health conditions continues to rise worldwide. As a result, many groups and decision makers are calling for greater use of interprofessional health care teams and education to effectively address the social, psychological, biological, environmental, and economic dimensions inherent in these health care challenges. This article examines interprofessional practice (IPP) and interprofessional education (IPE) and addresses the following questions: (1) What is IPP; (2) What is IPE; (3) What competencies are necessary to effectively engage in IPP; (4) Who should be educated to serve on IPP health delivery teams; and (5) What educational model can best prepare health care professionals with the skills and practice experiences needed to address complex health issues in a comprehensive fashion? We propose a unique university-based IPE model that effectively addresses complex health issues and maximizes collaboration among clinical, nonclinical, and community stakeholders.

The S.T.A.B.L.E.® Program: the evidence behind the 2012 update.

First released in 1996, the S.T.A.B.L.E.® Program has provided evidence-based education in the postresuscitation and pretransport stabilization care of sick newborns to more than a quarter million multidisciplinary perinatal healthcare team members from around the world. The program, aimed at preventing the leading causes of neonatal mortality, continues to be the subject of published peer-reviewed research and is periodically updated to ensure relevancy and inclusion of current best evidence. S.T.A.B.L.E. is a mnemonic for the 6 essential assessment parameters taught in the program: Sugar and Safe care, Temperature, Airway, Blood pressure, Lab work, and Emotional support. This mnemonic was specifically chosen to serve as a memory tool to remind staff of "what to do" during those infrequent but stressful times when they were expected to assess and stabilize sick newborns. Course completion of the S.T.A.B.L.E. Program is obtained as a result of didactic training and successful completion of content testing. The program's test questions are periodically evaluated and revised on the basis of psychometric analysis. The 6th edition of the S.T.A.B.L.E. Program learner/provider manual is scheduled for release in 2012 and will reflect the latest in stabilization guidelines throughout the program's 6 modules and supplemental content.

A combined field and laboratory investigation for the effective application of ergonomics in situ.

Despite extensive research on musculoskeletal disorders associated with manual labour, the enormity of the problems experienced in industry remains. Recognizing the importance of applying the science of ergonomics, the focus of this paper was to highlight the substantial difference between conducting rigorous controlled research in the laboratory and the less controlled, but more realistic research within the working environment. Our proposal is not to use one or the other methodology, but rather to combine basic assessments made in situ with rigorous laboratory experimentation investigating human responses both pre- and post-intervention, and finally to go back into the field to test the efficacy of the proposed ergonomics intervention. The combined 'field-lab-field' format presented in this paper is based on research conducted in an industrially developing country, and it is argued that this is the most likely means of assuring that the application of rigorous ergonomics theory will improve the poor working conditions so evident in developing regions.

Metabolic responses of South African soldiers during simulated marching with 16 combinations of speed and backpack load.

OBJECTIVES: This study assessed the metabolic responses of South African soldiers marching at different speeds and carrying varying loads. The main objective was to establish the physiological cost of a range of speed/load combinations to identify the energy requirements to meet a diversity of march objectives. METHODS: Thirty male soldiers marched on a treadmill for 6 minutes with varying combinations of speed and load, established through numerous pilot studies and in consultation with military personnel. The four speeds were 3.5, 4.5, 5.5, and 6.5 km x (-1), combined with the four loads of 20, 35, 50, and 65 kg, totaling 16 combinations. Each participant completed eight of the 16 conditions, during which the participants wore standardized military gear and were attached to a portable ergospirometer (the Metamax, Cortex, Leipzig, Germany) for the duration of the march. RESULTS: Based on the responses, five discrete categories of speed/load combinations were identified. These combinations were categorized as nominal (< 40% of maximal oxygen consumption [VO(2max)]), moderate (40-50% of VO(2max)), heavy (50-65% of VO(2max)), very heavy (65-80% of VO(2max)), and excessive (> 80% of VO(2max)), with each categorization incorporating diverse combinations of speed and load. CONCLUSION: The findings demonstrate that the interplay between marching speed and backpack load plays a crucial role in ensuring that similar metabolic demands are maintained at a bearable level to meet specific military circumstances, thus reducing the likelihood of injuries and the early onset of fatigue and ensuring that the soldiers are combat ready on arrival at their destination.