Shift-to-shift handoffs in the NICU: lessons learned from a large scale audit.

OBJECTIVE: Describe the frequency of best practice behaviors during NICU provider and nursing shift-to-shift handoffs and identify strengths and opportunities for improvement. STUDY DESIGN: Observational study of handoff characteristics among 40 centers participating in a learning collaborative over a 10-month period. Data were gathered using a handoff audit tool that outlined best practices. Comparisons of behaviors between nurse-to-nurse and provider-to-provider handoffs were made where appropriate. RESULTS: Overall, 946 audits of shift-to-shift handoffs were analyzed. While many behaviors were demonstrated reliably, differences between nurse-to-nurse vs provider-to-provider handoffs were noted. Families were present for 5.9% of handoffs and, among those who were present, 48.2% participated by contributing information, asking questions, and sharing goals. CONCLUSIONS: Observation and measurement of handoff behaviors can be used to identify opportunities to improve handoff communication, family participation, and human factors that support handoff. Auditing handoffs is feasible and necessary to improve these critical transitions in infants' care.

Maternal Milk Provision in the Neonatal Intensive Care Unit and Mother-Infant Emotional Connection for Preterm Infants.

Maternal milk (MM) intake during neonatal intensive care unit (NICU) hospitalization is associated with improved neurodevelopment in preterm infants. Underlying mechanisms may include stronger mother-infant emotional connection. This paper examines associations between MM provision in the NICU with maternal connection to her infant using three factors validated in our sample: maternal sensitivity, emotional concern, and positive interaction/engagement. We studied 70 mothers of infants born <1500 g and/or <32 weeks' gestation. Associations between MM provision and mother-infant connection were modeled using median regression adjusted for clustering. Mothers who provided exclusive MM (i.e., 100% MM, no other milk) reported higher levels of maternal sensitivity by a median score of 2 units (ß = 2.00, 95% CI: 0.76, 3.24, p = 0.002) than the mixed group (i.e., MM < 100% days, other milk ≥1 days), as well as greater emotional concern (ß = 3.00, 95% CI: -0.002, 6.00, p = 0.05). Among mothers of very preterm infants, greater milk provision was associated with greater maternal sensitivity, but also with greater emotional concern about meeting the infant's needs. These findings highlight the importance of supporting MM provision and early infant care as an integrated part of lactation support. The findings may also provide insight into links between MM provision in the NICU and infant neurodevelopment.

Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout.

OBJECTIVE: Test web-based implementation for the science of enhancing resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) burnout. DESIGN: RCT using two cohorts of HCWs of four NICUs each, to improve HCW well-being (primary outcome: burnout). Cohort 1 received WISER while Cohort 2 acted as a waitlist control. RESULTS: Cohorts were similar, mostly female (83%) and nurses (62%). In Cohorts 1 and 2 respectively, 182 and 299 initiated WISER, 100 and 176 completed 1-month follow-up, and 78 and 146 completed 6-month follow-up. Relative to control, WISER decreased burnout (-5.27 (95% CI: -10.44, -0.10), p = 0.046). Combined adjusted cohort results at 1-month showed that the percentage of HCWs reporting concerning outcomes was significantly decreased for burnout (-6.3% (95%CI: -11.6%, -1.0%); p = 0.008), and secondary outcomes depression (-5.2% (95%CI: -10.8, -0.4); p = 0.022) and work-life integration (-11.8% (95%CI: -17.9, -6.1); p < 0.001). Improvements endured at 6 months. CONCLUSION: WISER appears to durably improve HCW well-being. CLINICAL TRIALS NUMBER: NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133.

Variability in the systems of care supporting critical neonatal intensive care unit transitions.

OBJECTIVE: Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization. STUDY DESIGN: Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status. RESULTS: Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35-65%) for communication, 67% (IQR 33-83%) for teamwork, 50% (IQR 33-61%) for family integration, and 70% (IQR 56-85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit. CONCLUSIONS: We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.

Correction: Epidemiology of patient monitoring alarms in the neonatal intensive care unit.

The previously published version of this Article contained an error in Fig. 1 where the "HR low" and "HR high" labels were swapped.Furthermore, in Table 1 of this Article, the fifth row in the centre column contained a typographical error where the study population birth weight incorrectly read "2050 (1 450-2 650)", rather than "2050 (1450-2650)".These errors have now been corrected in both the PDF and HTML versions of the Article.

Epidemiology of patient monitoring alarms in the neonatal intensive care unit.

OBJECTIVE: To characterize the rate of monitoring alarms by alarm priority, signal type, and developmental age in a Level-IIIB Neonatal Intensive Care Unit (NICU) population. STUDY DESIGN: Retrospective analysis of 2,294,687 alarm messages from Philips monitors in a convenience sample of 917 NICU patients, covering 12,001 patient-days. We stratified alarm rates by alarm priority, signal type, postmenstrual age (PMA) and birth weight (BW), and reviewed and adjudicated over 21,000 critical alarms. RESULTS: Of all alarms, 3.6% were critical alarms, 55.0% were advisory alarms, and 41.4% were device alerts. Over 60% of alarms related to oxygenation monitoring. The average alarm rate (±SEM) was 177.1 ± 4.9 [median: 135.9; IQR: 89.2-213.3] alarms/patient-day; the medians varied significantly with PMA and BW (p < 0.001) in U-shaped patterns, with higher rates at lower and higher PMA and BW. Based on waveform reviews, over 99% of critical arrhythmia alarms were deemed technically false. CONCLUSIONS: The alarm burden in this NICU population is very significant; the average alarm rate significantly underrepresents alarm rates at low and high PMA and BW. Virtually all critical arrhythmia alarms were artifactual.

A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool: Challenges in Obtaining Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome.

BACKGROUND: Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs. PURPOSE: This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses. METHODS: One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training. RESULTS: Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology. IMPLICATIONS FOR PRACTICE: Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time. IMPLICATIONS FOR RESEARCH: This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Time-dependent changes in median nerve sensory amplitude after local anesthetic administration and tourniquet application.

Indirect visualization, as used in several newer mini-open and endoscopic carpal tunnel release (CTR) procedures, may increase the possibility of nerve injury in some cases. Intraoperative neural monitoring may be used to evaluate nerve location and integrity. In the study reported here, we assessed the feasibility of intraoperative neural monitoring by systematically exploring the effect of local anesthetic and tourniquet on median sensory amplitude. Results for 30 median nerves (7 symptomatic) showed that sensory amplitude decreased, on average, 54% with lidocaine injection, 15% with tourniquet application, and 47% with the combination. Sensory amplitudes of 9 of 10 nerves were still above 1.0 microV 15 minutes after anesthetic administration and tourniquet application. Study results demonstrate that intraoperative monitoring, using the amplitude of the median sensory nerve response, is viable under CTR conditions.