Reducing Variation in the Management of Apnea of Prematurity in the Intensive Care Nursery.

BACKGROUND: Premature infants have bradycardia and/or desaturation events due to apnea of prematurity that resolve as the infants mature. Despite American Academy of Pediatrics guidelines recommending a standard "event-free" period before discharge, length of observation in our Intensive Care Nursery was variable. By June 2018, for infants born <36 weeks' gestation in the Intensive Care Nursery, we aimed to standardize time to discharge after the last documented event at 5 days, when the baseline mean was 3.6 days (range 0-6 days). METHODS: A quality-improvement team used the Model for Improvement. Plan-do-study-act cycles improved nursing documentation of events and standardized discharge criteria after consensus on operational definitions. The outcome measure was days to discharge after last documented event. Process measures included percentage of events documented completely and correctly in the electronic medical record. Balancing measure was length of stay after 36 weeks' corrected gestational age. We used statistical process control. RESULTS: The baseline event watch ranged from 0 to 6 days. After defining significant events, documentation expectations, and consensus on a 5-day "watch" before discharge, the event watch range narrowed with a mean that shifted from 3.6 to 4.8 days on X-bar S statistical process control chart. Completeness of documentation increased from 38% to 63%, and documentation of significant events increased from 38% to 88%. Length of stay after 36 weeks' corrected gestational age was unchanged, and nursing satisfaction improved. CONCLUSIONS: We found decreasing variation in the management of apnea of prematurity while simultaneously improving staff satisfaction. Next steps include revising electronic medical record flowsheets and spread to network NICUs.

Intensive Care Neonates and Evidence to Support the Elimination of Hats for Safe Sleep.

BACKGROUND: Although the incidence of sudden unexplained infant deaths has decreased over time with the use of safe sleep practices, one area that remains unclear is the safety of hats during infant sleep. PURPOSE: Decrease the risk of overheating or suffocation by removing NICU infants' hats during sleep without increasing the relative risk of hypothermia during transition to an open crib. METHODS: Removal of hats for routine thermoregulation, beyond the initial infant resuscitation and stabilization of NICU infant was implemented in 2015. Retrospective chart audits were conducted on all NICU infants between February 2015 and December 2016. Hypothermia (≤ 97.6°F) data during transition to an open crib was collected. Exclusion criteria included concurrent diagnosis of: sepsis, hyperbilirubinemia, congenital anomaly inhibiting infants thermoregulation and noncompliance with unit guideline for weaning infant to open crib. FINDINGS: Over 18 months, 2.7% of infants became hypothermic (≤ 97.6°F) during transition to open crib, requiring return to isolettes. IMPLICATIONS FOR PRACTICE: Hats were found to be unnecessary in maintaining thermoneutrality after weaning infants toan open crib in our NICU. By avoiding the use of hats in an open crib, it's possible infants will avoid overheating and a risk of suffocation, creating a safer sleep environment. IMPLICATIONS FOR RESEARCH: The removal of hats during sleep to promote infant health should be considered for all infants.

An Evidence-Based Infant Safe Sleep Program to Reduce Sudden Unexplained Infant Deaths.

: Objective: The purpose of this project was to design, implement, and evaluate a safe sleep program for expectant mothers and the families of infants discharged from our hospital's neonatal intensive care unit (NICU). It was prompted by the sleep-related deaths of two infants in the community, both of whom had been discharged from our NICU. METHODS: A six-member interdisciplinary team comprising nurses, a physician, an occupational therapist, and a respiratory therapist developed a safe sleep program in an effort to identify and implement evidence-based safe sleep practices for infants in the NICU. The team examined the literature on sleep-related death and safe sleep practices, consulted with colleagues in NICUs at nearby hospitals and clinics, and conducted an audit of practices related to putting infants to sleep in the NICU. The initiative included the use of infant sleep sacks, the development of a clinical practice guideline to promote safe sleep, and the delivery of standardized discharge education for caregivers in the NICU and safe sleep classes for expectant mothers and caregivers in the community. The team educated NICU staff on the new practice guideline in November and December 2014, and implemented the clinical intervention in January 2015. RESULTS: Random unit audits showed that prior to implementation of the safe sleep program, NICU nurses had followed safe sleep practices only 20% of the time; after implementation, however, safe sleep practices were followed an average of about 90% of the time. In-hospital and community-oriented evidence-based teaching on safe sleep practices and environments was associated with no sleep-related infant deaths after discharge from our NICU in calendar year 2015. CONCLUSION: A multifaceted safe sleep program offers many benefits to both the NICU and its patients. The implementation of a standardized safe sleep program provides an enormous opportunity to improve the health and well-being of the community. All hospitals that care for mothers and infants should adopt a safe sleep program.