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.

Incidencia y Gravedad de la retinopatía del prematuro / The incidence and severity of retinopathy of prematurity

Objetivo. Mediante el presente trabajo, nos planteamos conocer la incidencia actual y la gravedad de la Retinopatía del Prematuro en el complejo hospitalario universitario de Vigo (CHUVI). Material y Métodos. Estudio restrospectivo de todos los recién nacidos prematuros entre los años 2006 y 2010 y sometidos a despistaje para ROP. Se realiza un análisis descriptivo y un estudio de asociación para valorar la incidencia y la gravedad de la ROP en nuestro área. Resultados. Se observa una incidencia global de ROP similar a los estudios de referencia universal, el CRYO-ROP y el ETROP, sin embargo el número de casos que reciben tratamiento es un poco inferior que el de otras series publicadas. Estas diferencias pueden ser debidas al componente subjetivo que tiene el diagnóstico y la indicación de tratamiento de esta enfermedad así como a la estructura burocrática disponible en cada centro hospitalario. Conclusiones. La mayor parte de los niños incluídos en el cribado para OP tenían algún grado de enfermedad, pero sólo un 6% tienen la gravedad suficiente para precisar tratamiento ocular (AU)

Objective. In the present work, we plan to meet the current incidence and severity of retinopathy of prematurity in the Vigo University Hospital Complex (CHUVI). aterial and Methods. Retrospective study of all preterm infants between 2006 and 2010 and subjected to screening for ROP. We performed a descriptive analysis and an association study to assess the incidence and severity of ROP in our area. Results. We observed an overall incidence of ROP similar to universal baseline studies, the CRYO-ROP and ETROP, however the number of treated cases is a bit lower than other published series. These differences ay be due to the subjective component that has the indicated diagnosis and treatment of this disease as well as the bureaucratic structure available in each hospital. Conclusions. The majority of children included in screening for ROPad some degree of disease, but only 6% are severe enough to require eye treatment (AU)

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): four-years of screening with telemedicine.

PURPOSE: To report the four-year experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative, which was developed to reduce the risk of blindness from retinopathy of prematurity (ROP). MATERIALS AND METHODS: A retrospective analysis of the SUNDROP archival data between 12/1/2005 and 11/30/2009. A total of 410 consecutively enrolled infants meeting ROP screening criteria had nurse-obtained fundoscopic images evaluated remotely by an ROP specialist. Every infant then received at least one dilated bedside binocular indirect ophthalmoscope (BIO) examination within one week of discharge. All infants were then followed with both telemedicine images and bedside evaluation in clinic according to recommended screening timelines. Primary outcomes were treatment-warranted ROP (TW-ROP), defined as Early Treatment of ROP Type 1, and adverse anatomical outcomes. RESULTS: The SUNDROP telemedicine screening initiative has not missed any TW-ROP in its four-year evaluation period. A total of 410 infants (820 eyes) were imaged, resulting in 1486 examinations and 18,097 unique images. An average of 12.2 images were obtained per patient. Fourteen infants met TW-ROP criteria on telemedicine examination. After bedside evaluation, 13 infants required laser photocoagulation and one was followed until he spontaneously regressed. Infants with TW-ROP had a significantly lower gestational age (24.9 weeks), birth weight (658.7 grams), and were more likely to be male than the no TW-ROP cohort (all p values <0.00001). Telemedicine had a calculated sensitivity of 100%, specificity of 99.8%, positive predicative value of 92.9% and negative predictive value of 100% for the detection of TW-ROP. No patient progressed to retinal detachment or any adverse anatomical outcome. CONCLUSIONS: The SUNDROP initiative demonstrated a high degree of diagnostic reliability and was able to capture all infants with TW-ROP. Telemedicine offers a cost-effective, reliable and accurate screening methodology for identifying infants with TW-ROP without sacrificing quality of care.

Use of digital retinal imaging in screening for retinopathy of prematurity.

The frequency of premature births is increasing world-wide. This factor, combined with improved survival and revised screening criteria, is resulting in an increased workload in screening for retinopathy of prematurity. Digital retinal imaging is emerging as an important alternative tool for diagnosing retinopathy of prematurity, and its use has even been extended to developing countries. Neonatal nurses and technicians can be trained to use digital imaging devices effectively. This is important in areas that do not have ready access to paediatric ophthalmologists. The ability to transfer images electronically makes it a valuable tool in telemedicine, while the ability to store and retrieve images is also advantageous from a medico-legal perspective. Image analysis software can further improve the accuracy of diagnosis. The main limitation of this technology is its high capital cost.

Sixty golden minutes.

The golden hour concept started in the trauma setting but is becoming more familiar in the neonatal intensive care unit (NICU). For a premature baby, the first hour of life can make the difference between a good outcome, a poor outcome, and death. The golden hour is 60 minutes of team-oriented and task-driven protocols. The focus is on resuscitation, thermoregulation, early administration of antibiotics for suspected sepsis, early intravenous parenteral nutrition, hypoglycemia management, and completed admission within one hour of life. To a premature baby, the first 60 minutes of life are golden and can last a lifetime.

The retinopathy of prematurity screening examination: ensuring a safe and efficient examination while minimizing infant discomfort.

Retinopathy of prematurity (ROP) examinations in the NICU are necessary to protect vision in premature infants, but the examinations are associated with risk and discomfort. ROP examination risks include adverse effects from mydriatic agents, systemic responses to the stress of examination, and nosocomial infection. Infant discomfort may be lessened by limiting examination length and possibly by measures such as topical anesthetic, oral sucrose, and certain nonpharmacologic techniques. A well-organized ROP service facilitates appropriate scheduling of examinations and education of the infant's parents. This article addresses causes of risk and infant discomfort, providing a framework for developing a safe and efficient ROP service while minimizing infant discomfort.

Pain management during retinopathy of prematurity eye examinations: a systematic review.

Retinopathy of prematurity (ROP) remains a concern for many preterm infants. Early detection and timely treatment have been shown to be effective in improving visual outcomes; moreover, it is crucial that a series of indirect ophthalmic examinations be performed until an infant is considered no longer at risk for the disease. The purpose of this systematic review is to summarize and evaluate the published evidence regarding characteristics and effectiveness of pain management interventions during the ROP examination. Implications for practice are discussed and suggestions for further research are made. Despite the general consensus that ROP examination is a painful procedure with considerable amount of discomfort, evidence shows that pain management during the ROP examination is inadequate. Although there are currently clear recommendations and guidelines for performing the ROP examination, there are no standard protocols for pharmacological and nonpharmacological pain management during the ROP examination. This is an area where much work is still needed to address the needs of the infant during this critical examination.

[Retinopathy of prematurity]. / Retinopathie bei Frühgeburten.

Retinopathy of prematurity (ROP) is a complex disease of the developing retinal vasculature in premature infants. Clinical manifestations range from mild, usually transient changes of the peripheral retina to severe progressive vasoproliferation, and potentally blinding retinal detachment. With better standards in premature units and with increased survival rate of low gestational age and low birth weight infants the incidence of ROP also increased. The incidence of ROP has been decreasing in developed countries over the past decade, and ROP has become potentially confined to immature neonates with birth weights less than 1000 grams in these countries. Prematurity and retinal immaturity are the major risk factors. Oxygenation, respiratory distress, apnea, bradycardia, hearth disease, infection, hypercarbia, acidosis, anemia, and the need for transfusion are thought by some to be contributory factors. All of the preterm babies with a birth weight under 1500 grams and a gestational age under 32 weeks should be followed for ROP.

Retinopathy of prematurity: an eye toward better outcomes.

Retinopathy of prematurity (ROP) results from the abnormal growth of blood vessels in the vascular bed supporting the developing retina. Estimated to cause up to 500 new cases of blindness in the U.S. each year, ROP affects primarily infants born at less than 1,500 g. Although its etiology is not well understood, ROP is thought to occur as a result of a complex interaction between oxygen and vascular growth factors. This article briefly reviews the history of ROP, discusses its pathophysiology, and addresses the risk factors and strategies for prevention.

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.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 18-month experience with telemedicine screening.

PURPOSE: To report the 18-month experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative. DESIGN: Retrospective analysis of the SUNDROP archival data between 1 December 2005 and 30 May 2007, evaluating this new diagnostic technology for ROP screening. PARTICIPANTS: All 97 consecutively enrolled infants in the SUNDROP network. METHODS: All patients were screened using the RetCam II, and evaluated by the SUNDROP reading center at Stanford University. Nurses were trained to obtain five images in each eye. All patients were screened by an ophthalmologist trained in diagnosing ROP within 1 week of discharge from the hospital. MAIN OUTCOME MEASURES: Outcomes included referral-warranted disease, need for treatment, and anatomic outcomes. Referral-warranted disease was defined as any Early Treatment Retinopathy of Prematurity Disease Type 2 or greater, threshold disease, any plus disease, and any stage 4 or higher disease. RESULTS: In the initial 18-month period, the SUNDROP telemedicine screening initiative has not missed any referral-warranted disease for ROP. A total of 97 infants (194 eyes) were enrolled, resulting in 443 unique examinations and 4,929 unique images. The mean birth weight of the infants was 1,186.9 grams, with a mean gestational age at birth of 28.9 weeks. Seven infants were identified with referral-warranted disease; six patients underwent laser photocoagulation and completely regressed. The one remaining patient regressed spontaneously, and did not require intervention. Calculated sensitivity and specificity was 100% and 98.9% respectively. No patient progressed to retinal detachment or other adverse outcome. Inadequate exposure, artifact, poor visualization of the periphery, and lack of a complete standardized image set in some patients were identified as areas requiring further assessment. CONCLUSIONS: The SUNDROP telemedicine screening initiative for ROP has proven to have a high degree of sensitivity and specificity for identification of referral-warranted disease. Training was easily implemented. All cases of referral-warranted disease were captured. There were no adverse outcomes.

Nursing update on retinopathy of prematurity.

One of the problems that plagues premature infants is retinopathy of prematurity, a potentially blinding disease that occurs because the retina is immature before 34 weeks gestation and must develop in a suboptimal environment when a baby is born early. Prevention by minimizing oxygen exposure has been somewhat effective, but survival of the tiniest babies has led to a recent resurgence in cases. Oxygen targeting and early surgery show promise to reduce the risk of blindness in the smallest premature infants. Nurses play an important role in oxygen management and parental support.

Analgesic effects of oral sucrose and pacifier during eye examinations for retinopathy of prematurity.

Oral sucrose reduces pain during heel sticks and venipunctures in preterm infants, but no studies have been done to determine the effectiveness of sucrose during eye examinations for retinopathy of prematurity. Therefore, the purpose of this study was to determine the effectiveness of local anesthetic eye drops and a pacifier, plus repeated doses of 24% sucrose, to relieve pain associated with eye examinations for retinopathy of prematurity. In this double-blind randomized controlled trial, 30 preterm infants were randomly assigned to one of two treatments, in which they received either local anesthetic eye drops, a pacifier, plus three doses of sterile water or local anesthetic eye drops, a pacifier, plus three doses of 24% sucrose during the eye examination. Treatment effectiveness was determined using a validated infant pain measure, the Premature Infant Pain Profile (PIPP), which includes measures of facial expressions, heart rate, and oxygen saturation and takes behavioral state and gestational age into consideration. Data were collected before, during, and following an examination of the left eye. Statistically significant differences in mean PIPP scores were found between the sucrose and water groups during the left eye examination. The mean PIPP score was 8.8 for the sucrose group and 11.4 for the water group ( t = 2.87, p = .008 two-tailed). No significant differences were found in PIPP scores immediately following the procedure. Sucrose and a pacifier may be beneficial for minimizing pain during eye examinations in preterm infants and should be considered as a part of evidence-based guidelines for relieving pain during this procedure.

Retinopatia del prematuro en el Paraguay / Retinopathy of the premature

Estudio de caracter retrospectivo. Se;ala la necesidad de optimizar los niveles de infraestructura y cuidados de enfermeria para el manejo adecuado del aporte de oxigeno de los pacientes prematuros de bajo peso