Striving for Neonatal Excellence

Nurses know the value of evidence-based practice. Quality care supported by research is essential to all patients, including the very youngest.

At each neonatal intensive care unit across Main Line Health, which is headquartered in Bryn Mawr, Penn., nurses incorporate the latest findings into daily practice. Barbara Mahoney, BSN, MHA, NE-BC, nurse manager, explained, “When we look at any clinical issue, we try and see what research is out there. Where are we compared to other NICUs?”

Staying on top of new clinical discoveries is a hallmark of evidence-based practice. The units rely on several benchmarks, one of which is the Vermont-Oxford Network, a worldwide database of over 1000 NICUs, to find outcome statistics on infants weighing 1500 grams or less.

New Discoveries
NICU nurses at Main Line Health are not just searching for published studies. “We’re trying to increase the number of nurses doing clinical research,” said Mahoney. About 60% of nursing staff are certified in at least one specialty. Maintaining those certifications requires staying up-to-date and even performing unique research.

The health system has a clinical ladder program where nurses must earn certain numbers of continuing education credits and do their own research to move up the ladder and earn different designations. One of the nurse-led NICU research projects looked at respiratory device-related dermal breakdowns. Nurses examined existing literature and also worked with respiratory technicians. The team asked: Did infants need different positioning? Were devices causing the problems?

The multidisciplinary workgroup developed a policy and instituted a practice change. They trialed different skin barriers. Monthly quality improvement meetings looked at the outcomes and education, which therefore increased staff awareness of the new protocol. Following these steps laid out by the research team led to a decrease in dermal breakdowns among the infants.

Another example of evidence-based practice influencing patient outcomes is breastfeeding. Mahoney said, “We’ve been working to promote exclusive breastfeeding among new parents. Providing human milk to infants decreases infection and morbidity.” Breastfeeding symposiums are mandatory for new NICU nurses. The units have moved to a total human breast milk diet for premature infants. To support that goal, they purchase milk from donor banks and increased the number of staff nurses who are certified breast milk counselors, and are therefore better able to assist new mothers. The addition of milk fortifiers supports the immune systems and adds nutrients for preterm babies.

“Safety is a top priority across Main Line Health.” Reducing hospital-acquired infections is a focal point for nurses everywhere. “Caring for central lines is something we continually focus on,” continued Mahoney. As part of this ongoing focus, the staff reviewed the latest evidence-based literature and created a bundle, or a group of practices, that each nurse consistently follows.. At daily NICU meetings to determine patient needs, the question of whether each baby still needs a central line, is asked. The amount of time a central line is used correlates to the risk of an infection.

Close Teams
Collaboration among other neonatal nurses is another avenue for the nurses at Main Line Health to gain knowledge. A vast network of resources is available via conferences and professional organizations. “There is great sharing of information between different hospitals in the greater Philadelphia area. It gives us a really nice network,” Mahoney acknowledged.

It’s not just external knowledge sharing that’s important to quality care. Within the hospital and within the units themselves are fairly close teams. “We have such a strong culture of teamwork in the NICU. The nurses, NPs, physicians, and respiratory therapists have close working relationships.” Weekly interdisciplinary rounds examine where the team can improve. Project groups examine clinical indicators with an interdisciplinary focus.

The Main Line Health NICUs follow an acuity-based staffing model to assure safe patient outcomes. “You have a variable census. You never know how many infants will be critically ill and there must be adequate staff to care for them,” noted Mahoney. A University of Pennsylvania Nursing study examined NICU nurses and their assignments. What was the baby to nurse ratio? Was it 1:1, 2:1, 3:1? Using the results of this study, Main Line Health realized that their staffing ratios were on target.

A robust per diem pool of experienced NICU nurses covers staffing needs. For more immediate needs, there is an internal resource team. The nurse managers can request a resource nurse from central staffing. Mahoney said, “We cross cover so our NICU nurses can work at one of the other NICUs in our system if their home hospital has less needs.”

Ready for Home
Other key players in the NICU team are the parents, who are very much involved in the care process. From the point of admission, the nurses start preparing the parents for when the infants will be discharged. Mahoney explained, “There is a checklist for what they need to do to bring the baby home. We try to prepare them to be independent.”

Parents change diapers, take temperatures, hold, wrap, bathe, and feed their babies. They learn the proper amounts of food the baby should consume. An overnight room lets the parents sleep in the hospital and be present for middle-of-the-night feedings, so they are accustomed to the responsibility. If there are complications, such as the infant needing a feeding tube at home, the nurses train the parents. Support services, like social work and home care nursing, are available too. Mahoney praised, “Our social worker is fantastic. She talks to the parents to see if they need anything.”

Whether it’s staffing ratios, infection prevention, or feeding protocols, NICU nurses rely on both their own experiences and evidence-based research to create safe environments for the tiniest patients.

Danielle Bullen is on staff at ADVANCE. Contact: [email protected].