Neonates PDF

Klein, L.
I N N O VAT I V E P R O G R A M S
Proceedings of the 2012 AWHONN Convention
A Pilot Project to Improve Neonatal Peripheral Intravenous Site Assessment and Documentation
Newborn Care
Purpose for the Program here is currently no consistent protocol described in the literature for documentation of the nursing assessment of neonatal peripheral intravenous sites. Most authors concur that hourly assessments are the minimum frequency and indicate what the assessment parameters should be; however, they do not discuss a protocol for documentation of the assessments. Multiple authors and professional nursing groups have identied that problems exist in the care of peripheral intravenous sites in neonates. This project attempted to determine if nurses in a neonatal intensive care unit (NICU) could conduct and document an hourly evidence-based focused assessment of neonatal peripheral intravenous sites.
Lisa Klein, MSN, RNC-OB, RNC-LRN, CNS, Marymount University, Reston, VA Keywords neonatal nursing peripheral intravenous assessment documentation
in neonates. This project introduced a documentation form that includes the ve evidence-based parameters to indicate the status of the peripheral intravenous sites. It attempted to determine if an instrument on which to document the assessment was relevant to the practice of the NICU nurses providing care. The project also determined the time needed to perform and document the peripheral intravenous site assessment and if that time was considered reasonable by the NICU nurses providing care. Implementation, Outcomes, and Evaluation The documentation form was piloted in a large suburban NICU. The short-term goal of this pilot project was to determine if the instrument on which to document the assessment and the time to perform and document it was deemed reasonable by the nurses providing care. The nurses are still participating in the pilot project. Early data suggest that the tool may be helpful but nurses are unsure if all of the parameters are necessary for an adequate assessment. Implications for Nursing Practice It is hoped that this project will stimulate further study of the individual assessment parameters to determine if any or all of them in a tool format are valid and reliable in predicting inltrations and extravasations, which would be useful in improving patient outcomes.
Paper Presentation
An additional purpose of the project was to obtain input from direct care nurses before initiating a change in practice. Critical care nurses perform multiple hourly assessments and care interventions on each patient. Additional documentation of ve measurement parameters may not be realistic to add to the workload of the direct care nurse. By having the nurses who participated in data collection provide feedback regarding the complexity or simplicity of the instrument, they were able to evaluate the potential value of the process and the instrument to their care. Proposed Change Many NICUs use a system of charting by exception for assessment of peripheral intravenous sites
The Great Pretenders: Utilizing Evidence-Based Practice to Optimize Clinical Outcomes for the Late Preterm Infant
Jaimi S. Hall, MSN, RNC-OB, Peninsula Regional Medical Center, Salisbury, MD Angela T. Houck, DNPc, RNC-nic, RN-BC, Peninsula Regional Medical Center, Salisbury, MD Keywords late preterm infant evidence-based practice
Newborn Care Paper Presentation
Purpose for the Program he late preterm infant faces many challenges associated with prematurity. In 2010, 99 late preterm infants (approximately 5% of the total birth volume) were born at Peninsula Regional Medical Center. Nearly 29% of these infants were admitted to the neonatal intensive care unit (NICU), and 12.8% were readmitted to the pediatric unit for complications associated with prematurity. The purpose of this program was to determine if adopting an evidence-based model of care utilizing the Association of Womens Health, Obstetric and Neonatal Nurses Assessment and Care of the Late Preterm Infant Guideline will improve clinical
outcomes and reduce late preterm infant neonatal intensive care unit admissions and readmissions to the pediatric unit. Proposed Change To adopt, institute, and practice Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) clinical guidelines for every infant born between 34.0 and 36.6 weeks of gestation at Peninsula Regional Medical Center. Implementation, Outcomes, and Evaluation Data collection took place over a 6-month period to determine baseline rates of hypothermia,
JOGNN 2012; Vol. 41, Supplement 1
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hypoglycemia, respiratory distress, feeding difculties, phototherapy, excessive weight loss, neonatal intensive care unit admissions, and readmissions to the pediatric unit. A multidisciplinary team developed the late preterm infant initiative utilizing AWHONNs clinical guidelines. Components of the initiative included policy and order set development, predelivery and predischarge education, and individualized feeding plans. Beginning March 22, 2011, all late preterm infants were admitted to the intermediate care nursery and cared for with a nurse-to-patient ratio of 1:3 to 4. All aspects of the clinical guidelines were utilized based on the individual needs of the infant. Data collection on these infants began May 1, 2011. To date, 31 late preterm infants have been cared for under the new initiative. Eight of these infants were subsequently admitted to the neonatal intensive care unit (25.8%), and no infants were readmitted to the pediatric unit. The overall goal is to improve clinical outcomes while reducing admissions to the neonatal intensive care unit by 10%
and readmissions to the pediatric unit by 5%, as compared with the 2010 rates. Implications for Nursing Practice As the primary bedside caregiver, nurses are extremely vested in their patients outcomes. This initiative has led to an increased staff awareness of this population, their unique needs, and the challenges they face. This knowledge, coupled with the utilization of evidence-based care, translates into improved clinical outcomes for the late preterm infant. This initiative also has improved teamwork and communication and has fostered relationships between nurses and other health professionals. Family-centered care is at the core of obstetric nursing as well as this initiative. Providing care that enhances family bonding, empowers parents, and improves clinical outcomes increases patient and nurse satisfaction. In this era of rising health care costs and nonreimbursement for preventable readmissions, it behooves nurses to adopt practices that anticipate and prevent possible sequelae related to late prematurity.
Tackling Newborn Hypoglycemia in the Delivery Room: Utilizing Colostrum, Skin to Skin and State of the Art Policies
Purpose for the Program ewborn hypoglycemia in the delivery room is a widespread challenge. Most often infants who are breastfed and are temporarily separated from their mothers receive formula as a quick x to increase blood glucose levels. This approach not only decreases breastfeeding success, but it also exposes the newborn to unstable levels of glucose because of the formulas stimulation of insulin production. Too many infants who are breastfed receive excessive amounts of formula within the rst hour of life because their glucose values are checked before feeding, as soon as 15 to 30 minutes after birth. After witnessing a 40-minute-old newborn receive 40 ml of formula for a glucose level of 40, then promptly vomit, gag, and turn dusky, I decided it was time to act on my concerns that something was out of balance regarding the blood sugar/feeding issue.
edge, coupled with my nursing experience, prepared me well for presenting my ideas to the administration. I also proposed that we establish ways to give colostrum to babies who were not ready to latch effectively. I wanted to rewrite the existing breastfeeding policy, have nurses adhere more vigilantly to our skin-to-skin policy, write a policy on prebirth hand expression of colostrum, and be a driving force to change many of the parameters of the newborn hypoglycemia algorithm.
Pamela Kinney Tozier, BSN, RNC, CCE, IBCLC, Maine Medical Center, Portland, ME Keywords hypoglycemia diabetics hand expression colostrums skin-to-skin
Proposed Change To attain stable glucose levels in babies who are breastfed by giving infants drops of colostrum, feeding them before labs are checked, and keeping them in continuous skin-to-skin contact. I had recently become an international board certied lactation consultant, and that new level of knowl-
Implementation, Outcomes, and Evaluation We have successfully implemented a new hypoglycemia algorithm that accepts lower glucose values initially, has the newborn feed rst, and then the rst glucose level checked by 90 minutes of age. We have implemented widespread hand expression of colostrum, before and after childbirth, for all of our diabetic patients who are breastfeeding, and we have maintained continuous skin-to-skin contact as a norm. The outcomes to date have been a decrease in separation of the mother and baby, higher newborn glucose levels, higher patient satisfaction, and better success of breastfeeding.
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JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
http://jognn.awhonn.org
Lawson, T.
Implications for Nursing Practice Labor and delivery nurses are the rst line of defense in helping stabilize newborn glucose lev-
els without the introduction of formula, thereby upholding the standard of best practice. It is possible for just one nurse with a vision to apply evidencebased practice to achieve quality outcomes.
Premature Infant Nutrition Clinic

Terry Lawson, RN, IBCLC, University of California San Diego Medical Center, San Diego, CA Keywords human milk premature infant nutrition lactation consultant
Purpose for the Program he benets of human breast milk for term infants outweigh formula. Breast milk is an even greater benet to the preterm infant because it provides infection prevention and promotes improved neurodevelopment. In 2006, the University of California San Diego Medical Center was designated as Baby Friendly. The Supporting Premature Infant Nutrition program was launched in 2007. The goal was to improve the growth and nutrition of preterm infants. It was noted that following hospital discharge, most mothers were not successfully breastfeeding their premature infants. These infants continued to require fortiers, but we did not know how much or for how long. Mothers continued to need to pump, but supply was decreasing. Both parents were exhausted and overwhelmed.
one-time only to several visits 1 to 3 weeks apart. A follow-up letter is sent to the primary provider with appointment highlights and recommendations. Implementation, Outcomes, and Evaluation It was noted during the rst year, 97 patients/183 visits occurred; the second year, 83 new patients; and the third year, 130 new patients/637 visits occurred. During the 3 years, the gestational age breakdown included the following: 46 newborns less than 30 weeks of gestation, 90 newborns 30 to 33 6/7 weeks of gestation, 104 newborns 34 to 33 6/7 weeks of gestation, and 40 newborns greater than 37 weeks of gestation. Multiples data included 215 singletons, 83 sets of twins, and 12 sets of triplets. Currently, the team sees 7 to 8 patients in a 4-hour session, 1 day a week. There is a need to expand to 2 days to manage the increase in consultations. Outcomes have improved, such as increased breast milk for longer duration of time, more breastfeeding, decreased/no breast pumping, and increased exclusive breastfeeding. Implications for Nursing Practice Assuring best practice and performing research is exemplied by the projects in progress, including a Premature Infant Nutrition Clinic Quality Assurance project, research of liquid fortication of the mothers milk at discharge, and an international multicenter validation of a preterm growth chart. Both providers and nurses are involved in every aspect leading to increased patient and staff satisfaction.
Proposed Change In August 2008, the Premature Infant Nutrition Clinic was established by a pediatrician and registered nurse. Utilizing a team approach, visits included infants growth and development assessments and discussions of the mothers concerns. After the assessment and discussion, the registered nurse performs a lactation consult and assesses the infant feeding, looking for ways to improve milk transfer, increase milk supply, and increase breastfeeding and decrease breast pumping. At the end of the 45- to 60-minute session, a plan is developed to help the mother reach the desired goal. Visits are individualized, ranging from
Implementing Practice Protocols and Education to Improve the Care of Infants with Neonatal Abstinence Syndrome
Katherine Y. Lucas, DNP, APRN, NNP-BC, Cape Fear Valley Health System, Fayetteville, NC
Purpose of the Program he National Council on Alcoholism and Drug Dependency estimates that between 1% and 11% of babies born each year are exposed to illicit substances in utero. The American Academy of Pediatrics reported that 50% to 95% of infants exposed to opioids or opioid derivatives, including heroin and methadone, develop neonatal abstinence syndrome (NAS). Research that is more recent describes an increasing incidence of infants
exposed to harmful substances prior to birth. Babies exposed to opioids or opioid derivatives during pregnancy are at increased risk of developing NAS. Optimal treatment of this NAS population is hampered by the current lack of evidence-based standardized guidelines and protocols for pharmacologic management and care that promote improved outcomes for NAS patients. Care and management of these infants can be improved with practice guidelines and education.
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Proposed Change To develop and implement evidence-based clinical practice guidelines and an educational program on NAS and the Finnegan Neonatal Abstinence Scoring Tool (FNAST), to improve nursing assessment and care of the NAS infant, and improve scoring accuracy with use of the FNAST. Implementation, Outcomes, and Evaluation This study was a nonexperimental, pretest/ posttest study that evaluated change in nursing knowledge about NAS and use of the FNAST after the implementation of a quality improvement, educational project. Nurses were tested before and after participation in education about NAS. A subset of 10 nurses was evaluated using the FNAST with video of infants having NAS. Volunteer participation in the NAS educational project occurred in 81% of the neonatal intensive care unit nurses. All nurses showed some improvement in scores
on the posttest, with 2% to 44% improvement. All 10 nurses who participated in the interactive video test scored 90% or higher against the FNAST criterion 1 week after participation in the educational project. Implications for Nursing Practice Evidenced-based clinical practice guidelines and education on NAS and the FNAST equip caregivers with the necessary tools to consistently and accurately assess an infant with NAS when using the FNAST. Recent research shows that providing education to nurses can result in knowledge gained, improved professional practice, and improved patient treatment goals. Education also can equip nurses with the necessary knowledge to care for patients with complex medical problems like NAS. Further, providing nurses with specic information about a medical problem is correlated with improved adherence to best practice.
Keywords NICU FNAST education
Perinatal Palliative Care: Support of Mothers, Infants and Families

Purpose for the Program o support mothers, infants, and families through the Perinatal Palliative Care program. Proposed Change To enhance the existing bereavement program to include infants with low viability or no viability through palliative care. Implementation, Outcomes, and Evaluation Implementation is in process and awaiting nal approval of pertinent policies and procedures to
support this program. The evaluation will be based upon a patient satisfaction survey taken by telephone follow-up of patients discharged from the hospital.
J. Frances Fusco, MHS, BSN, RN, University Community Hospital, Tampa, FL Theresa Bish, RN, IBCLC, University Community Hospital, Tampa, FL
Implications for Nursing Practice Provide care and support to both infants and mothKeywords ers going through this experience. perinatal palliative care
infant advanced directives
Newborn Care Poster Presentation
Neonatal Head Trauma: Implementation of a Care Algorithm to Improve Safety

Purpose for the Program o create a process by which newborns with head trauma or at risk of complications of neonatal head trauma are identied, assessed, and monitored differently with the goal of improving safety.
Sandra Hoffman, MS, RN, Proposed Change To create and implement a neonatal head trauma CNS-BC, Abbott Northwestern algorithm that is part of the newborn standing or- Hospital, Minneapolis, MN ders across a large multihospital health system to ensure that newborns who are at risk of head trauma or who have head trauma, are evaluated more closely to ensure their safety.
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JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Braithwaite, P., Donahue, N. and Bayne, L. E.
Keywords neonatal head trauma vacuum extraction forceps delivery subgaleal hemorrhage
Implementation, Outcomes, and Evaluation Neonatal head trauma can result in catastrophic outcomes, and it is essential that infants at risk of complications of a difcult or instrumented delivery are identied and monitored more closely. Complications, such as subgaleal hemorrhages may manifest at birth or may occur over many hours, so identication of infants at risk and increased vigilance is important for patient safety. After a review of the literature, a multidisciplinary team of neonatal and birthing clinical nurse specialists, pediatricians, a neonatologist, and a neonatal nurse practitioner created a neonatal head trauma algorithm to become part of the newborn standing orders. Staff and physician education was done regarding neonatal head trauma,
and the neonatal head trauma algorithm was implemented across a large multihospital health system. The evaluation of this change is ongoing.
Implications for Nursing Practice Nurses caring for newborns are in a key position to identify complications of neonatal head trauma that may result from the birthing process. A standardized approach can ensure the identication and closer monitoring of infants who may have an injury that may not manifest for many hours after delivery. Education about neonatal head trauma increases awareness of the risks, promotes appropriate pain management, and helps to keep newborns safe.
Help! Im Cold! Improving the Warmth of Our Newborns

Purpose for the Program ozy Cuties is a multidisciplinary performance improvement team convened to address hypothermia from birth to admission to the neonaNicole Donahue, BSN, MSN, RNC, Christiana Care, tal intensive care unit among inborn preterm inMiddletown, DE fants at less than 31 weeks gestational age. ReLynn E. Bayne, PhD, NNP-BC, view of facility data over the past 5 years showed that the initial admission temperatures of these RN, Christiana Care Health System, Newark, DE infants were signicantly lower than average in our neonatal intensive care unit (NICU) than the Keywords benchmark of 850 NICUs within the Vermont Oxpreterm ford Network. Across this time period, 61% of the hypothermia shbone diagram infants who were less than 31 weeks gestational root-cause analysis age had body temperatures less than 36 C at admorbidity mission and were classied as hypothermic using mortality the World Health Organization denition. Two large polyethylene studies of infants from 23 weeks to 30 completed weeks of gestation, suggested that when infants are admitted to the NICU with hypothermia, their Newborn Care chances of survival decrease by approximately Poster Presentation 10% for every degree below 36 C, independent of any disease conditions. In addition, late onset sepsis is increased by 11% and odds of death are increased by 28%.
Pamela Braithwaite, BSN, RNC, Christiana Care Health System, Bear, DE
mal intervention bundle was developed and implemented. The bundle included a timeout-style thermal checklist, increased room temperature, proper radiant warmer preheat and use, shortened infant time at point of delivery for both vaginal birth and cesarean birth, change in transfer technique of newborn to a warmer from point of delivery, effective use of polyethylene wrap, attention to application of pulse oximetry, warming of surfactant, and warming of caregiver hands. Aggressive clinical staff education in labor and delivery and NICU was conducted using a variety of methods, including video and social media. Post-implementation, infants who were less than 31 weeks gestational age were prospectively followed and the incidence of the outcome variables was collected. Implementation, Outcomes, and Evaluation Data were analyzed, and ndings showed that our admission hypothermia rates have been reduced from 61% over the past 5 years to approximately 18% over the past 6 months. Ongoing monitoring for sustained improvement is now in place. Implications for Nursing Practice A multidisciplinary team can be an extremely effective agent of change. It is important to bring key stakeholders in a project to realize gains. Clinicians are obligated to benchmark practices that may contribute silently to patient illness. Body temperature should never be taken for granted. The goal should always be to keep a warm infant warm, not to rewarm a cold infant.
Proposed Change Root cause analysis using sh bone techniques was conducted on the rst ve cases of admission of hypothermia for each calendar month over the 12-month period prior to project inception. Literature was reviewed to establish potential causes. A facility tour determined how many potential causes existed and coupled the potential cause with evidence-based interventions. A ther-
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Welcome Aboard and Homeward Bound: The NICU Familys Journey for a Safe Voyage to Discharge
Purpose for the Program mprove parent and staff satisfaction with the discharge process and complex follow-up care for the very premature or sick infant. Involve parents in the plan of care, the daily care of their infants, and their personal preferences early on.
Implementation, Outcomes, and Evaluation Implementation using Plan-Do-Study-Act cycles, staff and patient satisfaction, as well as chart audits were used for measurement and feedback.
Geraldine Tamborelli, MS, RN, Maine Medical Center, Portland, ME
Proposed Change To standardize teaching, timing of education, documentation, and communication of education to better prepare parents for discharge.
Keywords discharge Implications for Nursing Practice satisfaction The best practice was identied and we continue best practice to maintain the gains by evaluating satisfaction education family centered care levels and random chart audits. multidisciplinary
Birthways Lactation Services: A Model for Breastfeeding Support

Purpose for the Program he purpose of the Birthways Lactation Services program is twofold. We want to increase breastfeeding initiation and duration rates and thereby improve long-term health for every infant. We also want to increase the lactation consultants productivity while decreasing full time equivalents and cost. Most lactation programs have lost state funding in recent years and are now funded by hard-to-nd grants, or as in our hospitals case, by community benet dollars.
Proposed Change For 10 years, our program was set up to provide home visits to our clients (within a 50 mile radius) who either chose to have a visit or when a visit was physician ordered. Eight years ago, it was determined this was a costly way to deliver care even with funds provided by a grant and some insurance reimbursement. At that time we started the clinic model and were encouraged by the positive results. Our lactation consultants cross-train to the discharge planning position of the Birthways Lactation Services program where they round with the pediatricians, schedule the clinic visits at discharge, and provide a discharge feeding plan for babies with feeding problems. Implementation, Outcomes, and Evaluation Three to ve times per day, the coordinator of the lactation program and her team perform checks
that include weight, jaundice, and lactation evaluation. We believe our outcomes reect the success of the program. Our breastfeeding initiation rate is 87.6% as compared with the states 73.9%. Our 6-month breastfeeding rate is 79.3% (one of the best in the state) as compared with the national rate of 17%. We are ahead of the Healthy People 2020 goals of an 81.9% initiation of breastfeeding and a 6-month breastfeeding duration of 60.6%. Our home visit model took 3.1 full time equivalents, and our clinic model takes 1.2 full time equivalents, which represents a savings of more than $140,000 in salaries and mileage reimbursement. Our lactation consultants can see ve more infants per day or 25 more per week, which makes it possible to provide second visits for those clients who need them. Implications for Nursing Practice The advantages of breastfeeding are well researched and well documented. We believe our program model is the best practice and is leading the way in breastfeeding promotion and support of the American Academy of Pediatrics Policy Statement and the U.S. Surgeon Generals Call to Action to Support Breastfeeding. Our service model decreases hospital readmission rates and promotes exclusive breastfeeding with increased productivity and decreased cost.
Angela Carswell, RN, IBCLC, Mary Greeley Medical Center, Ames, IA Keywords lactation program exceeding national and state breastfeeding rates
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JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Keller, A. and Brenneman, A.
Operation Kangaroo Care

Purpose for the Program angaroo care is recommended in the Guidelines for Perinatal Care for stable newborns. Alicia Brenneman, BSN, RNC, The act of placing the infant skin-to-skin (also Grant Medical Center OhioHealth, Columbus, OH called Kangaroo care) with the mother has been shown to maintain skin temperature regulation Keywords of the newborn, increase initiation of successful Kangaroo Care breastfeeding, and ease the transition for intrautercesarean birth ine to extrauterine life. The practice of Kangaroo care has been well adopted in our setting. During 2010, 75% of all mothers who gave birth vaginally Newborn Care participated in skin-to-skin care. The staff started Poster Presentation to initiate Kangaroo care in the postanesthesia care unit to provide all the benets to the mothers who had cesarean births.
Anne Keller, MS, RNC, CNP, OhioHealth, Columbus, OH
The process before leaving the operating room is to now initiate skin-to-skin with the infant (who is dressed only with a diaper and hat) and apply warm blankets against the back of the infant while leaving its chest exposed. Implementation, Outcomes, and Evaluation The implementation was started by staff nurses who considered the evidence-based practice of Kangaroo care to be best for the newborn. Staff began by placing the infant skin-to-skin after moving the mother from the operating room table to a hospital bed. Both are transported to the postanesthesia care unit, initial checks are preformed, and a baseline set of vitals is obtained on the infant. The mother-infant pair is left skinto-skin for the next 60 to 90 minutes. Outcomes have been measured by patient satisfaction and stable infant temperatures during the time frame. Patients report they would initiate Kangaroo care with their next birth. Implications for Nursing Practice Empowering nurses to change practice to overcome traditional barriers of medical care to promote the empowerment of motherhood.
Proposed Change Before the initiation of skin-to-skin in the postanesthesia care unit, infants had been removed from the warmer after being wrapped with warm blankets and a hat and given to the mother to hold or breastfeed. This process was not satisfying to the staff. The staff stated that if the vaginal birth infant could benet from skin-to-skin, then we should adopt the practice with the cesarean birth infant.
Infant Feeding Plan: An Innovative Documentation Tool to Improve Communication between Caregivers and Families
Jennifer Peterman, RN, BSN, IBCLC, Hospital of the University of Pennsylvania, Philadelphia, PA Keywords breastfeeding infant feeding plan patientfamily centered care
Purpose for the Program lack of communication was identied surrounding a mothers feeding decision and multiple health care providers. This lack of communication resulted in a mothers perceived lack of respect by providers regarding her preference for newborn feeding. To address this issue, an innovative, crib side, infant feeding plan documentation tool was created to identify a mothers preference for feeding her newborn from birth through discharge. Providers also noted a large variation between provider practices related to newborn feeding and maternal preference.
document. The development of the individualized plan began at maternal admission, with the use of a scripted narrative, to discuss maternal newborn feeding preferences. Once feeding preferences were identied, a mutually agreed upon feeding plan was created and signed by both the mother and the nurse. Throughout the infants stay, the plan was located at the infants crib. If any changes to the feeding plan were needed, both the nurse and mother discussed, updated, and signed the revised feeding plan. Outcomes and evaluation are ongoing Prior to the implementation of the feeding plan, breastfeeding rates were 68% and during the year postimplementation, breastfeeding rates have continued to increase to 74%. Anecdotally, patients report feeling that their infant feeding choices are respected and that the use of this plan prompts infant feeding discussions. Providers commented that the plan is convenient and useful in practice, and the Joint Commission recognized it as a best practice model of care.
Proposed Change To improve communication between providers and mothers, a crib side infant feeding plan documentation tool was implemented. Implementation, Outcomes, and Evaluation Prior to implementation, representatives from each provider group involved in newborn care collaborated on the creation of the infant feeding plan
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Implications for Nursing Practice This initiative provided an opportunity for nursing to re-energize their commitments to patient communication and infant feeding, especially breastfeeding. Patientfamily centered care is based on respect and honest communication between providers and families. This tool gave nurses an opportunity to dialogue with the infants mothers
regarding feeding options and changes in infant feeding as needed. At admission, nurses were able to review with the family the evidence associated with optimal infant feeding. Also, the tool served as a contract between the mother and the providers to ensure that the mothers feeding preference plan was implemented. The tool also served as an easy way to communicate to any provider caring for the infant.
A Baby Weigh Station: Continuum of Care for Late Preterm Breastfeeding Infants
Purpose for the Program ate preterm infants who breastfeed are the largest segment of preterm infants. In Columbus, Ohio, the incidence of late preterm infants who breastfed was 9.1% of live births (in 2008) and the rate at our hospital was 7.7% (of 6,456 births/year in 2010). Late preterm infants often appear to be able to breastfeed successfully during hospitalization, (hence, their nickname the great imposter), but this may not be sustained following discharge. As 1 of 15 sites for the Association of Womens Health, Obstetric and Neonatal Nurses 2010 Late Preterm Infant EvidenceBased Practice Guidelines research study, commitment occurred in this hospitals outpatient setting to measure and improve post-discharge care of late preterm infants who breastfed.
Proposed Change To ensure a successful continuum of care for the postdischarge late preterm infant via a community resource where 90% of late preterm infants will gain weight after events of lactation consultation and rst weight measurement. Implementation, Outcomes, and Evaluation Utilize a baby weigh station within a user-friendly lactation support center to offer a community accessible onsite, free service, monitored by ap-
proachable staff and expert professionals. Identify late preterm infants who return for repeat weight measurement, track weight gain, and generate monthly progress reports. To estimate the total number of late preterm infants who were consulted and weighed on more than one visit, the following formula was used: Numerator number of late preterm infants who gain weight of more than 0.5 ounces at more than 5 days of age and thereafter; Denominator total number of late preterm infants consulted/weighed. Over 12 months, 151 individual late preterm infant weights were measured: 116 had repeated weights and 99% demonstrated weight gain (monthly averages). Additional benets included referrals to lactation, pediatrics, pediatric surgery, and behavioral services. An accessible weigh station was evaluated to be an effective pathway to ongoing care and support for late preterm infants. Late preterm infants gained weight appropriately and their mothers reported sustained breastfeeding. Implications for Nursing Practice Accessible community service, monitored by approachable staff and expert professionals is an effective means to continue and grow client relationships. Monitor at-risk groups for anticipated problems and provide a portal for continuing care.
Kathleen H. Bright, BSN, RNC, IBCLC, Doctors Hospital-Ohiohealth, Columbus, OH Joyce Sheppard, RN, IBCLC, Womens Health Services, Riverside Methodist Hospital, Columbus, OH Whitney Lenger Mirvis, BSN, RN, IBCLC, Riverside Methodist Hospital, Columbus, OH Jane Lamp, MS, RN-BC, CNS, Riverside Methodist Hospital, Columbus, OH Keywords late preterm breastfeeding weigh
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JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O.
Increasing Exclusive Breast Milk Feeding Rates at an Urban Academic Hospital

Laurie Dohnalek, RN, MBA, Purpose for the Program NE-BC, Georgetown University o increase exclusive breast milk feeding rates Hospital, Washington, DC Cynthia Heer, RNC-OB, RN-BC, MSN, Georgetown University Hospital, Washington, DC
at an urban academic hospital.
r r
Elizabeth Starrels, RN, BSN, IBCLC, Georgetown University Implementation, Outcomes, and Evaluation Hospital, Washington, DC Carol A. Ryan, MSN, RN, IBCLC, FILCA, Georgetown University Hospital, Washington, DC Margaret Howland, RN, BSN, RNCOB, Georgetown University Hospital, Washington, DC, DC Lauren O. Wurster, RN, MSN, Georgetown University Hospital, Washington, DC Keywords exclusive breastfeeding exclusive breast milk feeding breastfeeding rates Joint Commission perinatal core measure
Proposed Change Over an 18-month period interventions were implemented to increase exclusive breast milk feeding rates by at least 10%.
cussion of obstacles to exclusive breast milk feeding Feeding care plans (for complicated situations) developed collaboratively with nurses and international board certied lactation consultants Implementation of mother and newborn quiet time
To implement this program, the following interventions were completed:
r r r r r r r r r r
Creation and implementation of Donor Pasteurized Milk Policy; all nurses attended mandatory education session Implementation of 24-hour rooming in (no separation of mothers and newborns via standard nursery) Survey given to patients to identify the most popular reasons for supplementation Journal clubs discussing breastfeeding issues Consultations with lactation consultants at other facilities Increasing rates and duration of initial skin-toskin contact and rst breastfeeding session Daily patient rounds and assessments by international board certied lactation consultant Mandatory interdisciplinary breastfeeding education for all nurses, obstetricians, and pediatricians Education related to alternative breast milk feeding methods Outside speaker (international board certied lactation consultant) that moderated dis-
These interventions were implemented and the result was an increase in the staffs knowledge and skills, thus changing practice and creating condence. The outcome was that our exclusive breast milk feeding rates increased. A data collection tool was created to monitor and track exclusive breast milk feeding rates. We also are utilizing a patientbased survey to evaluate the effectiveness of the interventions. Implications for Nursing Practice Education is a major aspect of our initiative to increase exclusive breast milk feeding rates. The low incidence of exclusive breastfeeding is partially due to a lack of breastfeeding knowledge among health care professionals. Educational programs that increase nurses knowledge and improve attitudes toward breastfeeding promote accurate and reliable delivery of breastfeeding information and skills to the mothers. These programs also encourage positive role modeling of supportive breastfeeding attitudes. This may improve exclusive breast milk feeding rates because of the effect that this has on patients. Many of the interventions included in our program are directly aimed at increasing breastfeeding knowledge of our staff and patients.
Exclusive Breastfeeding: It Takes Our Village

Julie Delcasino, RNC-MNN, BSN, Presbyterian Healthcare, Charlotte, NC Diane Slough, RN, BSN, IBCLC, Presbyterian Hospital, Charlotte, NC Keywords exclusive breastfeeding
Purpose for the Program xclusive breastfeeding is best for the infant and mother. Evidence-based practice describes this choice, but who can say their hospital truly promotes exclusive breastfeeding? We are a 600-bed hospital with more than 7,000 births/year. It takes our village to educate the mother, family, and staff within womens services. It is the responsibility of us all to help mothers be successful and promote the recommendations of the Association of Womens Health, Obstetric and Neonatal Nurses, World Health Organization, American Academy of Pediatrics, American College of Ob-
stetricians and Gynecologists, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and the Joint Commission for exclusive breastfeeding. Proposed Change We want to provide best patient care. In May 2010, our exclusive breastfeeding rate was 37%. We realized our shortfall and discussed ways to improve our rate. Within our shared governance structure, we have a unit research council. The topic of change regarding exclusive breastfeeding, hospital supplementation, and education for
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staff was our new project. Our council consists of staff nurses from the departments of motherbaby and gynecology. The nurse educator and lactation consultant are also committee members. We began with a literature search. How do you treat a baby with low blood sugar but still exclusively breastfeed? What do you do when a mother is medically unable to breastfeed after birth? What about mothers who want to sleep all night and request that staff bottle feed their infants? What about the obstetrician or pediatrician who tells the mother, You need your sleep at night. A little formula never hurt. What about labor and delivery nurses who say, Breastfeeding is not our job, its the lactation consultants job. Extensive education was needed for womens services staff, physicians, parents, and families. Implementation, Outcomes and Evaluation The nurse educator and lactation consultant developed an education program for all womens services staff. The major health care organizations that recommended exclusive breastfeeding were
cited. Articles from the literature search were presented. Benets of breastfeeding for the mother, infant, and community were discussed. Many examples of hospital practices that decrease success of exclusive breastfeeding were recalled. Skin-to-skin care and rooming in were discussed. In North Carolina, we have the Perinatal Quality Collaborative of North Carolina for exclusive breastfeeding. The Perinatal Quality Collaborative of North Carolinas well-baby track focuses on supporting mothers choice to provide exclusive breastfeeding for their term infants. We became an active member of the Perinatal Quality Collaborative of North Carolina project for exclusive breastfeeding. Implications for Nursing Practice We want to provide the best practice and the literature supports exclusive breastfeeding. As obstetric nurses, we have power to educate and support mothers and families to make informed decisions about their individual infants care.
Now I Lay Me Back to Sleep . . . .Safely

Purpose for the Program ne of the Healthy People 2020 goals is to improve the health and well being of women, infants, children, and families. One way to accomplish this goal is by reducing the rate of fetal and infant deaths. In Virginia, from 2003 to 2007, there were approximately 78 infant deaths/year due to sudden infant death syndrome (SIDS). This rate is greater than the national average. It has been proven that supine sleeping is the greatest factor in reducing the risk of SIDS even though many nurses still feel more comfortable placing the baby prone. Hospital nurses are the rst professional role models for new parents. Modeling suggested behaviors, such as back sleeping, can be a powerful education tool as well as parental education through verbal and written educational materials.
Implementation, Outcomes, and Evaluation The safe sleep task force was initiated and a hospital policy on safe sleep was written. The staff received mandatory in-services regarding SIDS to ensure consistency in parental education. One inservice was on SIDS and SIDS risks in the term newborn and the other addressed the needs of the premature infant. Safe sleep education was added to the March of Dimes notebook, which all parents of infants admitted to the neonatal critical care center receive. This is reviewed with the parents prior to discharge. An education record is signed at discharge acknowledging that the information was reviewed. After discharge the charts are retrospectively audited for safe sleep education and supine positioning at least 24 hours prior to discharge.
Courtnie J. Burrell, RNC, Henrico Doctors Hospital, Richmond, VA Diane Stairs, RN, Henrico Doctors Hospital, Richmond, VA Keywords SIDS safe sleep model
Proposed Change Infants are no longer able to have stuffed animals or extra blankets in the incubator or crib. Once the infant is transitioned to an open crib, the infant should be placed in a supine position unless a physicians order indicates otherwise. Nurses are to model safe sleep positioning at least 24 hours prior to discharge and provide parental education on SIDS and SIDS risk reduction. SIDS education is also offered at infant cardiopulmonary resuscitation classes.
Implications for Nursing Practice The expectation is to provide consistent safe sleep education to the parents and to model safe sleep positioning. Data collected will be used to validate success of the program and to encourage the staff continued participation and support. Integrating evidence-based ndings into practice will facilitate further involvement into addressing the higher incidence of sudden infant death syndrome in the African American population.
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Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O.
Implementing Skin-to-Skin Care in a Baby-Friendly Community Hospital

Jennifer L. Reeg, MSN, RNC, Health First Cape Canaveral Hospital, Cocoa Beach, FL Tracy Lott, RNC, BSN, MS, Health First Cape Canaveral Hospital, Cocoa Beach, FL Keywords breastfeeding skin-to-skin care kangaroo care newborn
Purpose for the Program o improve motherinfant attachment and breastfeeding.
Proposed Change To implement skin-to-skin care in a baby friendly community hospital. Implementation, Outcomes, and Evaluation Health First, Inc. Cape Canaveral Hospital, a Baby-Friendly facility since June 2000, launched a skin-to-skin initiative in 2009. An evidence-based practice protocol for placing newborns skin-toskin at birth and in the immediate postpartum period was incorporated into our labor, delivery, recovery, and postpartum (LDRP) unit, and encouraged during the entirety of the postpartum stay. Staff nurses were educated in appropriate skin-toskin techniques and patient instruction, rst in a small group interactive setting and later followed with a video and discussion format. Patient education pamphlets were distributed to women in labor and Kangaroo care shirts were loaned to new mothers during their hospital stay. Families were encouraged to attempt to keep their newborn skin-to-skin for up to 6 hours a day for the rst week of life and a minimum of 2 hours a day for the second week through fourth week. Mothers were assured that anyone, e.g., fathers and grandmothers, can engage in the skin-to-skin care with the infant. Studies have reported benets of skin-toskin care of the newborn to include reduced crying, improved motherinfant interaction, warmer babies, and greater breastfeeding success. Ad-
ditional positive effects on neonatal self-regulation during the transition from intrauterine to extrauterine life include increased sleep, decreased apnea and bradycardia, improved respiration and oxygen saturation, accelerated weight gain, and, for the mother, increased milk production. The staff at Cape Canaveral Hospital has observed anecdotal evidence of these benets. The nursing and lactation staff at Cape Canaveral Hospital strive to achieve skin-to-skin care with every new motherbaby couplet, making allowance for individual circumstances and infant condition. A chart audit was conducted from 2010 to 2011 for evidence of skin-to-skin care attempted and encouraged immediately after birth and within the rst hour of life, and of documentation of mother education on benets of skin-to-skin care. Results show a 90% success rate, indicative of a positive trend in the number of motherbaby couplets opting for this practice and verbalizing their intent to continue skin-to-skin care at home. Mothers seen one-on-one in the lactation clinic after discharge are further encouraged to continue skin-to-skin care in the rst weeks. Implications for Nursing Practice The practice of skin-to-skin care as a component of our baby friendly philosophy contributes positively to neonatal transition, enhances attachment, and promises long-term benet to new families. We at Cape Canaveral Hospital are committed to continuing promotion of skin-to-skin care as part of best practice.
Cue-Based Feeding: Implementation in an 83 Bed, Level Three, Metropolitan Neonatal Intensive Care Unit
Lindsay Newland, RN, BSN, IBCLC, Baylor University Medical Center Dallas, Dallas, TX Keywords cue based feeding infant driven feeds NICU feeding
Purpose for the Program he purpose of this program was to implement cue-based feeding in our neonatal intensive care unit (NICU).
Proposed Change Achievement of full oral feedings is often times the last milestone reached prior to discharge from the NICU. Many NICUs still used a scheduled feeding method to initiate and progress oral feedings. Several studies have come out to support that a cue-based feeding approach, also known as an infant-driven approach, may help
the NICU infant achieve full oral feedings up to 6 days sooner than a scheduled feeding method. A cue-based feeding approach tailors the progression of oral feedings for each individual, with close attention paid to the infants developmental cues to decrease stress. The following outlines our transition from scheduled feedings to cue-based feedings. Implementation, Outcomes, and Evaluation We introduced a cue-based feeding program in our 83-bed, level three, metropolitan NICU, which has more than 200 nurses and staff. This was
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achieved with a multidisciplinary team approach. Staff education was given by nurses, including one team leader and four super-trainers on each shift. Education was given in the form of bedside in-services, updates in the unit newsletter, a nursing policy and guideline, and a continuing education offering. The education ranged in topics, such as benets of cue-based feeding, how to read infant cues, how to use a cue-based feeding scale form, educating parents, and trouble shooting. After implementation, bedside charts were audited to assess staff adherence with cue-based feeding and address issues. Concerns and common issues were addressed in the form of bedside
in-services, questions and answers, updates in emails and newsletters, as well as focus groups on each shift. A multidisciplinary meeting took place 6 months after implementation to address concerns and update the program. Implications for Nursing Practice Cue-based feeding has become a common language in our unit and is considered a success. Research is currently underway in our unit to assess time to full oral feedings and the effect on direct breastfeeding rates. Future research to consider is the effect that cue-based feedings has on oral aversion after discharge.
Be Quiet! You Are Getting On My Neurons! Noise Reduction in the Neonatal Intensive Care Unit
Purpose for the Program ultiple studies have shown that excessive noise affects neurodevelopment in infants. Our clinical excellence committee wanted to explore the noise levels in our neonatal intensive care unit (NICU). Our ndings were that our levels exceeded recommended levels. Based on these ndings, we felt that changes needed to be made.
Proposed Change We provided education on the effects of excess noise on neonates to our NICU staff and implemented noise-reduction strategies in an attempt to decrease our overall noise level. Implementation, Outcomes, and Evaluation Our clinical excellence committee presented education on the effects of excess noise with the sup-
Keywords noise neurodevelopment Implications for Nursing Practice neonate Research has shown that the immediate effects neonatal intensive care unit
port of the hospital leadership. Education included presentations in unit meetings as well as poster presentations. Specic noise-reduction strategies were proposed by the clinical excellence committee and agreed upon by the staff. Strategies were implemented by the staff and follow-up monitoring was completed to assess effectiveness.
Jennifer L. Notestine, BSN, RNC-NIC, Mount Carmel East Hospital, Columbus, OH Teresa L. Rapp, RN, NNP-BC, Mount Carmel East Hospital, Columbus, OH
of elevated levels of sound show that environmental noise can be a major source of stressful stimulation, can cause agitation, and bring about complications in the medical management of the neonate. Heightened awareness of the effects of noise in the NICU promotes an optimal environment for positive developmental outcomes.
Exploring New Frontiers: Providing Skin-to-Skin Contact for Mothers and Newborns during Cesarean Birth
Purpose for the Program s cesarean birth rates increased in the United States in response to the American College of Obstetricians and Gynecologists statement concerning vaginal birth after cesarean, studies demonstrated higher dissatisfaction with childbirth experiences. Women giving birth by cesarean are more prone to postpartum depression, bonding difculties, and unsuccessful breastfeeding.
Keywords skin-to-skin Implementation, Outcomes, and Evaluation patient satisfaction Informal surveys of patient satisfaction since im- neonatal thermoregulation
surgical environment and the delivery room and required collaboration between the departments of surgical services, anesthesia, pediatrics, and obstetrics.
Nora C. Fortin, RNC-OB, BSN, Wentworth Douglass Hospital, Dover, NH
plementation have been positive. A more formal evaluation of the process will include a review of newborn thermoregulation in the operating room and a postpartum survey of patient satisfaction. Implications for Nursing Practice This new service is an example of how nurses are empowered to question tradition to advocate for their patients.
Proposed Change To increase maternal delivery satisfaction, we developed a plan to provide skin-to-skin contact immediately after cesarean births. The proposed change broke the barriers between the traditional
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Moms Own Milk Bundle: Increasing Supply in an 83 Bed, Level III, Neonatal Intensive Care Unit
E. Christina Conner, BSN, RN, Purpose for the Program IBCLC, Baylor University ospitals are encouraged to step up Medical Center at Dallas, evidence-based practices with various iniDallas, TX
face when providing milk and discovering an innovative game plan to reduce those barriers. Implementation, Outcomes, and Evaluation Implementation of this quality initiative focuses on staff and family education. After looking at the average length of stay, baseline breastfeeding rates, number of donor milk bottles used each day, and scal expenditures spent on donor milk, our goal is projected to decrease donor milk use, decrease medical and surgical necrotizing enterocolitis rates, and decrease length of stay. Implications for Nursing Practice The MOM Bundle is a collaborative approach to increase the availability and volume of mothers milk in our Level III, 83-bed, NICU. Working together with our medical, nursing, and NICU support staff, we project an increase in moms own milk, which benets the mother, the infant, and the hospital goals.
Keywords breast milk NICU quality initiatives collaborative increasing milk supply
tiatives, such as The Joint Commission Perinatal Core Measures and Baby Friendly Hospital Initiative, which both recognize the protection and value of moms own milk. The use of human donor milk in the neonatal intensive care unit (NICU) has been expensive but worth the payoff with less very low birth weight morbidity and mortality in our large NICU. The purpose of the Moms Own Milk (MOM) Bundle is a multidisciplinary, collaborative approach to gently encourage and support a mothers decision to provide her precious milk for her baby in the NICU.
Proposed Change The MOM Bundle uses quality initiatives throughout the Women and Childrens Service line to initiate and maintain the mothers milk supply. Improvements are focused on the barriers mothers
Virtual Special Care Nursery: A Cost Savings Idea

Michelle M. McFail, MSN, Purpose for the Program RNC-OB, Baptist Health, Little he purpose of the virtual special care nursRock, AR Keywords special care length of stay late preterm infant
ery is to decrease the length of stay for these patients while maintaining quality care.
Proposed Change A majority of infants born 35 to 36 6/7 weeks of gestation and infants born to mothers who were diabetic and insulin-dependent were admitted to the neonatal intensive care unit (NICU) for monitoring within 24 hours of birth. The average length of stay for the special care infant was 7 days. It was decided that the differing needs of these infants from full-term newborns could be provided for in a virtual setting. Nurses would be trained following evidence-based guidelines. The care would be provided in the mothers room or the well-baby nursery. Implementation, Outcomes, and Evaluation Over a 6-month timeframe, information was gathered, equipment purchased, protocols established, and a plan was implemented to care for the special care infant on the postpartum unit. The
team estimated that within 24 hours after birth, approximately 75% of late preterm infants were admitted to the NICU prior to the implementation of the special care nursery. After 6 months of implementation, the admissions had decreased to 9%. Each year since implementation, the number of admissions to the NICU has decreased for this population. The length of stay has decreased from 7 days to approximately 2 days for this group as well. Implications for Nursing Practice Nursing staff in the special care nursery are trained to evaluate and intervene quickly based on evidence-based protocols. This allows for the infant to remain with the family. Having the infant in close proximity increases the time available for educating the mother about the unique needs of the special care infant and allows her to feel an increased sense of condence when taking the infant home. This process increases the nursing staffs satisfaction about the care they provide.
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Two Phase Innovative Approach for Newborns at Risk of Hyperbilirubinemia

Purpose for the Program ach year approximately 60% of the 4 million newborns in the United States receive a diagnosis of clinical jaundice. The American of Academy of Pediatrics has instituted guidelines for the assessment and management of hyperbilirubinemia in newborns. The purpose of this project was to develop an innovative approach to identify newborns at risk of hyperbilirubinemia at delivery and at 24 hours of life and to improve neonatal outcomes for at-risk infants with hyperbilirubinemia after discharge during the weekend and holiday. Most infants with hyperbilirubinemia who are discharged before 72 hours should be seen within 2 days of discharge.
Proposed Change Previously, discharged infants with hyperbilirubinemia who required follow-up on weekends and holidays were seen in the emergency room, which delayed evaluation and treatment. We sought to identify infants at risk and streamline the evaluation and treatment process by instituting a weekend and holiday Bili Clinic on the mother-baby unit.
bin test performed and if the result was greater than 6 a serum bilirubin specimen was collected. The goal was to identify those at risk of hyperbilirubinemia and initiate treatment in a timely manner. The weekend and holiday Bili Clinic opened in April 2010. During the week, newborn health care providers (from the departments of pediatrics or family medicine) identied newborns requiring outpatient follow-up on the weekend and holiday and initiated the process for pre-admission to the Bili Clinic, maintained a logbook, and informed parents of required follow-up. Parents received an information form with the follow-up appointment to the Bili Clinic (scheduled anytime from 8:00 a.m. to 4:00 p.m.). As parents arrived for followup, the staff activated the Bili Clinic process, notied the newborn health care provider of the newborns arrival, and initiated procedures (weight, transcutaneous bilirubin, or serum bilirubin) as requested. Based on the test results, the decision was made to provide further patient follow-up, discharge home, or admit the newborn for treatment. This process for at-risk infants bypassed the emergency department and facilitated prompt treatment at the Bili Clinic. Implications for Nursing Practice Evaluation is ongoing based on patient comments and efciency of workow for nursing staff. Infants received phototherapy in a timelier manner and thus increased patient and nurse satisfaction, decreased overall costs, and promoted better outcomes for the patient.
Martha Montes, BSN, RN, University of Illinois Medical Center, Chicago, IL Lourdes Notario, BSN, RN, University of Illinois Medical Center, Chicago, IL Keywords hyperbilirubinemia phototherapy transcutaneous bilirubin (Tcb) Bili clinic
Implementation, Outcomes, and Evaluation To identify infants at risk, we instituted collection of cord blood type and Coombs testing at delivery for mothers with blood type O positive or RH negative blood types. Furthermore, all newborns after 24 hours of life had a transcutaneous biliru-
Operationalizing Palliative Care Processes through a Perinatal Palliative Care Program

Purpose for the Program arents who receive a life-limiting fetal diagnosis face many unexpected decisions: continue the pregnancy or proceed with early termination, comfort care or pursue neonatal intensive care intervention, treatment options with second opinions or withdrawal of life sustaining measures. The program offers a formalized care process for families choosing to continue the pregnancy and utilize comfort care for their newborn at the time of birth.
Proposed Change The University of Minnesota Amplatz Childrens Hospitals Perinatal Palliative Care is a familycentered, multidisciplinary program that provides a continuum of medical, emotional, psychosocial, and spiritual support through diagnosis, pregnancy, birth, and death. Throughout this process, parents are supported in creating a plan of care for their baby that is consistent with their goals and wishes. The program goals address the National Quality Forums Preferred Practices for Palliative Care and support caregivers in meeting palliative care outcomes.
Becky Gams, RN, MS, CNP, University of Minnesota Medical Center, Fairview, Minneapolis, MN Keywords comfort care palliative loss newborn life-limiting fetal

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Implementation, Outcomes, and Evaluation Historically, care for these families was heroically pulled together by a few dedicated and passionate individuals. However, as the newly established Fetal Diagnostic and Treatment Centers patient volume grew, the needs for families choosing to continue pregnancy and newborn comfort care were expected to grow as well. Steps to formalize the program, led by the advanced practice nurse leader, included a literature review, interviews with leaders from established programs, development of support from hospital administration and key individuals willing to operationalize the program, and creation of a multidisciplinary education process. The palliative care approach is enhanced by our established Pregnancy and Newborn Loss program. Although current numbers are small, averaging four per year from 2008 to 2010, eight families were served in 2011 (year-to-date). Families
commented that this was the happiest and saddest day of my life. Data from patient satisfaction surveys and multidisciplinary debriengs are disseminated to the health care team. Within this supportive formalized structure, a broad health care team accommodates the individual needs and circumstances of each family in the program. Implications for Nursing Practice The Perinatal Palliative Care program offers this care model within an institution with an established pregnancy and newborn loss program and a recently established Fetal Diagnostic and Treatment Center. Program scope, role denitions, responsibilities for maternal and neonatal medical management, program access, and multidisciplinary education will be described. A detailed birth plan template, newborn comfort care orders, care conference documentation, and process workow will be displayed.
Baby Cuddlers Make a Difference

Monica C. Kraynek, MS, Purpose for the Program RNC-LRN, RN-BC, The he number of newborn infants treated every Western Pennsylvania Hospital, year at the Western Pennsylvania Hospital Pittsburgh, PA
for neonatal abstinence syndrome (NAS) has in-
Mona Patterson, RN, BSN, The creased more than 150% since 2004. Nurses conWestern Pennsylvania Hospital, duct the Finnegan Neonatal Abstinence Scoring Pittsburgh, PA
Tool every 2 hours to analyze the infants with-
Christina Westbrook, RN, BSN, drawal symptoms and determine if pharmacoMSN, MBA, The Western logic intervention is necessary and/or effective. Pennsylvania Hospital, Up to 30% of infants may be managed without Pittsburgh, PA Keywords baby cuddler neonatal abstinence length of stay
medication. Interventions for treatment of these infants include medication and supportive care. The purpose of the program, as a unit evidencebased practice project, was to learn if the addition of baby cuddlers as caregivers could affect the length of stay required for treatment of these infants.
Proposed Change A baby cuddler is a trained baby holder who can ll the gaps when parents are not able to be present. The cuddler provides an important component of the developmental care for the hospitalized infant. The importance of human contact and touch in the well being of all hospitalized infants has been well documented. Baby cuddlers on a daily basis held, rocked, and comforted the infants suffering from drug withdrawal.
Implementation, Outcomes, and Evaluation Seventy-ve infants were admitted to the department with the diagnosis of NAS in the 1-year study period from May 2009 to May 2010. Length of stay was compared from the rst 6 months without the baby cuddler program to the last 6 months after the initiation of the program. From May 2009 to October 2009, the average length of stay for infants with NAS was 26.2 days without the baby cuddler program. From November 2009 to May 2010, the average length of stay for infants with NAS was 22.4 days, a decrease in length of stay of 3.8 days. After the ofcial evidence-based project ended, from May 2010 to April 30, 2011, the pediatric unit cared for an additional 75 NAS patients. The length of stay average was 23.9 days, a decrease in length of stay of 2.3 days compared with the initial noncuddler group. Baby cuddlers completed an orientation to their role and received education on hand washing and Health Insurance Portability and Accountability Act regulations. From initiation of the project on October 1, 2009, to February 28, 2011, baby cuddlers have contributed 2,855 hours of cuddling to patients suffering from NAS. Implications for Nursing Practice Nurses have implemented a low-cost intervention that decreases length of stay and, thus, affects hospital nances and provides quality patient care to a vulnerable population.
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Normal Newborn Nursery Neonatal Intensive Care Unit: Whats in Between?

Purpose for the Program trend of term newborns requiring transfer from the newborn nursery to the neonatal intensive care unit (NICU) was identied in a Level III NICU at a Magnet hospital. This offering will detail the pragmatic strategies utilized to decrease NICU admissions of high-risk transition newborns and present specic obstetric-related diagnoses.
Proposed Change To develop standards in clinical practice to promote newborn stabilization specic to newborns delivered between 35 and 36 weeks of gestation, born to mothers with chorioamnionitis or diabetes who received intravenous (IV) insulin during labor. Nurses are critical to assess, plan, act, and evaluate care for high-risk transition newborns to improve clinical outcomes and increase efciency. Implementation, Outcomes, and Evaluation A collaborative team approach was taken to establish clinical criteria to identify infants at risk of transfer to the NICU. Standards were developed for newborns delivered between 35 and 36 weeks gestation, born to mothers with chorioamnionitis or diabetes who received IV insulin during labor. These infants, high-risk transition newborns, are admitted to the NICU for up to 6 hours of observation. Glucose management, breastfeeding, and newborn admission policies were revised to reect new processes. The criteria and interventions were standardized and embedded into practice. A
multidisciplinary approach was utilized to assure all care providers involved with maternalnewborn care received education, including process ow charts, algorithms, and reference cards. The criteria were communicated to the family prior to delivery to ensure inclusion with all aspects of care. To foster family-centered care, families were made aware of where their newborns would be admitted. Since July 2008, full-term hypoglycemic newborn transfers decreased 15% from the motherbaby unit to the NICU, the admission of high-risk transition newborns to the NICU increased 27%, and the transfer of all newborns back to the motherbaby unit is about 80%. Implications for Nursing Practice Clinical criteria to identify newborns at risk of instability during extrauterine transition of life were standardized and embedded into practice. These criteria provided necessary collaborative nursing and medical management of the newborn patient care for the newborn nursery registered nurse and the primary care pediatrician. Clinical autonomy was maintained for the NICU nurse who provided care to the newborn during the transitional time frame. Standard processes and care requirements enabled nurses in a NICU to make prudent and timely decisions to improve neonatal outcomes. Improved quality outcomes for the newborn and improved patient satisfaction are a direct result of a standardized plan of care for high-risk transition newborns.
Judith Pfeiffer, BSN, RN-C, Lehigh Valley Health Network, Allentown, PA Denise Keeler, BSN, RNC-NIC, Lehigh Valley Health Network, Allentown, PA Keywords transitional NICU transitional newborn nursery observational nursery
Wait for Eight: Improvement of Newborn Outcomes by the Implementation of Newborn Bath Delay
Purpose for the Program o improve newborn outcomes by implementing the evidence-based research to delay bathing the newborn.
Proposed Change To improve newborn outcomes, implementation of evidence-based research was initiated. Implementation of bath delay showed that regardless of gestational age, the incidence of newborns experiencing hypothermia and hypoglycemia during the transitional period was reduced by changing the focus of unnecessary interventions.
Implementation, Outcomes, and Evaluation To review the current practice and identify the prioritization of the nursing task over the outcomes of bathing, the newborn, newborn care guidelines including revision of newborn order sets were established. Reference to evidence-based research and data collection post-implementation of guidelines were utilized. Multidisciplinary team actions involved evidence-based practice data regarding the effectiveness of newborn bath delay. Scripting to parents and families were created, which included the development of crib cards in order for clinical staff to facilitate the process change by direct hands-on education.
Diana V. Lipka, RNC, BA, Baycare/Saint Josephs Womens Hospital, Tampa, FL Marcia K. Schulz, RNC, MS, Baycare/Saint Josephs Womens Hospital, Tampa, FL Keywords newborn bath delay skin-to-skin transition
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The description of the process from admission to discharge identied the value in bath delay related to skin-to-skin research. Global hospital staff education was initiated and staff were presented with advice to give to parents and families during newborn care education. The value of skin-to-skin care with transition, bonding, and breastfeeding was emphasized. Our efforts were validated by the improved outcomes of practice change of newborn bath delay, which resulted in increased patient satisfaction. Implications for Nursing Practice Historical review of newborn care delivery demonstrated that nursing has shown to place priority on the completion of nursing tasks over the
outcomes related to the newborn transitional period. To improve newborn outcomes, implementation of evidence-based research was initiated to foster practice change. The research of skin-toskin practice directly correlated the need to review newborn care and practices thereof. The need to review one such practice was the newborn bath. Recognition of the importance of an uninterrupted newborn transition resulted in positive newborn outcomes and patient satisfaction. Implementation of bath delay showed that regardless of gestational age, the incidence of newborns experiencing hypothermia and hypoglycemia during the transitional period was reduced by changing the focus of unnecessary interventions.
Buccal Care with Colostrum in the Low Birth Weight Infant

Kimberly Pinkerton, MSN, RN, Purpose for the Program RNC-NIC, IBCLC, Mission here is overwhelming evidence in the literature Hospital System, Asheville, NC
Jennifer Wilkinson, BSN, RNC-NIC, Mission Hospital System, Asheville, NC Keywords low birth weight babies breast milk NICU buccal care
that human milk is superior to any form of nutrition for the neonate. It contains immunological, nutritional, and developmental properties that prevent infection, provide individualized nutrition, and optimize brain growth and visual development. Recent studies have proven that the protective factors in colostrum are even more concentrated in the colostrum of women who deliver low birth weight infants. This population of patients in the neonatal intensive care unit (NICU) is most vulnerable to morbidities, including necrotizing enteral colitis and nosocomial infections. Human milk decreases the incidence and severity of nosocomial infections and necrotizing enteral colitis. It also has been proven to protect against gastrointestinal and respiratory infections. Its perfect combination of protein, carbohydrates, and plasma proteins improves gastric emptying, which promotes feeding tolerance. The purpose of this project is to promote buccal application of mothers colostrum for low birth weight infants in the NICU.
posed change in practice is to institute a policy of buccal application of colostrum in the NICU. The infants are being followed longitudinally for outcomes related to this care. Implementation, Outcomes, and Evaluation A protocol for the buccal application of a mothers colostrum as well as banked breast milk for all low birth weight infants (weighing less than 1,500 grams) was developed and implemented in January 2011. Staff education was completed at staff meetings via slide presentations. The completed policy also includes an education sheet for parents as a means of encouraging their participation in this bedside practice. Implications for Nursing Practice Due to the limited availability of colostrum, mothers are being encouraged to begin pumping within 6 hours of delivery and pump on a prescribed schedule. We created syringe kits with detailed instructions for the collection of a mothers breast milk to avoid waste. The initial review of charts since the start of this policy revealed that access to colostrum takes several days and adherence to the policy is varied. Currently, longitudinal data are being collected on the infant outcomes posttreatment. Ongoing education of staff and parents is imperative to the successful implementation of this policy.
Proposed Change The nursing intervention of buccal application of a mothers colostrum potentially decreases the incidence of certain morbidities and decreases the length of stay of these fragile infants. The pro-
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Dont Drop That Baby!

Purpose for the Program he purpose of this poster is to share information regarding the incidence of falls of infants, the education strategies employed to decrease the risk of falls, as well as to explore future plans for decreasing the rate of falls of infants at the maternal infant services unit at Sharp Mary Birch Hospital for Women & Newborns.
2.5 falls per 10,000 live births (8,568 live births in 2010). Three falls occurred in 2010 prior to the implementation of staff and patient education. From the implementation of education, there were no falls for nearly a year. At the time of this abstract submission, there were 0.43 falls per 10,000 live births (4,341 live births as of June, 2011). Implications for Nursing Practice The success of patient education may be attributed to the goal of educating the patients and visitors as well as providing education to illiterate or non-English speaking patients. The patient education posters were translated into Spanish; however, patients at Sharp Mary Birch Hospital for Women & Newborns originate from a variety of countries and speak many different languages. To optimize comprehension of patient education, consideration should be given to utilizing pictures in addition to text.
Ellen Fleischman, MBA, RD, RN, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Monika Lanciers, BSN, RN, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Keywords falls of infants health literacy cultural barriers staff education
Proposed Change Investigations were completed to identify trends in the falls of infants. Staff and patient education were developed utilizing the ndings from incident reports. Picture-based patient education was developed and posted in patient rooms for easy access by patients and visitors. Implementation, Outcomes, and Evaluation Focused staff and patient education were implemented in April 2010. In 2009, there were 5.83 falls per 10,000 live births, and in 2010 there were
Reducing Catheter Associated Bloodstream Infections in the Neonatal Intensive Care Unit: Challenging Nurses to Be Champions
Purpose for the Program entral line-associated bloodstream infections (CLABSI) are associated with increased mortality and adverse outcomes in multiple systems in the neonatal intensive care unit (NICU) patient. All of the literature in the past 2 years regarding CLABSI has shown that with the implementation of evidence-based strategies, CLABSI can be signicantly reduced and in some cases completely eliminated. In June 2009, a designated committee at St. Josephs Womens Hospitals NICU began reviewing central line care and the current literature concerning best practices for central line management.
tion and dressing changes, (d) competency validation for all staff performing central line blood sampling, (e) standardized central line tubing change policy, (f) daily audits of all central lines for integrity and necessity, (g) scrub the hub care, (h) random audits, and (i) development of a standardized sterilized PICC dressing change kit. CLABSI rates in the NICU decreased progressively from 10.17 per 1,000-catheter days just before the initiative begun in June 2009 to 5.84 per 1,000-catheter days by the end of the year. The CLABSI rate for 2010 was 3.37 per 1000-catheter days. The number of bloodstream infections decreased from 30 in 2009 to 10 in 2010, a 67% decline. Implications for Nursing Practice A comprehensive program of central line management, led by a quality champion, is effective in signicantly reducing CLABSI in the NICU. The designation of a quality champion who is responsible for the initiative is vital to the success of this program. This role includes overseeing and participating in staff education, motivating and communicating with the team, random audits, and gathering surveillance data for quality improvement.
Jayne Solomon, MSN, ARNP-BC, St. Josephs Womens Hospital, Tampa, FL Keywords central line associated blood stream infections quality champion central line bundle hand hygiene random audit neonatal intensive care unit
Proposed Change A comprehensive program was developed, and a timeline was established to implement multiple interventions into the units guidelines for the management of central lines. Implementation, Outcomes, and Evaluation Strategies included the following: (a) hand hygiene, (b) development and implementation of central line insertion and maintenance bundles, (c) validation for a team of nurses to perform peripherally inserted central catheter (PICC) inser-
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Bagby, K. and Bowen, S.
Kangaroo Care Increases Breastfeeding Rates

Kim Bagby, RNC, BSN, PCE, University of Louisville Hospital, Louisville, KY Susanna Bowen, RN, BSN, PCE, University of Louisville Hospital, Louisville, KY Keywords kangaroo care skin-to-skin contact breastfeeding barriers to kangaroo care
Purpose for the Program or eligible motherinfant dyads, does implementation of Kangaroo care at birth increase breastfeeding rates compared to retrospective breastfeeding rates?
Proposed Change Kangaroo care, or skin-to-skin contact, began in 1979 in Bogota, Columbia, as a way to keep infants warm and provide optimal nutrition following birth. Research has shown that Kangaroo care has many benets for mothers and infants, including increased breast milk supply and greater breastfeeding success. The American Academy of Pediatrics recommends skin-to-skin contact as a strategy to increase breastfeeding success. In 2007, a Kangaroo care program for healthy infants and their mothers at the University of Louisville Hospital (ULH) was implemented. However, the philosophy was not adopted as a standard of care until 2010. Strategies were developed to hardwire the process and facilitate a change in practice that supported the use of Kangaroo care. Implementation, Outcomes, and Evaluation Current literature was examined, policies were revised, and staff expectations for participation were established. Kangaroo care champions were identied and assisted other staff with completion of Kangaroo care competencies; also three staff
members received certication in Kangaroo care. Documentation was improved to facilitate accurate data collection. Breastfeeding and Kangaroo care progress was shared monthly with staff. Breastfeeding initiation rates increased from 51% in July 2010, to 74% in July 2011. During this time the percentage of eligible infants who were placed in Kangaroo care at birth increased from 60% to 73%. The percentage of mothers and infants documented as participating in Kangaroo care in the motherbaby unit also increased from 35% to 51%. Ninety percent of the labor and delivery staff and motherbaby staff completed the Kangaroo care competency assessment in the 12 months following July 2010. Implications for Nursing Practice Implementation of the Kangaroo care initiative improved breastfeeding rates in the population served by the ULH. It is essential that all levels of leadership support and monitor standard of care practice at the bedside. In addition, accurate data collection and a comprehensive educational program are vital to support the initiative. Staff accountability is crucial to any successful change in practice. Our journey continues with further education and improved practices. This quality initiative is being shared with 57 birthing hospitals throughout Kentucky.
The Perfect Pouch: A March of Dimes Intervention to Enhance Onset and Frequency of Kangaroo Care
Liza G. Cooper, LMSW, March Purpose for the Program of Dimes Foundation, White he national evaluation results of the March Plains, NY Keywords Kangaroo Care skin-to-skin staff resistance parent awareness
of Dimes NICU Family Support program revealed that neonatal intensive care unit (NICU) parents felt that the most comforting activity that could be offered in the NICU would be to hold their infants. Staff respondents also reported the benets of Kangaroo care include reduced stress, enhanced comfort, and increased parentinfant bonding, but only 8% of staff reported routinely offering Kangaroo care to families. The March of Dimes developed the Close to Me intervention to increase the early onset and frequency of Kangaroo care in NICUs.
Proposed Change The Close to Me intervention includes parent education and awareness materials, staff education materials, and items of comfort and encouragement for families. This presentation will share the components of the Close to Me intervention as well as what was shown to be most effective in the evaluation. Implementation, Outcomes, and Evaluation Close to Me was unveiled in March of Dimes NICU Family Support R program sites nationwide. In 2011, a national evaluation of Close to Me was conducted in four NICU sites using an outside consultant who conducted staff focus groups and surveys preintervention and postintervention,
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parent surveys, and a special parent journaling technique. Results will be shared regarding the most effective components of Close to Me and the changes in parent and staff perceptions from preintervention to postintervention. We worked closely with a large team of NICU staff on adapting our materials for the full-term NICU infants and the full-term, well-baby audiences of professionals and parents. Key ndings from this work also will be discussed. Implications for Nursing Practice Kangaroo care is a proven benet to newborns and parents. Staff resistance to its implementation can be overcome with awareness, education, and
hands-on instruction. Parents can learn to ask for and advocate for this activity if they know about it and its benets early in their babys hospitalization. Researching Kangaroo care by having parents maintain a journal is appealing to parents who have the opportunity to heal and process as they participate in the study. Kangaroo care can be vital to many if not all babies in the NICU, including fullterm babies and those in the NICU for a short stay. The physiological, medical, and emotional benets of Kangaroo care are worth the additional time required in educating staff and providing comforting space and opportunities for parents to Kangaroo care their infants.
A New Look At Infection Control in the Neonatal Intensive Care Unit

Purpose for the Program o reduce infection rates in the neonatal intensive care unit (NICU) by 30%.
proved by the medical director and delivered to Michele L. Carson, MSN-CNL, RNC-NIC, UCSD Medical the core group for the unit.
Center, Del Mar, CA Keywords NICU CLABSI quality initiative
Proposed Change To educate and implement policy to reduce the NICU infection rates. Implementation, Outcomes, and Evaluation To change the way we look at preventing infections in the NICU, the aim of this project was to recreate the policy and procedure on infection control for the NICU. This project was started in July 2008 after the unit joined the California Childrens Quality Initiative in January 2008. The initial goal for 2008 was to reduce infection rates in the NICU by at least 30%. This project was completed as follows: the California Childrens Quality Initiative guidelines were collected and incorporated into the current infection control policy for the unit; each policy concerning infection control was reviewed; the last 5 years of peer-reviewed literature on infection control pertaining to neonatal intensive care was reviewed, and pertinent information was added to the policy and procedure; and each multidisciplinary group in the NICU was met with (for example the peripherally inserted central catheter team). These teams compiled input, and the information was added as appropriate to the policy. Finally, the policy was reviewed and ap-
Once the policy was nished, the staff members were educated through the creation of a six-panel poster session on the policy. Each staff member was required to walk through the poster session and answer a set of competency questions that pertained to the poster session. Also, a parent agreement was created that centered on infection control, which holds parents to the same standards as the nurses and doctors. During this time, specic audit tools were used to assess staff adherence to the components of the policy. Overall, the infection rate was reduced by 58% and audit data showed adherence to be at 96% and greater. These data were presented to the 2009 California Perinatal Quality Control Collaborative annual meeting in Sacramento and at the hospital-wide infection control committee. The policy was approved by the hospital-wide infection control committee and is under review for adoption on other hospital units. Implications for Nursing Practice At this time our efforts are focused on sustaining the gains. We are accomplishing this by reviewing current evidence-based practice yearly and changing practice accordingly, continuing to complete audits on practice, and providing continuing education to new and current staff.
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Woodson, L.
What Do You Mean You Dropped Your Baby? Changing and Hardwiring Nursing Practice to Eliminate Infant Falls
Linda Woodson, RN, BSN, Baylor All Saints Medical Center- Andrews Womens Hospital, Fort Worth, TX Keywords education newborn safety sheet snuggle time hourly rounding
Purpose for the Program n the rst 2 years that Andrews Womens Hospital was open, we experienced eight infant falls. The proposed changes were to hardwire hourly rounding on all shifts, to educate families on safe sleeping arrangement, and to promote maternal rest.
Proposed Change Our goal was to eliminate infant falls at Andrews Womens Hospital. Implementation, Outcomes, and Evaluation We implemented the project by rst using a tally sheet to identify common trends that occurred in the falls of newborns. Then, we educated both the newborn nursery and the postpartum staff on the need to hardwire the hourly rounding on all shifts. Next, we developed a newborn safety sheet that described the elements of safe sleeping and re-
quired that both the mother and the signicant other sign the sheet because three infants had been dropped by fathers. In addition, we emphasized with the newborn nursery staff and postpartum staff how important it was to make sure that the mother has the call bell within reach, even when she is placed in a chair. We began an extensive campaign to make sure that the mothers understood the adverse effects of pain medication. In addition, the postpartum registered nurse (RN) would alert the RN nurse when the mother had taken pain medication. Finally, we initiated snuggle time every day from 2:00 to 4:00 to promote maternal rest without interruptions. The outcome has been very positive, and it has been 1 year since the last fall of a newborn occurred. Implications for Nursing Practice Education of families and hourly rounding are absolutely necessary for keeping our infants safe.
Supporting Breastfeeding in the Hospital: A Better Start

Purpose for the Program reast milk feeding is the best option for infants and exclusive breast milk feeding is Maggie Redmon, RN, C-EFM, supported by the American Academy of PediBristol Regional Medical atrics for the rst 6 months of life. In addition, the Center, Bristol, TN Joint Commission recently introduced PC-05, recommending exclusive breast milk feeding during Keywords an infants entire hospital stay. Our goal was to inskin to skin early pumping crease the rates of breast milk feeding during the exclusive breast milk feeding duration of the hospital stay and the rates of infants easy access for rental supplies who were exclusively fed breast milk at discharge to promote what is best for infants and comply with the the Joint Commissions recommendation.
Tessa Brown, BSN, RN, CLC, Bristol Regional Medical Center, Bristol, TN
Proposed Change Our plan was to increase the support and duration of exclusive breast milk feeding by placing infants skin-to-skin during the immediate post delivery period. Second, we planned to begin encouraging early pumping for mothers of infants that were not breastfeeding well or were unable to nurse. We then planned to make breast pumps and supplies more readily available for our patients. Our staff would then be educated on the changes. Implementation, Outcomes, and Evaluation Our unit began implementing changes to support the breastfeeding relationship in the above mentioned areas. We began placing all breastfeed-
ing infants skin-to-skin within the rst hour and allowed them to self-attach to the breast for the rst feeding, which has been shown to increase the success of breastfeeding by approximately 80%. Second, we began to encourage early pumping for infants that were not feeding well at the breast or were unable to be at the breast because of medical conditions. We then looked at how we could support the use of breast pumps for our patient population. This was accomplished by partnering with a pharmacy in the Bristol Regional Medical Center to provide easy rental of breast pumps as well as breastfeeding supplies at competitive prices. Finally, we educated our nursing staff on the importance of supporting breastfeeding, allowing them to become breastfeeding advocates for our patients. Implications for Nursing Practice By implementing these changes, we were able to provide the early intervention and support necessary for our patient population. Patients are excited about the skin-to-skin process and our early support and intervention. Our partnership with the pharmacy has allowed our patients easy access to breast pump rentals and supplies. Combining these interventions has a great potential to increase the rates of exclusive breast milk feeding during the hospital stay and beyond.
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Babies, Bonding and Breastfeeding in the Post-Anesthesia Care Unit: Innovative Family Centered Care in a Community Hospital
Purpose for the Program n many cultures, newborns are placed naked on their mothers chests immediately after birth, which is viewed by many as necessary for the infants survival. In most community hospitals, mothers and infants are separated quickly after cesarean birth and not reunited until hours later. In collaboration with our post-anesthesia recovery team, our obstetric nurses created a seamless process to keep the mother and infant together throughout the challenging postoperative period.
Proposed Change In an effort to provide immediate skin-to-skin contact and allow for early breastfeeding for mothers and their healthy infants after operative deliveries, the roles and responsibilities of the labor and delivery nurses were changed. These changes enable the nurse to be off of the labor and delivery oor and provide both intraoperative and postoperative one-on-one care for the newborn and mother as a unit. Implementation, Outcomes, and Evaluation A multidisciplinary team was formed that consisted of labor and delivery nurses, postanesthesia recovery team members, lactation consultants,
and the director of womens services. This team was formed to change the policies and procedures to allow infants to remain with their mothers after a cesarean birth and the immediate postpartum surgical recovery period. A process was developed to assist with the implementation of the new procedures and to educate and direct nursing teams involved with cesarean births. Evidencebased best practice was used to guide staff education. The education incorporated the importance of skin-to-skin contact between the mother and baby and early breastfeeding after an operative delivery. Evaluation revealed that keeping the mother and baby together after cesarean birth increased patient satisfaction, enhanced quality of care, allowed skin-to-skin contact, promoted early breastfeeding, and supported thermal regulation of the newborn. Implications for Nursing Practice Implementing Babies, Bonding, and Breastfeeding in the Post-anesthesia Care Unit enhances overall postpartum operative care, fosters teamwork between nursing units, and supports the Association of Womens Health, Obstetric and Neonatal Nurses commitment to positive perinatal outcomes.
Lauren Grifn-Walls, BSN, RNC-OB, Milford Memorial Hospital-Bayhealth, Milford, DE Jaclyn Lewis, RN-CPN, Milford Memorial Hospital-Bayhealth, Milford, DE Keywords babies bonding breastfeeding PACU
Decline of the Gold Standard! Umbilical Cord Tissue Provides Timely and Accurate Results to Enhance Quality Outcomes for the Neonate
Purpose for the Program ecent literature reviews stated that approximately 5% to 10% of women self-report the use of illicit drugs during pregnancy; however, universal testing in high-risk populations indicates higher rates of illicit drug use. Facilities should establish their own testing protocols and unbiased guidelines to identify when testing should occur because the literature does not indicate consensus on universal screening. A positive maternal test result determines the initiation of the protocol to test newborns.
Proposed Change Meconium drug screening is considered the gold standard for drug testing in the neonate, but be-
cause of false positive test results and the length of time to obtain conrmatory results it was identied that a practice change was necessary. Because of the sensitive nature of this test, accuracy in patient test results is crucial. Increase in false positive test results lead to questioning the truthfulness of the test. The goal was to identify a process that provided ease of obtaining specimen sampling and accurate patient test results. The proposed change was to implement umbilical cord tissue screening. The advantages of this process included samples being sent immediately after birth, receiving only conrmatory results, and a chain of custody. Because of the sensitive nature of drug testing and possible legal ramications, a chain of custody
Tanyelle Bellamy, RNC, MSN, FNP-BC, Mountain States Health Alliance, Johnson City, TN Keywords drug testing substance abuse umbilical cord testing neonatal abstinence scoring
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Bellamy, T.
was seen as a necessary piece of our process improvement. Implementation, Outcomes, and Evaluation The plan was discussed and approved by the neonatologists and pediatricians. Nursing leadership met with pathology and lab directors to discuss switching the testing location from a local laboratory to sending the tests to an outside reference lab. Initial implementation began at a regional tertiary care facility and a smaller community hospital where the largest volumes of maternal substance abuse were experienced. The outcomes focused
on increasing result turnaround times, potentially decreasing the newborns length of stay, and decreasing rates of false positive test results. Implications for Nursing Practice The implications for the nursing practice included the need for a standardized order set for newborns experiencing neonatal abstinence symptoms, which was developed in collaboration between the departments of nursing and neonatology. All nursing staff received in-service on neonatal abstinence scoring to help staff provide more consistent and accurate scores.
At Home with Your Baby

Deborah Raines, PhD, EdS, Purpose for the Program RN, ANEF, Walden University, his community-based program is designed Boca Raton, FL Keywords NICU discharge simulation caregiver competence
to enhance parents competence and condence as caregivers after their infants discharge from the neonatal intensive care unit (NICU).
Proposed Change By enhancing parent condence and competence, this program will improve infant, parent, and overall family well being. The program also has the potential to decrease the use of health care resources, such as 911 calls, emergency resources visits, and hospital readmission. Implementation, Outcomes, and Evaluation The program is conducted in the department for caregiver education and uses a preemie high-delity simulator. The specic activities are
adapted to the anticipated discharge needs of the infant. The program accepts referrals from all the NICUs in the county and from the Health Department. The program began accepting referrals in January 2011. To date, the evaluation of parents and staff has been overwhelmingly positive and the funding has been extended for a second year. Data are being collected on the specic outcomes of parent condence and competence as caregivers as well as on unscheduled use of health care resources on infants. Implications for Nursing Practice The use of high-delity simulators may have a signicant role in the process of discharge teaching in the NICU.
Making Kangaroo Care the Norm: Implementation of a New Model of Care

Lynn Barabach, MSN, RNC, Purpose for the Program Lakewood Hospital, Lakewood, n 2009, the Lakewood Hospital Birthing CenOH Joy Sedlock, MSN, CNM, IBCLC, Lakewood Hospital, Lakewood, OH Kate Salmon, RNC, MSN, IBCLC, Lakewood Hospital, Lakewood, OH Keywords kangaroo care infant childbirth breastfeeding
ter embarked on the journey to obtain BabyFriendly, USA designation. It was identied that a key component for a successful journey was the implementation of Kangaroo care, or skin-toskin care, in the immediate postpartum period. In the fall of 2009, the Birthing Center began training the nurses on Kangaroo care and implementation soon followed.
Proposed Change Our goal was that all appropriate infants would be placed in Kangaroo care shortly after birth and would remain with their mother or the mothers support person for 60 to 90 minutes. The time in Kangaroo care with the mother would facilitate transition to extrauterine life and allow the infant to self-latch at the breast.
Implementation, Outcomes, and Evaluation Nursing leadership worked with a nationally recognized expert on Kangaroo care to provide education to the nurses. A 4-hour program on Kangaroo care was developed and included discussion of the benets, infant placement, and ongoing care of the infant, including assessment. Placing the infant in Kangaroo care was demonstrated to validate understanding. The electronic health record was modied to include documentation of time in and out of Kangaroo care and with whom the infant was in Kangaroo care. Patient education included handouts on Kangaroo care for distribution during prenatal appointments, prepared childbirth classes, and breastfeeding classes. Kangaroo care also is discussed during tours of the Birthing Center. Pediatric, midwifery, obstetric, and anesthesia providers were educated about Kangaroo care and the Birthing
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Centers change in the model of care immediately following birth. As barriers were identied, nursing leadership worked on the issues to minimize interruptions of Kangaroo care. The percentage of appropriate infants in Kangaroo care following birth is reviewed monthly. Between 90% and 98% of appropriate infants are placed in Kangaroo care. Infants also are placed in Kangaroo care shortly after a cesarean birth while the mother remains in the operating room. Anecdotally, lactation consultants report a decrease in the incidence of delayed latch and breastfeeding problems. Families have
reported increased satisfaction with their birthing experiences. Implications for Nursing Practice Kangaroo care assists the infant with transition and facilitates initial breastfeeding, it is benecial to the infant, mother, and family, and it is utilized throughout the hospital stay and families are encouraged to continue Kangaroo care at home, especially in conjunction with breastfeeding. The use of Kangaroo care is truly a nursing intervention. This nursing intervention quickly became a model of care for the Birthing Center.
Discharge Planning in the Neonatal Intensive Care Unit

Purpose for the Program o improve parents ability to care for their infants at discharge.
Proposed Change To implement the following improvements in the neonatal intensive care unit (NICU):
r r
r r
Cultural: More parental involvement. Parents would hold infants every day. Parents get a picture on admission. Long-term infants get a journal with weekly pictures. Teaching: A parent admission and discharge tool was created. Videos will be added to our television system for parental viewing. Registered nurses will be held accountable for daily teaching and documentation. Parental Accountability: Parents will be actively involved in teaching and take responsibility for learning. Discharge map created: Outline discharge teaching with daily accountability for updates, holding, and teaching.
included the following: an emotional approach, a literature review, and a discussion of unit expectations. Issues with discharge planning, parents being unprepared to take their infants home, and the associated risks were reviewed, along with the American Academy of Pediatrics guidelines for discharge planning, including rooming in. Our evaluations have been overwhelmingly positive. Our parent surveys improved from the 30th percentile for discharge planning to the 99th percentile. Parents state that they feel at home within the NICU and are prepared to care for their infants. We offer all parents rooming in. Implications for Nursing Practice Discharge planning should begin on admission. It is not only a teaching process but should involve the parents in every aspect of their infants care. We must change our culture of isolation to one of inclusion. The more involved the family is, the more prepared they are to care for their infant at home. Nurses must be held accountable for discharge teaching on a daily basis. Parents should be actively involved and accountable for knowledge acquisition. Discharge mapping is an excellent tool to ensure that parents have covered all discharge information.
Kathy J. Loughren, MSN, NNP-BC, Memorial Hospital Miramar, Miramar, FL Keywords neonatal intensive care unit (NICU)
Implementation, Outcomes, and Evaluation The clinical manager recruited two staff nurses. The classes were mandatory for NICU nurses and
Nurses Commitment to Best Practice Infant Care and Family Bonding Founded on Evidence-Based Research: A Journey of Infant Bathing
Purpose for the Program he Professional Practice Committee hypothesized that we could improve postpartum wellborn baby care by switching from sponge bathing to immersion bathing. A research review revealed evidence supporting the theory that immersion
bathing improved temperature stability, bonding, breastfeeding, and parental education. The current practice in the Providence Alaska Medical Center Maternity Center is to perform sponge bathing under a radiant warmer on newborns within 2 hours of birth in the absence of birth stress
Rebecca Heimann, RN, Providence Alaska Medical Center, Anchorage, AK Melissa Heath, RN, Providence Alaska Medical Center, Anchorage, AK
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Heimann, R. and Heath, M.
Keywords bathing education thermoregulation infant stability newborn care
or trauma. Parental involvement is minimal because of decreased mobility from anesthesia, exhaustion, and environmental or social distractions during the immediate postpartum period. Nurses also reported that breastfeeding and skin-to-skin bonding time often was interrupted to complete baths in the allotted 2-hour recovery time. Proposed Change The Professional Practice Committee proposed a policy and procedural change to immersion bathing founded on evidence-based research, which incorporated these key principles:
Infants at risk of transmission of hepatitis B and human immunodeciency virus from maternal sources will be bathed within 2 hours of birth.
r r
Delay infant baths 2 to 4 hours to establish thermoregulation and decrease negative side effects of hypothermia, including increased oxygen consumption, respiratory distress, and hypoglycemia. Stable temperature dened as 97.7 F to 99.5 F for 2 to 4 hours. Tub bathing appears to be more effective than sponge bathing at maintaining body temperature and preventing temperature loss. Also, studies showed there is no difference in umbilical cord infection and healing rates and infants appeared more relaxed and less agitated during tub baths.
Implementation, Outcomes, and Evaluation The Professional Practice Council presented their research and ndings to the Nursery Committee and received permission to proceed with a practice change. Currently, the Professional Practice Council is developing a training video, policy, and care competency. These tools will be presented to the staff at regularly scheduled staff meetings. Hands-on training of nurses and techs will be conducted to assure comfort and competency in practice. The goals for this project are consistent immersion bathing per guidelines, increased infant relaxation, increased parental involvement and education covering proper positioning, temperature regulation, and signs and symptoms of infant distress. Implications for Nursing Practice Increased parental involvement in newborn care results in greater uninterrupted bonding time, improved breastfeeding, extended skin-to-skin contact in the postpartum period, as well as improved neonatal outcomes from decreased cold stress and calmer stabilization.
Outpatient Newborn Hearing Screening Program

Nicole Giangregorio, BS, CLE, Purpose for the Program LCCE, Sharp Mary Birch he Newborn Hearing Screening Program is a Hospital for Women & California state mandated program requiring Newborns, San Diego, CA
Keywords outpatient community hospital growth
all infants to have a hearing screening prior to discharge. Sharp Mary Birch Hospital for Women & Newborns additionally offers an outpatient hearing program for our well-baby population leading to increased patient satisfaction and delayed appointment times.
Proposed Change To increase the number of patients receiving outpatient hearing rescreenings, decrease the time between the initial hearing screening and the follow-up hearing screening, and increase revenue. Implementation, Outcomes, and Evaluation The outpatient program allows our hospital to schedule the follow-up appointment for all wellbabies prior to discharge, ensure a reminder call is made, complete all necessary paperwork, and guarantee an appointment well within the state recommended 4-week timeframe. Compared to our region, our outpatient no-show rate is considerably lower. The region reported a no-show rate of 12.3% for July 2011 and Sharp Mary Birch Hospital for Women & Newborns reported a 0% no-show
rate (the overall program no show rate is currently being calculated by the Regional Hearing Coordinating Center). Each outpatient appointment receives a reminder phone call 48 hours prior to their appointment. On the day of their appointment, the family is received and escorted to the outpatient clinic by a hearing screening technician. New parents are relieved to come back to the hospital where they gave birth versus going to a different clinic and navigating a new health system. As a result, our patients are more satised. The outpatient revenues previously went to other hospitals within the community, and Sharp Mary Birch Hospital for Women & Newborns now receives revenues from the insurance companies and the state for MediCal and/or uninsured patients. Since the outpatient program began in October 2008, we have seen 382 outpatients with a steady increase each scal year. The outpatient program is open to the community at-large allowing for quicker access to a follow-up hearing screening. Implications for Nursing Practice It is important for families to have their outpatient follow-up appointments within the same health system for convenience, increased patient satisfaction, and increased revenue.
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An Innovative Program to Support and Promote Breastfeeding: What Have You Done for Me Lately?
Purpose for the Program espite evidence for breastfeeding benets, hospitals fall short in breastfeeding rates and duration. Recent Centers for Disease Control and Prevention data suggest less than 4% of U.S. hospitals offer the full support necessary to meet enduring, committed breastfeeding, and nearly 75% do not provide maternal support after discharge. This challenges an institutional ability to meet the Healthy People 2020 goals to have 81.9% of mothers initiate breastfeeding, 60.6% breastfeed at 6 months, and 34.1% breastfeed at 1 year. The Surgeon Generals Call to Action to Support Breastfeeding underscores this critical need, noting low priorities for breastfeeding, and use of nonevidence-based practices as barriers to enduring breastfeeding.
mothers are being offered relevant information, logs were subjected to qualitative analysis, which determined the nature of maternal concerns. Ten themes emerged and specic, predictable breastfeeding topics developed at key points during the rst year of life. Data from 1,025 mothers who breastfed and called during 2009 were examined. Findings were then compared to the nurses perceived breastfeeding barriers by care area, as dened in a separate performance improvement project. Results of both projects clearly indicated the need to initiate breastfeeding education activities during prenatal classes, maintain momentum during the inpatient phase, and provide anticipatory postdischarge guidance so that a successful support program would be in place to meet the aforementioned goals. Implications for Nursing Practice A team approach focused on breastfeeding to support maternal-child nurses and mothers is one way to improve hospital practices and meet goals. Inpatient nurses should address predictable areas of concern with new mothers, particularly concerning milk supply, baby behaviors, and pumping. Outpatient clinicians can offer anticipatory guidance based on consistent patterns of data across the postpartum period, such as drug and diet interaction with milk, stooling patterns, and weaning among other issues. Information and available resources that are appropriately timed and offered when the mother is ready to learn improve the chances that the mother will be able to process and retain the shared information.
Lynn E. Bayne, PhD, NNP-BC, RN, Christiana Care Health System, Newark, DE Elizabeth Chance, EdD, RN, Christiana Care Health System, Newark, DE Lydia Henry, MSN, RNC-OB, CCE, IBCLC, Christiana Care Health System, Newark, DE Keywords comprehensive breastfeeding program Christiana Care Health System (CCHS)
Proposed Change To create a comprehensive breastfeeding program to meet the challenges stated above Implementation, Outcomes, and Evaluation Christiana Care Health System has built an enduring lactation program available across the continuum of perinatal care aimed to meet these action calls. Support is offered to mothers and other perinatal clinicians by experienced lactation consultants to overcome breastfeeding obstacles. This program promotes the development of knowledgeable mothers and health care providers. Our facility maintains a free, breastfeeding hotline that is staffed by lactation consultants. Mothers may initiate a call at any time during their breastfeeding experience when they encounter questions or concerns. As part of this program, logs document telephone conversations. To ensure that
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JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

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Klein, L.

Newborn Care Paper Presentation

JOGNN 2012; Vol. 41, Supplement 1

Newborn Care Paper Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Premature Infant Nutrition Clinic

Newborn Care Paper Presentation

JOGNN 2012; Vol. 41, Supplement 1

Keywords NICU FNAST education

Newborn Care Paper Presentation

Perinatal Palliative Care: Support of Mothers, Infants and Families

infant advanced directives

Newborn Care Poster Presentation

Neonatal Head Trauma: Implementation of a Care Algorithm to Improve Safety

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Braithwaite, P., Donahue, N. and Bayne, L. E.

Newborn Care Poster Presentation

Help! Im Cold! Improving the Warmth of Our Newborns

JOGNN 2012; Vol. 41, Supplement 1

Geraldine Tamborelli, MS, RN, Maine Medical Center, Portland, ME

Newborn Care Poster Presentation

Birthways Lactation Services: A Model for Breastfeeding Support

Newborn Care Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Keller, A. and Brenneman, A.

Operation Kangaroo Care

Newborn Care Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1

Newborn Care Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Increasing Exclusive Breast Milk Feeding Rates at an Urban Academic Hospital

at an urban academic hospital.

To implement this program, the following interventions were completed:

Newborn Care Poster Presentation

Exclusive Breastfeeding: It Takes Our Village

Newborn Care Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1

Now I Lay Me Back to Sleep . . . .Safely

Newborn Care Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Implementing Skin-to-Skin Care in a Baby-Friendly Community Hospital

Purpose for the Program o improve motherinfant attachment and breastfeeding.

Newborn Care Poster Presentation

Newborn Care Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1

Newborn Care Poster Presentation

Nora C. Fortin, RNC-OB, BSN, Wentworth Douglass Hospital, Dover, NH

Newborn Care Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Newborn Care Poster Presentation

Virtual Special Care Nursery: A Cost Savings Idea

Newborn Care Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1

Two Phase Innovative Approach for Newborns at Risk of Hyperbilirubinemia

Newborn Care Poster Presentation

Operationalizing Palliative Care Processes through a Perinatal Palliative Care Program

Newborn Care Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Baby Cuddlers Make a Difference

for neonatal abstinence syndrome (NAS) has in-

Tool every 2 hours to analyze the infants with-

Newborn Care Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1