From Pediatric News
By Mindy Morris, DNP, NNP-BC, CNS
Decades ago, a baby born at just 28 weeks gestation and weighing less than 1,000 grams would not likely survive. Today, thanks to the latest advances in neonatal intensive care, the survival rates for these infants have significantly improved.
Survival is just the first hurdle on these patients’ journey. Despite numerous medical advancements, many of these “micro-preemies” may still be discharged with significant challenges, including neurodevelopmental delays and/or chronic medical problems.
Our goal at Children’s Hospital of Orange County (CHOC Children’s) is to ensure that extremely low birth weight (ELBW) babies not only survive, but that they do so with fewer long-term complications.
Outcomes from our Small Baby Unit (SBU) show we’re doing just that.
Unique environment, bonds
Established in 2010, the 12-bed unit consists of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional neonatal intensive care unit (NICU), this smaller unit allows a darker, quieter environment that encourages developmentally supportive care.
In the SBU, patients lie inside covered incubators that keep light away from their underdeveloped eyes. Families and staff members speak in “library voices,” because even a whisper is too harsh for these babies’ ears in the early stages of care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely.
Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences. Only another parent of an ELBW baby can truly understand the fear felt when delivering an infant 12 to 16 weeks early; the trial of a months-long hospital stay; and the elation on discharge day. Anecdotally, these bonds have shown to sometimes last years after discharge.
Dedicated, coordinated care
An objective of the initiative was to cohort ELBW infants in a single location physically separated from the main NICU, and to recognize that progressive changes in unit culture were essential for successfully shifting the practice model.
Experienced multidisciplinary NICU staff with interest and expertise in caring for ELBW patients became the initiative’s core tore team members. Staff received education – both independent study as well as an eight-hour class – prior to opening the SBU, and continuing education and team building remain key components of program development.
By utilizing a dedicated team with expertise in the care of these patients, CHOC Children’s clinicians have determined that establishing a unit dedicated to the care of ELBW patients has led to improved quality and outcomes.
Reducing chronic lung disease (CLD) was a top motivation for the creation of the unit, and rates of CLD dropped from 47.5 percent of babies two years prior to the unit’s 2010 opening to an average of 35.4 percent after the first four years of the program. The percentage of babies discharged on oxygen decreased from 23 to 18 percent. Continued improvement over time showed as well in both areas.
Infants being discharged with growth restriction (combined weight and head circumference <10th percentile) decreased from 62.3 to 37.3 percent, and continued improvement showed over time.
Rates of hospital-acquired infections decreased from 39.3 to 19.4 percent, which led to fewer days of antibiotic administration.
Coordinated care from a dedicated multidisciplinary team also led to the reduction of ordering unnecessary tests. For example, the mean number per patient of routine laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22 during their hospitalization.
Eliminating practice variation
Because practice variation often complicates care, the SBU cares for patients through a standardized, evidence-based practice that incorporates guidelines and checklists.
Evidence and unit culture informed the development of guidelines, and input was sought from the whole team: nursing staff, neonatal nurse practitioners, neonatologists, respiratory therapists, developmental specialists, dietitians, lactation support, pharmacists, social services, transport services and high-risk infant follow-up clinic staff.
Checklists helped standardize practices, reduce variation and improve safety.
Culture, consistency are key
Our clinicians found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location.
Additionally, there was a reduction in complications among infants prior to leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes, including improved staff satisfaction.
Mindy Morris is a neonatal nurse practitioner and coordinator of the extremely low birth weight program at Children’s Hospital of Orange County in Southern California.