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Klein, L. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Newborn
Care
A Pilot Project to Improve Neonatal Peripheral Intravenous
Site Assessment and Documentation
Lisa Klein, MSN, RNC-OB,
RNC-LRN, CNS, Marymount
University, Reston, VA
Keywords
neonatal
nursing
peripheral intravenousassessment
documentation
Paper Presentation
Purpose for the Program
There is currently no consistent protocol de-scribed in the literature for documentation of
the nursing assessment of neonatal peripheral in-
travenous sites. Most authors concur that hourly
assessments are the minimum frequency and in-
dicate what the assessment parameters should
be; however, they do not discuss a protocol for
documentation of the assessments. Multiple au-
thors and professional nursing groups have iden-
tified that problems exist in the care of periph-
eral intravenous sites in neonates. This project
attempted to determine if nurses in a neonatal in-
tensive care unit (NICU) could conduct and docu-
ment an hourly evidence-based focused assess-
ment of neonatal peripheral intravenous sites.
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 interven-
tions on each patient. Additional documentation of
five measurement parameters may not be realistic
to add to the workload of the direct care nurse. By
having the nurses who participated in data collec-
tion 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 excep-tion for assessment of peripheral intravenous sites
in neonates. This project introduced a documen-
tation form that includes the five evidence-basedparameters 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 periph-
eral 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 instru-
ment 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 infiltrations and ex-
travasations, which would be useful in improvingpatient outcomes.
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
The late preterm infant faces many challenges
associated with prematurity. In 2010, 99 late
preterminfants (approximately 5% of the total birthvolume) were born at Peninsula Regional Medi-
cal Center. Nearly 29% of these infants were ad-
mitted 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 wasto determine if adopt-
ing 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 pe-
riod to determine baseline rates of hypothermia,
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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
hypoglycemia, respiratory distress, feeding dif-
ficulties, phototherapy, excessive weight loss,
neonatal intensive care unit admissions, and read-
missions to the pediatric unit. A multidisciplinary
team developed the late preterm infant initiative
utilizing AWHONNs clinical guidelines. Compo-
nents of the initiative included policy and order
set development, predelivery and predischargeeducation, and individualized feeding plans. Be-
ginning 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 in-
fant. 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 inten-
sive care unit (25.8%), and no infants were read-
mitted to the pediatric unit. The overall goal is to
improve clinical outcomes while reducing admis-sions 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 ex-
tremely 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, trans-
lates 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. Provid-
ing care that enhances family bonding, empow-
ers parents, and improves clinical outcomes in-
creases patient and nurse satisfaction. In this era
of rising health care costs and nonreimbursement
for preventable readmissions, it behooves nurses
to adopt practicesthat anticipate and prevent pos-sible sequelae related to late prematurity.
Tackling Newborn Hypoglycemia in the Delivery Room:
Utilizing Colostrum, Skin to Skin and State of the Art
Policies
Pamela Kinney Tozier, BSN,
RNC, CCE, IBCLC, Maine
Medical Center, Portland, ME
Keywords
hypoglycemia
diabetics
hand expression
colostrums
skin-to-skin
Newborn Care
Paper Presentation
Purpose for the Program
N
ewborn hypoglycemia in the delivery room
is a widespread challenge. Most often in-
fants who are breastfed and are temporarily sep-
arated from their mothers receive formula as a
quick fix to increase blood glucose levels. This
approach not only decreases breastfeeding suc-
cess, but it also exposes the newborn to unsta-
ble levels of glucose because of the formulas
stimulation of insulin production. Too many infants
who are breastfed receive excessive amounts of
formula within the first hour of life because their
glucose values are checked before feeding, as
soon as 15 to 30 minutes after birth. After wit-
nessing 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 wasout of balance regarding the blood sugar/feeding
issue.
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 keep-
ing them in continuous skin-to-skin contact. I had
recently become an international board certified
lactation consultant, and that new level of knowl-
edge, coupled with my nursing experience, pre-
pared me well for presenting my ideas to the
administration. I also proposed that we estab-
lish ways to give colostrum to babies who werenot 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.
Implementation, Outcomes, and Evaluation
We have successfully implemented a new hypo-
glycemia algorithm that accepts lower glucose
values initially, has the newborn feed first, andthen the first glucose level checked by 90 min-
utes 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 continu-
ous 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.
S32 JOGNN, 41, S1-S118; 2012.DOI: 10.1111/j.1552-6909.2012.01360.x http://jognn.awhonn.org
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Lawson, T. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Implications for Nursing Practice
Labor and delivery nurses are the first line of de-
fense in helping stabilize newborn glucose lev-
els without the introduction of formula, thereby up-
holding the standard of best practice. It is possible
for just one nurse with a vision to apply evidence-
based practice to achieve quality outcomes.
Premature Infant Nutrition ClinicTerry Lawson, RN, IBCLC,
University of California San
Diego Medical Center, San
Diego, CA
Keywords
human milk
premature infant nutrition
lactation consultant
Newborn Care
Paper Presentation
Purpose for the Program
The benefits of human breast milk for term in-
fants outweigh formula. Breast milk is an even
greater benefit to the preterm infant because it
provides infection prevention and promotes im-
proved neurodevelopment. In 2006, the University
of California San Diego MedicalCenter was desig-
nated as Baby Friendly. The Supporting Premature
Infant Nutrition program was launched in 2007.
Thegoalwas to improve the growth and nutrition of
preterm infants. It was noted that following hospi-
tal discharge, most mothers were not successfully
breastfeeding their premature infants. These in-fants continued to require fortifiers, but we did not
know how much or for how long. Mothers contin-
ued to need to pump, but supply was decreasing.
Both parents were exhausted and overwhelmed.
Proposed Change
In August 2008, the Premature Infant Nutrition
Clinic was established by a pediatrician and reg-
istered nurse. Utilizing a team approach, visits in-
cluded infants growth and development assess-
ments and discussions of the mothers concerns.
After the assessment and discussion, the regis-
tered nurse performs a lactation consult and as-
sesses the infant feeding, looking for ways to im-prove milk transfer, increase milk supply, and in-
crease breastfeeding and decrease breast pump-
ing. At the end of the 45- to 60-minute session, a
plan is developed to help the mother reach the de-
sired goal. Visits are individualized, ranging from
one-time only to severalvisits 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 first year, 97 patients/183
visits occurred; the second year, 83 new patients;
and the third year, 130 new patients/637 visits oc-
curred. 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 newbornsgreater 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 pa-
tients 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 exemplified by the projects in progress, includ-
ing a Premature Infant Nutrition Clinic Quality As-
surance project, research of liquid fortification ofthe mothers milk at discharge, and an interna-
tional multicenter validation of a preterm growth
chart. Both providers and nurses are involved in
every aspect leading to increasedpatient andstaff
satisfaction.
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
The National Council on Alcoholism and Drug
Dependency estimates that between 1% and
11% of babies born each year are exposed to il-
licit 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 absti-
nence syndrome (NAS). Research that is more re-
cent describes an increasing incidence of infants
exposed to harmful substances prior to birth. Ba-bies exposed to opioids or opioid derivatives dur-
ing 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 phar-
macologic 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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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Proposed Change
To develop and implement evidence-based clin-
ical practice guidelines and an educational pro-
Keywords
NICU
FNAST
education
Newborn Care
Paper Presentation
gram on NAS and the Finnegan Neonatal Absti-
nence Scoring Tool (FNAST), to improve nursing
assessment and care of the NAS infant, and im-
prove 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, ed-
ucational project. Nurses were tested before and
after participation in education about NAS. A sub-
set of 10 nurses was evaluated using the FNAST
with video of infants having NAS. Volunteer par-
ticipation 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 cri-
terion 1 week after participation in the educational
project.
Implications for Nursing Practice
Evidenced-based clinical practice guidelines andeducation on NAS and the FNAST equip care-
givers with the necessary tools to consistently and
accurately assess an infant with NAS when using
the FNAST. Recent research shows that provid-
ing education to nurses can result in knowledge
gained, improved professional practice, and im-
proved patient treatment goals. Education also
can equip nurses with the necessary knowledge
to care for patients with complex medical prob-
lems like NAS. Further, providing nurses with
specific information about a medical problem
is correlated with improved adherence to best
practice.
Perinatal Palliative Care: Support of Mothers,
Infants and Families
J. Frances Fusco, MHS, BSN,
RN, University Community
Hospital, Tampa, FL
Theresa Bish, RN, IBCLC,
University CommunityHospital, Tampa, FL
Keywords
perinatal palliative care
infant advanced directives
Newborn Care
Poster Presentation
Purpose for the Program
To support mothers, infants, and families
through the Perinatal Palliative Care program.
Proposed Change
To enhance the existing bereavement programto include infants with low viability or no viability
through palliative care.
Implementation, Outcomes, and Evaluation
Implementation is in process and awaiting final
approval of pertinent policies and procedures to
supportthis program. The evaluation will be based
upon a patient satisfaction survey taken by tele-
phone follow-up of patients discharged from the
hospital.
Implications for Nursing Practice
Provide care andsupport to both infants and moth-
ers going through this experience.
Neonatal Head Trauma: Implementation of a Care Algorithm
to Improve Safety
Sandra Hoffman, MS, RN,
CNS-BC, Abbott Northwestern
Hospital, Minneapolis, MN
Purpose for the Program
To create a process by which newborns with
head trauma or at risk of complications of
neonatal head trauma are identified, assessed,
and monitored differently with the goal of improv-
ing safety.
Proposed Change
To create and implement a neonatal head trauma
algorithm that is part of the newborn standing or-
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.
S34 JOGNN, 41, S1-S118; 2012.DOI: 10.1111/j.1552-6909.2012.01360.x http://jognn.awhonn.org
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Braithwaite, P., Donahue, N. and Bayne, L. E. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Keywords
neonatal head trauma
vacuum extraction
forceps delivery
subgaleal hemorrhage
Newborn Care
Poster Presentation
Implementation, Outcomes, and Evaluation
Neonatal head trauma can result in catastrophic
outcomes, and it is essential that infants at risk
of complications of a difficult or instrumented de-
livery are identified and monitored more closely.
Complications, such as subgaleal hemorrhages
may manifest at birth or may occur over many
hours, so identification of infants at risk and in-creased vigilance is important for patient safety.
After a review of the literature, a multidisciplinary
team of neonatal and birthing clinical nurse spe-
cialists, pediatricians, a neonatologist, and a
neonatal nurse practitioner created a neonatal
head trauma algorithm to become part of the new-
born standing orders. Staff and physician educa-
tion was done regarding neonatal head trauma,
and the neonatal head trauma algorithm was im-
plemented across a large multihospital health sys-
tem. 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 traumathat may result from the birthing process. A stan-
dardized approach can ensure the identification
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 ap-
propriate pain management, and helps to keep
newborns safe.
Help! Im Cold! Improving the Warmth of Our Newborns
Pamela Braithwaite, BSN,RNC, Christiana Care Health
System, Bear, DE
Nicole Donahue, BSN, MSN,
RNC, Christiana Care,
Middletown, DE
Lynn E. Bayne, PhD, NNP-BC,
RN, Christiana Care Health
System, Newark, DE
Keywords
preterm
hypothermia
fishbone diagram
root-cause analysis
morbidity
mortalitypolyethylene
Newborn Care
Poster Presentation
Purpose for the Program
Cozy Cuties is a multidisciplinary performance
improvement team convened to address hy-
pothermia from birth to admission to the neona-
tal intensive care unit among inborn preterm in-
fants at less than 31 weeks gestational age. Re-
view of facility data over the past 5 years showed
that the initial admission temperatures of these
infants were significantly lower than average in
our neonatal intensive care unit (NICU) than the
benchmark of 850 NICUs within the Vermont Ox-
ford Network. Across this time period, 61% of the
infants who were less than 31 weeks gestational
age had body temperatures less than 36C at ad-
mission and were classified as hypothermic using
the World Health Organization definition. Two large
studies of infants from 23 weeks to 30 completed
weeks of gestation, suggested that when infants
are admitted to the NICU with hypothermia, their
chances of survival decrease by approximately
10% for every degree below 36C, independent
of any disease conditions. In addition, late onset
sepsis is increased by 11% and odds of death are
increased by 28%.
Proposed Change
Root cause analysis using fish bone techniques
was conducted on the first five cases of ad-
mission of hypothermia for each calendar month
over the 12-month period prior to project incep-tion. Literature was reviewed to establish potential
causes. A facility tour determined how many po-
tential causes existed and coupled the potential
cause with evidence-based interventions. A ther-
mal intervention bundle was developed and im-plemented. The bundle included a timeout-style
thermal checklist, increased room temperature,
proper radiant warmer preheat and use, short-
ened infant time at point of delivery for both vagi-
nal birth and cesarean birth, change in transfer
technique of newborn to a warmer from point of
delivery, effective use of polyethylene wrap, at-
tention 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 vari-
ety of methods, including video and social media.
Post-implementation, infants who were less than
31 weeks gestational age were prospectively fol-
lowed and the incidence of the outcome variableswas collected.
Implementation, Outcomes, and Evaluation
Data were analyzed, and findings 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 ef-
fective agent of change. It is important to bring
key stakeholders in a project to realize gains. Clin-
icians are obligated to benchmark practices thatmay contribute silently to patientillness. Body tem-
perature should never be taken for granted. The
goal shouldalwaysbe tokeepa warm infantwarm,
not to rewarm a cold infant.
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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Welcome Aboard and Homeward Bound: The NICU
Familys Journey for a Safe Voyage to Discharge
Geraldine Tamborelli, MS, RN,
Maine Medical Center,Portland, ME
Keywords
discharge
satisfaction
best practice
education
family centered care
multidisciplinary
Newborn Care
Poster Presentation
Purpose for the Program
Improveparent andstaffsatisfaction with the dis-charge 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.
Proposed Change
To standardize teaching, timing of education, doc-
umentation, and communication of education to
better prepare parents for discharge.
Implementation, Outcomes, and Evaluation
Implementation using Plan-Do-Study-Act cycles,staff and patient satisfaction, as well as chart au-
dits were used for measurement and feedback.
Implications for Nursing Practice
The best practice was identified and we continue
to maintain the gains by evaluating satisfaction
levels and random chart audits.
Birthways Lactation Services: A Model
for Breastfeeding Support
Angela Carswell, RN, IBCLC,
Mary Greeley Medical Center,
Ames, IA
Keywords
lactation program
exceeding national and state
breastfeeding rates
Newborn CarePoster Presentation
Purpose for the Program
The purpose of the Birthways Lactation Ser-
vices 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-find grants, or as in our hospitals case, bycommunity benefit 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 tohave a visit or when a visit was
physician ordered. Eight years ago, it was deter-
mined this was a costly way to deliver care even
with funds provided by a grant and some insur-
ance reimbursement. At that time we started the
clinic model and were encouraged by the pos-
itive 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 dis-charge, and provide a discharge feeding plan for
babies with feeding problems.
Implementation, Outcomes, and Evaluation
Three to five times per day, the coordinator of the
lactation program and her team perform checks
that include weight, jaundice, and lactation evalu-
ation.We believe ouroutcomes reflectthe 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,andour clinic model takes 1.2full time equivalents,
which represents a savings of more than $140,000
in salaries and mileage reimbursement. Our lacta-
tion consultants can see five 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 re-
searched and well documented. We believe our
program model is the best practice and is leading
the way in breastfeeding promotion and supportof
the American Academy of Pediatrics Policy State-
ment and theU.S. Surgeon Generals Call to Actionto Support Breastfeeding. Our service model de-
creases hospital readmission rates and promotes
exclusive breastfeeding with increased productiv-
ity and decreased cost.
S36 JOGNN, 41, S1-S118; 2012.DOI: 10.1111/j.1552-6909.2012.01360.x http://jognn.awhonn.org
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Keller, A. and Brenneman, A. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Operation Kangaroo Care
Anne Keller, MS, RNC, CNP,
OhioHealth, Columbus, OH
Alicia Brenneman, BSN, RNC,
Grant Medical CenterOhioHealth, Columbus, OH
Keywords
Kangaroo Care
cesarean birth
Newborn Care
Poster Presentation
Purpose for the Program
Kangaroo care is recommended in the Guide-
lines for Perinatal Care for stable newborns.
The act of placing the infant skin-to-skin (alsocalled Kangaroo care) with the mother has been
shown to maintain skin temperature regulation
of the newborn, increase initiation of successful
breastfeeding, and ease the transition for intrauter-
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
participated in skin-to-skin care. The staff started
to initiate Kangaroo care in the postanesthesia
care unit to provide all the benefits to the moth-
ers who had cesarean births.
Proposed Change
Before the initiation of skin-to-skin in the postanes-thesia care unit, infants had been removed from
the warmer after being wrapped with warm blan-
kets 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 in-
fant could benefit from skin-to-skin, then we should
adopt the practice with the cesarean birth infant.
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 whileleaving 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 mov-
ing the mother from the operating room table
to a hospital bed. Both are transported to the
postanesthesia care unit, initial checks are pre-
formed, and a baseline set of vitals is obtained
on the infant. The mother-infant pair is left skin-
to-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 over-
come traditional barriers of medical care to pro-
mote the empowerment of motherhood.
Infant Feeding Plan: An Innovative Documentation Tool to
Improve Communication between Caregivers and FamiliesJennifer Peterman, RN, BSN,
IBCLC, Hospital of the
University of Pennsylvania,
Philadelphia, PA
Keywords
breastfeeding
infant feeding plan
patientfamily centered care
Newborn Care
Poster Presentation
Purpose for the Program
A lack of communication was identified sur-
rounding a mothers feeding decision and
multiple health care providers. This lack of com-
munication resulted in a mothers perceived lack of
respect by providers regarding her preference for
newbornfeeding. To address this issue, an innova-
tive, crib side, infant feeding plan documentation
tool was created to identify a mothers preference
for feeding her newborn from birth through dis-
charge. Providers also noted a large variation be-
tween provider practices related to newborn feed-
ing and maternal preference.
Proposed Change
To improve communication between providers
and mothers, a crib side infant feeding plan doc-
umentation tool was implemented.
Implementation, Outcomes, and Evaluation
Prior to implementation, representatives from each
provider group involved in newborn care collab-
orated on the creation of the infant feeding plan
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 identified, a mutually agreed upon feeding
plan was created and signed by both the mother
and the nurse. Throughout the infants stay, the
plan waslocated 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 ongoingPrior 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, pa-
tients 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.
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Implications for Nursing Practice
This initiative provided an opportunity for nursing
to re-energize their commitments to patient com-
munication and infant feeding, especially breast-
feeding. 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 asso-
ciated 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 anyprovider caring for the infant.
A Baby Weigh Station: Continuum of Care for Late Preterm
Breastfeeding Infants
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
Newborn Care
Poster Presentation
Purpose for the Program
Late preterm infants who breastfeed are the
largest segment of preterm infants. In Colum-
bus, 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 6,456births/year in 2010). Late preterm infants often ap-
pear to be able to breastfeed successfully during
hospitalization, (hence, their nickname the great
imposter), but this may not be sustained follow-
ing discharge. As 1 of 15 sites for the Associ-
ation of Womens Health, Obstetric and Neona-
tal Nurses 2010 Late Preterm Infant Evidence-
Based Practice Guidelines research study, com-
mitment occurred in this hospitals outpatient set-
ting 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 commu-nity resource where 90% of late preterm infants
will gain weight after events of lactation consulta-
tion and first weight measurement.
Implementation, Outcomes, and Evaluation
Utilize a baby weigh station within a user-friendly
lactation support center to offer a community ac-
cessible 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 preterminfants who were consulted
and weighed on more than one visit, the followingformula 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 individ-
ual late preterm infant weights were measured:
116 had repeated weights and 99% demonstrated
weight gain (monthly averages). Additional bene-
fits included referrals to lactation, pediatrics, pe-
diatric surgery, and behavioral services. An ac-
cessible weigh station was evaluated to be an ef-
fective 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 ap-
proachable staff and expert professionals is an
effective means to continue and grow client re-
lationships. Monitor at-risk groups for anticipated
problems and provide a portal for continuing care.
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Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Increasing Exclusive Breast Milk Feeding Rates at an Urban
Academic Hospital
Laurie Dohnalek, RN, MBA,
NE-BC, Georgetown UniversityHospital, Washington, DC
Cynthia Heer, RNC-OB,
RN-BC, MSN, Georgetown
University Hospital,
Washington, DC
Elizabeth Starrels, RN, BSN,
IBCLC, Georgetown University
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
Newborn Care
Poster Presentation
Purpose for the Program
To increase exclusive breast milk feeding ratesat an urban academic hospital.
Proposed Change
Over an 18-month periodinterventions were imple-
mented to increase exclusive breast milk feeding
rates by at least 10%.
Implementation, Outcomes, and Evaluation
To implement this program, the following interven-
tions were completed:
Creation and implementation of Donor Pas-
teurized Milk Policy; all nurses attended
mandatory education session
Implementation of 24-hour rooming in (noseparation of mothersand newborns viastan-
dard nursery) Survey given to patients to identify the most
popular reasons for supplementation Journal clubs discussing breastfeeding is-
sues Consultations with lactation consultants at
other facilities Increasing rates and duration of initial skin-to-
skin contact and first breastfeeding session Daily patient rounds and assessments by in-
ternational board certified lactation consul-
tant Mandatory interdisciplinary breastfeeding
education for all nurses, obstetricians, andpediatricians
Education related to alternative breast milk
feeding methods Outside speaker (international board certi-
fied lactation consultant) that moderated dis-
cussion of obstacles to exclusive breast milk
feeding Feeding care plans (for complicated situa-
tions) developed collaboratively with nurses
and international board certified lactation
consultants Implementation of mother and newborn
quiet time
These interventions were implemented and the re-
sult was an increase in the staffs knowledge and
skills, thus changing practice and creating confi-
dence. 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 patient-
based survey to evaluate the effectiveness of the
interventions.
Implications for Nursing Practice
Education is a major aspect of our initiative to in-
crease exclusive breast milk feeding rates. The
low incidence of exclusive breastfeeding is par-
tially due to a lack of breastfeeding knowledge
among health care professionals. Educational pro-
grams that increase nurses knowledge and im-
prove attitudes toward breastfeeding promote ac-
curate and reliable delivery of breastfeeding infor-
mation and skills to the mothers. These programs
also encourage positive role modeling of support-
ive breastfeeding attitudes. This may improve ex-clusive breast milk feeding rates because of the
effect that this has on patients. Many of the in-
terventions 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
Newborn Care
Poster Presentation
Purpose for the Program
E
xclusive breastfeeding is best for the infant
and mother. Evidence-based practice de-
scribes 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, fam-
ily, and staff within womens services. It is the re-
sponsibility of us all to help mothers be successful
and promote the recommendations of the Asso-
ciation of Womens Health, Obstetric and Neona-
tal 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 breastfeed-
ing, 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 lacta-
tion 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? Whatabout 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 for-
mula never hurt. What about labor and delivery
nurses who say, Breastfeeding is not our job, its
the lactation consultants job. Extensive educa-
tion was needed for womens services staff, physi-
cians, parents, and families.
Implementation, Outcomes and Evaluation
The nurse educator and lactation consultant de-
veloped 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 pre-
sented. Benefits of breastfeeding for the mother,
infant, and community were discussed. Many ex-
amples of hospital practices that decrease suc-
cess of exclusive breastfeeding were recalled.
Skin-to-skin care and rooming in were discussed.
In North Carolina, we have the Perinatal Qual-
ity Collaborative of North Carolina for exclusivebreastfeeding. 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 Col-
laborative of North Carolina project for exclusive
breastfeeding.
Implications for Nursing Practice
We want to provide thebest practice and the litera-
ture supports exclusive breastfeeding. As obstet-
ric nurses, we have power to educate andsupport
mothers and families to make informed decisions
about their individual infants care.
Now I Lay Me Back to Sleep . . . .Safely
Courtnie J. Burrell, RNC,
Henrico Doctors Hospital,
Richmond, VA
Diane Stairs, RN, Henrico
Doctors Hospital, Richmond,
VA
Keywords
SIDS
safe sleepmodel
Newborn Care
Poster Presentation
Purpose for the Program
One of the Healthy People 2020 goals is to im-
prove the health and well being of women,
infants, children, and families. One way to accom-
plish 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 beenproven that supine sleeping is the greatest fac-
tor in reducing the risk of SIDS even though many
nurses still feel more comfortable placingthe baby
prone. Hospital nurses are the first professional
role models for new parents. Modeling suggested
behaviors, such as back sleeping, can be a pow-
erful education tool as well as parental education
through verbal and written educational materials.
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 resusci-
tation classes.
Implementation, Outcomes, and Evaluation
The safe sleep task force was initiated and a hos-
pital policy on safe sleep was written. The staff
received mandatory in-services regarding SIDS to
ensure consistency in parental education. One in-
service was on SIDS and SIDS risks in the term
newbornand the other addressed the needs of the
prematureinfant. Safe sleep education was added
to the March of Dimes notebook, which all parentsof 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.
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 andto encourage the staff
continued participation and support. Integrating
evidence-based findings into practice will facili-
tate 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. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Implementing Skin-to-Skin Care in a Baby-Friendly
Community Hospital
Jennifer L. Reeg, MSN, RNC,
Health First Cape CanaveralHospital, 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
Newborn Care
Poster Presentation
Purpose for the Program
To improve motherinfant attachment andbreastfeeding.
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-to-
skin at birth and in the immediate postpartum pe-
riod was incorporated into our labor, delivery, re-
covery, and postpartum (LDRP) unit, and encour-
aged during the entirety of the postpartum stay.Staff nurses were educated in appropriate skin-to-
skin techniques and patient instruction, first in a
small group interactive setting and later followed
with a video and discussion format. Patient ed-
ucation 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 new-
born skin-to-skin for up to 6 hours a day for the first
week oflife and a minimum of2 hours a day for the
second week through fourth week. Mothers were
assured that anyone, e.g., fathersand grandmoth-
ers, can engage in the skin-to-skin care with the
infant. Studies have reported benefits of skin-to-skin care of the newborn to include reduced cry-
ing, improved motherinfant interaction, warmer
babies, and greater breastfeeding success. Ad-
ditional positive effects on neonatal self-regulation
during the transition from intrauterine to extrauter-ine life include increased sleep, decreased apnea
and bradycardia, improved respiration and oxy-
gen saturation, accelerated weight gain, and, for
the mother, increased milk production. The staff at
Cape Canaveral Hospital has observed anecdotal
evidence of these benefits.
The nursing and lactation staff at Cape Canaveral
Hospital strive to achieve skin-to-skin care with ev-
ery 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
first hour of life, and of documentation of mothereducation on benefits of skin-to-skin care. Results
show a 90% success rate, indicative of a positive
trend in the number of motherbaby couplets opt-
ing 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 first weeks.
Implications for Nursing Practice
The practice of skin-to-skin care as a component
of our baby friendly philosophy contributes posi-
tively to neonatal transition, enhances attachment,
and promises long-term benefit 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
Newborn Care
Poster Presentation
Purpose for the Program
T
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 sched-
uled feeding method to initiate and progress oral
feedings. Several studies have come out to sup-
port 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 pro-
gression of oral feedings for each individual, withclose attention paid to the infants developmental
cuesto 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 nurs-
ing policy and guideline, and a continuing educa-
tion offering. The education ranged in topics, such
as benefits of cue-based feeding, how to read in-fant cues, how to use a cue-based feeding scale
form, educating parents, and trouble shooting. Af-
ter implementation, bedside charts were audited
to assess staff adherence with cue-based feed-
ing 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 lan-guage in our unit and is considered a success.
Research is currently underway in our unit to as-
sess time to full oral feedings and the effect on
direct breastfeeding rates. Future research to con-
sider 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
Jennifer L. Notestine, BSN,RNC-NIC, Mount Carmel East
Hospital, Columbus, OH
Teresa L. Rapp, RN, NNP-BC,
Mount Carmel East Hospital,
Columbus, OH
Keywords
noise
neurodevelopment
neonate
neonatal intensive care unit
Newborn Care
Poster Presentation
Purpose for the Program
Multiple studies have shown that excessive
noise affects neurodevelopment in infants.
Our clinical excellence committee wanted to ex-
plore the noise levels in our neonatal intensive
care unit (NICU). Our findings were that our levels
exceeded recommended levels. Based on these
findings, 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 imple-
mented noise-reduction strategies in an attempt
to decrease our overall noise level.
Implementation, Outcomes, and Evaluation
Our clinical excellence committee presented edu-
cation on the effects of excess noise with the sup-
portof the hospital leadership. Education includedpresentations in unit meetings as well as poster
presentations. Specific noise-reduction strategies
were proposed by the clinical excellence commit-
tee and agreed upon by the staff. Strategies were
implemented by the staff and follow-up monitoring
was completed to assess effectiveness.
Implications for Nursing Practice
Research has shown that the immediate effects
of elevated levels of sound show that environ-
mental noise can be a major source of stressful
stimulation, can cause agitation, and bring about
complications in the medical management of theneonate. Heightened awareness of the effects of
noise in the NICU promotes an optimal environ-
ment for positive developmental outcomes.
Exploring New Frontiers: Providing Skin-to-Skin Contact
for Mothers and Newborns during Cesarean Birth
Nora C. Fortin, RNC-OB, BSN,
Wentworth Douglass Hospital,
Dover, NH
Keywords
skin-to-skin
patient satisfaction
neonatal thermoregulation
Newborn Care
Poster Presentation
Purpose for the Program
As cesarean birth rates increased in the United
States in response to the American Col-
lege of Obstetricians and Gynecologists state-
ment concerning vaginal birth after cesarean,
studies demonstrated higher dissatisfaction with
childbirth experiences. Women giving birth by ce-
sarean are more prone to postpartum depression,
bonding difficulties, and unsuccessful breastfeed-
ing.
Proposed Change
To increase maternal delivery satisfaction, we de-
veloped a plan to provide skin-to-skin contact
immediately after cesarean births. The proposed
change broke the barriers between the traditional
surgical environment and the delivery room and
required collaboration between the departments
of surgical services, anesthesia, pediatrics, and
obstetrics.
Implementation, Outcomes, and Evaluation
Informal surveys of patient satisfaction since im-
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.
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Fortin, N. C. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Moms Own Milk Bundle: Increasing Supply in an 83 Bed,
Level III, Neonatal Intensive Care Unit
E. Christina Conner, BSN, RN,
IBCLC, Baylor University
Medical Center at Dallas,
Dallas, TX
Keywords
breast milk
NICU
quality initiatives
collaborative
increasing
milk supply
Newborn Care
Poster Presentation
Purpose for the Program
Hospitals are encouraged to step up
evidence-based practices with various ini-
tiatives, such as The Joint Commission Perinatal
Core Measures and Baby Friendly Hospital Ini-
tiative, 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, collabo-
rative 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 through-
out the Women and Childrens Service line to ini-
tiate and maintain the mothers milk supply. Im-
provements are focused on the barriers mothers
face when providing milk and discovering an in-
novative 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 fiscal expenditures spent on donor milk,
our goal is projected to decrease donor milk use,
decrease medical and surgical necrotizing ente-
rocolitis rates, and decrease length of stay.
Implications for Nursing Practice
The MOM Bundle is a collaborative approach toincrease the availability and volume of mothers
milk in our Level III, 83-bed, NICU. Working to-
gether with our medical, nursing, and NICU sup-
port staff, we project an increase in moms own
milk, which benefits the mother, the infant, and the
hospital goals.
Virtual Special Care Nursery: A Cost Savings Idea
Michelle M. McFail, MSN,
RNC-OB, Baptist Health, LittleRock, AR
Keywords
special care
length of stay
late preterm infant
Newborn Care
Poster Presentation
Purpose for the Program
The purpose of the virtual special care nurs-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 monitor-
ing 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 follow-
ing evidence-based guidelines. The care wouldbe provided in the mothers room or the well-baby
nursery.
Implementation, Outcomes, and Evaluation
Over a 6-month timeframe, information was gath-
ered, equipment purchased, protocols estab-
lished, 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 wereadmitted to the NICU prior to the implementation
of the special care nursery. After 6 months of im-
plementation, 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 theinfant to remain with the family. Having the in-
fant in close proximity increases the time avail-
able for educating the mother about the unique
needs of the special care infant and allows her
to feel an increased sense of confidence when
taking the infant home. This process increases
the nursing staffs satisfaction about the care they
provide.
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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Two Phase Innovative Approach for Newborns at Risk
of Hyperbilirubinemia
Martha Montes, BSN, RN,
University of Illinois MedicalCenter, Chicago, IL
Lourdes Notario, BSN, RN,
University of Illinois Medical
Center, Chicago, IL
Keywords
hyperbilirubinemia
phototherapy
transcutaneous bilirubin (Tcb)
Bili clinic
Newborn Care
Poster Presentation
Purpose for the Program
Each year approximately 60% of the 4 mil-lion 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 hyper-
bilirubinemia 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 hyper-
bilirubinemia 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 hyperbiliru-
binemia 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 evalua-
tion and treatment process by instituting a week-
end and holiday Bili Clinic on the mother-baby
unit.
Implementation, Outcomes, and Evaluation
To identify infants at risk, we instituted collection
of cord blood type and Coombs testing at deliv-
ery for mothers with blood type O positive or RHnegative blood types. Furthermore, all newborns
after 24 hours of life had a transcutaneous biliru-
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 hyper-
bilirubinemia andinitiate treatment in a timelyman-
ner. 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) identified 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 follow-
up, the staff activated the Bili Clinic process, noti-
fied the newborn health care provider of the new-
borns arrival, and initiated procedures (weight,
transcutaneous bilirubin, or serum bilirubin) as re-
quested. Based on the test results, the decision
was made to provide further patient follow-up,
discharge home, or admit the newborn for treat-
ment. 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 efficiency of workflow for nursing staff. Infants
received phototherapy in a timelier manner and
thus increased patient and nurse satisfaction, de-creased overall costs, and promoted better out-
comes for the patient.
Operationalizing Palliative Care Processes through a
Perinatal Palliative Care Program
Becky Gams, RN, MS, CNP,
University of Minnesota
Medical Center, Fairview,
Minneapolis, MN
Keywords
comfort care
palliative
loss
newborn
life-limiting
fetal
Newborn Care
Poster Presentation
Purpose for the Program
Parents who receive a life-limiting fetal diag-
nosis face many unexpected decisions: con-
tinue the pregnancy or proceed with early termi-
nation, 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 family-
centered, multidisciplinary program that provides
a continuum of medical, emotional, psychosocial,
and spiritual support through diagnosis, preg-
nancy, birth, and death. Throughout this process,
parents are supported in creating a plan of care
for theirbabythatis consistent with their goalsand
wishes. The program goals address the National
Quality Forums Preferred Practices for Palliative
Care and support caregivers in meeting palliative
care outcomes.
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Gams, B. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Implementation, Outcomes, and Evaluation
Historically, care for these families was heroically
pulled together by a few dedicated and passion-
ate 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 formalizethe 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 pro-
cess. The palliative care approach is enhanced
by our established Pregnancy and Newborn Loss
program. Although current numbers are small, av-
eragingfourper year from 2008 to 2010, eight fam-
ilies were served in 2011 (year-to-date). Families
commented that this was the happiest and sad-
dest day of my life. Data from patient satisfaction
surveys and multidisciplinary debriefings are dis-
seminated to the health care team. Within this sup-
portive formalized structure, a broad health care
team accommodates the individual needs and cir-
cumstances 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 re-
cently established Fetal Diagnostic and Treatment
Center. Program scope, role definitions, respon-
sibilities for maternal and neonatal medical man-
agement, program access, and multidisciplinary
education will be described. A detailed birth plan
template, newborn comfort care orders, care con-
ference documentation, and process workflow will
be displayed.
Baby Cuddlers Make a Difference
Monica C. Kraynek, MS,
RNC-LRN, RN-BC, The
Western Pennsylvania Hospital,
Pittsburgh, PA
Mona Patterson, RN, BSN, The
Western Pennsylvania Hospital,
Pittsburgh, PA
Christina Westbrook, RN, BSN,
MSN, MBA, The WesternPennsylvania Hospital,
Pittsburgh, PA
Keywords
baby cuddler
neonatal abstinence
length of stay
Newborn Care
Poster Presentation
Purpose for the Program
The number of newborn infants treated every
year at the Western Pennsylvania Hospital
for neonatal abstinence syndrome (NAS) has in-
creased more than 150% since 2004. Nurses con-
duct the Finnegan Neonatal Abstinence Scoring
Tool every 2 hours to analyze the infants with-
drawal symptoms and determine if pharmaco-
logic intervention is necessary and/or effective.Up to 30% of infants may be managed without
medication. Interventions for treatment of these
infants include medication and supportive care.
The purpose of the program, as a unit evidence-
based practice project, was to learn if the addition
of baby cuddlers as caregivers could affect the
length of stay required for treatment of these in-
fants.
Proposed Change
A baby cuddler is a trained baby holder who
can fill the gaps when parents are not able to bepresent. The cuddler provides an important com-
ponent of the developmental care for the hospi-
talized infant. The importance of human contact
and touch in the well being of all hospitalized in-
fants 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-five infants were admitted to the depart-
ment with the diagnosis of NAS in the 1-year study
period from May 2009 to May 2010. Length of stay
was compared from the first 6 months without the
baby cuddler program to the last 6 months after
the initiation of the program. From May 2009 to Oc-
tober 2009, the average length of stay for infants
with NAS was 26.2 days without the baby cud-dler 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 official 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 ini-
tial 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 2,855hours 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 financesand provides quality patient care
to a vulnerable population.
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I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
Normal Newborn Nursery Neonatal Intensive Care Unit:
Whats in Between?
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
Newborn Care
Poster Presentation
Purpose for the Program
A trend of term newborns requiring transferfrom the newborn nursery to the neonatal in-
tensive care unit (NICU) was identified in a Level
III NICU at a Magnet hospital. This offering will de-
tail the pragmatic strategies utilized to decrease
NICU admissions of high-risk transition newborns
and present specific obstetric-related diagnoses.
Proposed Change
To develop standards in clinical practice to pro-
mote newborn stabilization specific to newborns
delivered between 35 and 36 weeks of gestation,
born to mothers with chorioamnionitis or diabetes
who received intravenous (IV) insulin during la-
bor. Nurses are critical to assess, plan, act, and
evaluate care for high-risk transition newborns to
improve clinical outcomes and increase efficiency.
Implementation, Outcomes, and Evaluation
A collaborative team approach was taken to es-
tablish 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 obser-
vation. Glucose management, breastfeeding, and
newborn admission policies were revised to re-
flect new processes. The criteria and interventionswere standardized and embedded into practice. A
multidisciplinary approach was utilized to assure
all care providers involved with maternalnewborncare received education, including process flow
charts, algorithms, and reference cards. The cri-
teria were communicated to the family prior to de-
livery 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 transi-
tion 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 in-
stability 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 transitionnewborns.
Wait for Eight: Improvement of Newborn Outcomes
by the Implementation of Newborn Bath Delay
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
Newborn Care
Poster Presentation
Purpose for the Program
To improve newborn outcomes by implement-
ing the evidence-based research to delay
bathing the newborn.
Proposed Change
To improve newborn outcomes, implementation
of evidence-based research was initiated. Imple-
mentation of bath delay showed that regardless
of gestational age, the incidence of newborns ex-
periencing 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 pri-
oritization of the nursing task over the outcomes
of bathing, the newborn, newborn care guidelines
including revision of newborn order sets were es-
tablished. Reference to evidence-based research
and data collection post-implementation of guide-
lines were utilized. Multidisciplinary team actions
involved evidence-based practice data regarding
the effectiveness of newborn bath delay. Script-
ing 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.
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Lipka, D. V. and Schulz, M. K. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention
The description of the process from admission to
discharge identified the value in bath delay related
to skin-to-skin research. Global hospital staff edu-
cation was initiated and staff were presented with
advice to give to parents and families during new-
born care education.The value of skin-to-skin care
with transition, bonding, and breastfeeding was
emphasized. Our efforts were validated by the im-proved outcomes of practice change of newborn
bath delay, which resulted in increasedpatient sat-
isfaction.
Implications for Nursing Practice
Historical review of newborn care delivery demon-
strated that nursing has shown to place prior-
ity on the completion of nursing tasks over the
outcomes related to the newborn transitional pe-
riod. To improve newborn outcomes, implemen-
tation of evidence-based research was initiated
to foster practice change. The research of skin-to-
skin practice directly correlated the needto review
newborn care and practices thereof. The need to
review one such practice was the newborn bath.
Recognition of the importance of an uninterruptednewborn transition resulted in positive newborn
outcomes and patient satisfaction. Implementa-
tion of bath delay showed that regardless of ges-
tational age, the incidence of newborns experi-
encing 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,
RNC-NIC, IBCLC, Mission
Hospital System, Asheville, NC
Jennifer Wilkinson, BSN,
RNC-NIC, Mission Hospital
System, Asheville, NC
Keywords
low birth weight babies
breast milk
NICU
buccal care
Newborn CarePoster Presentation
Purpose for the Program
There is overwhelming evidence in the literature
that human milk is superior to any form of nu-
trition for the neonate. It contains immunological,
nutritional, and developmental properties that pre-
vent 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 vulner-
able to morbidities, including necrotizing enteral
colitis and nosocomial infections. Human milk de-
creases the incidence and severity of nosocomialinfections and necrotizing enteral colitis. It also
has been proven to protect against gastrointesti-
nal and respiratory infections. Its perfect combi-
nation of protein, carbohydrates, and plasma pro-
teins 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.
Proposed Change
The nursing intervention of buccal application of a
mothers colostrum potentially decreases the inci-
dence of certain morbidities and decreases the
length of stay of these fragile infants. The pro-
posed change in practice is to institute a policyof 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 Jan-
uary 2011. Staff education was completed at staff
meetings via slide presentations. The completed
policy also includes an education sheet for par-
ents as a means of encouraging their participation
in this bedside practice.
Implications for Nursing Practice
Due to the limited availability of colostrum, moth-
ers arebeing encouraged to begin pumping within
6 hours of delivery and pump on a prescribed
schedule. We created syringe kits with detailed
instruct