MILLENIUM NEONATOLOGY: BUILDING FOR THE FUTURE James Padbury, MD Pediatrician-In-Chief Marybeth Taub, RN, BSN Nurse ManagerNICU Abbot Laptook, MD Medical Director, NICU Jesse Bender, MD Co-Director Simulation The Dilemma Background Move to the new building: • Site visits • 10,000 sq ft to 50,000 sq ft • Huge cultural shift • Model of care and flow of care changes • Simulation for orientation to the new facility This was not how to optimally care for these children and their families. Can refinements in the design of facilities lead to additional improvements in outcomes for children? For their families? • The “NICU Study” Guiding Principles Family-centered care: parents as “partners” Developmentally supportive care environment Clinical excellence Design Principles Welcoming and reassuring Single family rooms Staff invested Clarity of organization Incorporate established evidence-based clinical and Zoning of NICU safety practices Point of service care Planning/incorporating future flexibility/sustainability Location: single NICU Balance between staff and family needs “Green Design” Sensitivity to end of life issues Unique W&I identity 1 Overview Things we did right Benchmarking: Site Visits Vanderbilt University Children’s Hospital Nashville, Tennessee Blank Children’s Hospital Des Moines, Iowa Mock Room Floor Floor 32 Northside Hospital Atlanta, Georgia Scottish Rite Children’s Hospital Atlanta, Georgia Children’s Hospitals – St. Paul St. Paul, Minnesota Women & Infants Providence, Rhode Island New Site Plan NICU Room Multidisciplinary Team Center 20 Bed Neighborhood Suzanne and Terrance Murray Family Center 20 Bed Neighborhood 70 rooms, 80 beds, 2 floors The overall design, “green” construction and improved quality of life led to LEEDS Gold Certification! 2 NICU Room Twin Room “Neighborhood” Corridor Nurses Alcove Clustering and Visual Communication 3 “TESTPILOT” Family Center Transportable Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing Scope • Using Simulation created 4‐6 complex scenarios to play out. • Scripted established and new roles • Used an entire “neighborhood” • Done 6‐9 weeks prior to the move. • Used Sim New BabyTm and other mannequins to provide as real life as possible. • New technology and computer use adapted, tested, and refined. New Technology Developed for the new unit: ASCOM Phones • Functionality (In our unit) o o o o o o o Bedside Alarms Buddy Groups Nurse Call Code Blue Delivery Team “Bridge Phone” to 10 people Critical labs CPOE Issue Types Facilities 21% Organizational 23% Technical 12% Resolution Ergonomics 19% Communication 25% Process Integrated 30% Training into practice 43% Ergonomics 19% Unresolved 7% New Technology Developed for the new unit: Share Point Communication • Functionality In our unit o o o o o o Who is where Who is on what phone Who has each child What is theme for the day in each room Who is coming, who is going and who is post‐ op Who is critical 4 Team 1 Team II Assignments: UpdatedSeptember 20, 2010 Sunday Lisa Hutchison Beth Brannan Lauren Ward Caitlin Hurley Carrie Gregory call post-call call 6 August 2010 Monday 7 Tuesday Wednesday 8 9 Diossa-Spell watch DelNegro-AL feeds Thomson-Spell watch Res 3: 4680 Pierce Hache A Beck A Wingate Hebert Coelho Beltran Pagano David McGrady B Medeiros 10 Res 4: 4681 2347 Mota 2440 Blevins 2441 Sperlongano 2442 Picci 2415 Eldridge 2414 Robey 2413 2315 Kaminski Ciccarone Smotherman Hernandez A Hernandez B Bello B 2348 2352 2412 2410 2410 3316 Res 6: 4683 Simpson Tith Izzi Grandy Henault Res 7: 4684 2311 Vacarro 2344 Lenney A 2350 Lenney B 2351 Mabrouk 2448 Lach Sargent 2312 2314 2314 2346 2417 2446 Marcoux Rodriguez-Spell watch Dossantos-Growth, crib Ribiero-Spell watch Skaarup-Spell watch 13 6 6 5 Team II Census 6 33 Attending 4687 Dr. Stonestreet CALL Fellow 4689 Delivery Dr. Nayak Paula Intern: Beth Senior: Farid Senior 4680 Lisa H. Fellow: Mirza Swing 4679 Farid 4679 20 Alvira-need 48 hrs feeds w/o desat TEAM II Overview Friday 11 Museler-Spell watch Saap-HIDA scan results Alvarenga-Wean to crib, feeds Saturday 12 Chase B-Feeds, Spell Watch Medina-watch temp, feeds KaplunNovakB-AL feeds 14 15 16 17 18 19 DeBrotto? Board NN if feeds wel Scotti-if gaining wt Furlong A-wean to crib, PereiraDomara-all F/U feeds arranged Voeul-if no spells & nl wt gain NoonanB-if bili is ok and feeds well 21 22 23 24 Bogie: if clinically stable, neg bd cx, feeding Riguer - no A/B/Ds 2416 2445 ADMISSIONS TEAM I Res 5: 4682 2313 2317 2450 2447 2444 2349 Thursday 10 Copley B-Sweat test, repeat bili Threats-family teaching Killory-if all PO feeds Furlong B-if no spells Kerr-if no spells Chase-five day spell ??Folco-after MRI & watch Rx teaching NoonanA-if wt is good and Rx training Debrito-NNN; no desats & wnl wt gain 27 28 Jackson- end spell Folco - after skin 29 30 25 26 Dipanni-if no desats w/feeds 31 Mabbett - wt gain/feeds/crib Parent Satisfaction Press Ganey Scores FY 2008 ‐ 2010 Is it working? • Database Ranking 2008, 10‐40% • Database ranking 2009 ‐12, 88.9% ‐ 95% • Peer Group Ranking 2009 ‐12, 99.9% 5/10 quarters 5 NICU Design and Infant Outcomes Data Analysis: Model Pulmonary Infant Medical & Neurobehavioral Outcomes Open Bay vs. Single Room Implement DevCare Cardiovascular Nutrition/GI Infectious Dis Family Centered Care Medical Medical Practice Practice AttPractice Att / Practice AttAttPractice / Practice (Nurse M) (Nurse) Parents Family Centered Care Developmental Care Nurse Educator CNS Developmental Care Infant Infant Outcome Outcome NICU Parent/Family Factors Stress Staff Behavior/Attitudes Burnout Parent// Parent family family Staff StaffBehavior/ Behavior / Attitude Attitude Practice Environment Medical Practices Parenting Behavior Parent Stress Maternal Concerns Maternal Depression Parent Satisfaction Family Function Timeline 2008-2009 OPEN BAY NICU Medical Outcomes Neurobehavior Outcomes Family Centered Care Developmental Care Parent/Family X X X X X X X X Staff X X X X Medical Practices X X X X < 26 week Gestation Goals Aids to Self Regulation At Rest 1)Promote rest/sleep/energy conservation. 2)Enhance physiologic & temperature regulation. 3)Minimize discomfort and energy expenditure. 4)Acknowledge & support role of family in infant care (bedspace personalized for infant; parents’ presence at bedside encouraged;explanation of care procedures/equipment.) 2010-2011 SINGLE ROOM NICU T R A N S I T I O N 27 & 28 week Gestation X X X X X X X X X X X X X X X x 29 & 30 week Gestation 31 to 32 week Gestation 1) Infant will be able to tolerate care without a loss of physiologic stability. 2) Parents will be able to recognize infant cues & needs. 3) Parents will have a steadily increasing role in providing infant care. Data Analysis: Model 1) Increasing awake/quiet alert states 2) Increasing ability to self-soothe. 3) Increasing repertoire & quality of active m 1)Bedspace free of drafts; heat lamp Schedule for blood draws, radiologic tests, infant assessments modified to accommodate rest/sleep/tolerance. 2)Supine/sidelying: Head toward midline; shoulders forward toward ventral support (e.g., “inchworm”). 3)Prone: Ventral support; arms & legs flexed and tucked; hips & ankles in neutral (using props as needed). 4)Proper diaper size to avoid excessive hip abduction. 5)Containment/boundaries provided when appropriate (i.e., effective nesting, swaddling &/or snuggle-up). 6)Gel pad beneath head when appropriate. Pulmonary Aids to Self Regulation During Care 1)Containment & slow handling during position changes. 2)Pacifier/finger-hold/swaddling/facilitative tucking provided during stressful handling/procedures, e.g., : (1)Suctioning (2)PIV/Venipuncture (3)Heel-sticks (4)Retinal Exam 3) Modified/reduced stimulation during care in response to infant’s behavioral cues of stress. 1) Heat lamp/draped for warmth during sponge bath 1)Minimal activity/handling. 2)Reduced activity/sound levels at bedside. 3)Shield eyes from bright lighting. 4)Correctly-sized pacifier for non-nutritive sucking when awake. Developmenta lly Appropriate Sensory Experiences Family Participation Nutrition/GI Infectious Dis Medical Medical Practice Practice AttPractice Att / Practice AttAttPractice / Practice (Nurse M) (Nurse) Parents Family Centered Care Developmental Care Nurse Educator CNS 1) Infant Infant Outcome Outcome Swaddle- 1)Cycle lighting 2)Social stimuli (parent/caregiver face &/or voice). 3)Speak softly before touching/changing position. 4)Provide finger to grasp. 5)Sustained touch/Kangaroo Care/containment). 6)Non-nutritive sucking on own hand/pacifier when awake or during feedings. 7)Parent holding/Kangaroo Care. 8)Semi-upright position & social approaches during awake periods. 9)Provide one sensory modality at a time. 10)Introduce music/pleasant sounds for brief periods of time. 11)Gentle rocking/upright holding at shoulder. 12)Initiate infant massage if appropriate. 13)Encourage hand to mouth/face; non-nutritive sucking on hand/pacifier. 1. Encourage social responsiveness. 2. Visual fixation & following – patterned stimu 2) Musical toys/ soft sounds (e.g., aquarium) 1)Teach attunement to infant cues of stress & self-regulation, containment vs.. stroking, swaddling. 2)Kangaroo Care when infant is deemed sufficiently stable. 3)Encourage journaling. 4)Introduce Care-Pages Website. 5) Encourage attendance at Parent Hours/Kids Klub. Implement DevCare Cardiovascular 1) Begin back to s 2) Monitor for hea 3) Educate paren NICU Stress Burnout Parent/ Parent / family family Staff StaffBehavior/ Behavior / Attitude Attitude Practice Environment Parenting Behavior Parent Stress Maternal Concerns Maternal Depression Parent Satisfaction Family Function 1) Instruct parent (s) in infant massage 6 Structural Equation Modeling Medical Practice Hypothetical: NICU Main Effect Family Centered Care Developmental Care Infant Outcome NICU β=.70 Infant Outcome NICU Parent/ family Staff Behavior/ Attitude Hypothetical: NICU Reduced Effect Hypothetical: No NICU Effect Comparative Fit Index >.95 Comparative Fit Index >.95 Medical Practice β=.21 Family Centered Care Developmental Care β=.19 NICU β=.23 β=.24 Medical Practice β=.27 β=.50 β=.20 β=.28 β=.22 Staff Behavior/ Attitude β=.31 β=.18 Parent/ family Things we did wrong • • • • • • • • • β=.29 β=.20 Infant Outcome Sinks at each entrance foyer Size of the front door Breakaway doors (out vs in) Plugs in the hallways Weight of the storage cabinetry Pixus deployment Triplet rooms, NO! Twin room in ea neighborhood, YES! Family kitchen area is smallish Family Centered Care Developmental Care β=.33 β=.37 β=.34 β=.30 NICU Infant Outcome β=.N.S β=.30 β=.38 Staff Behavior/ Attitude β=.32 β=.28 Parent/ family Acknowledgements Carter Family NICU Staff, Families and Donors! Brown Center for Children at Risk 7
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