newborn nursing care standards - saskatchewan union...

Newborn Nursing Care Standards

Patient Safety and Positive Outcomes

Presented by: Jana Poitras & Barb Lauman-Hartmier Date: September 26, 2012

Location: TCU Place, Saskatoon

Why a Committee ??

Why did we create a Newborn Nursing Committee??

Why was the Committee formed ??

• Once born, baby is looked after by 2, possibly 3 separate units.

• All 3 units had different practices and expectations, and poor communication, which often resulted in errors and caused many frustrations for parents and staff.

Project Team Members

Missing: Jennifer Cherwinski, Julie Johnson, Kim Comrie, Ruby Forstner,

Jacki Shannon, Tom Sorensen, Glenys Weisshaar, Michelle Downton as well as everyone on the Mother Baby Unit, Newborn Nursery, and the Labour and Birth Unit.

Anita’s Vision

"Wouldn't it be nice if the Regina General Hospital, a hospital in Saskatchewan, the birthplace of Medicare, was so exceptional it was the standard to which all other hospitals in Saskatchewan, and in fact, Canada are measured."

What were some of the challenges we faced ???

Our future state: What we Envisioned !!!

Goal: Ensure all healthy newborns receive consistent, clinical best practice care across the continuum of care.

Improvement: What actions did we take?

Kaizen #1: (Jan 31-Feb 2) Creating Standardized Processes for Consistent Care of the

Newborn Baby Kaizen #2: (Mar 6-8) Creating a Clear Concise Communication Document for

Baby’s Information Kaizen #3: (Mar 26-28) Creation of Breastfeeding Support Room Kaizen #4: (May 1 - 3) Communication for parents about their newborn baby

Pre-project Phase for Kaizen #1

• Baseline Data: breastfeeding, delays of transfer, newborn temperature upon admission to Mother Baby unit, delays and errors in administration of medications and treatments.

• Environmental Scan: Standardized processes for consistent care based on best practice guidelines.

• Literature Search

RQHR Baseline Data

Measurement: How did we know that the changes were an

improvement?

Developed Standard Work

Standardized processes for consistent care based on best practice guidelines:

RQHR Care of the Healthy Newborn

Responsibility Time Process Step L&B / NICU

1min & 5 Min, and prn APGARS

L&B / NBN Within 1Hr,

and prn Temp, HR, Respirations, Colour, Activity, Tone

L&B / NBN/ MBU

Within 2Hr,

and prn Temp, HR, Respirations, Colour, Activity, Tone

L&B/ MBU/ NBN

At 6Hr, and prn Temp, HR, Respirations, Colour, Activity, Tone

MBU / NBN Q Shift (At Time Of

Nurses Choice) and PRN (as needed)

Temp, HR, Respirations, Colour, Activity, Tone

Reference: 1) Perinatal Services BC; March 2011; Newborn Guidelines 13: Newborn Care Pathway

RQHR Care of the Healthy Newborn Standard Work for Vital Signs


Responsibility Time Process Step

LB/ MBU/ NBN

Within 1 hr of Birth

1. Gather Vitamin K, needle/syringe & alcohol swabs 2. Position Babe appropriately 3. Draw up Vitamin K (0.5mls = 1.0 mg) in a 27 gauge ½” needle 4. Wash hands, don your gloves 5. Landmark site (refer to teaching package) on “L” Leg 6. Clean site with alcohol swab 7. Firmly bend knee with non dominant hand, pull skin tight prior to

injection 8. Administer Vitamin K 9. Document on both MAR and Labour 2 , site given time.

LB/ MBU/ NBN

Refused by Parents

1. Provide parents with information regarding benefits of Vitamin K document

2. Contact Baby Dr as soon as info is known, keeping in mind Vit K to be given within 6 hrs after birth

3. Have refusal of treatment form available References: 1) CPS (Compendium of Pharmaceuticals and Specialties) 2) Canadian Pediatric Society

RQHR Care of the Healthy Newborn Standard Work for Administration of Vitamin K


References: 1) Timing of the Newborn First Bath: A Replication; Behring A, Vezeau TM, Fink R; Neonatal Netw. 2003; Jan – Feb 22(1) 39-46 2) Practical Approaches to Baby Skin Care Recommendations and Fundamentals; Evidence-Based Skin Care Key Tips; 2011 CAPWHN Conference 3) Assoc of Women’s Hlth, Obstet & Neonat Nurses; Neonatal skin care evidence-based clinical practice guidelines; Washington DC 2007 4) The Effect of Timing of Initial Bath on Newborn’s Temperature; Varda KE, Behnke RS; Journ Obstet Gyne Neon Nursing 28 Jul 2006

Responsibility Time Process Step MBU/ NBN sign on bassinette alerting staff to babe not bathed. MBU/ NBN

After 2 consecutive temps at least one hour apart

Can be bathed after two consecutive temps > 36.6 (self – sustained) without any intervention. Postpone bath till above is achieved.

MBU/ NBN

Flexible bathing time is encouraged to coincide with parent’s wants and babe’s stability. Parents have the option to bath their baby without assistance if desired.

MBU NBN

Initial bath to be done when parents or parent able and ready to participate and learn.

MBU/ NBN

Assess cord daily. Cleanse cord once daily and prn with warm water and dry

MBU/ NBN

> 24 hrs Clamp cord removed if dry

MBU/ NBN

Bathing frequency is to be left up to parent’s desire. Recommend bathe every other day with water only. Use soap once per week.

MBU/ NBN

30 – 60 minutes Babies born to moms with known Hep B, C or HIV + - bathe within 30 – 60 minutes (see standard work for bathing baby whose Mom is known Hep B, C or HIV+)

RQHR Care of the Healthy Newborn: Standard Work for Bathing Baby


Responsibility Time Process Step L&D Immediately

Babe to be transferred to nursery within 30-60min.

NBN

30-60min Bathe under radiant warmer and administer Hep B immunoglobulin/ AZT/ Hep immunization/ Vit K/ Erythromycin

NBN

As soon as possible

Return to L&B

MBU

Assess cord daily. Cleanse cord once daily and prn with warm water and dry

MBU/NBN

Bathing frequency is to be left up to parent’s desire. Recommend bathe every other day with water only. Use soap once per week.

References: 1. RQHR Infectious Diseases 2. Canadian Immunization Guide 2006 3. Saskatchewan Immunization Manual

RQHR Care of the Healthy Newborn Standard Work for Bathing and Medication Administration for Babies Born to

Moms with Known Hep B/HepC/HIV



Primary Nurse

Within 1 hour All babies (of Moms who want to breastfeed) are to be put to breast (cesarean section and vaginal births) as long as mom and babe stable.

Primary Nurse

Within 3 hours

If mom unable to breastfeed, if feed ineffective, or if newborn unwell, milk to be expressed by hand expression or pumping. Teach and observe hand expression technique. Provide pump if unable to hand express.

Primary Nurse

On demand, q2-3h

Babies to be put to breast. Attempts to be undertaken to arouse sleeping baby. If mom unable to breastfeed, if feed ineffective, or if newborn unwell, milk to be expressed by hand expression or pumping.

NICU Nurse in

operating room

Whenever possible

Whenever possible, a dedicated nurse to be assigned to deliveries/resuscitation- to provide follow up assessment as needed and to help with breast feeding and skin to skin.

References: 1) Mannel R, Martens P, Walker M; Core Curriculum Lactation Consultant Practice; 2008; 2nd edition; Jones & Bartlett; Sudbury ON 2) Mohrbacher N; Breastfeeding Answers Made Simple: A Guide for Helping Mothers; 2010; Hale Publishing; Amarillo TX 3) Newman J; Breastfeeding Inc: The Importance of Skin to Skin Contact; 2009; www.breastfeedinginc.ca 4) Glover J; Breastfeeding Flow Chart; 2008

RQHR Care of the Healthy Newborn Standard Work for _Breast Feeding Support & Frequency of


Asymptomatic Symptomatic

Guidelines for Management of Hypoglycemia in Newborns

At risk for hypoglycemia

No Yes

Feed within one hour of age

Feed within one hour of age

Check initial chemstrip at 2 hrs of age & Q2-3 hourly

< 1.8 mmol/l @ 2 hrs or

< 2 mmol/l @ subsequent checks

Inform MRP Call NICU Needs IV fluids

1.8 - 2 mmol/l @ 2 hrs or

2-2.5 mmol/l @ subsequent checks

Inform MRP Feed & recheck chemstrip in 1 hour

Remains <2.6mmol/l despite feeding

Rises to > 2.6mmol/l after feeding

Feed Q 2-3 hrly, monitor chemstrip (before feeds) until stablex2

>2mmol/l @ 2 hrs or >2.6mmol/l @ subsequent checks

Chemstrip now, if <2.6mmol, call

NICU/Nursery, inform MRP, needs IV

See on the reverse for definitions, risk factors & signs & symptoms of hypoglycemia

Routine Care Feed on Demand

Baby shows signs & symptoms of hypoglycemia

or appears unwell

Baby shows no signs & symptoms of hypoglycemia

appears well

Chemstrip > 2.6 Treat symptoms

As needed

Guidelines for Hypoglycemia Management of Newborns

Signs and Symptoms of Hypoglycemia

• Jitteriness, Tremors

Episodes of cyanosis

Convulsions

Apnea

Tachypnea

Weak or high-pitched cry

Limpness, lethargy, hypotonia

Difficulty Feeding, refusal to feed

Eye rolling

Sweating, sudden pallor

Risk Factors for Hypoglycemia

Maternal hypertension treated with beta blockers

Any maternal diabetes (gestational, type I or II with or without insulin including single dose)

SGA – less than10th percentile

LGA – greater than 90th percentile

Preterm – less than 37 0/7 weeks

Cold stress – hypothermia – axilla temperature less than 36.5 C

Newborns with medical conditions, Eg. respiratory distress, sepsis etc.

< 2.5kg

• SGA/LGA PARAMETERS

• SGA: less than 10th percentile for birth weight and gestational age

• LGA: greater than 90th percentile for birth weight and gestational age

Gestation (completed

weeks)

Male Weight in GM

Female Weight in GM

SGA LGA SGA LGA

37 ≤ 2550 ≥ 3665 ≤ 2450 ≥ 3540

38 ≤ 2765 ≥ 3875 ≤ 2660 ≥ 3740

39 ≤ 2940 ≥ 4050 ≤ 2825 ≥ 3895

40 ≤ 3080 ≥ 4200 ≤ 2955 ≥ 4035

41 ≤ 3180 ≥ 4330 ≤ 3050 ≥ 4155

42 ≤ 3230 ≥ 4430 ≤ 3115 ≥ 4250

• References:

• 1) Screening Guidelines for newborns at risk of low blood sugars; Canadian Pediatric Society: Fetus and Newborn Committee; Pediatric Child Health 2004,9 (10) 723-9

• 2) ACoRN – Acute Care of at-Risk Newborns (26)

• 3) Hamilton Health Sciences; McMaster University Medical Centre 2006



MBU /LB and NBN

Wipe away any visible mucous Encourage Crying, by sitting baby upright and patting baby on the back Repeat as necessary

MBU /LB and NBN

If babe unable to clear airway, turn head to side and clear mouth using suction catheter #10 catheter (do not suction past throat)

MBU /LB and NBN

No Deep Suctioning

MBU /LB and NBN

If Mucous Present in Nose: May require use of NS drops to assist with clearing mucous from nose Repeat as necessary If babe unable to clear nares, turn head to side and clear nose using Nasal Aspirator (nose) @ 80-100 MMHG, up to resistance

MBU /LB and NBN Continue monitoring and repeat as needed

MBU /LB If baby remains mucousy and nurse is concerned, consult Nursery. May notify

Physician MBU /LB and

NBN Educate the Parents

Reference: Neonatal Resuscitation Program Heart & Stroke Foundation of Ontario

RQHR Care of the Healthy Newborn Standard Work for Care of the Mucousy Baby


Weight (Once Daily)

Disorganized sucking or swallowing

Feeding: weak or absent suck (W/A)

Feeding: Duration (minutes)

Vomiting (amount)

Loose, watery, or explosive stools (L/W/E)

Excoriation or abrasions (specify area)

NAS – primary reference is Fir Square Program: BC Womens Hospital

Neonatal Observation Sheet

Signs & Symptoms

Gestational age at birth ______________________

Birth weight ___________________________Date

Time



MBU/ NBN

Before Discharge Identify baby requiring Care seat challenge as per hospital guidelines ( Infant < 37 wks or < 2300 grams @ discharge)

MBU/ NBN Notify MRP

NBN Car seat challenge to be done in Nursery by RN in Nursery

NBN

Notify MRP of challenge failure References: 1) Car Seat Challenge – RQHR “Transportation of Newborns at Time of Discharge” policy 2) Sask. Traffic Safety Guidelines

RQHR Care of the Healthy Newborn Standard Work for Car Seat Challenge Test


References: 1) Levels of Newborn Care; Canadian Pediatric Society: Fetus and Newborn Committee; Pediatric Child Health; 2006; 11(5): 303-6 2) American Academy of Pediatrics; American Heart Association; Canadian Pediatric Society; 2011; Neonatal Resuscitation extbook 6th edition

Definition: Baby who requires O2 or giving breaths with pos pressure ventilation after “1” minute.

Responsible

Person (job title) Time Process Step

L & B and NICU RN’s, NNP Assessment by resuscitation Nurse

L & B and NICU RN’s, NNP

Determine need for observation in the NBN

L & B and NICU RN’s, NNP

Care and Treatment Temp (Controlled)

HR O2 Sat

BP

RQHR Care of the Healthy Newborn Standard Work for Post Resuscitation

Kaizen #2

Creating a Clear Concise Communication Document

for Baby’s Information

Kaizen #2

Kaizen #3 and 4

Kaizen #3: (Mar 26-28) Creation of Breastfeeding Support Room In October 2007 Anita had the opportunity to

experience the former Mother Baby Unit. She was very grateful for the support the nursery provided, especially at night, when her husband had to return home, and she craved support as she learned to nurse her son. With the birth of her second child and the new Mother Baby Unit there was no gathering place for mothers and their babies. Without this community space Anita shared her feelings of isolation.

Mom & Baby Gathering Room

“A place at night when the world is asleep”

Vision:

A welcoming space where moms and their babies can gather day or night to find

support from others.

Kaizen #4: (May 1 - 3) Communication for parents about their

newborn baby Through discussions with families we

discovered that they needed: - access to facility information prior to

admission - consistent information - easy to read information when they are ready

to learn.

Next Steps

Monthly meetings: review success, challenges and implement new changes

Teach and mentorin

g staff

Trial and ongoing evaluation

with standard work

Work together to create positive change

Staff experiences

• “It’s not about us it’s about the baby”

• “We learned we like each other!” We developed new friendships and are more supportive of our colleagues.

• “We all came in with our guard up, protecting our own units and how we do things. Now we empathize with each other and the challenges we face on our units”

• “We should have been doing this all along”

• “This has been so good working together rather than against each other”

What we have learned:

• A new awareness of what each unit really does and challenges they face

• Better understanding of clinical best practice care for healthy newborns

• Appreciated opportunity to work with people from all three units and front line staff’s input.

• Having the client’s perspective was very helpful to keep us patient focused

• Decision by team to engage in on-going collaboration

The End

Questions ????

newborn nursing care standards - saskatchewan union...

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