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Inside Pediatrics, Neonatology

Debriefing after Resuscitation: A Quality Improvement Initiative

Resuscitation_WEB

In October 2018, the Children’s of Alabama Neonatal Intensive Care Unit embarked on a quality improvement project, Debriefing Following Resuscitation/Code Events in the NICU, to identify opportunities to improve the resuscitation process, including staff satisfaction. It is one of several quality initiatives led by the Children’s Hospitals Neonatal Consortium.

The Neonatal Intensive Care Unit (NICU) can be an intimidating and stressful place to work.  One of the most stressful events in the NICU is a neonatal code or resuscitation, which may require intubation, chest compressions and special medications, all delivered under the pressure of knowing that seconds count. This requires that the team of doctors, nurses, respiratory therapists, pharmacists and other practitioners work together like a well-oiled machine.

Resuscitation codes are, by definition, rare events, said Children’s of Alabama neonatologist Hannah Hightower, M.D. Weeks may go by without any and then they might have several in one month. But they are definitely disruptive and stressful.

In October 2018, the Children’s of Alabama NICU embarked on a quality improvement project, Debriefing Following Resuscitation/Code Events in the NICU, to identify opportunities to improve the resuscitation process, including staff satisfaction. It is one of several quality initiatives led by the Children’s Hospitals Neonatal Consortium (CHNC), a group of more than 30 children’s hospitals around the country dedicated to using performance improvement methods to improve the delivery and quality of care in Level IV NICUs, which care for high acuity and medically complicated neonates.

The premise is simple. As soon as possible after the code, everyone gathers for a few minutes to discuss what went well, any equipment or medication problems, communication quality, and, of course, highlighting what could go better next time. They also complete a short form documenting the discussion. In just three months, the team at Children’s exceeded its goal of holding post-resuscitation debriefings after 80 percent of codes.

Such approaches can lead to improved resuscitation quality and reduced mortality, research finds. [1]

“The goal is to help everyone involved in the process improve skills, cope with the stress, and ultimately and most importantly, improve the process and patient outcomes by identifying potential latent safety threats,” Hightower said. “We want everyone on the team to feel free to express any concerns as well as provide support. Even the caregivers need a chance to decompress.”  “Not only does it provide a venue for raising issues related to caring for the patient, she said, “but it also lets us show appreciation for the things that went well.”

“It wasn’t a surprise to hear that one of the biggest issues is communication in a stressful period,” Hightower said. “We can always improve communication, whether that means discussing who is leading the code or controlling the volume so everyone can hear and understand what’s going on.” Discussing communication issues shortly after the code is important, she said, “because it’s at the front of your mind. By doing this immediately, you remember things you may not later and can articulate issues that might not be apparent in a week or two.”

Since implementing the initiative, the team has begun a proposal to further improve communication by emphasizing who is leading the code. Future projects include providing each member a way to give real time feedback not just to the code event, but also to the quality and effectiveness of the debrief. “We want to quickly identify systemic matters that can be improved for the next event. This is to develop a culture of freely expressing ideas and working through issues together as a team,” Hightower said.

The team is still collecting data on the primary outcome of latent safety events, a key component of any quality improvement initiative. Secondary outcomes include quality of the debriefs and composition of the responding code team.

“I credit our success to our strong nursing leadership and the willingness of the staff to be actively involved in quality improvement and do the extra work required to accomplish that goal,” Hightower said. “They have to step away from the patient and cover for each other during the debrief and even though it may take just a few minutes, to ask a nurse to step away from the patient is a big task.”

Although the team is still collecting data on the impact on staff satisfaction, she said, “anecdotally we have heard from nurses and other staff who feel they had a chance to say what they needed during the code or might need in the future. That’s gotten positive feedback.”

“It’s important to highlight the goal of this project is improved patient care, patient outcomes and staff satisfaction,” Hightower said. It’s also important that Children’s of Alabama is a part of a national collaborative with other major children’s hospitals, she said, and has been one of the most successful programs in the CHNC in terms of demonstrated outcomes. Other performance improvement initiatives with the CHNC include improving pain management and reducing nephrotoxic injury.

Resuscitation_CHART

In just three months after embarking on its quality improvement project, the NICU team at Children’s of Alabama exceeded its goal of holding post-resuscitation debriefings after 80 percent of codes.


[1] Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU Cardiac Arrest Debriefing Improves Survival Outcomes Crit Care Med. 2014 Jul; 42(7): 1688–1695.

 

Neonatology

Initiative Targets Pain Management in NICU Babies

neonatology_pain

Adults and children can tell you when they’re in pain. Infants can’t. Which is why Children’s of Alabama is participating in a national quality improvement initiative called Erase Post-Op Pain designed to reduce pain after invasive procedures. The initiative is part of the Children’s Hospital Neonatal Consortium (CHNC), an international group of children’s hospitals dedicated to improving care in the neonatal intensive care unit (NICU).

“There is really no ‘gold standard’ for pain assessment in preverbal children,” said NICU Associate Medical Director Allison Black, M.D. “Nor is there much data on the best way to treat pain in neonates.” However, there is data showing that preterm  babies who experience repeated pain can develop physiologic instability, altered brain development and abnormal stress response systems that persists into childhood. “The immature brain can potentially have a more diffuse and exaggerated response to pain,” she said.

The Erase initiative is designed to apply a multidisciplinary approach, including physicians, bedside nurses, pharmacologists, and even parents, to implement a standardized method to assess, document and manage postoperative pain.

The first action the team took was to adopt a single objective pain assessment tool, the N-PASS score, which measures sedation and pain based on vital signs such as heart rate and breathing, as well as behavior such as agitation, crying, facial expressions and neurologic resting tone. “These are things parents can help us assess as well,” Black said. Parents will also complete a survey after each procedure about how well they thought their baby’s pain was assessed and controlled.

The NICU pharmacist worked closely with other team members to develop different guidelines and different algorithms of what medications to use for each specific patient. Each guideline is unique, and the algorithm used depends upon the invasiveness of the procedure, whether the patient has had similar drugs in the past and if they are breathing spontaneously or with the help of assisted ventilation.

“By considering the history of the patient, the type of procedure performed. and looking closely at each drug’s  time to onset and duration of action, the treatment should be more effective,” Black said.

The initiative dovetails nicely with another CHNC performance improvement project, the STEPP-IN initiative. STEPP-IN works to reduce perioperative stress and instability  in NICU patients through improved handoffs and communication. “I think the projects will compliment each another and help improve our overall care of these small infants during the high-risk perioperative period,” Black said.

Babies in Need

Learn more about the Neonatal Intensive Care Unit at Children’s of Alabama.

Neonatology

NeuroNICU B.R.A.I.N. Program Aims to Improve Outcomes in High-Risk Neonates

Neonatology_Care Protocols

Preterm infants born at 30 weeks or earlier are at higher risk for developing intraventricular hemorrhage (IVH), which is associated with long-term neurocognitive deficits. The risk is also higher for infants with hypoxic-ischemic encephalopathy (HIE), those undergoing ECMO therapy, or those with seizures, metabolic disorders or stroke. Now, a new initiative in the University of Alabama at Birmingham (UAB) Division of Neonatology called NeuroNICU B.R.A.I.N. (Brain Rescue and Avoidance of Injury in Neonates) aims to prevent or reduce that risk.

The core of the initiative is a multidisciplinary team of professionals who work to provide neurodevelopmental care for infants at risk for developing brain injury and cognitive deficits. The team includes a pediatric neurologist, pediatric rehabilitation medicine specialist, pediatric neuro-radiologist, neonatal nurse practitioners, nurse manager, physical therapist, occupational therapist, speech therapist, respiratory therapist and nurse champions. The program also makes parents an integral part of the team.

“We all come together every week and discuss every baby on the unit,” said Allison Black, M.D., NICU associate medical director at Children’s of Alabama. “Before the NeuroNICU program, we would consult individually on an as-needed basis.”

Even though an infant may not need every aspect of care, she said, “everyone working together to integrate the different expertise we have in our field will result in better care for the babies.” The program also uses a standardized bundle of care designed to stabilize the infant and carefully monitor for clinical signs that can increase the risk of IVH.

“The process for the brain injury prevention program starts at birth and continues throughout the entire hospital stay,” said Maran Ramani, M.D., who directs the NeuroNICU program. The protocols call for preventing hypothermia, hypoglycemia and extreme variations in the blood pressure and carbon dioxide levels, and for maintaining fluid intake, all with minimal stimulation. Once discharged, all infants are followed long-term and continually assessed for developmental milestones, he said.

In addition to multidisciplinary care, the program provides near infrared spectroscopy monitoring for preterm and term infants to assess the oxygen saturations in the brain. It also uses transcutaneous CO2 monitoring for preterm infants to assess variations in serum CO2 levels, which plays a critical role in the development of IVH. Term and preterm infants also receive a head ultrasound in to screen for IVH, while preterm infants with grade III and IV IVH undergo   conventional electroencephalogram to detect subclinical seizures. Finally, infants with HIE have an MRI with spectroscopy to assess any damage.

Despite the multifactorial etiology of IVH, Ramani said, standardizing the neuroprotective care is reducing the overall rate of IVH in preterm infants (Figure 1).

Figure 1           Rate of IVH Before and After NeuroNICU B.R.A.I.N. Program

Neonatology Care Protocols Chart

Arrow indicates NeuroNICU roll out

Managing Neurologic Disorders
Visit www.uab.edu/medicine/peds/patient-care/neuro-related-programs-centers to learn about the Division of Pediatric Neurology’s subspecialty clinics at the University of Alabama at Birmingham.