newborn nursing care standards - saskatchewan union...
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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
RQHR Care of the Healthy Newborn
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
RQHR Care of the Healthy Newborn
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
RQHR Care of the Healthy Newborn
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
RQHR Care of the Healthy Newborn
Responsibility Time Process Step
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
RQHR Care of the Healthy Newborn
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
RQHR Care of the Healthy Newborn
Responsibility Time Process Step
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
RQHR Care of the Healthy Newborn
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
RQHR Care of the Healthy Newborn
Responsibility Time Process Step
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
RQHR Care of the Healthy Newborn
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 ????