A Pilot Project To Improve Neonataal

I N N O VAT I V E P R O G R A M S
Klein, L.
Proceedings of the 2012 AWHONN Convention
A Pilot Project to Improve Neonatal Peripheral Intravenous

Site Assessment and Documentation
Newborn
Care
Lisa Klein, MSN, RNC-OB,

RNC-LRN, CNS, Marymount
University, Reston, VA
Keywords
neonatal
nursing
peripheral intravenous
assessment
documentation
Paper Presentation
Purpose for the Program

here is currently no consistent protocol described in the literature for documentation of
the nursing assessment of neonatal peripheral intravenous sites. Most authors concur that hourly
assessments are the minimum frequency and indicate what the assessment parameters should
be; however, they do not discuss a protocol for
documentation of the assessments. Multiple authors and professional nursing groups have identified that problems exist in the care of peripheral intravenous sites in neonates. This project
attempted to determine if nurses in a neonatal intensive care unit (NICU) could conduct and document an hourly evidence-based focused assessment 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 interventions 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 collection 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 exception for assessment of peripheral intravenous sites
in neonates. This project introduced a documentation form that includes the five evidence-based
parameters 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 peripheral 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 instrument 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 extravasations, which would be useful in improving
patient 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

he late preterm infant faces many challenges
associated with prematurity. In 2010, 99 late
preterm infants (approximately 5% of the total birth
volume) were born at Peninsula Regional Medical Center. Nearly 29% of these infants were admitted 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 was to determine if adopting 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
JOGNN 2012; Vol. 41, Supplement 1
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.
Data collection took place over a 6-month period to determine baseline rates of hypothermia,
S31
hypoglycemia, respiratory distress, feeding difficulties, phototherapy, excessive weight loss,

neonatal intensive care unit admissions, and readmissions to the pediatric unit. A multidisciplinary
team developed the late preterm infant initiative
utilizing AWHONNs clinical guidelines. Components of the initiative included policy and order
set development, predelivery and predischarge
education, and individualized feeding plans. Beginning 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 infant. 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 intensive care unit (25.8%), and no infants were readmitted to the pediatric unit. The overall goal is to
improve clinical outcomes while reducing admissions to the neonatal intensive care unit by 10%
and readmissions to the pediatric unit by 5%, as

compared with the 2010 rates.
As the primary bedside caregiver, nurses are extremely 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, translates 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. Providing care that enhances family bonding, empowers parents, and improves clinical outcomes increases patient and nurse satisfaction. In this era
of rising health care costs and nonreimbursement
for preventable readmissions, it behooves nurses
to adopt practices that anticipate and prevent possible sequelae related to late prematurity.
Tackling Newborn Hypoglycemia in the Delivery Room:

Utilizing Colostrum, Skin to Skin and State of the Art
Policies
ewborn hypoglycemia in the delivery room
is a widespread challenge. Most often infants who are breastfed and are temporarily separated from their mothers receive formula as a
quick fix to increase blood glucose levels. This
approach not only decreases breastfeeding success, but it also exposes the newborn to unstable 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 witnessing 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 was
out 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 keeping them in continuous skin-to-skin contact. I had
recently become an international board certified
lactation consultant, and that new level of knowl-
S32
edge, coupled with my nursing experience, prepared me well for presenting my ideas to the
administration. I also proposed that we establish ways to give colostrum to babies who were
not 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.
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

We have successfully implemented a new hypoglycemia algorithm that accepts lower glucose
values initially, has the newborn feed first, and
then the first glucose level checked by 90 minutes 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 continuous 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.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
http://jognn.awhonn.org
Lawson, T.

Labor and delivery nurses are the first line of defense in helping stabilize newborn glucose lev-
els without the introduction of formula, thereby upholding the standard of best practice. It is possible
for just one nurse with a vision to apply evidencebased practice to achieve quality outcomes.
Premature Infant Nutrition Clinic

Terry 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

he benefits of human breast milk for term infants outweigh formula. Breast milk is an even
greater benefit to the preterm infant because it
provides infection prevention and promotes improved neurodevelopment. In 2006, the University
of California San Diego Medical Center was designated as Baby Friendly. The Supporting Premature
Infant Nutrition program was launched in 2007.
The goal was to improve the growth and nutrition of
preterm infants. It was noted that following hospital discharge, most mothers were not successfully
breastfeeding their premature infants. These infants continued to require fortifiers, but we did not
know how much or for how long. Mothers continued 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 registered nurse. Utilizing a team approach, visits included infants growth and development assessments and discussions of the mothers concerns.
After the assessment and discussion, the registered nurse performs a lactation consult and assesses the infant feeding, looking for ways to improve milk transfer, increase milk supply, and increase breastfeeding and decrease breast pumping. At the end of the 45- to 60-minute session, a
plan is developed to help the mother reach the desired goal. Visits are individualized, ranging from
one-time only to several visits 1 to 3 weeks apart. A

follow-up letter is sent to the primary provider with
appointment highlights and recommendations.
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 occurred. 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 newborns
greater 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 patients 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.
Assuring best practice and performing research
is exemplified by the projects in progress, including a Premature Infant Nutrition Clinic Quality Assurance project, research of liquid fortification of
the mothers milk at discharge, and an international multicenter validation of a preterm growth
chart. Both providers and nurses are involved in
every aspect leading to increased patient and staff
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

he National Council on Alcoholism and Drug
Dependency estimates that between 1% and
11% of babies born each year are exposed to illicit 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 abstinence syndrome (NAS). Research that is more recent describes an increasing incidence of infants
exposed to harmful substances prior to birth. Babies exposed to opioids or opioid derivatives during 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 pharmacologic management and care that promote
improved outcomes for NAS patients. Care and
management of these infants can be improved
with practice guidelines and education.
S33
Proposed Change
To develop and implement evidence-based clinical practice guidelines and an educational program on NAS and the Finnegan Neonatal Abstinence Scoring Tool (FNAST), to improve nursing
assessment and care of the NAS infant, and improve scoring accuracy with use of the FNAST.
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, educational project. Nurses were tested before and
after participation in education about NAS. A subset of 10 nurses was evaluated using the FNAST
with video of infants having NAS. Volunteer participation 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 criterion 1 week after participation in the educational
project.
Keywords
NICU
FNAST
education

Evidenced-based clinical practice guidelines and
education on NAS and the FNAST equip caregivers with the necessary tools to consistently and
accurately assess an infant with NAS when using
the FNAST. Recent research shows that providing education to nurses can result in knowledge
gained, improved professional practice, and improved patient treatment goals. Education also
can equip nurses with the necessary knowledge
to care for patients with complex medical problems like NAS. Further, providing nurses with
specific information about a medical problem
is correlated with improved adherence to best
practice.
Newborn Care
Paper Presentation
Perinatal Palliative Care: Support of Mothers,

Infants and Families
o support mothers, infants, and families
through the Perinatal Palliative Care program.
Proposed Change
To enhance the existing bereavement program
to include infants with low viability or no viability
through palliative care.
Implementation is in process and awaiting final
approval of pertinent policies and procedures to
support this program. The evaluation will be based

upon a patient satisfaction survey taken by telephone follow-up of patients discharged from the
hospital.
J. Frances Fusco, MHS, BSN,

RN, University Community
Hospital, Tampa, FL
Theresa Bish, RN, IBCLC,
University Community
Hospital, Tampa, FL

Provide care and support to both infants and mothKeywords
ers going through this experience.
perinatal palliative care
infant advanced directives
Newborn Care
Poster Presentation
Neonatal Head Trauma: Implementation of a Care Algorithm

to Improve Safety
o 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 improving safety.
S34
Sandra Hoffman, MS, RN,

Proposed Change
To create and implement a neonatal head trauma CNS-BC, Abbott Northwestern
algorithm that is part of the newborn standing or- Hospital, Minneapolis, MN
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.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Braithwaite, P., Donahue, N. and Bayne, L. E.
Keywords
neonatal head trauma
vacuum extraction
forceps delivery
subgaleal hemorrhage
Newborn Care
Poster Presentation

Neonatal head trauma can result in catastrophic
outcomes, and it is essential that infants at risk
of complications of a difficult or instrumented delivery 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 increased vigilance is important for patient safety.
After a review of the literature, a multidisciplinary
team of neonatal and birthing clinical nurse specialists, pediatricians, a neonatologist, and a
neonatal nurse practitioner created a neonatal
head trauma algorithm to become part of the newborn standing orders. Staff and physician education was done regarding neonatal head trauma,
and the neonatal head trauma algorithm was implemented across a large multihospital health system. The evaluation of this change is ongoing.

Nurses caring for newborns are in a key position
to identify complications of neonatal head trauma
that may result from the birthing process. A standardized 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 appropriate pain management, and helps to keep
newborns safe.
Help! Im Cold! Improving the Warmth of Our Newborns

ozy Cuties is a multidisciplinary performance
improvement team convened to address hypothermia from birth to admission to the neonaNicole Donahue, BSN, MSN,
RNC, Christiana Care,
tal intensive care unit among inborn preterm inMiddletown, DE
fants at less than 31 weeks gestational age. ReLynn E. Bayne, PhD, NNP-BC, view of facility data over the past 5 years showed
that the initial admission temperatures of these
RN, Christiana Care Health
System, Newark, DE
infants were significantly lower than average in
our neonatal intensive care unit (NICU) than the
Keywords
benchmark of 850 NICUs within the Vermont Oxpreterm
ford Network. Across this time period, 61% of the
hypothermia
fishbone diagram
infants who were less than 31 weeks gestational
root-cause analysis
age had body temperatures less than 36 C at admorbidity
mission and were classified as hypothermic using
mortality
the World Health Organization definition. Two large
polyethylene
studies of infants from 23 weeks to 30 completed
weeks of gestation, suggested that when infants
are admitted to the NICU with hypothermia, their
Newborn Care
chances of survival decrease by approximately
Poster Presentation 10% for every degree below 36 C, independent
of any disease conditions. In addition, late onset
sepsis is increased by 11% and odds of death are
increased by 28%.

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.
Proposed Change
Root cause analysis using fish bone techniques
was conducted on the first five cases of admission of hypothermia for each calendar month
over the 12-month period prior to project inception. Literature was reviewed to establish potential
causes. A facility tour determined how many potential causes existed and coupled the potential
cause with evidence-based interventions. A ther-

A multidisciplinary team can be an extremely effective agent of change. It is important to bring
key stakeholders in a project to realize gains. Clinicians are obligated to benchmark practices that
may contribute silently to patient illness. Body temperature should never be taken for granted. The
goal should always be to keep a warm infant warm,
not to rewarm a cold infant.
Pamela Braithwaite, BSN,

RNC, Christiana Care Health
System, Bear, DE
mal intervention bundle was developed and implemented. The bundle included a timeout-style
thermal checklist, increased room temperature,
proper radiant warmer preheat and use, shortened infant time at point of delivery for both vaginal birth and cesarean birth, change in transfer
technique of newborn to a warmer from point of
delivery, effective use of polyethylene wrap, attention 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 variety of methods, including video and social media.
Post-implementation, infants who were less than
31 weeks gestational age were prospectively followed and the incidence of the outcome variables
was collected.
S35
Welcome Aboard and Homeward Bound: The NICU

Familys Journey for a Safe Voyage to Discharge
mprove parent and staff satisfaction with the discharge 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, documentation, and communication of education to
better prepare parents for discharge.

Implementation using Plan-Do-Study-Act cycles,
staff and patient satisfaction, as well as chart audits were used for measurement and feedback.
Geraldine Tamborelli, MS, RN,

Maine Medical Center,
Portland, ME
Keywords
discharge
satisfaction
The best practice was identified and we continue best practice
to maintain the gains by evaluating satisfaction education
family centered care
levels and random chart audits.
multidisciplinary
Newborn Care
Poster Presentation
Birthways Lactation Services: A Model

for Breastfeeding Support
he purpose of the Birthways Lactation Services 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, by
community 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 to have a visit or when a visit was
physician ordered. Eight years ago, it was determined this was a costly way to deliver care even
with funds provided by a grant and some insurance reimbursement. At that time we started the
clinic model and were encouraged by the positive 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 discharge, and provide a discharge feeding plan for
babies with feeding problems.
Three to five times per day, the coordinator of the
lactation program and her team perform checks
S36
that include weight, jaundice, and lactation evaluation. We believe our outcomes reflect the 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,
and our clinic model takes 1.2 full time equivalents,
which represents a savings of more than $140,000
in salaries and mileage reimbursement. Our lactation 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.
Angela Carswell, RN, IBCLC,

Mary Greeley Medical Center,
Ames, IA
Keywords
lactation program
exceeding national and state
breastfeeding rates
Newborn Care
Poster Presentation

The advantages of breastfeeding are well researched and well documented. We believe our
program model is the best practice and is leading
the way in breastfeeding promotion and support of
the American Academy of Pediatrics Policy Statement and the U.S. Surgeon Generals Call to Action
to Support Breastfeeding. Our service model decreases hospital readmission rates and promotes
exclusive breastfeeding with increased productivity and decreased cost.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Keller, A. and Brenneman, A.
Operation Kangaroo Care

angaroo care is recommended in the Guidelines for Perinatal Care for stable newborns.
Alicia Brenneman, BSN, RNC,
The act of placing the infant skin-to-skin (also
Grant Medical Center
OhioHealth, Columbus, OH
called Kangaroo care) with the mother has been
shown to maintain skin temperature regulation
Keywords
of the newborn, increase initiation of successful
Kangaroo Care
breastfeeding, and ease the transition for intrautercesarean birth
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
Newborn Care
participated in skin-to-skin care. The staff started
Poster Presentation to initiate Kangaroo care in the postanesthesia
care unit to provide all the benefits to the mothers who had cesarean births.
Anne Keller, MS, RNC, CNP,
OhioHealth, Columbus, OH
Proposed Change
Before the initiation of skin-to-skin in the postanesthesia care unit, infants had been removed from
the warmer after being wrapped with warm blankets 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 infant 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 while
leaving its chest exposed.
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 moving the mother from the operating room table
to a hospital bed. Both are transported to the
postanesthesia care unit, initial checks are preformed, and a baseline set of vitals is obtained
on the infant. The mother-infant pair is left skinto-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.
Empowering nurses to change practice to overcome traditional barriers of medical care to promote the empowerment of motherhood.
Infant Feeding Plan: An Innovative Documentation Tool to

Improve Communication between Caregivers and Families
Jennifer Peterman, RN, BSN,
IBCLC, Hospital of the
University of Pennsylvania,
Philadelphia, PA
Keywords
breastfeeding
infant feeding plan
patientfamily centered care
Newborn Care
Poster Presentation

lack of communication was identified surrounding a mothers feeding decision and
multiple health care providers. This lack of communication resulted in a mothers perceived lack of
respect by providers regarding her preference for
newborn feeding. To address this issue, an innovative, crib side, infant feeding plan documentation
tool was created to identify a mothers preference
for feeding her newborn from birth through discharge. Providers also noted a large variation between provider practices related to newborn feeding and maternal preference.
Proposed Change
To improve communication between providers
and mothers, a crib side infant feeding plan documentation tool was implemented.
Prior to implementation, representatives from each
provider group involved in newborn care collaborated 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 was located 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 ongoing
Prior 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, patients 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.
S37

This initiative provided an opportunity for nursing
to re-energize their commitments to patient communication and infant feeding, especially breastfeeding. 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 associated 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 any
provider caring for the infant.
A Baby Weigh Station: Continuum of Care for Late Preterm

Breastfeeding Infants
ate preterm infants who breastfeed are the
largest segment of preterm infants. In Columbus, 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 6,456
births/year in 2010). Late preterm infants often appear to be able to breastfeed successfully during
hospitalization, (hence, their nickname the great
imposter), but this may not be sustained following discharge. As 1 of 15 sites for the Association of Womens Health, Obstetric and Neonatal Nurses 2010 Late Preterm Infant EvidenceBased Practice Guidelines research study, commitment occurred in this hospitals outpatient setting 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 community resource where 90% of late preterm infants
will gain weight after events of lactation consultation and first weight measurement.
Utilize a baby weigh station within a user-friendly
lactation support center to offer a community accessible onsite, free service, monitored by ap-
S38
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 preterm infants who were consulted
and weighed on more than one visit, the following
formula 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 individual late preterm infant weights were measured:
116 had repeated weights and 99% demonstrated
weight gain (monthly averages). Additional benefits included referrals to lactation, pediatrics, pediatric surgery, and behavioral services. An accessible weigh station was evaluated to be an effective pathway to ongoing care and support for
late preterm infants. Late preterm infants gained
weight appropriately and their mothers reported
sustained breastfeeding.
Accessible community service, monitored by approachable staff and expert professionals is an
effective means to continue and grow client relationships. Monitor at-risk groups for anticipated
problems and provide a portal for continuing care.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
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
Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O.
Increasing Exclusive Breast Milk Feeding Rates at an Urban

Academic Hospital
Laurie Dohnalek, RN, MBA,
NE-BC, Georgetown University
o increase exclusive breast milk feeding rates
Hospital, Washington, DC
Cynthia Heer, RNC-OB,

RN-BC, MSN, Georgetown
University Hospital,
Washington, DC
at an urban academic hospital.
Proposed Change
Over an 18-month period interventions were implemented to increase exclusive breast milk feeding
rates by at least 10%.
Elizabeth Starrels, RN, BSN,

IBCLC, Georgetown University
Carol A. Ryan, MSN, RN,
IBCLC, FILCA, Georgetown
Washington, DC
Margaret Howland, RN, BSN,
RNCOB, Georgetown
Washington, DC, DC
Lauren O. Wurster, RN, MSN,
Georgetown University
To implement this program, the following interventions were completed:
r
r
r
r
Keywords
exclusive breastfeeding
exclusive breast milk feeding
breastfeeding rates
Joint Commission
perinatal core measure
Newborn Care
Poster Presentation
r
r
r
r
Creation and implementation of Donor Pasteurized Milk Policy; all nurses attended
mandatory education session
Implementation of 24-hour rooming in (no
separation of mothers and newborns via standard nursery)
Survey given to patients to identify the most
popular reasons for supplementation
Journal clubs discussing breastfeeding issues
Consultations with lactation consultants at
other facilities
Increasing rates and duration of initial skin-toskin contact and first breastfeeding session
Daily patient rounds and assessments by international board certified lactation consultant
Mandatory interdisciplinary breastfeeding
education for all nurses, obstetricians, and
pediatricians
Education related to alternative breast milk
feeding methods
Outside speaker (international board certified lactation consultant) that moderated dis-
cussion of obstacles to exclusive breast milk

feeding
Feeding care plans (for complicated situations) developed collaboratively with nurses
and international board certified lactation
consultants
Implementation of mother and newborn
quiet time
These interventions were implemented and the result was an increase in the staffs knowledge and
skills, thus changing practice and creating confidence. 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 patientbased survey to evaluate the effectiveness of the
interventions.
Education is a major aspect of our initiative to increase exclusive breast milk feeding rates. The
low incidence of exclusive breastfeeding is partially due to a lack of breastfeeding knowledge
among health care professionals. Educational programs that increase nurses knowledge and improve attitudes toward breastfeeding promote accurate and reliable delivery of breastfeeding information and skills to the mothers. These programs
also encourage positive role modeling of supportive breastfeeding attitudes. This may improve exclusive breast milk feeding rates because of the
effect that this has on patients. Many of the interventions 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

xclusive breastfeeding is best for the infant
and mother. Evidence-based practice describes 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, family, and staff within womens services. It is the responsibility of us all to help mothers be successful
and promote the recommendations of the Association of Womens Health, Obstetric and Neonatal 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 breastfeeding, hospital supplementation, and education for
S39
staff was our new project. Our council consists of

staff nurses from the departments of motherbaby
and gynecology. The nurse educator and lactation 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? What
about 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 formula never hurt. What about labor and delivery
nurses who say, Breastfeeding is not our job, its
the lactation consultants job. Extensive education was needed for womens services staff, physicians, parents, and families.
Implementation, Outcomes and Evaluation
The nurse educator and lactation consultant developed 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 presented. Benefits of breastfeeding for the mother,
infant, and community were discussed. Many examples of hospital practices that decrease success of exclusive breastfeeding were recalled.
Skin-to-skin care and rooming in were discussed.
In North Carolina, we have the Perinatal Quality Collaborative of North Carolina for exclusive
breastfeeding. 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 Collaborative of North Carolina project for exclusive
breastfeeding.
We want to provide the best practice and the literature supports exclusive breastfeeding. As obstetric nurses, we have power to educate and support
mothers and families to make informed decisions
about their individual infants care.
Now I Lay Me Back to Sleep . . . .Safely

ne of the Healthy People 2020 goals is to improve the health and well being of women,
infants, children, and families. One way to accomplish 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 been
proven that supine sleeping is the greatest factor in reducing the risk of SIDS even though many
nurses still feel more comfortable placing the baby
prone. Hospital nurses are the first professional
role models for new parents. Modeling suggested
behaviors, such as back sleeping, can be a powerful education tool as well as parental education
through verbal and written educational materials.

The safe sleep task force was initiated and a hospital policy on safe sleep was written. The staff
received mandatory in-services regarding SIDS to
ensure consistency in parental education. One inservice was on SIDS and SIDS risks in the term
newborn and the other addressed the needs of the
premature infant. Safe sleep education was added
to the March of Dimes notebook, which all parents
of 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.
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 resuscitation classes.

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 and to encourage the staff
continued participation and support. Integrating
evidence-based findings into practice will facilitate further involvement into addressing the higher
incidence of sudden infant death syndrome in the
African American population.
S40
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Courtnie J. Burrell, RNC,

Henrico Doctors Hospital,
Richmond, VA
Diane Stairs, RN, Henrico
Doctors Hospital, Richmond,
VA
Keywords
SIDS
safe sleep
model
Newborn Care
Poster Presentation
Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O.
Implementing Skin-to-Skin Care in a Baby-Friendly

Community Hospital
Jennifer L. Reeg, MSN, RNC,
Health First Cape Canaveral
Hospital, 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

o improve motherinfant attachment and
breastfeeding.
Proposed Change
To implement skin-to-skin care in a baby friendly
community hospital.
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-toskin at birth and in the immediate postpartum period was incorporated into our labor, delivery, recovery, and postpartum (LDRP) unit, and encouraged during the entirety of the postpartum stay.
Staff nurses were educated in appropriate skin-toskin techniques and patient instruction, first in a
small group interactive setting and later followed
with a video and discussion format. Patient education 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 newborn skin-to-skin for up to 6 hours a day for the first
week of life and a minimum of 2 hours a day for the
second week through fourth week. Mothers were
assured that anyone, e.g., fathers and grandmothers, can engage in the skin-to-skin care with the
infant. Studies have reported benefits of skin-toskin care of the newborn to include reduced crying, improved motherinfant interaction, warmer
babies, and greater breastfeeding success. Ad-
ditional positive effects on neonatal self-regulation

during the transition from intrauterine to extrauterine life include increased sleep, decreased apnea
and bradycardia, improved respiration and oxygen 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 every 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 mother
education on benefits of skin-to-skin care. Results
show a 90% success rate, indicative of a positive
trend in the number of motherbaby couplets opting 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.
The practice of skin-to-skin care as a component
of our baby friendly philosophy contributes positively 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

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 scheduled feeding method to initiate and progress oral
feedings. Several studies have come out to support 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 progression of oral feedings for each individual, with
close attention paid to the infants developmental
cues to decrease stress. The following outlines our
transition from scheduled feedings to cue-based
feedings.
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
S41
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 nursing policy and guideline, and a continuing education offering. The education ranged in topics, such
as benefits of cue-based feeding, how to read infant cues, how to use a cue-based feeding scale
form, educating parents, and trouble shooting. After implementation, bedside charts were audited
to assess staff adherence with cue-based feeding 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.
Cue-based feeding has become a common language in our unit and is considered a success.
Research is currently underway in our unit to assess time to full oral feedings and the effect on
direct breastfeeding rates. Future research to consider 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
ultiple studies have shown that excessive
noise affects neurodevelopment in infants.
Our clinical excellence committee wanted to explore 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 implemented noise-reduction strategies in an attempt
to decrease our overall noise level.
Our clinical excellence committee presented education on the effects of excess noise with the sup-
port of the hospital leadership. Education included

presentations in unit meetings as well as poster
presentations. Specific noise-reduction strategies
were proposed by the clinical excellence committee and agreed upon by the staff. Strategies were
implemented by the staff and follow-up monitoring
was completed to assess effectiveness.
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
Research has shown that the immediate effects neonatal intensive care unit
of elevated levels of sound show that environmental noise can be a major source of stressful
stimulation, can cause agitation, and bring about
complications in the medical management of the
neonate. Heightened awareness of the effects of
noise in the NICU promotes an optimal environment for positive developmental outcomes.
Newborn Care
Poster Presentation
Exploring New Frontiers: Providing Skin-to-Skin Contact

for Mothers and Newborns during Cesarean Birth
s cesarean birth rates increased in the United
States in response to the American College of Obstetricians and Gynecologists statement concerning vaginal birth after cesarean,
studies demonstrated higher dissatisfaction with
childbirth experiences. Women giving birth by cesarean are more prone to postpartum depression,
bonding difficulties, and unsuccessful breastfeeding.
Keywords
skin-to-skin
patient satisfaction
Informal surveys of patient satisfaction since im- neonatal thermoregulation
Proposed Change
To increase maternal delivery satisfaction, we developed a plan to provide skin-to-skin contact
immediately after cesarean births. The proposed
change broke the barriers between the traditional

This new service is an example of how nurses are
empowered to question tradition to advocate for
their patients.
S42
surgical environment and the delivery room and

required collaboration between the departments
of surgical services, anesthesia, pediatrics, and
obstetrics.
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.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Nora C. Fortin, RNC-OB, BSN,

Wentworth Douglass Hospital,
Dover, NH
Newborn Care
Poster Presentation
Fortin, N. C.
Moms Own Milk Bundle: Increasing Supply in an 83 Bed,

Level III, Neonatal Intensive Care Unit
E. Christina Conner, BSN, RN, Purpose for the Program
IBCLC, Baylor University
ospitals are encouraged to step up
Medical Center at Dallas,
evidence-based practices with various iniDallas, TX
Keywords
breast milk
NICU
quality initiatives
collaborative
increasing
milk supply
Newborn Care
Poster Presentation
tiatives, such as The Joint Commission Perinatal

Core Measures and Baby Friendly Hospital Initiative, 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, collaborative 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 throughout the Women and Childrens Service line to initiate and maintain the mothers milk supply. Improvements are focused on the barriers mothers
face when providing milk and discovering an innovative game plan to reduce those barriers.
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 enterocolitis rates, and decrease length of stay.
The MOM Bundle is a collaborative approach to
increase the availability and volume of mothers
milk in our Level III, 83-bed, NICU. Working together with our medical, nursing, and NICU support 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, Little
he purpose of the virtual special care nursRock, AR
Keywords
special care
length of stay
late preterm infant
Newborn Care
Poster Presentation
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 monitoring 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 following evidence-based guidelines. The care would
be provided in the mothers room or the well-baby
nursery.
Over a 6-month timeframe, information was gathered, equipment purchased, protocols established, 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 were
admitted to the NICU prior to the implementation
of the special care nursery. After 6 months of implementation, 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.
Nursing staff in the special care nursery are
trained to evaluate and intervene quickly based
on evidence-based protocols. This allows for the
infant to remain with the family. Having the infant in close proximity increases the time available 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.
S43
Two Phase Innovative Approach for Newborns at Risk

of Hyperbilirubinemia
ach year approximately 60% of the 4 million 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 hyperbilirubinemia 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 hyperbilirubinemia 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 hyperbilirubinemia 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 evaluation and treatment process by instituting a weekend and holiday Bili Clinic on the mother-baby
unit.
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 hyperbilirubinemia and initiate treatment in a timely manner. 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 followup, the staff activated the Bili Clinic process, notified the newborn health care provider of the newborns arrival, and initiated procedures (weight,
transcutaneous bilirubin, or serum bilirubin) as requested. Based on the test results, the decision
was made to provide further patient follow-up,
discharge home, or admit the newborn for treatment. This process for at-risk infants bypassed
the emergency department and facilitated prompt
treatment at the Bili Clinic.

To identify infants at risk, we instituted collection
of cord blood type and Coombs testing at delivery for mothers with blood type O positive or RH
negative blood types. Furthermore, all newborns
after 24 hours of life had a transcutaneous biliru-

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, decreased overall costs, and promoted better outcomes for the patient.
Martha Montes, BSN, RN,

University of Illinois Medical
Center, 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
Operationalizing Palliative Care Processes through a

Perinatal Palliative Care Program
arents who receive a life-limiting fetal diagnosis face many unexpected decisions: continue the pregnancy or proceed with early termination, 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.
S44
Proposed Change
The University of Minnesota Amplatz Childrens
Hospitals Perinatal Palliative Care is a familycentered, multidisciplinary program that provides
a continuum of medical, emotional, psychosocial,
and spiritual support through diagnosis, pregnancy, birth, and death. Throughout this process,
parents are supported in creating a plan of care
for their baby that is consistent with their goals and
wishes. The program goals address the National
Quality Forums Preferred Practices for Palliative
Care and support caregivers in meeting palliative
care outcomes.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
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
Gams, B.

Historically, care for these families was heroically
pulled together by a few dedicated and passionate 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 formalize
the 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 process. The palliative care approach is enhanced
by our established Pregnancy and Newborn Loss
program. Although current numbers are small, averaging four per year from 2008 to 2010, eight families were served in 2011 (year-to-date). Families
commented that this was the happiest and saddest day of my life. Data from patient satisfaction
surveys and multidisciplinary debriefings are disseminated to the health care team. Within this supportive formalized structure, a broad health care
team accommodates the individual needs and circumstances of each family in the program.
The Perinatal Palliative Care program offers this
care model within an institution with an established
pregnancy and newborn loss program and a recently established Fetal Diagnostic and Treatment
Center. Program scope, role definitions, responsibilities for maternal and neonatal medical management, program access, and multidisciplinary
education will be described. A detailed birth plan
template, newborn comfort care orders, care conference documentation, and process workflow will
be displayed.
Baby Cuddlers Make a Difference

Monica C. Kraynek, MS,
RNC-LRN, RN-BC, The
he number of newborn infants treated every
Western Pennsylvania Hospital,
year at the Western Pennsylvania Hospital
Pittsburgh, PA
for neonatal abstinence syndrome (NAS) has in-
Mona Patterson, RN, BSN, The creased more than 150% since 2004. Nurses conWestern Pennsylvania Hospital, duct the Finnegan Neonatal Abstinence Scoring
Pittsburgh, PA
Tool every 2 hours to analyze the infants with-
Christina Westbrook, RN, BSN, drawal symptoms and determine if pharmacoMSN, MBA, The Western
logic intervention is necessary and/or effective.
Pennsylvania Hospital,
Up to 30% of infants may be managed without
Pittsburgh, PA
Keywords
baby cuddler
neonatal abstinence
length of stay
Newborn Care
Poster Presentation
medication. Interventions for treatment of these

infants include medication and supportive care.
The purpose of the program, as a unit evidencebased practice project, was to learn if the addition
of baby cuddlers as caregivers could affect the
length of stay required for treatment of these infants.
Proposed Change
A baby cuddler is a trained baby holder who
can fill the gaps when parents are not able to be
present. The cuddler provides an important component of the developmental care for the hospitalized infant. The importance of human contact
and touch in the well being of all hospitalized infants has been well documented. Baby cuddlers
on a daily basis held, rocked, and comforted the
infants suffering from drug withdrawal.

Seventy-five infants were admitted to the department 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 October 2009, the average length of stay for infants
with NAS was 26.2 days without the baby cuddler 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 initial 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 2,855
hours of cuddling to patients suffering from NAS.
Nurses have implemented a low-cost intervention
that decreases length of stay and, thus, affects
hospital finances and provides quality patient care
to a vulnerable population.
S45
Normal Newborn Nursery Neonatal Intensive Care Unit:

Whats in Between?
trend of term newborns requiring transfer
from the newborn nursery to the neonatal intensive care unit (NICU) was identified in a Level
III NICU at a Magnet hospital. This offering will detail 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 promote 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 labor. Nurses are critical to assess, plan, act, and
evaluate care for high-risk transition newborns to
improve clinical outcomes and increase efficiency.
A collaborative team approach was taken to establish 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 observation. Glucose management, breastfeeding, and
newborn admission policies were revised to reflect new processes. The criteria and interventions
were standardized and embedded into practice. A
multidisciplinary approach was utilized to assure

all care providers involved with maternalnewborn
care received education, including process flow
charts, algorithms, and reference cards. The criteria were communicated to the family prior to delivery 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 transition newborns to the NICU increased 27%, and the
transfer of all newborns back to the motherbaby
unit is about 80%.
Clinical criteria to identify newborns at risk of instability 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 transition
newborns.
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
Wait for Eight: Improvement of Newborn Outcomes

by the Implementation of Newborn Bath Delay
o improve newborn outcomes by implementing the evidence-based research to delay
bathing the newborn.
Proposed Change
To improve newborn outcomes, implementation
of evidence-based research was initiated. Implementation of bath delay showed that regardless
of gestational age, the incidence of newborns experiencing hypothermia and hypoglycemia during
the transitional period was reduced by changing
the focus of unnecessary interventions.
S46

To review the current practice and identify the prioritization of the nursing task over the outcomes
of bathing, the newborn, newborn care guidelines
including revision of newborn order sets were established. Reference to evidence-based research
and data collection post-implementation of guidelines were utilized. Multidisciplinary team actions
involved evidence-based practice data regarding
the effectiveness of newborn bath delay. Scripting 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.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Diana V. Lipka, RNC, BA,

Baycare/Saint Josephs
Womens Hospital, Tampa, FL
Marcia K. Schulz, RNC, MS,
Baycare/Saint Josephs
Keywords
newborn bath delay
skin-to-skin
transition
Newborn Care
Poster Presentation
Lipka, D. V. and Schulz, M. K.
The description of the process from admission to

discharge identified the value in bath delay related
to skin-to-skin research. Global hospital staff education was initiated and staff were presented with
advice to give to parents and families during newborn care education. The value of skin-to-skin care
with transition, bonding, and breastfeeding was
emphasized. Our efforts were validated by the improved outcomes of practice change of newborn
bath delay, which resulted in increased patient satisfaction.
Historical review of newborn care delivery demonstrated that nursing has shown to place priority on the completion of nursing tasks over the
outcomes related to the newborn transitional period. To improve newborn outcomes, implementation of evidence-based research was initiated
to foster practice change. The research of skin-toskin practice directly correlated the need to review
newborn care and practices thereof. The need to
review one such practice was the newborn bath.
Recognition of the importance of an uninterrupted
newborn transition resulted in positive newborn
outcomes and patient satisfaction. Implementation of bath delay showed that regardless of gestational age, the incidence of newborns experiencing 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, Purpose for the Program
RNC-NIC, IBCLC, Mission
here is overwhelming evidence in the literature
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 Care
Poster Presentation
that human milk is superior to any form of nutrition for the neonate. It contains immunological,
nutritional, and developmental properties that prevent 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 vulnerable to morbidities, including necrotizing enteral
colitis and nosocomial infections. Human milk decreases the incidence and severity of nosocomial
infections and necrotizing enteral colitis. It also
has been proven to protect against gastrointestinal and respiratory infections. Its perfect combination of protein, carbohydrates, and plasma proteins 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 incidence of certain morbidities and decreases the
length of stay of these fragile infants. The pro-
posed change in practice is to institute a policy

of buccal application of colostrum in the NICU.
The infants are being followed longitudinally for
outcomes related to this care.
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 January 2011. Staff education was completed at staff
meetings via slide presentations. The completed
policy also includes an education sheet for parents as a means of encouraging their participation
in this bedside practice.
Due to the limited availability of colostrum, mothers are being encouraged to begin pumping within
6 hours of delivery and pump on a prescribed
schedule. We created syringe kits with detailed
instructions for the collection of a mothers breast
milk to avoid waste. The initial review of charts
since the start of this policy revealed that access
to colostrum takes several days and adherence
to the policy is varied. Currently, longitudinal data
are being collected on the infant outcomes posttreatment. Ongoing education of staff and parents
is imperative to the successful implementation of
this policy.
S47
Dont Drop That Baby!

he purpose of this poster is to share information regarding the incidence of falls of infants,
the education strategies employed to decrease
the risk of falls, as well as to explore future plans
for decreasing the rate of falls of infants at the
maternal infant services unit at Sharp Mary Birch
Hospital for Women & Newborns.
2.5 falls per 10,000 live births (8,568 live births in

2010). Three falls occurred in 2010 prior to the implementation of staff and patient education. From
the implementation of education, there were no
falls for nearly a year. At the time of this abstract
submission, there were 0.43 falls per 10,000 live
births (4,341 live births as of June, 2011).
Proposed Change
Investigations were completed to identify trends
in the falls of infants. Staff and patient education
were developed utilizing the findings from incident
reports. Picture-based patient education was developed and posted in patient rooms for easy access by patients and visitors.

The success of patient education may be attributed to the goal of educating the patients and
visitors as well as providing education to illiterate or non-English speaking patients. The patient
education posters were translated into Spanish;
however, patients at Sharp Mary Birch Hospital
for Women & Newborns originate from a variety
of countries and speak many different languages.
To optimize comprehension of patient education,
consideration should be given to utilizing pictures
in addition to text.

Focused staff and patient education were implemented in April 2010. In 2009, there were 5.83
falls per 10,000 live births, and in 2010 there were
Ellen Fleischman, MBA, RD,

RN, Sharp Mary Birch Hospital
for Women & Newborns, San
Diego, CA
Monika Lanciers, BSN, RN,
Sharp Mary Birch Hospital for
Women & Newborns, San
Diego, CA
Keywords
falls of infants
health literacy
cultural barriers
staff education
Newborn Care
Poster Presentation
Reducing Catheter Associated Bloodstream Infections

in the Neonatal Intensive Care Unit: Challenging Nurses
to Be Champions
entral line-associated bloodstream infections
(CLABSI) are associated with increased mortality and adverse outcomes in multiple systems
in the neonatal intensive care unit (NICU) patient.
All of the literature in the past 2 years regarding
CLABSI has shown that with the implementation
of evidence-based strategies, CLABSI can be significantly reduced and in some cases completely
eliminated. In June 2009, a designated committee
at St. Josephs Womens Hospitals NICU began
reviewing central line care and the current literature concerning best practices for central line
management.
Proposed Change
A comprehensive program was developed, and
a timeline was established to implement multiple
interventions into the units guidelines for the management of central lines.
Strategies included the following: (a) hand hygiene, (b) development and implementation of
central line insertion and maintenance bundles,
(c) validation for a team of nurses to perform peripherally inserted central catheter (PICC) inser-
S48
tion and dressing changes, (d) competency validation for all staff performing central line blood
sampling, (e) standardized central line tubing
change policy, (f) daily audits of all central lines
for integrity and necessity, (g) scrub the hub
care, (h) random audits, and (i) development of
a standardized sterilized PICC dressing change
kit. CLABSI rates in the NICU decreased progressively from 10.17 per 1,000-catheter days just before the initiative begun in June 2009 to 5.84 per
1,000-catheter days by the end of the year. The
CLABSI rate for 2010 was 3.37 per 1000-catheter
days. The number of bloodstream infections decreased from 30 in 2009 to 10 in 2010, a 67%
decline.
Jayne Solomon, MSN,

ARNP-BC, St. Josephs
Keywords
central line associated blood
stream infections
quality champion
central line bundle
hand hygiene
random audit
neonatal intensive care unit
Newborn Care
Poster Presentation

A comprehensive program of central line management, led by a quality champion, is effective in
significantly reducing CLABSI in the NICU. The
designation of a quality champion who is responsible for the initiative is vital to the success of this
program. This role includes overseeing and participating in staff education, motivating and communicating with the team, random audits, and gathering surveillance data for quality improvement.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Bagby, K. and Bowen, S.
Kangaroo Care Increases Breastfeeding Rates

Kim Bagby, RNC, BSN, PCE,
University of Louisville
Hospital, Louisville, KY
Susanna Bowen, RN, BSN,
PCE, University of Louisville
Hospital, Louisville, KY
Keywords
kangaroo care
skin-to-skin contact
breastfeeding
barriers to kangaroo care
Newborn Care
Poster Presentation

or eligible motherinfant dyads, does implementation of Kangaroo care at birth increase
breastfeeding rates compared to retrospective
breastfeeding rates?
Proposed Change
Kangaroo care, or skin-to-skin contact, began in
1979 in Bogota, Columbia, as a way to keep infants warm and provide optimal nutrition following
birth. Research has shown that Kangaroo care has
many benefits for mothers and infants, including
increased breast milk supply and greater breastfeeding success. The American Academy of Pediatrics recommends skin-to-skin contact as a strategy to increase breastfeeding success. In 2007,
a Kangaroo care program for healthy infants and
their mothers at the University of Louisville Hospital (ULH) was implemented. However, the philosophy was not adopted as a standard of care until
2010. Strategies were developed to hardwire the
process and facilitate a change in practice that
supported the use of Kangaroo care.
Current literature was examined, policies were
revised, and staff expectations for participation
were established. Kangaroo care champions were
identified and assisted other staff with completion
of Kangaroo care competencies; also three staff
members received certification in Kangaroo care.

Documentation was improved to facilitate accurate data collection. Breastfeeding and Kangaroo care progress was shared monthly with staff.
Breastfeeding initiation rates increased from 51%
in July 2010, to 74% in July 2011. During this time
the percentage of eligible infants who were placed
in Kangaroo care at birth increased from 60%
to 73%. The percentage of mothers and infants
documented as participating in Kangaroo care in
the motherbaby unit also increased from 35% to
51%. Ninety percent of the labor and delivery staff
and motherbaby staff completed the Kangaroo
care competency assessment in the 12 months
following July 2010.
Implementation of the Kangaroo care initiative
improved breastfeeding rates in the population
served by the ULH. It is essential that all levels of
leadership support and monitor standard of care
practice at the bedside. In addition, accurate data
collection and a comprehensive educational program are vital to support the initiative. Staff accountability is crucial to any successful change
in practice. Our journey continues with further education and improved practices. This quality initiative is being shared with 57 birthing hospitals
throughout Kentucky.
The Perfect Pouch: A March of Dimes Intervention

to Enhance Onset and Frequency of Kangaroo Care
Liza G. Cooper, LMSW, March Purpose for the Program
of Dimes Foundation, White
he national evaluation results of the March
Plains, NY
Keywords
Kangaroo Care
skin-to-skin
staff resistance
parent awareness
Newborn Care
Poster Presentation
of Dimes NICU Family Support program revealed that neonatal intensive care unit (NICU)
parents felt that the most comforting activity that
could be offered in the NICU would be to hold
their infants. Staff respondents also reported the
benefits of Kangaroo care include reduced stress,
enhanced comfort, and increased parentinfant
bonding, but only 8% of staff reported routinely
offering Kangaroo care to families. The March of
Dimes developed the Close to Me intervention to
increase the early onset and frequency of Kangaroo care in NICUs.
Proposed Change
The Close to Me intervention includes parent education and awareness materials, staff education
materials, and items of comfort and encouragement for families. This presentation will share the
components of the Close to Me intervention as
well as what was shown to be most effective in the
evaluation.
Close to Me was unveiled in March of Dimes
R
program sites nationwide.
NICU Family Support
In 2011, a national evaluation of Close to Me
was conducted in four NICU sites using an outside consultant who conducted staff focus groups
and surveys preintervention and postintervention,
S49
parent surveys, and a special parent journaling

technique. Results will be shared regarding the
most effective components of Close to Me and
the changes in parent and staff perceptions from
preintervention to postintervention. We worked
closely with a large team of NICU staff on adapting our materials for the full-term NICU infants and
the full-term, well-baby audiences of professionals and parents. Key findings from this work also
will be discussed.
Kangaroo care is a proven benefit to newborns
and parents. Staff resistance to its implementation
can be overcome with awareness, education, and
hands-on instruction. Parents can learn to ask for

and advocate for this activity if they know about
it and its benefits early in their babys hospitalization. Researching Kangaroo care by having parents maintain a journal is appealing to parents who
have the opportunity to heal and process as they
participate in the study. Kangaroo care can be vital
to many if not all babies in the NICU, including fullterm babies and those in the NICU for a short stay.
The physiological, medical, and emotional benefits of Kangaroo care are worth the additional time
required in educating staff and providing comforting space and opportunities for parents to Kangaroo care their infants.
A New Look At Infection Control in the Neonatal Intensive

Care Unit
o reduce infection rates in the neonatal intensive care unit (NICU) by 30%.
Proposed Change
To educate and implement policy to reduce the
NICU infection rates.
To change the way we look at preventing infections in the NICU, the aim of this project was to
recreate the policy and procedure on infection
control for the NICU. This project was started in
July 2008 after the unit joined the California Childrens Quality Initiative in January 2008. The initial
goal for 2008 was to reduce infection rates in the
NICU by at least 30%. This project was completed
as follows: the California Childrens Quality Initiative guidelines were collected and incorporated
into the current infection control policy for the unit;
each policy concerning infection control was reviewed; the last 5 years of peer-reviewed literature on infection control pertaining to neonatal intensive care was reviewed, and pertinent information was added to the policy and procedure; and
each multidisciplinary group in the NICU was met
with (for example the peripherally inserted central
catheter team). These teams compiled input, and
the information was added as appropriate to the
policy. Finally, the policy was reviewed and ap-
S50
proved by the medical director and delivered to Michele L. Carson, MSN-CNL,

RNC-NIC, UCSD Medical
the core group for the unit.
Center, Del Mar, CA
Once the policy was finished, the staff members

were educated through the creation of a six-panel
poster session on the policy. Each staff member
was required to walk through the poster session
and answer a set of competency questions that
pertained to the poster session. Also, a parent
agreement was created that centered on infection control, which holds parents to the same standards as the nurses and doctors. During this time,
specific audit tools were used to assess staff adherence to the components of the policy. Overall,
the infection rate was reduced by 58% and audit
data showed adherence to be at 96% and greater.
These data were presented to the 2009 California Perinatal Quality Control Collaborative annual
meeting in Sacramento and at the hospital-wide
infection control committee. The policy was approved by the hospital-wide infection control committee and is under review for adoption on other
hospital units.
Keywords
NICU
CLABSI
quality initiative
Newborn Care
Poster Presentation

At this time our efforts are focused on sustaining
the gains. We are accomplishing this by reviewing current evidence-based practice yearly and
changing practice accordingly, continuing to complete audits on practice, and providing continuing
education to new and current staff.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Woodson, L.
What Do You Mean You Dropped Your Baby? Changing

and Hardwiring Nursing Practice to Eliminate Infant Falls
Linda Woodson, RN, BSN,
Baylor All Saints Medical
Center- Andrews Womens
Hospital, Fort Worth, TX
Keywords
education
newborn safety sheet
snuggle time
hourly rounding
Newborn Care
Poster Presentation

n the first 2 years that Andrews Womens Hospital was open, we experienced eight infant falls.
The proposed changes were to hardwire hourly
rounding on all shifts, to educate families on safe
sleeping arrangement, and to promote maternal
rest.
Proposed Change
Our goal was to eliminate infant falls at Andrews
Womens Hospital.
We implemented the project by first using a tally
sheet to identify common trends that occurred in
the falls of newborns. Then, we educated both the
newborn nursery and the postpartum staff on the
need to hardwire the hourly rounding on all shifts.
Next, we developed a newborn safety sheet that
described the elements of safe sleeping and re-
quired that both the mother and the significant

other sign the sheet because three infants had
been dropped by fathers. In addition, we emphasized with the newborn nursery staff and postpartum staff how important it was to make sure that the
mother has the call bell within reach, even when
she is placed in a chair. We began an extensive
campaign to make sure that the mothers understood the adverse effects of pain medication. In
addition, the postpartum registered nurse (RN)
would alert the RN nurse when the mother had
taken pain medication. Finally, we initiated snuggle time every day from 2:00 to 4:00 to promote
maternal rest without interruptions. The outcome
has been very positive, and it has been 1 year
since the last fall of a newborn occurred.
Education of families and hourly rounding are absolutely necessary for keeping our infants safe.
Supporting Breastfeeding in the Hospital: A Better Start

reast milk feeding is the best option for infants and exclusive breast milk feeding is
Maggie Redmon, RN, C-EFM, supported by the American Academy of PediBristol Regional Medical
atrics for the first 6 months of life. In addition, the
Center, Bristol, TN
Joint Commission recently introduced PC-05, recommending exclusive breast milk feeding during
Keywords
an infants entire hospital stay. Our goal was to inskin to skin
early pumping
crease the rates of breast milk feeding during the
exclusive breast milk feeding
duration of the hospital stay and the rates of infants
easy access for rental supplies
who were exclusively fed breast milk at discharge
to promote what is best for infants and comply with
the the Joint Commissions recommendation.
Tessa Brown, BSN, RN, CLC,
Bristol Regional Medical
Center, Bristol, TN
Newborn Care
Poster Presentation
Proposed Change
Our plan was to increase the support and duration
of exclusive breast milk feeding by placing infants
skin-to-skin during the immediate post delivery period. Second, we planned to begin encouraging
early pumping for mothers of infants that were not
breastfeeding well or were unable to nurse. We
then planned to make breast pumps and supplies
more readily available for our patients. Our staff
would then be educated on the changes.
Our unit began implementing changes to support
the breastfeeding relationship in the above mentioned areas. We began placing all breastfeed-
ing infants skin-to-skin within the first hour and allowed them to self-attach to the breast for the first
feeding, which has been shown to increase the
success of breastfeeding by approximately 80%.
Second, we began to encourage early pumping
for infants that were not feeding well at the breast
or were unable to be at the breast because of medical conditions. We then looked at how we could
support the use of breast pumps for our patient
population. This was accomplished by partnering
with a pharmacy in the Bristol Regional Medical
Center to provide easy rental of breast pumps
as well as breastfeeding supplies at competitive
prices. Finally, we educated our nursing staff on
the importance of supporting breastfeeding, allowing them to become breastfeeding advocates
for our patients.
By implementing these changes, we were able to
provide the early intervention and support necessary for our patient population. Patients are excited about the skin-to-skin process and our early
support and intervention. Our partnership with the
pharmacy has allowed our patients easy access
to breast pump rentals and supplies. Combining
these interventions has a great potential to increase the rates of exclusive breast milk feeding
during the hospital stay and beyond.
S51
Babies, Bonding and Breastfeeding in the Post-Anesthesia

Care Unit: Innovative Family Centered Care in a Community
Hospital
n many cultures, newborns are placed naked
on their mothers chests immediately after birth,
which is viewed by many as necessary for the infants survival. In most community hospitals, mothers and infants are separated quickly after cesarean birth and not reunited until hours later.
In collaboration with our post-anesthesia recovery team, our obstetric nurses created a seamless
process to keep the mother and infant together
throughout the challenging postoperative period.
Proposed Change
In an effort to provide immediate skin-to-skin contact and allow for early breastfeeding for mothers
and their healthy infants after operative deliveries,
the roles and responsibilities of the labor and delivery nurses were changed. These changes enable
the nurse to be off of the labor and delivery floor
and provide both intraoperative and postoperative
one-on-one care for the newborn and mother as a
unit.
A multidisciplinary team was formed that consisted of labor and delivery nurses, postanesthesia recovery team members, lactation consultants,
and the director of womens services. This team

was formed to change the policies and procedures to allow infants to remain with their mothers
after a cesarean birth and the immediate postpartum surgical recovery period. A process was
developed to assist with the implementation of the
new procedures and to educate and direct nursing
teams involved with cesarean births. Evidencebased best practice was used to guide staff education. The education incorporated the importance of skin-to-skin contact between the mother
and baby and early breastfeeding after an operative delivery. Evaluation revealed that keeping the
mother and baby together after cesarean birth increased patient satisfaction, enhanced quality of
care, allowed skin-to-skin contact, promoted early
breastfeeding, and supported thermal regulation
of the newborn.
Lauren Griffin-Walls, BSN,

RNC-OB, Milford Memorial
Hospital-Bayhealth, Milford,
DE
Jaclyn Lewis, RN-CPN,
Milford Memorial
Hospital-Bayhealth, Milford,
DE
Keywords
babies
bonding
breastfeeding
PACU
Newborn Care
Poster Presentation

Implementing Babies, Bonding, and Breastfeeding in the Post-anesthesia Care Unit enhances
overall postpartum operative care, fosters teamwork between nursing units, and supports the
Association of Womens Health, Obstetric and
Neonatal Nurses commitment to positive perinatal
outcomes.
Decline of the Gold Standard! Umbilical Cord Tissue

Provides Timely and Accurate Results to Enhance Quality
Outcomes for the Neonate
ecent literature reviews stated that approximately 5% to 10% of women self-report the
use of illicit drugs during pregnancy; however, universal testing in high-risk populations indicates
higher rates of illicit drug use. Facilities should establish their own testing protocols and unbiased
guidelines to identify when testing should occur
because the literature does not indicate consensus on universal screening. A positive maternal
test result determines the initiation of the protocol
to test newborns.
Proposed Change
Meconium drug screening is considered the gold
standard for drug testing in the neonate, but be-
S52
cause of false positive test results and the length

of time to obtain confirmatory results it was identified that a practice change was necessary. Because of the sensitive nature of this test, accuracy in patient test results is crucial. Increase
in false positive test results lead to questioning the truthfulness of the test. The goal was
to identify a process that provided ease of obtaining specimen sampling and accurate patient
test results. The proposed change was to implement umbilical cord tissue screening. The advantages of this process included samples being sent immediately after birth, receiving only
confirmatory results, and a chain of custody. Because of the sensitive nature of drug testing and
possible legal ramifications, a chain of custody
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Tanyelle Bellamy, RNC, MSN,

FNP-BC, Mountain States
Health Alliance, Johnson City,
TN
Keywords
drug testing
substance abuse
umbilical cord testing
neonatal abstinence scoring
Newborn Care
Poster Presentation
Bellamy, T.
was seen as a necessary piece of our process

improvement.
The plan was discussed and approved by the
neonatologists and pediatricians. Nursing leadership met with pathology and lab directors to discuss switching the testing location from a local laboratory to sending the tests to an outside reference
lab. Initial implementation began at a regional tertiary care facility and a smaller community hospital
where the largest volumes of maternal substance
abuse were experienced. The outcomes focused
on increasing result turnaround times, potentially

decreasing the newborns length of stay, and decreasing rates of false positive test results.
The implications for the nursing practice included the need for a standardized order set
for newborns experiencing neonatal abstinence
symptoms, which was developed in collaboration
between the departments of nursing and neonatology. All nursing staff received in-service on neonatal abstinence scoring to help staff provide more
consistent and accurate scores.
At Home with Your Baby

Deborah Raines, PhD, EdS,
RN, ANEF, Walden University,
his community-based program is designed
Boca Raton, FL
Keywords
NICU discharge
simulation
caregiver competence
Newborn Care
Poster Presentation
to enhance parents competence and confidence as caregivers after their infants discharge
from the neonatal intensive care unit (NICU).
Proposed Change
By enhancing parent confidence and competence, this program will improve infant, parent, and
overall family well being. The program also has the
potential to decrease the use of health care resources, such as 911 calls, emergency resources
visits, and hospital readmission.
The program is conducted in the department
for caregiver education and uses a preemie
high-fidelity simulator. The specific activities are
adapted to the anticipated discharge needs

of the infant. The program accepts referrals
from all the NICUs in the county and from
the Health Department. The program began accepting referrals in January 2011. To date, the
evaluation of parents and staff has been overwhelmingly positive and the funding has been
extended for a second year. Data are being collected on the specific outcomes of parent confidence and competence as caregivers as well as
on unscheduled use of health care resources on
infants.
The use of high-fidelity simulators may have a significant role in the process of discharge teaching
in the NICU.
Making Kangaroo Care the Norm: Implementation of a New

Model of Care
Lynn Barabach, MSN, RNC,
Lakewood Hospital, Lakewood,
n 2009, the Lakewood Hospital Birthing CenOH
Joy Sedlock, MSN, CNM,
IBCLC, Lakewood Hospital,
Lakewood, OH
Kate Salmon, RNC, MSN,
IBCLC, Lakewood Hospital,
Lakewood, OH
Keywords
kangaroo care
infant
childbirth
breastfeeding
Newborn Care
Poster Presentation
ter embarked on the journey to obtain BabyFriendly, USA designation. It was identified that
a key component for a successful journey was
the implementation of Kangaroo care, or skin-toskin care, in the immediate postpartum period. In
the fall of 2009, the Birthing Center began training
the nurses on Kangaroo care and implementation
soon followed.
Proposed Change
Our goal was that all appropriate infants would
be placed in Kangaroo care shortly after birth and
would remain with their mother or the mothers support person for 60 to 90 minutes. The time in Kangaroo care with the mother would facilitate transition to extrauterine life and allow the infant to
self-latch at the breast.

Nursing leadership worked with a nationally recognized expert on Kangaroo care to provide
education to the nurses. A 4-hour program on
Kangaroo care was developed and included discussion of the benefits, infant placement, and ongoing care of the infant, including assessment.
Placing the infant in Kangaroo care was demonstrated to validate understanding. The electronic
health record was modified to include documentation of time in and out of Kangaroo care and
with whom the infant was in Kangaroo care. Patient education included handouts on Kangaroo
care for distribution during prenatal appointments,
prepared childbirth classes, and breastfeeding
classes. Kangaroo care also is discussed during tours of the Birthing Center. Pediatric, midwifery, obstetric, and anesthesia providers were
educated about Kangaroo care and the Birthing
S53
Centers change in the model of care immediately

following birth. As barriers were identified, nursing
leadership worked on the issues to minimize interruptions of Kangaroo care. The percentage of appropriate infants in Kangaroo care following birth
is reviewed monthly. Between 90% and 98% of
appropriate infants are placed in Kangaroo care.
Infants also are placed in Kangaroo care shortly
after a cesarean birth while the mother remains in
the operating room. Anecdotally, lactation consultants report a decrease in the incidence of delayed
latch and breastfeeding problems. Families have
reported increased satisfaction with their birthing

experiences.
Kangaroo care assists the infant with transition and
facilitates initial breastfeeding, it is beneficial to the
infant, mother, and family, and it is utilized throughout the hospital stay and families are encouraged
to continue Kangaroo care at home, especially in
conjunction with breastfeeding. The use of Kangaroo care is truly a nursing intervention. This nursing intervention quickly became a model of care
for the Birthing Center.
Discharge Planning in the Neonatal Intensive Care Unit

o improve parents ability to care for their infants at discharge.
Proposed Change
To implement the following improvements in the
neonatal intensive care unit (NICU):
r
r
r
r
Cultural: More parental involvement. Parents

would hold infants every day. Parents get a
picture on admission. Long-term infants get
a journal with weekly pictures.
Teaching: A parent admission and discharge
tool was created. Videos will be added to our
television system for parental viewing. Registered nurses will be held accountable for
daily teaching and documentation.
Parental Accountability: Parents will be actively involved in teaching and take responsibility for learning.
Discharge map created: Outline discharge
teaching with daily accountability for updates, holding, and teaching.

The clinical manager recruited two staff nurses.
The classes were mandatory for NICU nurses and
included the following: an emotional approach, a

literature review, and a discussion of unit expectations. Issues with discharge planning, parents
being unprepared to take their infants home, and
the associated risks were reviewed, along with
the American Academy of Pediatrics guidelines
for discharge planning, including rooming in. Our
evaluations have been overwhelmingly positive.
Our parent surveys improved from the 30th percentile for discharge planning to the 99th percentile. Parents state that they feel at home within
the NICU and are prepared to care for their infants.
We offer all parents rooming in.
Kathy J. Loughren, MSN,

NNP-BC, Memorial Hospital
Miramar, Miramar, FL
Keywords
neonatal intensive care unit
(NICU)
Newborn Care
Poster Presentation

Discharge planning should begin on admission.
It is not only a teaching process but should involve the parents in every aspect of their infants
care. We must change our culture of isolation to
one of inclusion. The more involved the family is,
the more prepared they are to care for their infant at home. Nurses must be held accountable
for discharge teaching on a daily basis. Parents
should be actively involved and accountable for
knowledge acquisition. Discharge mapping is an
excellent tool to ensure that parents have covered
all discharge information.
Nurses Commitment to Best Practice Infant Care and

Family Bonding Founded on Evidence-Based Research:
A Journey of Infant Bathing
he Professional Practice Committee hypothesized that we could improve postpartum wellborn baby care by switching from sponge bathing
to immersion bathing. A research review revealed
evidence supporting the theory that immersion
S54
bathing improved temperature stability, bonding,

breastfeeding, and parental education. The current practice in the Providence Alaska Medical
Center Maternity Center is to perform sponge
bathing under a radiant warmer on newborns
within 2 hours of birth in the absence of birth stress
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Rebecca Heimann, RN,

Providence Alaska Medical
Center, Anchorage, AK
Melissa Heath, RN, Providence
Alaska Medical Center,
Anchorage, AK
Heimann, R. and Heath, M.
Keywords
bathing
education
thermoregulation
infant stability
newborn care
Newborn Care
Poster Presentation
or trauma. Parental involvement is minimal because of decreased mobility from anesthesia, exhaustion, and environmental or social distractions
during the immediate postpartum period. Nurses
also reported that breastfeeding and skin-to-skin
bonding time often was interrupted to complete
baths in the allotted 2-hour recovery time.
Proposed Change
The Professional Practice Committee proposed
a policy and procedural change to immersion
bathing founded on evidence-based research,
which incorporated these key principles:
r
r
Delay infant baths 2 to 4 hours to establish thermoregulation and decrease negative side effects of hypothermia, including
increased oxygen consumption, respiratory
distress, and hypoglycemia.
Stable temperature defined as 97.7 F to
99.5 F for 2 to 4 hours.
Tub bathing appears to be more effective than sponge bathing at maintaining
body temperature and preventing temperature loss. Also, studies showed there is no difference in umbilical cord infection and healing rates and infants appeared more relaxed
and less agitated during tub baths.
Infants at risk of transmission of hepatitis B

and human immunodeficiency virus from maternal sources will be bathed within 2 hours
of birth.

The Professional Practice Council presented their
research and findings to the Nursery Committee
and received permission to proceed with a practice change. Currently, the Professional Practice
Council is developing a training video, policy, and
care competency. These tools will be presented
to the staff at regularly scheduled staff meetings.
Hands-on training of nurses and techs will be
conducted to assure comfort and competency in
practice. The goals for this project are consistent immersion bathing per guidelines, increased
infant relaxation, increased parental involvement
and education covering proper positioning, temperature regulation, and signs and symptoms of
infant distress.
Increased parental involvement in newborn care
results in greater uninterrupted bonding time, improved breastfeeding, extended skin-to-skin contact in the postpartum period, as well as improved
neonatal outcomes from decreased cold stress
and calmer stabilization.
Outpatient Newborn Hearing Screening Program

Nicole Giangregorio, BS, CLE, Purpose for the Program
LCCE, Sharp Mary Birch
he Newborn Hearing Screening Program is a
Hospital for Women &
California state mandated program requiring
Newborns, San Diego, CA
Keywords
outpatient
community
hospital growth
Newborn Care
Poster Presentation
all infants to have a hearing screening prior to discharge. Sharp Mary Birch Hospital for Women &
Newborns additionally offers an outpatient hearing program for our well-baby population leading
to increased patient satisfaction and delayed appointment times.
Proposed Change
To increase the number of patients receiving outpatient hearing rescreenings, decrease the time
between the initial hearing screening and the
follow-up hearing screening, and increase revenue.
The outpatient program allows our hospital to
schedule the follow-up appointment for all wellbabies prior to discharge, ensure a reminder call
is made, complete all necessary paperwork, and
guarantee an appointment well within the state
recommended 4-week timeframe. Compared to
our region, our outpatient no-show rate is considerably lower. The region reported a no-show rate of
12.3% for July 2011 and Sharp Mary Birch Hospital for Women & Newborns reported a 0% no-show
rate (the overall program no show rate is currently

being calculated by the Regional Hearing Coordinating Center). Each outpatient appointment receives a reminder phone call 48 hours prior to their
appointment. On the day of their appointment, the
family is received and escorted to the outpatient
clinic by a hearing screening technician. New parents are relieved to come back to the hospital
where they gave birth versus going to a different
clinic and navigating a new health system. As a result, our patients are more satisfied. The outpatient
revenues previously went to other hospitals within
the community, and Sharp Mary Birch Hospital for
Women & Newborns now receives revenues from
the insurance companies and the state for MediCal and/or uninsured patients. Since the outpatient program began in October 2008, we have
seen 382 outpatients with a steady increase each
fiscal year. The outpatient program is open to the
community at-large allowing for quicker access to
a follow-up hearing screening.
It is important for families to have their outpatient
follow-up appointments within the same health
system for convenience, increased patient satisfaction, and increased revenue.
S55
An Innovative Program to Support and Promote

Breastfeeding: What Have You Done for Me Lately?
espite evidence for breastfeeding benefits,
hospitals fall short in breastfeeding rates and
duration. Recent Centers for Disease Control and
Prevention data suggest less than 4% of U.S. hospitals offer the full support necessary to meet
enduring, committed breastfeeding, and nearly
75% do not provide maternal support after discharge. This challenges an institutional ability to
meet the Healthy People 2020 goals to have 81.9%
of mothers initiate breastfeeding, 60.6% breastfeed at 6 months, and 34.1% breastfeed at 1 year.
The Surgeon Generals Call to Action to Support
Breastfeeding underscores this critical need, noting low priorities for breastfeeding, and use of
nonevidence-based practices as barriers to enduring breastfeeding.
Proposed Change
To create a comprehensive breastfeeding program to meet the challenges stated above
Christiana Care Health System has built an enduring lactation program available across the continuum of perinatal care aimed to meet these
action calls. Support is offered to mothers and
other perinatal clinicians by experienced lactation
consultants to overcome breastfeeding obstacles.
This program promotes the development of knowledgeable mothers and health care providers. Our
facility maintains a free, breastfeeding hotline that
is staffed by lactation consultants. Mothers may
initiate a call at any time during their breastfeeding experience when they encounter questions
or concerns. As part of this program, logs document telephone conversations. To ensure that
S56
mothers are being offered relevant information,

logs were subjected to qualitative analysis, which
determined the nature of maternal concerns. Ten
themes emerged and specific, predictable breastfeeding topics developed at key points during the
first year of life.
Lynn E. Bayne, PhD, NNP-BC,

RN, Christiana Care Health
System, Newark, DE
Data from 1,025 mothers who breastfed and called

during 2009 were examined. Findings were then
compared to the nurses perceived breastfeeding barriers by care area, as defined in a separate performance improvement project. Results
of both projects clearly indicated the need to
initiate breastfeeding education activities during
prenatal classes, maintain momentum during the
inpatient phase, and provide anticipatory postdischarge guidance so that a successful support program would be in place to meet the aforementioned goals.
Lydia Henry, MSN, RNC-OB,

CCE, IBCLC, Christiana Care
Health System, Newark, DE
Elizabeth Chance, EdD, RN,

Christiana Care Health System,
Newark, DE
Keywords
comprehensive breastfeeding
program
Christiana Care Health System
(CCHS)
Newborn Care
Poster Presentation

A team approach focused on breastfeeding to
support maternal-child nurses and mothers is one
way to improve hospital practices and meet goals.
Inpatient nurses should address predictable areas of concern with new mothers, particularly
concerning milk supply, baby behaviors, and
pumping. Outpatient clinicians can offer anticipatory guidance based on consistent patterns
of data across the postpartum period, such as
drug and diet interaction with milk, stooling patterns, and weaning among other issues. Information and available resources that are appropriately timed and offered when the mother is
ready to learn improve the chances that the mother
will be able to process and retain the shared
information.
JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x
Copyright of JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email articles for
individual use.

A Pilot Project To Improve Neonataal

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

A Pilot Project To Improve Neonataal

Transféré par

Droits d'auteur :

Formats disponibles

I N N O VAT I V E P R O G R A M S

Proceedings of the 2012 AWHONN Convention

A Pilot Project to Improve Neonatal Peripheral Intravenous

Lisa Klein, MSN, RNC-OB,

Purpose for the Program

An additional purpose of the project was to obtain

The Great Pretenders: Utilizing Evidence-Based Practice

Purpose for the Program

JOGNN 2012; Vol. 41, Supplement 1

outcomes and reduce late preterm infant neonatal

hypoglycemia, respiratory distress, feeding difficulties, phototherapy, excessive weight loss,

and readmissions to the pediatric unit by 5%, as

Tackling Newborn Hypoglycemia in the Delivery Room:

Pamela Kinney Tozier, BSN,

Implementation, Outcomes, and Evaluation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Proceedings of the 2012 AWHONN Convention

Implications for Nursing Practice

Premature Infant Nutrition Clinic

Purpose for the Program

one-time only to several visits 1 to 3 weeks apart. A

Implementing Practice Protocols and Education to Improve

Purpose of the Program

JOGNN 2012; Vol. 41, Supplement 1

on the posttest, with 2% to 44% improvement. All

Implications for Nursing Practice

Perinatal Palliative Care: Support of Mothers,

support this program. The evaluation will be based

J. Frances Fusco, MHS, BSN,

Implications for Nursing Practice

infant advanced directives

Neonatal Head Trauma: Implementation of a Care Algorithm

Sandra Hoffman, MS, RN,

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Braithwaite, P., Donahue, N. and Bayne, L. E.

Implementation, Outcomes, and Evaluation

Implications for Nursing Practice

Help! Im Cold! Improving the Warmth of Our Newborns

Implementation, Outcomes, and Evaluation

Implications for Nursing Practice

Pamela Braithwaite, BSN,

JOGNN 2012; Vol. 41, Supplement 1

Welcome Aboard and Homeward Bound: The NICU

Implementation, Outcomes, and Evaluation

Geraldine Tamborelli, MS, RN,

Birthways Lactation Services: A Model

Angela Carswell, RN, IBCLC,

Implications for Nursing Practice

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Keller, A. and Brenneman, A.

Proceedings of the 2012 AWHONN Convention

Operation Kangaroo Care

The process before leaving the operating room is

Infant Feeding Plan: An Innovative Documentation Tool to

Purpose for the Program

JOGNN 2012; Vol. 41, Supplement 1

document. The development of the individualized

Implications for Nursing Practice

regarding feeding options and changes in infant

A Baby Weigh Station: Continuum of Care for Late Preterm

proachable staff and expert professionals. Identify

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x

Kathleen H. Bright, BSN,