Altering the NICU and measuring infants' responses

Medical staff's sentiments on the establishment of quiet time in the NICU

AIM

To explore the sentiments of medical staff in setting quiet time in a tertiary neonatal intensive care unit.

BACKGROUND

Quiet time, which can help create a healing neonatal intensive care unit environment, is increasingly being valued by hospital administrators.

METHODS

Semi-structured interviews were used to interview twelve neonatal intensive care unit staff members, with data analyzed using the content analysis method.

RESULTS

This study extracted four themes: support, concern, education, and teamwork.

CONCLUSIONS

If quiet time needs to be set up, implemented, and maintained in the neonatal intensive care unit, it is necessary to establish a quiet time culture throughout the whole ward, to carry out detailed management of quiet time, and to cooperate and communicate with multidisciplinary departments.

IMPLICATIONS FOR NURSING MANAGEMENT

To keep the ward quiet and minimize handling during quiet time, it is necessary to take adequate steps from a management level. Targeted staff training and education allow staff to appreciate the necessity and urgency of setting quiet time for themselves and babies. It is also necessary to refine the educational content of noise reduction and minimal handling, and provide clear guidance on the best means to carry out clinical work during quiet time. Nursing managers need to establish a monitoring system for NICU noise and manage various noise sources made from equipment and people.

Neonatal intensive care unit incubators reduce language and noise levels more than the womb

OBJECTIVE

To assess the sound reducing characteristics of modern incubators in the neonatal intensive care unit (NICU) and to better characterize auditory and language exposures for NICU infants.

STUDY DESIGN

Sound frequency spectral analysis was conducted on language and noise audio acquired simultaneously inside and outside incubators located in the NICU.

RESULTS

Sound transmission into the incubators was nonuniform. Very low-frequency sounds (<100 Hz) were unattenuated or even slightly amplified inside the incubators. Maximal reduction was observed for low-to-mid frequencies (300-600 Hz) and high frequencies (>2000 Hz), which convey important language information.

CONCLUSIONS

Sound reductions observed across NICU incubator walls are more severe than those reported for sound transmission into the intrauterine environment, particularly for midrange frequencies that are important for language. Although incubator walls may serve as a protection against noxious noise levels, these findings reveal a potentially detrimental effect on language exposure for infants inside a NICU incubator.

The prevalence of hypovitaminosis D and its risk factors in pregnant women and their newborns in the Middle East: A systematic review

BACKGROUND

Pregnant women and newborns are at risk for vitamin D deficiency (VDD). Also, poor health outcomes for pregnant women with VDD are reported in the published literature.

OBJECTIVE

The aim of this systematic review was to estimate the prevalence of hypovitaminosis D and the associated risk factors for hypovitaminosis D in Middle Eastern pregnant women and their newborns.

RESULTS

The prevalence of circulating 25-hydroxyvitamin D (25(OH)D) < 50 nmol/L as a marker of vitamin D status in pregnant women and their newborns was between 24.5-98% and 22-100%, respectively. The prevalence of 25(OH) D < 25 nmol/L in pregnant women and their newborns was over a wide range between 16.7-80% and 22-82%, respectively. Predictors for low maternal and neonatal 25(OH)D concentrations included decreased vitamin D synthesis due to reduced exposure to sunlight and decreased nutritional intake of vitamin D. A predictor of low neonatal 25(OH)D concentrations included maternal vitamin D status and the correlation between vitamin D concentrations in maternal and cord blood.

CONCLUSION

The high prevalence of VDD in the pregnant women of the Middle East underscores the necessity of implementing national prevention and intervention strategies. A clear policy for clinicians and healthcare workers is needed for screening and maintaining sufficient vitamin D status during pregnancy.

Reduced environmental stimuli is associated with improved insulin-like growth factor-1 levels and physical growth in very low birth weight premature infants

Standard environmental features of the neonatal intensive care unit (NICU) may be stressful and not optimal for the maturation of very low birth weight premature infants (VLBWPIs). The present study investigated whether structured no-touch periods and reducing periods of light and sound stimulation may influence the developmental indices of VLBWPIs. Between June 2012 and June 2013, 60 consecutive VLBWPIs were equally apportioned to either an experimental or control group. The groups were statistically comparable with regard to sex ratio, gestational age and birth weight. Each group received routine nursing care, but infants in the experimental group were additionally cared for in a separate room with 3 h of rest every 8 h, and reduced light and sound from staff and instruments. At 7 and 14 days following birth, plasma insulin-like growth factor 1 (IGF-1) levels of the experimental group were significantly higher than that of the control group. Furthermore, at day 7 and 14, the body weight and crown-to-heel lengths were significantly increased in the experimental group compared with the control group. In summary, during the first 2 weeks following birth, the reduction of touch, sound and light stimulation in the NICU were associated with higher plasma IGF-1 levels and physical growth of VLBWPIs. These results may have implications for the better management of VLBWPIs in the NICU.

False alarm reduction in critical care

High false alarm rates in the ICU decrease quality of care by slowing staff response times while increasing patient delirium through noise pollution. The 2015 PhysioNet/Computing in Cardiology Challenge provides a set of 1250 multi-parameter ICU data segments associated with critical arrhythmia alarms, and challenges the general research community to address the issue of false alarm suppression using all available signals. Each data segment was 5 minutes long (for real time analysis), ending at the time of the alarm. For retrospective analysis, we provided a further 30 seconds of data after the alarm was triggered. A total of 750 data segments were made available for training and 500 were held back for testing. Each alarm was reviewed by expert annotators, at least two of whom agreed that the alarm was either true or false. Challenge participants were invited to submit a complete, working algorithm to distinguish true from false alarms, and received a score based on their program's performance on the hidden test set. This score was based on the percentage of alarms correct, but with a penalty that weights the suppression of true alarms five times more heavily than acceptance of false alarms. We provided three example entries based on well-known, open source signal processing algorithms, to serve as a basis for comparison and as a starting point for participants to develop their own code. A total of 38 teams submitted a total of 215 entries in this year's Challenge. This editorial reviews the background issues for this challenge, the design of the challenge itself, the key achievements, and the follow-up research generated as a result of the Challenge, published in the concurrent special issue of Physiological Measurement. Additionally we make some recommendations for future changes in the field of patient monitoring as a result of the Challenge.

Spatial learning and memory deficits in young adult mice exposed to a brief intense noise at postnatal age

Noise pollution is a major hazardous factor to human health and is likely harmful for vulnerable groups such as pre-term infants under life-support system in an intensive care unit. Previous studies have suggested that noise exposure impairs children's learning ability and cognitive performance and cognitive functions in animal models in which the effect is mainly attributed to the oxidant stress of noise on the cognitive brain. The potential role of noise induced hearing loss (NIHL), rather than the oxidant stress, has also been indicated by a depression of neurogenesis in the hippocampus long after a brief noise exposure, which produces only a tentative oxidant stress. It is not clear if noise exposure and NIHL during early development exerts a long term impact on cognitive function and neurogenesis towards adulthood. In the present study, a brief noise exposure at high sound level was performed in neonatal C57BL/6J mice (15 days after birth) to produce a significant amount of permanent hearing loss as proved 2 months after the noise. At this age, the noise-exposed animals showed deteriorated spatial learning and memory abilities and a reduction of hippocampal neurogenesis as compared with the control. The averaged hearing threshold was found to be strongly correlated with the scores for spatial learning and memory. We consider the effects observed are largely due to the loss of hearing sensitivity, rather than the oxidant stress, due to the long interval between noise exposure and the observations.

Motor responses and weight gaining in neonates through use of two methods of earmuff and receiving silence in NICU

Background and Aims. With technological advances in NICUs the survival rate of preterm infants has been increased. Because NICU environment is a potent source of stress for infants, its modification is an essential measure to decrease infants' morbidity. The purposes of this study were to compare the effects of wearing earmuff and provision silence for infants on their motor responses and gaining weight. Methods. In a randomized clinical trial 96 preterm infants were enrolled. Their motor responses were evaluated for two consecutive days in the morning and afternoon shifts, in the groups of earmuff and silence, and at similar time points in the control group. Also their weight was measured at days 1 and 10. Results. In the two intervention groups, means of motor responses in infants were significantly less than in the control group, and weight gain of infants was more than the control group. However weight gain was more pronounced in the earmuff group. Conclusion. Both interventions led to decreasing number of motor responses and improvement of weight gain pattern, but these effects were more pronounced in earmuff group; thus because implementation of silence in NICUs has many barriers, it is suggested to use earmuff for preterm infants in these units. This trial obtained IRCT registration number IRCT2012092010812N2.

Exposure to virtual social stimuli modulates subjective pain reports

BACKGROUND

Contextual factors, including the gender of researchers, influence experimental and patient pain reports. It is currently not known how social stimuli influence pain percepts, nor which types of sensory modalities of communication, such as auditory, visual or olfactory cues associated with person perception and gender processing, produce these effects.

OBJECTIVES

To determine whether exposure to two forms of social stimuli (audio and visual) from a virtual male or female stranger modulates cold pressor task (CPT) pain reports.

METHODS

Participants with similar demographic characteristics conducted a CPT in solitude, without the physical presence of an experimenter or another person. During the CPT, participants were exposed to the voice and image of a virtual male or female stranger. The voices had analogous vocal prosody, provided no semantic information (spoken in a foreign language) and differed only in pitch; the images depicted a middle-age male or female health care practitioner.

RESULTS

Male participants, but not females, showed higher CPT pain intensity when they were exposed to the female stimuli compared with the male stimuli. Follow-up analyses showed that the association between the social stimuli and variability in pain sensitivity was not moderated by individual differences in subjective (eg, self-image) or objective measurements of one's physical stature.

DISCUSSION

The findings show that exposure to virtual, gender-based auditory and visual social stimuli influences exogenous pain sensitivity.

CONCLUSION

Further research on how contextual factors, such as the vocal properties of health care examiners and exposure to background voices, may influence momentary pain perception is necessary for creating more standardized methods for measuring patient pain reports in clinical settings.

Laboratory personnel gender and cold pressor apparatus affect subjective pain reports

BACKGROUND

There is no standardized method for cold pressor pain tasks across experiments. Temperature, apparatus and aspects of experimenters vary widely among studies. It is well known that experimental pain tolerance is influenced by setting as well as the sex of the experimenter. It is not known whether other contextual factors influence experimental pain reporting.

OBJECTIVES

The present two-part experiment examines whether minimizing and standardizing interactions with laboratory personnel (eg, limiting interaction with participants to consenting and questions and not during the actual pain task) eliminates the influence of examiner characteristics on subjective pain reports and whether using different cold pain apparatus (cooler versus machine) influences reports.

METHODS

The present experiment manipulated the gender of the experimenter (male, female and transgender) and the type of cold pressor task (CPT) apparatus (ice cooler versus refrigerated bath circulator). Participants conducted the CPT at one of two pain levels (5°C or 16°C) without an experimenter present.

RESULTS

Men and women showed lower pain sensitivity when they were processed by biological male personnel than by biological female personnel before the CPT. Women who interacted with a transgendered researcher likewise reported higher pain sensitivity than women processed by biological male or female researchers. The type of CPT apparatus, despite operating at equivalent temperatures, also influenced subjective pain reports.

DISCUSSION

The findings show that even minimal interactions with laboratory personnel who differ in gender, and differences in laboratory materials impact the reliable measurement of pain.

CONCLUSION

More standardized protocols for measuring pain across varying research and clinical settings should be developed.

Light Reduction Capabilities of Homemade and Commercial Incubator Covers in NICU

Reduction of high-risk neonates' exposure to aversive light stimulation is an important component of developmentally supportive care. In neonatal intensive care unit (NICU), usually light is reduced by reducing the room's light level or by using incubator covers. Many types of incubator covers are in use, including homemade and commercial covers. A comparative study was used to determine the light reducing capabilities of 19 homemade incubator covers, 2 commercial covers, and 1 receiving blanket. The covers were tested by covering and uncovering an incubator and an oxygen hood in the NICU during daytime and nighttime lightings. The light reducing capabilities value was determined for each cover using an Extech light dosimeter when the cover was placed over and removed from an oxyhood, and an incubator. The study showed that the light reducing capability of the commercial covers was 91.2%, the homemade covers capability was 72.1%, and the receiving blankets capability was 55.1%. A significant difference between the commercial and homemade covers was found (F = 452.50, P < 0.00). Commercial incubator covers are the most effective covers to achieve light reduction; homemade covers can be effective if made large enough so that they completely cover all sides of the incubator.

Level of NICU quality of developmental care and neurobehavioral performance in very preterm infants

OBJECTIVE

To examine the relation between the neurobehavior of very preterm infants and the level of NICU quality of developmental care.

METHODS

The neurobehavior of 178 very preterm infants (gestational age ≤29 weeks and/or birth weight ≤1500 g) from 25 NICUs participating in a large multicenter, longitudinal study (Neonatal Adequate Care for Quality of Life, NEO-ACQUA) was examined with a standardized neurobehavioral assessment, the NICU Network Neurobehavioral Scale (NNNS). A questionnaire, the NEO-ACQUA Quality of Care Checklist was used to evaluate the level of developmental care in each of the NICUs. A factor analyses applied to NEO-ACQUA Quality of Care Checklist produced 2 main factors: (1) the infant-centered care (ICC) index, which measures parents' involvement in the care of their infant and other developmentally oriented care interventions, and (2) the infant pain management (IPM) index, which measures the NICU approach to and the procedures used for reducing infant pain. The relations between NNNS neurobehavioral scores and the 2 indexes were evaluated.

RESULTS

Infants from NICUs with high scores on the ICC evidenced higher attention and regulation, less excitability and hypotonicity, and lower stress/abstinence NNNS scores than infants from low-care units. Infants from NICUs with high scores on the IPM evidenced higher attention and arousal, lower lethargy and nonoptimal reflexes NNNS scores than preterm infants from low-scoring NICUs.

CONCLUSIONS

Very preterm infant neurobehavior was associated with higher levels of developmental care both in ICC and in IPM, suggesting that these practices support better neurobehavioral stability.

Efficacy and mode of action of a noise-sensor light alarm to decrease noise in the pediatric intensive care unit: a prospective, randomized study

OBJECTIVES

To determine whether a sound-activated light-alarm device could reduce the noise in the central area of our pediatric intensive care unit and to determine whether this reduction was significant enough to decrease the noise that could be perceived by a patient located in a nearby room. The secondary objective was to determine the mode of action of the device.

DESIGN

In a 16-bed pediatric and neonatal intensive care unit, a large and clearly noticeable sound-activated light device was set in the noisiest part of the central area of our unit, and noise measurements were made in the central area and in a nearby room. In a prospective, quasi-experimental design, sound levels were compared across three different situations--no device present, device present and turned on, and device present but turned off--and noise level measurements were made over a total of 18 days.

PATIENTS/SUBJECTS

None.

INTERVENTIONS

Setting a sound-activated light device on or off.

RESULTS

When the device was present, the noise was about 2 dB lower in the central area and in a nearby room, but there was no difference in noise level with the device turned on vs. turned off.

CONCLUSION

The noise decrease in the central area was of limited importance but was translated in a nearby room. The sound-activated light device did not directly decrease noise when turned on, but repetition of the visual signal throughout the day raised staff awareness of noise levels over time.

Reducing false alarm rates for critical arrhythmias using the arterial blood pressure waveform

BACKGROUND

Over the past two decades, high false alarm (FA) rates have remained an important yet unresolved concern in the Intensive Care Unit (ICU). High FA rates lead to desensitization of the attending staff to such warnings, with associated slowing in response times and detrimental decreases in the quality of care for the patient. False arrhythmia alarms are commonly due to single channel ECG artifacts and low voltage signals, and therefore it is likely that the FA rates may be reduced if information from other independent signals is used to form a more robust hypothesis of the alarm's etiology.

METHODS

A large multi-parameter ICU database (PhysioNet's MIMIC II database) was used to investigate the frequency of five categories of false critical ("red" or "life-threatening") ECG arrhythmia alarms produced by a commercial ICU monitoring system, namely: asystole, extreme bradycardia, extreme tachycardia, ventricular tachycardia and ventricular fibrillation/tachycardia. Non-critical ("yellow") arrhythmia alarms were not considered in this study. Multiple expert reviews of 5386 critical ECG arrhythmia alarms from a total of 447 adult patient records in the MIMIC II database were made using the associated 41,301 h of simultaneous ECG and arterial blood pressure (ABP) waveforms. An algorithm to suppress false critical ECG arrhythmia alarms using morphological and timing information derived from the ABP signal was then tested.

RESULTS

An average of 42.7% of the critical ECG arrhythmia alarms were found to be false, with each of the five alarm categories having FA rates between 23.1% and 90.7%. The FA suppression algorithm was able to suppress 59.7% of the false alarms, with FA reduction rates as high as 93.5% for asystole and 81.0% for extreme bradycardia. FA reduction rates were lowest for extreme tachycardia (63.7%) and ventricular-related alarms (58.2% for ventricular fibrillation/tachycardia and 33.0% for ventricular tachycardia). True alarm (TA) reduction rates were all 0%, except for ventricular tachycardia alarms (9.4%).

CONCLUSIONS

The FA suppression algorithm reduced the incidence of false critical ECG arrhythmia alarms from 42.7% to 17.2%, where simultaneous ECG and ABP data were available. The present algorithm demonstrated the potential of data fusion to reduce false ECG arrhythmia alarms in a clinical setting, but the non-zero TA reduction rate for ventricular tachycardia indicates the need for further refinement of the suppression strategy. To avoid suppressing any true alarms, the algorithm could be implemented for all alarms except ventricular tachycardia. Under these conditions the FA rate would be reduced from 42.7% to 22.7%. This implementation of the algorithm should be considered for prospective clinical evaluation. The public availability of a real-world ICU database of multi-parameter physiologic waveforms, together with their associated annotated alarms is a new and valuable research resource for algorithm developers.

Spectral analysis of noise in the neonatal intensive care unit

OBJECTIVE

To perform spectral analysis of noise generated by equipments and activities in a level III neonatal intensive care unit (NICU) and measure the real time sequential hourly noise levels over a 15 day period.

METHODS

Noise generated in the NICU by individual equipments and activities were recorded with a digital spectral sound analyzer to perform spectral analysis over 0.5 - 8 KHz. Sequential hourly noise level measurements in all the rooms of the NICU were done for 15 days using a digital sound pressure level meter . Independent sample t test and one way ANOVA were used to examine the statistical significance of the results. The study has a 90 % power to detect at least 4 dB differences from the recommended maximum of 50 dB with 95 % confidence.

RESULTS

The mean noise levels in the ventilator room and stable room were 19.99 dB (A) sound pressure level (SPL) and 11.81 dB (A) SPL higher than the maximum recommended of 50 dB (A) respectively ( p < 0.001). The equipments generated 19.11 dB SPL higher than the recommended norms in 1 - 8 KHz spectrum. The activities generated 21.49 dB SPL higher than the recommended norms in 1 - 8 KHz spectrum ( p< 0.001). The ventilator and nebulisers produced excess noise of 8.5 dB SPL at the 0.5 KHz spectrum.

CONCLUSION

Noise level in the NICU is unacceptably high .Spectral analysis of equipment and activity noise have shown noise predominantly in the 1 - 8 KHz spectrum. These levels warrant immediate implementation of noise reduction protocols as a standard of care in the NICU.

Behavioural and physiological reactivity to noise in the newborn

OBJECTIVE

To assess the electromyographic (EMG) and behavioural reactivity of a group of newborn infants exposed to noisy stimulation of various intensity recorded in the Paediatric intensive care Unit (PICU).

METHODS

The study was performed at the nursery of the Paediatrics Department (University of Padova) on a group of 21 healthy newborns (mean 39 weeks of gestation), assessed between 24 and 72 h after birth. The study involved taking EMG recordings of the corrugator supercilii muscle and assessing the infant's behaviour at the baseline (15 seconds before stimulation), during noisy stimulation (for 1-2 seconds) and during recovery (15 seconds in three subphases). The noises, previously recorded in PICU, had four different intensities and were administered in random order to all infants. Descriptive analysis and repeated-measures analysis of variance (anova) were performed on the EMG and behavioural data.

RESULTS

The infants demonstrated a significant reaction to the noises both in the EMG recordings and in behavioural changes, especially during intense noisy stimulation. The reaction lasted longer than the stimulation period, preventing the infants from returning to the baseline condition.

CONCLUSIONS

Exposure to high-intensity noise produced in PICU causes evident behavioural and physiological effects (EMG). This is a field of study that could have important repercussions, given the medium- and long-term effects of repeated noise stimulation.