Developmental Care Practice and Documentation Variability in the Cardiac ICU

The newborn individualised developmental care and assessment program: A model of care for infants and families in hospital settings

AIM

The Newborn Individualised Developmental Care and Assessment Program (NIDCAP) is an intervention and education programme that uses developmental observation for multidisciplinary healthcare professionals (HCP) caring for high-risk infants and families. Infants prosper with the ongoing co-regulation process of infant and family that is influenced by the physical and social environment.

METHODS

The Template for Intervention Description and Replication (TIDieR) Guidelines were applied to the NIDCAP intervention. The estimation of the individual infant's current goals is described from direct observation of behaviour in the context of ongoing care delivery. The infant's behaviour guides all caregivers to articulate current strengths and functioning for the development of individualised plans of care and support. The NIDCAP Nursery Program supports the full integration of NIDCAP into the healthcare system.

RESULTS

NIDCAP is a system-based, process-oriented, attuned and responsive intervention for individualised developmental care for infants and families. Evidence shows NIDCAP significantly improves medical outcomes, with less time on the ventilator, improved weight gain, decreased length of stay, improved developmental outcomes and enhanced infant and family relationships. Evidence suggests that NIDCAP as an intervention improves parental competence, decreases stress for HCP teams and improves HCP satisfaction.

CONCLUSION

NIDCAP improves outcomes for infants and families requiring hospital care.

Cognitive Outcomes and Delirium After Cardiac Neurodevelopmental Program Implementation for Children With Congenital Heart Disease

Importance

A recent advisory from the American Heart Association delineated the potential benefits of developmental care for hospitalized children with congenital heart disease (CHD) and a critical gap in research evaluating the association of such inpatient programs with neurodevelopmental outcomes.

Objective

To investigate associations between the Cardiac Inpatient Neurodevelopmental Care Optimization (CINCO) program interventions, delirium, and neurodevelopment in young children (newborn through age 2 years) hospitalized with CHD.

Design, Setting, and Participants

This cohort study used quality improvement data from inpatient cardiac units at a tertiary care children's hospital in the US. Participants were children aged 0 to 2 years who were admitted for at least 7 days from September 1, 2018, to September 1, 2023. The CINCO program was implemented on September 1, 2020, in 6-month plan-do-study-act phases.

Exposures

The 5 CINCO interventions were medical and/or nursing order panels, developmental kits, bedside developmental plans, caregiver mental health support handouts, and developmental care rounds.

Main Outcomes and Measures

Number of days with delirium per patient, which was measured using the Cornell Assessment of Pediatric Delirium (a score higher than 9 indicated delirium). Neurodevelopment was measured using the Bayley Scales of Infant and Toddler Development, Fourth Edition (BSID-4).

Results

The full sample included 1331 qualifying admissions for 1019 unique pediatric patients (median [range] age at admission, 3.65 [0-34.62] months; 771 males [57.9%]), with a subcohort of 121 unique patients (median [range] age at admission, 0.00 [0-9.85] months; 77 males [63.6%]) whose initial hospitalization occurred before age 10 months and who underwent BSID-4 evaluation at age 12 months or older. The mean (SD) number of days with delirium per patient was stable for 2 years prior to CINCO implementation, decreased by 54.0% between phases 1 and 2 of the CINCO program (from 3.05 [0.60] to 1.38 [0.21]), and then remained stable over time. Each of the 5 CINCO interventions was associated with lower delirium after false discovery rate (FDR) correction (eg, medical and/or nursing order panel: B = -1.376 [95% CI, -1.767 to -0.986]; F2,1273 = 47.767; partial η2 = 0.036; P < .001). Mean (SD) BSID-4 cognitive index scores were stable for 2 years prior to implementation, higher between phases 1 and 2 of the program (from 81.67 [14.14] to 93.92 [19.43]), and then remained stable over time. Four of the 5 interventions were associated with higher BSID-4 cognitive scores after FDR correction (eg, bedside developmental plans: B = 8.585 [95% CI, 2.247-14.923]; F5, 101 = 7.221; partial η2 = 0.067; P = .008). Delirium was associated with lower BSID-4 cognitive scores. There were no associations between delirium and BSID-4 language or motor scores.

Conclusions and Relevance

This cohort study found that among hospitalized children with CHD, the implementation of an inpatient developmental care program was associated with reduced incidence of delirium and higher cognitive scores. Pediatric cardiac centers may consider adopting these low-cost, low-risk, generalizable program interventions.

Perceived family-centered care and post-traumatic stress in parents of infants cared for in the paediatric cardiac intensive care unit

BACKGROUND

Family-centred care (FCC), while a core value of paediatric hospitals, has not been well-studied in the paediatric cardiac intensive care unit (PCICU).

AIM

To describe parents' perceptions of FCC provided by nurses in the PCICU during their infant's recovery from neonatal cardiac surgery and explore associations of perceptions of FCC on parent post-traumatic stress (PTS) 4 months post-discharge.

STUDY DESIGN

Data obtained from a previously conducted randomized clinical trial (RCT) on telehealth home monitoring after neonatal cardiac surgery at three free-standing paediatric hospitals were analysed from a subset of 164 parents who completed the FCC Scale at hospital discharge, which measures a parent's experience of nursing care that embodies core principles of FCC. The RCT intervention was provided after hospital discharge, having no influence on parent's perception of FCC. The intervention also had no effect on PTS.

RESULTS

Perceived FCC was lowest for items 'nurses helped me feel welcomed' and 'nurses helped me feel important in my child's care'. Having 12%-19% points lower perception of FCC at hospital discharge was associated with parent experience of six or more PTS symptoms, at least moderate PTS symptom severity, or PTS disorder diagnosis at 4-month follow-up. Every 10% increase in parental perceptions of FCC was associated with less PTS symptoms (β = -0.29, SE = 0.12; p = .02) and lower PTS symptom cluster scores of arousal (β = -0.18, SE = 0.08; p = .02).

CONCLUSIONS

Parents who perceived lower FCC during their infants' hospitalization were at increased risk for the development of PTS symptoms, more PTS symptom severity and PTS disorder diagnosis 4-months post-discharge.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a prominent role to support the implementation of FCC for infants with cardiac defects and their parents. FCC may positively influence overall parent mental health and well-being, reducing the trauma and distress of the PCICU experience.

Simulation Training to Increase Holding of Fragile Infants in Cardiac Intensive Care Units

BACKGROUND

Promoting bonding and neurodevelopmental care is an important element in the cardiovascular intensive care unit (CICU); however, holding of infants by family members is inconsistently practiced.

OBJECTIVES

This quality improvement study aimed to safely increase the holding of medically complex infants in the CICU by developing a holding guideline and offering simulation-based staff education.

METHODS

Using consensus methodology and high-fidelity simulation, an expert work group created a holding guideline and training to increase staff confidence and competence in holding critically ill infants in the CICU. The effectiveness of the intervention was tested via a postintervention survey used to assess participants' confidence in and comfort with holding critically ill infants and elicit suggestions for further support. Participants who engaged with the mannequin were surveyed to assess the validity of the simulation trainer.

RESULTS

After the intervention, participants (N = 130) reported increased confidence with infant holding (76%) and greater confidence in preparing families to hold their infants. Participants (95%) strongly agreed that the simulation enabled realistic, safe practice in holding a medically complex infant with catheters and tubes. More years of experience and engagement with the simulation trainer were associated with increased posttraining confidence. Participants cited increased resources, practice, and adherence monitoring as key supports for infant holding.

CONCLUSIONS

Expert group consensus with high-fidelity simulation training is a feasible, safe, and reliable method for teaching higher risk skills and guiding protocol development.

Parental holding of infants improves haemodynamics in the cardiac ICU

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery

OBJECTIVE

To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery.

STUDY DESIGN

A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery.

RESULTS

A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without.

CONCLUSIONS

Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.

Developmental Care for Hospitalized Infants With Complex Congenital Heart Disease: A Science Advisory From the American Heart Association

Developmental disorders, disabilities, and delays are a common outcome for individuals with complex congenital heart disease, yet targeting early factors influencing these conditions after birth and during the neonatal hospitalization for cardiac surgery remains a critical need. The purpose of this science advisory is to (1) describe the burden of developmental disorders, disabilities, and delays for infants with complex congenital heart disease, (2) define the potential health and neurodevelopmental benefits of developmental care for infants with complex congenital heart disease, and (3) identify critical gaps in research aimed at evaluating developmental care interventions to improve neurodevelopmental outcomes in complex congenital heart disease. This call to action targets research scientists, clinicians, policymakers, government agencies, advocacy groups, and health care organization leadership to support funding and hospital-based infrastructure for developmental care in the complex congenital heart disease population. Prioritization of research on and implementation of developmental care interventions in this population should be a major focus in the next decade.