What is stopping us? An implementation science study of kangaroo care in British Columbia's neonatal intensive care units

A Narrative Review of NICU Implementation of Evidence-Based Early Relational Health Interventions

BACKGROUND

Early relational health (ERH) interventions in the neonatal intensive care unit (NICU) buffer infants from toxic stress effects. Implementation science (IS) can guide successful uptake of evidence-based practice (EBP) ERH interventions. It is unknown if implementors of ERH interventions currently use the resources of IS to improve implementation.

PURPOSE

A narrative review of recent literature on implementation of ERH EBPs was completed to understand (a) which ERH interventions are currently being implemented in NICUs globally, (b) whether clinical implementors of ERH interventions have adopted the resources of IS, (c) existence of implementation gaps, and (d) implementation outcomes of ERH interventions in contemporary literature.

DATA SOURCES

Scopus, PubMed, and CINHAL were searched for original research regarding implementation of dyadic ERH interventions using key words related to IS and ERH.

STUDY SELECTION

For inclusion, ERH EBPs had to have been implemented exclusively in NICU settings, contained data addressing an IS domain, printed in English within the last 5 years. Twenty-four studies met inclusion criteria.

DATA EXTRACTION

Studies were distilled for intervention, IS domains addressed, location, aims, design, sample, and outcomes.

RESULTS

Eleven ERH interventions were described in the literature. Few studies utilized the resources of IS, indicating variable degrees of success in implementation. Discussions of implementation cost were notably missing.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementors of ERH interventions appear to be largely unfamiliar with IS resources. More work is needed to reach clinicians with the tools and resources of IS to improve implementation outcomes.

A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates

BACKGROUND

Skin-to-skin (STS) care effectively improves neonatal outcomes, particularly for preterm neonates. However, utilization of STS remains suboptimal for the most vulnerable preterm neonates in the first 4 weeks of life. This quality improvement (QI) project aimed to increase STS duration for neonates under 35 weeks gestation.

METHODS

The QI initiative was conducted in a 35-bed level IV NICU within a teaching hospital in New York City from July 2021 to January 2023. Six months of baseline data and a staff survey determined interventions across "Plan, Do, Study, Act" cycles. Interim analyses guided interventions using run charts. Interventions included parental counseling and information leaflets, discussion during rounds on STS eligibility, STS education for residents, nurses' feedback, and visual reminders. The primary outcome measure was the mean duration of STS per eligible patient day. The process measures were the age at first STS and documentation of eligibility for STS care in the electronic medical records. Balancing measures included adverse events such as apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tube.

RESULTS

The study included 185 infants with a mean gestational age of 29.1 weeks. The mean STS duration per eligible patient day increased from a baseline of 13.3 minutes to 32.4 minutes without significantly increasing adverse events.

CONCLUSIONS

The QI interventions implemented have successfully increased the duration of STS in preterm infants. Our interventions combined into an STS bundle can be a potential model for other NICUs to improve STS practice.

Effects of skin-to-skin contact in supported diagonal flexion positioning on movement quality in very preterm infants at term age

BACKGROUND

Preterm birth is associated with a high risk of long-term neuromotor disabilities such as coordination of movements, deficient antigravity limb movement, less adaptive postural control strategies, head deformities… AIMS: The aim of the present study was to examine the potential positive impact of a Supported Diagonal Flexion (SDF) skin-to-skin contact (SSC) positioning on the neuromotor development and movement quality of very preterm infants at term age.

STUDY DESIGN

Monocentric prospective matched-pair case-control study.

SUBJECTS

Thirty very preterm infants and their mother were proposed either SDF SSC positioning (n = 15) or Vertical SSC positioning (n = 15).

OUTCOME MEASURES

Amiel-Tison Neurological Assessment at Term (ATNAT) and observation of the spontaneous motor activity were assessed at term corrected age.

RESULTS

Infants in the SDF group had less dolichocephaly (adj. p = .014) and arms in candlestick position (adj. p = .048). Only 3 in the SDF group against 11 in the vertical group showed nonoptimal spontaneous motor activity. Infants in the SDF group had more positive signs such as foot-to-foot contact (adj. p = .047) or arms movements toward midline (adj. p = .046 and 0.011).

CONCLUSIONS

The present study shows that nonoptimal spontaneous motor activity was increased and dolichocephaly was more common in the vertical group. Consistently with current guidelines, it is critical to consider preterm infants' postures during SSC or while in incubators or cradles.

Implementation of infection prevention and control for hospitalized neonates: A narrative review

BACKGROUND

The most prevalent infections encountered in neonatal care are healthcare-associated infections. The majority of healthcare-associated infections are considered preventable with evidence-based infection prevention and control (IPC) practices. However, substantial knowledge gaps exist in IPC implementation in neonatal care. Furthermore, the knowledge of factors which facilitate or challenge the uptake and sustainment of IPC programmes in neonatal units is limited. The integration of implementation science approaches in IPC programmes in neonatal care aims to address these problems.

OBJECTIVES

The aim of this narrative review was to identify determinants which have been reported to influence the implementation of IPC programmes and best practices in inpatient neonatal care settings.

SOURCES

A literature search was conducted in PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) in May 2022. Primary study reports published in English, French, German, Spanish, Portuguese, Italian, Danish, Swedish or Norwegian since 2000 were eligible for inclusion. Included studies focused on IPC practices in inpatient neonatal care settings and reported determinants which influenced implementation processes.

CONTENT

The Consolidated Framework for Implementation Research was used to identify and cluster reported determinants to the implementation of IPC practices and programmes in neonatal care. Most studies reported challenges and facilitators at the organizational level as particularly relevant to implementation processes. The commonly reported determinants included staffing levels, work- and caseloads, as well as aspects of organizational culture such as communication and leadership.

IMPLICATIONS

The presented knowledge about factors influencing neonatal IPC can support the design, implementation, and evaluation of IPC practices.

Maternal-fetal and neonatal characteristics associated with Kangaroo-Mother Care Method adherence

OBJECTIVE

To describe the association of maternal and neonatal characteristics with the adherence status to the in-hospital stages of the Kangaroo-Mother Care Method - KMC (full, partial, and no-adherence).

METHODS

Retrospective cohort study including infants < 2500 g admitted to a reference maternity hospital for the KMC in Rio de Janeiro from January to December 2018. Maternal and neonatal characteristics were distributed according to the adherence status to the KMC in-hospital stages. In the first stage, KMC is performed in Neonatal Intensive Care Unit and Conventional Neonatal Intermediate Care Unit. The second stage is completed in Kangaroo Neonatal Intermediate Care Unit. Multinomial multiple regression was performed with KMC adherence as a three-category dependent variable and maternal and neonatal characteristics as independent variables.

RESULTS

Of 166 dyads, 102 (61.5%) participated in two stages. Those who did not participate in any stage (n = 52; 31.3%) had a lower level of education, a higher frequency of adverse conditions, and were more often single mothers; mothers who participated only in the first stage (n = 12; 7,2%) had more premature and sick infants. Conditions associated with adherence to the two stages compared to no adherence were: high school education (OR = 2.34; 95% CI = 1.08-5.07), presence of a partner (OR = 3.82; 95% CI = 1.7-8.61), no adverse conditions (OR = 3.54; 95% CI = 1.59-7.89) and no neonatal resuscitation (OR = 2.73; 95% CI = 1.22-6.1).

CONCLUSIONS

The study identified maternal and neonatal conditions associated with adherence status to the KMC. The results suggest opportunities to improve adherence.

Integrating Implementation Science with Quality Improvement to Improve Perinatal Outcomes

Implementation science is an interdisciplinary field that seeks to contribute generalizable knowledge that can improve the translation of clinical evidence in routine care. To promote the integration of implementation science approaches with health care quality improvement, the authors offer a framework that links the Model for Improvement with implementation strategies and methods. Perinatal quality improvement teams can leverage the robust frameworks of implementation science to diagnose implementation barriers, select implementation strategies, and assess the strategies' contribution to improving care. Partnerships between implementation scientists and quality improvement teams could accelerate efforts by both groups to achieve measurable improvements in care.

Initiation and duration of skin-to-skin contact for extremely and very preterm infants: A register study

AIM

This study sought to describe how skin-to-skin contact between extremely and very preterm infants and their parents is practised in Swedish neonatal units.

METHODS

Data from the Swedish Neonatal Quality Register from 2020 to 2021 were extracted to analyse initiation time and daily duration of skin-to-skin contact in different gestational ages and regions.

RESULTS

Of the 1475 infants in the cohort, mean (range) gestational age was 28 weeks (22-31), and mean (range) birthweight was 1205 g (360-2810). For extremely preterm infants (<28 weeks), median (interquartile range) skin-to-skin contact initiation time was at 88 postnatal hours (48-156) and 5% had skin-to-skin contact on the first day. For very preterm infants (<32 weeks), the corresponding numbers were 14 h (4-36) and 34%. Median (interquartile range) daily skin-to-skin contact duration for the entire cohort during the first day, first three and seven days and the remaining hospital stay was 0 (0-0), 0.7 (0-2.7), 1.6 (0.4-3.6) and 4.4 (3.0-6.1) h, respectively.

CONCLUSION

A minority of extremely and very preterm infants were exposed to skin-to-skin contact on the first postnatal day. Daily duration during the first week of life amounted to less than two hours. Initiation time and daily duration varied among gestational ages.