Debra Brandon

Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care

PURPOSE Electronic health records are expected to improve the quality of care provided to hospitalized patients. For nurses, use of electronic documentation sources becomes highly relevant because this is where they obtain the majority of necessary patient information. METHODS An integrative review of the literature examined the relationship between electronic nursing documentation and the quality of care provided to hospitalized patients. Donabedians quality framework was used to organize empirical literature for review. RESULTS To date, the use of electronic nursing documentation to improve patient outcomes remains unclear. CONCLUSIONS AND IMPLICATIONS Future research should investigate the day-to-day interactions between nurses and electronic nursing documentation for the provision of quality care to hospitalized patients. CLINICAL RELEVANCE The majority of U.S. hospital care units currently use paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic nursing documentation on patient care units, with the anticipated benefit of improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown, in part due to the lack of effective comparisons with paper-based nursing documentation.

Effect of environmental changes on noise in the NICU.

Purpose: To evaluate the effect of changes in the NICU environment on sound levels. Design: A prospective quasi-experimental design evaluated sound levels in a 43-bed NICU. Decibel levels were monitored utilizing a data-logging dosimeter for 24 hours weekly over 12 months. Sound levels were also measured inside four different incubator models. Sample: Forty-four 24-hour decibel recordings were obtained in one of eight randomly selected four-bed pods. In addition, a single 1-hour recording was obtained in four different models of vacant incubators. Main Outcome Variable: Ambient sound levels. Results: Decibel levels were analyzed to identify changes in noise levels following alterations in the NICU environment. Installation of motion-sensing motorized paper towel holders significantly increased levels at beds closest to the towel dispensers, as did the trial of a new communication system. Decibel levels in four different incubators revealed varying noise levels. This study suggests that all environmental changes must be monitored to ensure that they reduce rather than increase noise levels.

Development of behaviors in preterm infants: Relation to sleeping and waking

BackgroundAlthough nurse clinicians and researchers use infant behaviors to indicate the responses of preterm infant to stimulation, little is known about how the biological factors of development, sleeping and waking states, infant characteristics, and infant illness severity affect preterm infant behaviors. ObjectiveThis study examined the development of eight infant behaviors over the preterm period and determined the relation of these behaviors to sleeping and waking and to infant characteristics and illness severity. MethodsSeventy-one preterm infants were observed once per week from 7:00 p.m. to 11:00 p.m. from the time they were no longer critical until term or discharge. The occurrence of four sleep-wake states and eight behaviors were recorded every 10 seconds during the observations. ResultsNegative facial expressions increased over the preterm period; sighs, startle/jerks, jitters, and the likelihood of having hiccups decreased. Infant characteristics had only minor effects: boys had more negative facial expressions, and longer mechanical ventilation was associated with more sighs and jitters. All behaviors showed state-related differences in frequency. In addition, only startle/jerks and jitters showed the same developmental patterns within each state. ConclusionsSignificant development of infant behaviors occurs over the preterm period but involves changes not only in the absolute percentage of each behavior but also in the percentages within each sleeping and waking state. Thus, preterm infant behaviors cannot be used clinically for assessment without consideration of the state in which they occur.

Evaluation of human milk fortification from the time of the first feeding: effects on infants of less than 31 weeks gestational age

Objective:To determine whether human milk fortification from the time of the first feeding significantly improves weight gain and bone mineral status in infants of <31 weeks estimated gestational age as compared with delayed or standard human milk fortification.Study Design:This was a retrospective pre–post design. In all, 95 infants born at <31 weeks estimated gestational age were compared. There were 53 infants in the early fortification group (EFG) and 42 infants in the delayed fortification group (DFG). They were compared with regard to weight gain at 34 weeks postmenstrual age (PMA), and their serum levels of calcium, phosphorus and alkaline phosphatase levels were compared as an indicator of bone mineral status. The practice change of fortifying all human milk given to preterm infants at <34 weeks PMA commenced in June 2009. The usual practice of fortification took place once an infant had reached a feeding volume of 50 to 100 ml kg−1 per day. The new practice fortified all human milk with a powdered human milk fortifier to 24 calories per ounce, starting with the first feeding, no matter how small the volume.Result:There were no differences in weight gain between the EFG and the DFG. The group that received fortification from the time of the first feeding were significantly less likely to have alkaline phosphatase levels >500 U l−1 from 33 weeks PMA onward. There was no incidence of feeding intolerance with early fortification.Conclusion:Fortification of human milk from the time of the first feeding does not affect weight gain at 34 weeks PMA, but is related to a lower incidence of elevated alkaline phosphate levels and does not cause feeding intolerance.

Prune belly syndrome. A focused physical assessment.

Prune belly syndrome, a rare congenital anomaly, exists almost exclusively in males and consists of genital and urinary abnormalities with partial or complete absence of abdominal wall musculature. The syndrome, caused by urethral obstruction early in development, is the result of massive bladder distention and urinary ascites, leading to degeneration of the abdominal wall musculature and failure of testicular descent. The impaired elimination of urine from the bladder leads to oligohydramnios, pulmonary hypoplasia, and Potters facies. The syndrome has a broad spectrum of affected anatomy with different levels of severity. The exact etiology of prune belly syndrome is unknown, although several embryologic theories attempt to explain the anomaly. With advances in prenatal screening techniques, the diagnosis and possible treatment of prune belly syndrome can occur before birth, although controversy exists on the proper management of prune belly syndrome. This article explores the theories behind the pathophysiology and embryology of prune belly syndrome and its multisystemic effects on the newborn infant. Specific attention is paid to presentation, clinical features, head-to-toe physical assessment, family support, and nursing care of infants with prune belly syndrome.

Potential NICU Environmental Influences on the Neonate's Microbiome: A Systematic Review.

Objective:To identify how the neonatal intensive care unit (NICU) environment potentially influences the microbiome high-risk term and preterm infants. Data Sources:Electronic databases utilized to identify studies published in English included PubMed, Google Scholar, Cumulative Index for Nursing and Allied Health Literature, and BioMedSearcher. Date of publication did not limit inclusion in the review. Study Selection:Two hundred fifty articles were assessed for relevance to the research question through title and abstract review. Further screening resulted in full review of 60 articles. An in-depth review of all 60 articles resulted in 39 articles that met inclusion criteria. Twenty-eight articles were eliminated on the basis of the type of study and subject of interest. Data Extraction:Studies were reviewed for information related to environmental factors that influence microbial colonization of the neonatal microbiome. Environment was later defined as the physical environment of the NICU and nursery caregiving activities. Data Synthesis:Studies were characterized into factors that impacted the infants microbiome—parental skin, feeding type, environmental surfaces and caregiving equipment, health care provider skin, and antibiotic use. Conclusions:Literature revealed that various aspects of living within the NICU environment do influence the microbiome of infants. Caregivers can implement strategies to prevent environment-associated nosocomial infection in the NICU such as implementing infection control measures, encouraging use of breast milk, and decreasing the empirical use of antibiotics.

Factors associated with feeding progression in extremely preterm infants.

BackgroundAmong infants born prematurely, competence at oral feeding is necessary for growth and hospital discharge. Extremely preterm (EP) infants (28 weeks of gestational age [GA]) are at risk for a variety of medical complications, which can limit the infant’s capacity to develop oral feeding competence. ObjectiveThis study examined feeding progression by assessing timing of acquisition of five early feeding milestones among EP infants and the impact of immaturity and medical complications. DesignA chart review was conducted for 94 EP infants who participated in a larger longitudinal randomized study. Feeding progression was defined as infants’ postmenstrual age (PMA) at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. GA at birth and five medical complications (neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, and gastroesophageal reflux disease) were used as potential factors influencing the feeding progression. Linear mixed models were used to examine feeding progression across the milestones and contributions of GA at birth and five medical complications on the progression, after controlling for milk type as a covariate. ResultEP infants gradually achieved feeding milestones; however, the attainment of the feeding milestones slowed significantly for infants with younger GA at birth and the presence of medical complications, including neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, and patent ductus arteriosus but not gastroesophageal reflux disease. Milk type was a significant covariate for all analyses, suggesting that infants fed with breast milk achieved each of five milestones earlier than formula-fed infants. DiscussionImproved understanding of the timing of essential feeding milestones among EP infants and the contribution of specific medical conditions to the acquisition of these milestones may allow for more targeted care to support feeding skill development.

Retinopathy of prematurity: the disease process, classifications, screening, treatment, and outcomes.

Retinopathy of prematurity (ROP) is the cessation of normal eye development and subsequent abnormal vessel growth that occurs exclusively in premature infants. ROP was first discovered in the 1940s and was for two decades the leading cause of blindness in children. Currently, the disease causes about 500 new cases of blindness per year. The severity of the disease increases with decreasing gestational age. The pathogenesis of ROP involves disruption of normal retinal vascularization. Vessel endothelial growth factor, insulin-like growth factor, and oxygen play important roles in its development. ROP is classified using an international classification system that provides direction for screening and treatment of premature infants. Examinations are performed by ophthalmologists, who identify the scope of vascularization, the degree of abnormal vessel growth, and the amount of the eye that is affected. Treatment modalities include cryosurgery and laser photocoagulation. Long-term outcomes include both structural and functional vision problems.

Impact of a Palliative Care Program on End-of-life Care in a Neonatal Intensive Care Unit

Objective:Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit.Study design:Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education.Result:Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47).Conclusion:End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.

Effectiveness of No-Sting skin protectant and Aquaphor on water loss and skin integrity in premature infants

Objective:The purpose of this study was to evaluate the effects of No-Sting skin protectant and Aquaphor, a water-based emollient, on skin integrity measured by Neonatal Skin Condition Score (NSCS) and transepidermal water loss (TEWL) in premature infants. In addition, with no data regarding the use of No-Sting in the neonatal population and its desirability because it requires less infant manipulation and less nursing time, it was important to evaluate the use of this product.Study Design:In all, 69 premature infants born at <33 weeks gestation were randomly assigned to one of the two treatment groups: (1) No-Sting or (2) Aquaphor for a total of 14 days.Result:Gestational age and total fluid intake were related to NSCS whereas gestational age, incubator humidity levels and total daily fluid intake were significantly related to TEWL. Infants receiving Aquaphor had significantly higher NSCS, but the mean scores in both groups over the 14-day period were in the normal range (<4). There were no differences between Aquaphor and No-Sting in the rate of TEWL over the 14-day period.Conclusion:This study provides the first information regarding the use of No-Sting in the neonatal population. This skin protectant seems as effective as Aquaphor in decreasing TEWL and maintaining skin integrity, and is less resource intensive.