Karen New

Evidenced-based clinical practice guideline for management of newborn pain

Aim:  To facilitate the uptake of evidence and to reduce the evidence practice gap for management of newborn pain through the development of a clinical practice guideline.

Implementation of a clinical practice guideline for smoking cessation in a public antenatal care setting

Background:  Despite high level evidence showing that antenatal smoking cessation programs are effective in reducing the number of women who smoke during pregnancy and the number of low birthweight and preterm births, few Australian hospitals have adopted a systematic approach to assist pregnant women to stop smoking.

Intravascular Device Use,management, Documentation and Complications: A Point Prevalence Survey

OBJECTIVE To examine the use, management, documentation and complications for intravascular devices in cardiac, medical and surgical inpatients. METHODS A point prevalence survey was undertaken in a large tertiary hospital in Queensland. Descriptive statistics were used to analyse data. RESULTS Of the 327 patients assessed, 192 (58.7%) had one or more devices in situ. Of the 220 devices, 190 (86.4%) were peripheral venous catheters, 25 (11.4%) were peripherally inserted central catheters and five (2.3%) were central venous catheters. Sixty-two of 220 devices (28.2%) were in situ without a clear purpose, whereas 54 (24.7%) had one or more complications, such as redness, pain, tracking, oedema or oozing. There was no documentation on the daily patient care record to indicate that a site assessment had occurred within the past 8h for 25% of the devices in situ. CONCLUSIONS The present study identified several problems and highlighted areas for improvement in the management and documentation for intravascular devices. Ongoing education, promoting good clinical practice and reauditing, can be applied to improve the management of devices.

Every Newborn: the professional organisations' perspective

The International Federation of Gynecology and Obstetrics, the International Confederation of Midwives, the International Pediatric Association, and the Council of International Neonatal Nurses recognise and support the Every Newborn Action Plan, which is situated in the continuum of care for reproductive, maternal, newborn, and child health. The Every Newborn Action Plan calls for acceleration in action at country, regional, and local levels to accelerate reduction in stillbirth, and in neonatal and maternal mortality rates. Although some progress has been made since the Lancet Series on neonatal survival was published a decade ago, neonatal deaths have fallen at a slower rate than expected, stillbirths at an even slower rate, and, although maternal mortality has also declined, the relevant Millennium Development Goals for 2015 will not be achieved. Every year, 40 million mothers still give birth without any help from a midwife or another health worker trained and equipped to save the life of the baby or mother. Many babies die every year because mothers do not get the good quality care they need during labour and birth. Obstetricians and midwives are at the forefront of caring for the pregnant woman and newborn baby during the antenatal, intranatal, and postnatal periods. Often the midwife is the sole health-care professional responsible for both mother and baby. The causes of stillbirths and newborn and maternal deaths are closely related, and the solutions are known. Ensuring that essential care is provided around labour, delivery, and immediately afterwards is critical to ending newborn deaths. Available, skilled, well equipped birth attendants to assist women and newborn babies during labour and birth are vital to their survival. Additionally, because 85% of neonatal deaths relate to preterm complications, birth asphyxia, and infection, paediatricians, neonatologists, and neonatal nurses are essential to the care of preterm and ill newborn babies. There is a shortage of all health-care professionals, which is an issue that must be addressed; but most signifi cantly, because nurses and midwives are the most numerous health-care providers in many countries and are at the frontline of providing care, it is nurses and midwives with additional training in neonatal care that are needed to ensure that greater than 75% of all infants not breathing after birth receive bag and mask resuscitation, that all preterm or low birthweight (or both) infants receive kangaroo mother care, and that all newborn babies with possible infection receive appropriate antibiotic therapy within a short time after birth. Basic neonatal resuscitation and care in the so-called golden minute after birth reduces neonatal mortality in developing countries and is estimated to reduce full-term infant deaths by up to 30%. In countries challenged by social, economic, humanitarian, and health complexities, provision of interventions to every mother and newborn baby to improve survival will not be without diffi culty. However, the international professional organisations of obstetricians and gynaecologists, midwives, paediatricians, neonatologists, and neonatal nurses working together are able to promote a high standard of maternal and newborn care and requisite education and training; strengthen input into health plans and policy development; and foster international liaisons. Our organisations are pleased that The Lancet has published the Every Newborn Series, to bring attention to actions that are needed to accelerate progress towards Millennium Development Goals 4 and 5. The papers in this Series emphasise the important links between the various professional organisations to achieve the objectives of the Every Newborn Action Plan. The lifecourse approach is emphasised, highlighting the continuum of care needed from woman to newborn baby to childhood; the need for workforce planning and task Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60692-9

A point prevalence study of cancer nursing practices for managing intravascular devices in an Australian tertiary cancer center

PURPOSE The use of intravascular devices is associated with a number of potential complications. Despite a number of evidence-based clinical guidelines in this area, there continues to be nursing practice discrepancies. This study aims to examine nursing practice in a cancer care setting to identify nursing practice and areas for improvement respective to best available evidence. METHODS A point prevalence survey was undertaken in a tertiary cancer care centre in Queensland, Australia. On a randomly selected day, four nurses assessed intravascular device related nursing practices and collected data using a standardized survey tool. RESULTS 58 inpatients (100%) were assessed. Forty-eight (83%) had a device in situ, comprising 14 Peripheral Intravenous Catheters (29.2%), 14 Peripherally Inserted Central Catheters (29.2%), 14 Hickman catheters (29.2%) and six Port-a-Caths (12.4%). Suboptimal outcomes such as incidences of local site complications, incorrect/inadequate documentation, lack of flushing orders, and unclean/non intact dressings were observed. CONCLUSIONS This study has highlighted a number of intravascular device related nursing practice discrepancies compared with current hospital policy. Education and other implementation strategies can be applied to improve nursing practice. Following education strategies, it will be valuable to repeat this survey on a regular basis to provide feedback to nursing staff and implement strategies to improve practice. More research is required to provide evidence to clinical practice with regards to intravascular device related consumables, flushing technique and protocols.

Practice variation in the transfer of premature infants from incubators to open cots in Australian and New Zealand neonatal nurseries: Results of an electronic survey

BACKGROUND The incubator environment is essential for optimal physiological functioning and development of the premature infant but the infant is ultimately required to make a successful transfer from incubator to open cot in order to be discharged from hospital. Criteria for transfer lack a systematic approach because no clear, specific guideline predominates in clinical practice. Practice variation exists between continents, regions and nurseries in the same countries, but there is no recent review of current practices utilised for transferring premature infants from incubators to open cots. OBJECTIVE To document current practice for transferring premature infants to open cots in neonatal nurseries. DESIGN A descriptive, cross-sectional survey. SETTINGS Twenty-two neonatal intensive care units and fifty-six high dependency special care baby units located in public hospitals in Australia and New Zealand. PARTICIPANTS A sample of 78 key clinical nursing leaders (nurse unit managers, clinical nurse consultants or clinical nurse specialists) within neonatal nurseries identified through email or telephone contact. METHODS Data were collected using a web-based survey on practice, decision-making and strategies utilised for transferring premature infants from incubators to open cots. Descriptive statistics (frequencies and crosstabs) were used to analyse data. Comparisons between groups were tested for statistical significance using Chi-squared or Fishers exact test. RESULTS Significant practice variation between countries was found for only one variable, nursing infants clothed (p=0.011). Processes and practices undertaken similarly in both countries include use of incubator air control mode, current weight criterion, thermal challenging, single-walled incubators and heated mattress systems. Practice variation was significant between neonatal intensive care units and special care baby units for weight range (p=0.005), evidence-based practice (p=0.004), historical nursery practice (p=0.029) and incubator air control mode (p=0.001). Differences in these variables were also found between nurseries in metropolitan and rural locations. CONCLUSIONS Practice variation exists however; many practices are uniformly performed throughout neonatal nurseries in Australian and New Zealand. Commonality was seen between countries and in nurseries with a neonatal intensive care unit. Variation was significant between neonatal intensive care units and special care baby units and nurseries in metropolitan and rural locations.

Transferring preterm infants from incubators to open cots at 1600 g: a multicentre randomised controlled trial

Objectives To determine the effects on weight gain and temperature control of transferring preterm infants from incubators to open cots at a weight of 1600 g versus a weight of 1800 g. Design Randomised controlled trial. Setting One tertiary and two regional neonatal units in public hospitals in Queensland, Australia. Participants 182 preterm infants born with a birth weight less than 1600 g, who were at least 48 h old; had not required ventilation or continuous positive airways pressure within the last 48 h; were medically stable with no oxygen requirement, or significant apnoea or bradycardia; did not require phototherapy; and were enterally fed with an intake (breast milk/formula) of at least 60 ml/kg/day. Interventions Transfer into an open cot at 1600 or 1800 g. Main outcome measures The primary outcomes were temperature stability and average daily weight gain over the first 14 days following transfer to an open cot. Results 90 infants in the 1600 g group and 92 infants in the 1800 g group were included in the analysis. Over the first 72 h, more infants in the 1800 g group had temperatures <36.4°C than the 1600 g group (p=0.03). From post-transfer to discharge, the 1600 g group had more temperatures >37.1°C (p=0.02). Average daily weight gain in the 1600 g group was 17.07 (SD±4.5) g/kg/day and in the 1800 g group, 13.97 (SD±4.7) g/kg/day (p=<0.001). Conclusions Medically stable, preterm infants can be transferred to open cots at a birth weight of 1600 g without any significant adverse effects on temperature stability or weight gain. Trial registration: ACTRN12606000518561 (http://www.anzctr.org.au).

Dressing and securement for central venous access devices (CVADs): a Cochrane systematic review

OBJECTIVES To compare the available dressing and securement devices for central venous access devices (CVADs). DESIGN Systematic review of randomised controlled trials. DATA SOURCES Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews and of Effects, NHS Economic Evaluation Database, Ovid MEDLINE, CINAHL, EMBASE, clinical trial registries and reference lists of identified trials. REVIEW METHODS Studies evaluated the effects of dressing and securement devices for CVADs. All types of CVADs were included. Outcome measures were CVAD-related bloodstream infection, CVAD tip colonisation, entry and exit site infection, skin colonisation, skin irritation, failed CVAD securement, dressing condition and mortality. We used standard methodological approaches as expected by The Cochrane Collaboration. RESULTS We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. It is unclear whether there is a difference in the rate of CVAD-related bloodstream infection between securement with gauze and tape and standard polyurethane (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated dressings and standard polyurethane (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93). There is moderate quality evidence that chlorhexidine gluconate-impregnated dressings reduce the frequency of CVAD-related bloodstream infection per 1000 patient days compared with standard polyurethane dressings (RR 0.51, 95% CI 0.33 to 0.78). There is moderate quality evidence that catheter tip colonisation is reduced with chlorhexidine gluconate-impregnated dressings compared with standard polyurethane dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and standard polyurethane are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). CONCLUSIONS Medication-impregnated dressing products reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types. There is some evidence that chlorhexidine gluconate-impregnated dressings, relative to standard polyurethane dressings, reduce CVAD-related bloodstream infection for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of CVAD-related bloodstream infection. Most studies were conducted in intensive care unit settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVADs.

Co-sleeping and bed sharing in Australian maternity units: An electronic survey of midwifery clinicians' knowledge, practice and education

BACKGROUND: There is little published research regarding co-sleeping and bed sharing in maternity units. As primary carers of mothers and infants, midwives’ knowledge and practice may influence co-sleeping and bed sharing. AIM: To assess clinical midwives’ knowledge and practice surrounding co-sleeping and bed sharing in maternity units in the initial postpartum period. METHODS: A nationwide electronic survey assessed clinical knowledge and self-reported clinical practice and personal experiences of co-sleeping and bed sharing. FINDINGS: Eighty-six registered midwives from 48 hospitals responded to the survey. The majority responded with best practice to hypothetical scenarios. Mother–infant co-sleeping/bed sharing in maternity units was observed by 64% of midwives. All midwives reported providing some education to parents and most (80%) had received education on co-sleeping/bed sharing. CONCLUSION: Co-sleeping and bed sharing are relatively common in postnatal maternity units. Clinical practice documents should be consistent with the UNICEF guidelines, and midwives should be supported to implement best practice.

Co-sleeping and bed sharing in postnatal maternity units: a review of the literature and critique of clinical practice guidelines

BACKGROUND: This 2-part article reviews the primary research on co-sleeping and bed sharing in maternity units and critiques clinical practice guidelines on co-sleeping and bed sharing in maternity units. METHODS: Electronic search strategies were used to identify primary research and to access clinical practice guidelines about co-sleeping and bed sharing on maternity units. Primary research was reviewed and compared. Clinical practice guidelines were critiqued against the United Nations Children’s Fund (UNICEF; 2004) document, Babies sharing their mothers’ bed while in hospital: A sample policy. FINDINGS: There is little published primary research about co-sleeping and bed sharing in maternity units but that which is available is of high standard. Clinical practice guidelines are more plentiful but vary in quality and scope. The primary research and clinical practice guidelines recognize the positive correlates between co-sleeping and bed sharing and the establishment of breastfeeding and the potential for risks to infant safety. There are differences in the acceptance of co-sleeping and bed sharing between geographic regions. The role of health care providers in educating about the benefits and risks of co-sleeping and bed sharing in maternity units is acknowledged but not well explored. CONCLUSION: Further research on co-sleeping and bed sharing in maternity units is needed to provide evidence to inform clinical practice guidelines. KEYWORDS: infant sleep location; policy development and dissemination; risk assessment; maternal education and behavior modeling; co-sleeping; bed sharing