Improving Communication in the NICU
Cheryl Pouletsos, MS, RNC
Monday July 30, 2007
For Cheryl Pouletsos, RN (seated, second from right) and the interdisciplinary staff of Stony Brook University Hospital's NICU , every day is a DRAGON day.
Have you ever seen a dragon in the NICU? The Neonatal Intensive Care Unit at Stony Brook University Medical Center is proud to have a DRAGON as our mascot. He has helped us to standardize care, improve communication, and provide an opportunity for parents to participate in their child's care. He began as a contest to create a logo that would personify our goals to improve outcomes for selected neonates with a cute character and get the staff involved in the process. Our DRAGON was created first as an acronym for our goals and then as a way to identify the patients who met the criteria for the care bundles (a collection of best practices that are grouped together to ensure positive patient care outcomes) using the DRAGON logo.DRAGON stands for decrease retinopathy, airway goals (tighten oxygen parameters), optimize nutrition. By using DRAGON as our focus and taking a lesson from the Institute for Healthcare Improvement's Saving 100,000 Lives campaign, our team of care providers in the NICU has developed a series of protocols that address the needs of the neonatal patients who are born at less than 1,500 grams. Because IHI has no care bundles specific to the NICU, we created our own through the brainstorming of nurses, neonatologists, NICU fellows, nurse practitioners, respiratory therapists, a nutritionist, a pharmacist, and our quality management staff.This interdisciplinary team created flow diagrams outlining standardized practices for oxygen administration and ventilator management, enteral and parenteral feeding (including the introduction of vanilla TPN within hours of birth), and blood pressure management. Vanilla TPN is a clear solution of total parenteral nutrition without the vitamins, which gives TPN its characteristic yellow color.To ensure that all members of the team followed these guidelines, we developed a NICU Daily Goal Sheet that specifically addresses our goals and individualizes them for each baby. All members of the team assemble at the baby's bedside and briefly discuss —• current problems (and close out resolved problems)• respiratory status• hemodynamic status (includes invasive lines and blood products)• nutritional status• thermal management• medication levels and efficacy of treatment• pain management• parents are encouraged to participate and thus have a forum to bring concerns forward if they cannot attend• discharge planningNursing takes the lead during this focused discussion. The night nurses complete the daily goal sheet data section, the day nurses present the patient, and the entire team reviews the data to ensure that the goals set for this patient are met or the plan of care is adjusted as needed. All members of the team take credit for participating in the patient's plan of care by signing the Daily Goal Sheet, which is then available for review during standard teaching rounds. Another review of the goals between the medical team and nursing takes place between the day and the night shifts offering the night shift staff the opportunity for input into their patient's care, and ensuring that all team members can articulate and understand the goals. The daily goal sheet has empowered nursing to participate in the medical plan of care, has changed the workflow and dynamics of rounds, and has brought all disciplines together to ensure that the plan of care for each patient is well-communicated.Before beginning, our team reviewed currently available outcomes measures and selected patients that were less than 1,500 grams at birth as our first focus. Of primary concern were the numbers of infants who required laser surgery for developed retinopathy*, the incidence of bronchopulmonary dysplasia (BPD, a chronic neonatal respiratory problem), and length of time it took to initiate enteral feedings. We needed a communication tool that focused on our daily goals and designed patient care bundles to manage the care required to achieve those goals. Data collected for alternate reasons (Regional Perinatal Center Data, UHC submissions, nutritional outcomes, etc.) was reviewed to set the baseline and create targets for future outcomes measures. The initial targets were set at 20% below baseline, for example, reduce retinopathy requiring laser surgery by 20%. (When there are no other published data with which to compare yours the IHI recommends measuring a baseline and then selecting a target 20% above or below — depending upon whether you want to increase or decrease what you are measuring.)Workflow was altered to permit all shifts to have input into the plan of care and ensure the goals were well-communicated. We developed standardized care guidelines for —• oxygen saturation and ventilator management• ventilator weaning• vanilla TPN administration• enteral and parenteral nutritionBecause no standard protocols existed for any of these, we designed our own based on a literature search of existing research so that our guidelines would be evidence-based.The staff was introduced to the concept of the IHI campaign and DRAGON was rolled out. After many revisions to our daily goal sheet and care protocols, we have a smooth-flowing process that has —• empowered the nursing staff to be active participants in all aspects of medical rounds• standardized and improved the communication of the plan of care. The goal sheets (which are the plan of care) are used as a script to deliver a consistent report of current management and to ensure that important things aren't missed. This document remains in the chart, is reviewed by all staff that care for the patient, and is used again by the night shift (RN, MD, respiratory therapy) for another brief set of rounds to ensure that everyone knows what the plan of care is• standardized the medical approach based on evidence and research rather than individualized practices• reduced parental and nursing frustration with rapidly changing plans of care• created goals and targets to measure outcomes againstProgram results to date
Physicians now actively seek the input of the nurses during rounds. The incidence of BPD is inconclusive because of insufficient patient data but appears to show less deviation from the mean. We have enhanced protein intake (increased from 2.7gm/kg/day to 3.9gm/kg/day by the fourth day of life) and optimized nutrition with the use of vanilla TPN at birth. We have reduced our rate of laser surgery for retinopathy by almost 50% (6.4% down from 11.8%). We have also seen a dramatic impact on nutritional outcomes. We have initiated enteral feedings earlier (from 11.8 to 8.7 days), achieved full enteral feedings of 100 kcal/kg/day in half the time (from 31.5 to 16.3 days), and introduced of nipple feedings 21.3 days (down from 64.5 days).Both physicians and nurses have expressed improved satisfaction, communication, and collegiality since the inception of the DRAGON, and our Patient Satisfaction Survey results are extremely telling. Comments from parents tell the story —• "We received information about our baby's care often. It was truly appreciated!"• "The physicians and nursing staff at the NICU are second to none!"• "The NICU at Stony Brook was amazing! The staff was kind and informative about our baby's condition."Cheryl Pouletsos, MS, RNC, is NICU nurse manager at Stony Brook University Medical Center, Stony Brook, N.Y. To comment on this story, e-mail jspillane@gannetthg.com.Editor's Note: Laser surgery for retinopathy of prematurity was identified as a goal approximately six months prior to the formalized process described in this article. Outcomes described are retroactive to the original changes.
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