Transcript NIC/Q Quality Improvement Project: Oral Care Protocol for Intubated Infants in the Neonatal Intensive Care Unit (NICU)

NIC/Q Quality
Improvement Project:
Oral Care Protocol for
Intubated Infants in the
Neonatal Intensive Care
Unit (NICU)
Dianne L. Smith, RN, CPN
Patricia Cordner, RN, CLC
Fletcher Allen Health Care, NICU
Purpose
• VAP rates in the NICU reached a
significant high of 5 cases in Quarter
3 of 2010 based on STATIT data.
• The NIC/Q Committee determined
that preventive measures were
needed to decrease the NICU’s rate
of VAP.
What is NIC/Q?
• NIC/Q: The multidisciplinary QI
committee in the NICU at FAHC.
Meets weekly. Biannual national
meetings through Vermont Oxford
Network (VON).
What is VAP?
• VAP: Infant intubated & ventilated (trach or ETT)
at time of or within 48 hrs before onset of the
pneumonia & has S/S of worsening gas exchange
& at least three of the following 1. Temp
instability with no other recognized cause 2.
Leukopenia or leukocytosis 3. Change in sputum
or increasing resp. secretions or increasing
suctioning requirements 4. Apnea, increased RR,
flaring with retractions or grunting 5. Wheezing,
rales, or rhonchi 6. Bradycardia or tachycardia &
CXR findings for at least one of the following: a.
New infiltrate b. Consolidation c. Cavitation d.
Pneumatoceles OR two or more serial CXRs with
progressive or persistent infiltrate. And is
receiving treatment for > three days.
Literature Findings
• Fresh breast milk given via the oropharyngeal route can
protect against neonatal infections, as VAP
• How so?
• Colostrum, early breast milk, especially, is highly
concentrated with immune factors which offer barrier
protection and promote bacterial cell wall lysis, antiinflammation, and immunomodulation. Further research
has shown that these immune agents can interact directly
with oral mucous membranes and be absorbed.
• Breast-fed infants have benefited by this traditionally, but
not those infants unable to feed, notably those who are
intubated, typically ELBW infants (extremely low birth
weight, < 1000 gm).
Methods
• The NIC/Q committee therefore worked to
create infection prevention measures.
Nursing members of the committee
focused on developing a protocol
incorporating the use of breast milk as an
oral “cleansing” agent, swabbed in the
mouths of intubated infants.
• The protocol was completed and rolled out
in June, 2011.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Oral Care Protocol for Intubated Infants in the NICU
Dip a new swab into colostrum or mature milk (fresh, not
previously frozen)
Ensure the swab absorbs all drops of colostrum or is saturated
when there is ample supply
Coat the entire buccal mucosa
Perform every 3 hours prior to a scheduled gavage feeding; OR if
the infant is NPO, at least once daily for the duration of intubation
Document care in PRISM in NICU Combined Flow Sheet, “Newborn
Hygiene” row
Oral swabs are located in Cabinet 10, drawer # 5 on the
back wall of the NICU, near oral syringes. There are 2 sizes:
petite 6mm and petite 8mm.
Important Notes:
Use only fresh colostrum or breast milk, not previously frozen
(immune-protective properties are altered when milk is frozen)
Separate a small aliquot (3-5 ml) of fresh colostrum or mature milk
into a separate breast milk container to use for oral care within 48
hours of pumping and label as such
Fresh colostrum or mature milk may be frozen within 48 hours and
used later for feeding, once enteral feeds are established
Infants on enteral feedings receive mouth care q. 3 hr. before
gavage feedings
NPO infants receive mouth care at least once daily
If no fresh breast milk or colostrum, perform routine oral care with
sterile water (there is no harm in using thawed, previously frozen
breast milk for oral care; however you do not want to deplete
stores of milk that may be needed for feeds in the future)
Keep oral mucosa clean, moist and intact; keep lips clean, soft and
intact by providing routine oral care
* This oral care protocol was developed by the NIC/Q
Committee for the prevention of VAP. This care may benefit
any infant in the NICU, especially those who are NPO, who
have a Replogle, and who receive primarily gavage feeds.
Findings
• Exceptionally positive reception from nursing
staff. 25% of the ~ 80 NICU nurses, all shifts,
have been randomly interviewed by the NICU
Nurse Educator after roll-out of the oral care
protocol. No negative feedback.
• The EHR’s of two ELBW intubated infants were
audited for documentation of oral care for the
extent of their time intubated, spanning 4 weeks
collectively: oral care was documented ~ 75% of
the time as per the protocol, essentially equal on
each baby, demonstrating good compliance for a
new protocol.
PRISM Documentation
Baby’s Firsts Card
• “Firsts” for my family to remember!
•
•
•
•
•
First held (date):
First temp done by family (date):
First Oral Care done by family (date):
First diaper change by family (date):
Other important firsts:
By
By
By
By
Whom:
Whom:
Whom:
Whom:
FAHC VAP Rates
Q. 3
2010
Q. 4
2010
Q. 1
2011
Q. 2*
2011
Q.3
2011
5
2
1
1
0
* Oral Care Protocol started June, 2011
VAP Rates from 90 US Hospitals (2009):
Pooled means by birth weight category
</=
750 gm
1.8
751100115011000 gm 1500 gm 2500 gm
1.3
1.1
0.5
>2500
gm
0.3
•Benchmarking data from NHSN (National Healthcare Safety
Network, a CDC data base)
Conclusions
• Oropharyngeal administration of mother’s milk is
well-tolerated by NICU infants, even those who
are the most critically ill.
• The oral care protocol encourages familycentered care by providing a way for mothers to
be involved with their infant, despite being
unable to feed (i.e. by providing the milk and/or
by assisting with the care.)
• This is a simple and inexpensive method of oral
care, which will potentially promote decreased
VAP rates in the NICU.
• Further assessment of VAP rates will be followed
quarterly.
References
• American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding
and the use of human milk. Pediatrics. 2005; 115,496-506.
• Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding
and Maternal and Infant Health Outcomes in Developed Countries, Evidence
Report/Technology Assessment No. 153, AHRQ Publication No. 07-E007,
Rockville, Md: Agency for Healthcare Research and Quality. Retrieved
September 4, 2009 from
www.ahrq.gov/downloads/pub/pdf/brfout/brfout.pdf
• Marchbank T, Weaver G, Nilsen-Hamilton M, Playford RJ. Pancreatic
secretory trypsin inhibitor is a major motogenic and protective factor in
human breastmilk. American Journal of Physiology—Gastrointestinal and
Liver Physiology. 2009; 296, G697-703.
• Rodriguez N.A., Meier P.P., Groer MW, Zeller JM. Oropharyngeal
administration of colostrum to extremely low birth weight infants:
Theoretical Perspectives, Journal of Perinatology, Jan, 2009, 29, 1-7.
• Rodriguez, N.A., Meier, P.P., et al. A pilot study to determine the safety and
feasibility of oropharyngeal administration of own mother’s colostrum to
extremely low-birth-weight infants. Advances in Neonatal Care. 2010, 10
(4), 206–212.
• Spatz DL. Ten steps for protecting and promoting the use of human milk
and breastfeeding in vulnerable infants. Journal of Perinatal and Neonatal
Nursing. 2004; 18,385-396.