karnicurnc

I work in a 60 bed Level III unit. Admissions, CPAP, vents and stable HFJV/HFOV are 2 patients per RN. Other intensive care status patients are 1 of 3 patients cared for by 1 RN. Intermediate care (stepdown/PCU) patients are 1 of 4 infants in an assignment. This allows the bare minimum care to be given with no time for extra stuff. Pretty ridiculous. These decisions are dictated by state regulations and we have been fighting for better ratios for years, using NANN guidelines, to no avail. Family satisfaction scores (which sadly have become the benchmark by which quality care is given even though the two are often mutually exclusive) would improve if parents perceived that nurses had time to give that extra care.

I am a neonatal CNS who graduated in May of last year. My hospital paid for me to go to school as the state requires a CNS in a Level III or higher NICU. I am 1 of 11 CNS's in my hospital (a large teaching/tertiary regional facility) and we are well-utilized in the system. I have received offers from other centers looking for a neonatal CNS, so maybe it depends on what your focus is on. I am lucky to have quite a bit of autonomy in my role, and for that I am grateful. When I went to school I was 1 of 2 neonatal CNS students and our plan of study was a hybrid - taking classes with NNP students and adult CNS students. This year that school opened up a dedicated neonatal CNS track.

X-ray verification is the gold standard for tube placement, but is not a feasible option to irradiate an infant before every feeding or when the tube becomes dislodged. Best practice also dictates 2 methods be used. We have recently stopped checking aspirate (as there is no real predictive value in that from a GI standpoint) and the 2 methods we use are an xray at initial placement and weekly, and checking the tube cm marking before each feeding. We do still aspirate air to remove it from the belly but it is not a placement check.

Agree with post above about oxygen and it's detrimental effect. Pumping 100% FiO2 into a preemie's closed incubator can contribute to ROP (think Stevie Wonder). Also oxygen is a drug and I would think it is out of an RN's scope of practice to administer it for this purpose without an order. Just because it has always been done does not mean it is good practice. I would also be interested to see the evidence.

I wanted to share our newly developed feeding protocol related to gastric residuals. This is a section taken from our staff education presentation and explains the evidence behind our decision to no longer check residuals. Gastric residuals are a sign of poor gastric emptying and gastro-duodenal hypomotility or reflux common in the preterm infant and thus do not reflect pathology. Gastric residuals are influenced by feeding method (continuous vs. bolus), infant position, and feeding tube placement and size. Continuous feeds compared to bolus feeds increase the rate of gastric emptying. Position can influence gastric residual volume by as much as 25% . Prone or right lateral position following feeds decreases gastric residuals. Current evidence does not support that checking gastric residuals improves care or that gastric residuals are a predictor of NEC, sepsis, or feeding intolerance. Discarding gastric residuals may cause loss of essential gastric enzymes and/or acid and aspirating gastric residuals may damage or irritate the gastric mucosa. Although not statistically significant, in the study by Torrazza et al infants who did not receive evaluation of gastric residuals at every feed reached 150 ml per kg of enteral feeds six days sooner and required central venous access for six less days. Although infants who develop NEC have larger gastric residuals, a volume to guide practice has not been defined. In the study by Cobb there was an overlap between control infants and infants who developed NEC limiting the clinical utility of gastric residuals as a predictor of NEC. Bloody residuals were another marker in the study by Bertino et al but were not a risk factor by themselves. Gastric residuals in the absence of other clinical symptoms should not slow down enteral feeding advancement.

I agree, good idea to apply. All they can do is decline to interview, but you will never know if you don't try. Good luck!

We do weekly surveillance swabs. If positive then infants are isolated until d/c. We recently had a large group (about 20%) of MRSA-colonized infants. We had to isolate, cohort, treat with bactroban, bathe with CHG (those that qualified) and then retest. The rest of our large hospital had stopped even testing patients; MRSA is everywhere and the infants are probably getting colonized from their own families! Very frustrated with this process. We aren't routinely treating the colonized infants so what good is knowing they are positive?

We do not check abd girths as they are useless as stated previously. Here are two articles that helped to provide evidence to change our practice from checking residuals to NOT checking them unless there are other signs of feeding intolerance (abd distention and emesis). Residuals alone are not a useful tool and actually lead to increased TPN days, increased central line days (and all inherent risks), increased LOS and costs. Dilemmas Surrounding Interpretation of Gastric Residuals in the NICU Setting The value of routine evaluation of gastric residuals in very low birth weight infants. - PubMed - NCBI I am happy to email the articles directly to you if you are not able to access them.

We have used the Medela warmer for years, but only had 1 per pod of 12 infants, so it was not very useful except for the one person who got to it first for that round of feedings. We have also used warm tap water in Styrofoam cups for years (a horrible practice, I might add.) We will be installing 60 Creche Penguin micro-fridges and individual well warmers in January. There is a fair amount of literature to support banishing the cup of water warming method and to support storing and warming infants feedings in a precise and controlled manner. Eliminating 1 case of surgical NEC per year would pay for the fridges and warmers for a 60 bed unit like ours. From the Pediatrix STOP NEC Collaborative: "NEC is also associated with greatly increased healthcare costs, estimated at $200,000 during the 1st year of life." References Ganapathy V, Hay JW, Kim JH, Lee ML, Rechtman DJ. Long term healthcare costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid. BMC Pediatr. 2013;13:127. Bisquera JA, Cooper TR, Berseth CL. Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants. Pediatrics. 2002;109:423-428. Want to read more about contaminated hospital water? "Contamination of Hospital Tap Water For 40 years, hospital tap water has been identified as a potential source of nosocomial infections from bacteria and other contaminants including Cryptosporidium parvum, Legionelle spp, E Coli and Pseudomonas aeruginosa. 25-29 Patients at high risk of infection due to waterborne pathogens include AIDS patients, organ transplant recipients, oncology patients and neonates. 30 Healthcare-associated infections from water supplies have been identified in hospital nurseries. As recently as 2009, 23 strains of Pseudomonas aeruginosa were found in the water supply of a children's hospital in the US. 31 In another report Buyukyavuz, et al, 26 identified Staphylococcus and Klebsiella pneumoniae in hospital tap water used to heat infant milk. These bacteria were determined to be directly responsible for an outbreak of septicemia in the hospital's neonatal intensive care unit. Squier 28 and Angelbeck 30 have explained the process of microbial contamination of hospital tap water. A slime layer or biofilm containing microorganisms adheres to the lumen of pipes and fixtures in municipal and hospital plumbing systems and in hospital water tanks. Patient exposure to waterborne microorganisms can occur through any exposure to tap water including bathing, drinking, contact with medical equipment wet with water or health care provider hands rinsed in water. When tap water is used to warm infant feedings, there is potential for contamination of not only the container and the milk but also the nurse's hands. Squier recommends using dry-warming devices to heat fluids that come in contact with patients. In concurrence, the CDC in their 2003 Guideline for Infection Control in Health-Care Facilities, 32 suggested facilities remove sources of contaminated water whenever possible. These guidelines clearly recognize that moist environments and water-based solutions can serve as reservoirs for waterborne microorganisms in hospital settings." Reference http://www.nicmag.ca/pdf/NIC-25-3-MJ12-Medela-Supplement.pdf

From Medela's waterless warmer user guide: "Medela Disposable Inserts are a limited use item. Medela recommends changing the inserts every 12 hours. Inserts should be changed if human milk comes in contact with the inserts. Inserts should also be changed if visible damage has occurred that would offer the potential for human milk to come in direct contact with the warmer." https://www.medelabreastfeedingus.com/for-professionals/products/516/waterless-milk-warmer

Inter-rater reliability training can improve the accuracy of scoring and boost the confidence the providers have in the nursing staff related to scoring. I have read several research articles that use this training. Neo Advances

We use EPIC also, but don't let them sell you the adult ICU version and tell you they can modify it for NICU. Buy the NICU module to begin with.

I agree that is not enough time for orientation. Request more time, if you can. Talk with other newbies to see how they handled it. Ask for a buddy when off orientation - a person you can go to for advice, help.

The NICU is an intimidating place. The patients are often very sick, and families are extremely stressed. So it is good to heave a little bit of healthy fear. It will keep you on your toes. Make sure you have a good relationship with your preceptor, as she/he will be your guide to caring for the tiniest patients. I also recommend the STABLE and Merenstein and Gardner books as resources. Don't try to read M&G from cover to cover, but rather use it as a resource to further your understanding of a patient, such as a baby with PPHN, or NEC, or RDS. Think about your patient as you read the text and integrate what you did with how and why. Good luck!

I am quite concerned about how your unit is handling this escalation in level of care. The "blind leading the blind" puts everyone's license in jeopardy. You can't just start running a Level III NICU. I agree with the other posts about having APNs train and support as you transition to caring for patients with higher acuity.