Turning babies Every 2 hours?

[TeenyTinyBabyRN]

I work at a Level 4 NICU, in a pediatric hospital. Right now, skin care is a hot topic, for the whole hospital. Whenever we have a new initiative, we are expected to follow suit, whether or not it really applies to our unit.

Part of the new criteria, is that we turn our ALL patients every 2 hours! To me this seems excessive. Some of our babies are minimal stimulation and we only assess every 6 hours. Turning is one of the more stressful parts of the assessment and our very sensitive patients can take an hour or longer for vital signs to stabilize/return to baseline.

Our patients that feed every 3 hours, we are supposed to go in and bother them an hour before they are due to assess, just to turn them! Good luck getting them to go back to sleep, especially being so close to feeding time. So much for cluster care.

Our fresh micro preemie, that we usually kept midline and supine for 72 hours to prevent IVH, we now have to turn.

Personally, I rarely see pressure sores. Usually it is when the babies come from other hospitals, or a baby has been laying on their IV hub or a cap from labs, (which for those things, the solution is simple- be vigilant about what your patient is laying on). I feel like we are making an issue out of something that is not really and issue.

When we asked about NICU being expect from this change, we were told that because we are a critical care unit, our patients are at risk for skin break down, so we have to do what ICUs do. Is there any evidence based practice that is NICU specific, for turning their patients this often?

I was just wondering what other hospitals are doing. Has anyone else seen new skin care policies come into play? How often do you routinely turn your patients? Is your unit expected to follow whatever changes the other units make?

[Elvish, BSN, DNP, RN, NP]

Considering that your mgr is not from a NICU background, I would absolutely enlist the help of the docs and NNPs on this one if s/he isn't responsive to your concerns.

Our NICU is level IV and NICAP-certified and we do not turn q2h.

We do q3 cares/repositioning for our feeder/growers and q4-6 for the sicker/smaller ones.

We use no-sting spray & vaseline for the kids with no breakdown, then Stomadhesive powder & sensacare for

the bad hineys. No chemical wipes, just water wipes. Our butt breakdown isn't excessive.

I have terrible visions of your PPHNers crashing and burning with q2 turns.

[canoehead, BSN, RN]

Start a personalized part of the care plan, based on their needs. Personalized care trumps hospital policy. If need be, get personalized orders.

[Nunya, BSN]

Your NICU already turns preemies every 2 hours? What's the evidence based good practice for this??

[prmenrs, RN]

How to make an unstable baby crump: change their position. The best you can do is a "tilt" w/a rolled blanket, keeping the ET tube in line w/the head.

This policy is not compatible w/neonatal nursing practice.

[TiffyRN, BSN, PhD]

The implementation of turning patients every 2 hours is not compatible with the neonatal patient's pressure injuries. I'm going to list some literature, you may have to contact your hospital's librarian to get full-text copies or perhaps some nurse in your unit is in college/university and can access them through his/her school's library.

Pressure injuries to the skin in a neonatal unit: Fact or fiction. There are pressure injuries in the NICU, they do not tend to be on bony prominences (except the occiput), most are equipment related (NCPAP, lines, etc. . .)

Pressure injuries to the skin in a neonatal unit: Fact or fiction - ScienceDirect

Small Japanese study on incidence of pressure sores in a NICU. Basically, most were on the nose, one on the occiput. All the articles have a decent review of the literature you can mine for additional information:

https://pdfs.semanticscholar.org/6b09/5e17eb2b062cfb8a872cf80d7941745148f7.pdf

While paper on pressure ulcers by the National Pressure Ulcer Advisory Panel. They address how it's inappropriate to use adult guidelines on neonates because of the whole "touch me not" phenomenon.

http://www.npuap.org/wp-content/uploads/2012/01/peds_white_paper.pdf

Your unit needs to write their own age and developmentally appropriate skin guidelines. Perhaps propose a study to retrospectively (and prospectively) track skin breakdown and focus your interventions on the actual injuries documented.

It is beyond irresponsible to implement interventions designed for adults on infants.

[tinybbynurse]

This sounds horrible!! As you clearly know, we want to leave our babies alone as much as possible! Especially the micros and babies who are super sensitive to stim. I really hope someone in upper mgmt speaks out against this.

[TeenyTinyBabyRN, BSN, RN]

YAY! Due to so much resistance from our staff, it has been decided that we only need to turn our babies, WITH ASSESSMENTS! As is was, it is, and may it forever be!

Thank you for everyone's comments and suggestions!

It sounded crazy to me and everyone who works bedside with our little ones. Glad to know everyone else thought it was crazy and that this is not a new standard. This is part of the problem with cookie-cutter policies made by people with little or no bedside experience.

[TeenyTinyBabyRN, BSN, RN]

The implementation of turning patients every 2 hours is not compatible with the neonatal patient's pressure injuries. I'm going to list some literature, you may have to contact your hospital's librarian to get full-text copies or perhaps some nurse in your unit is in college/university and can access them through his/her school's library.

Pressure injuries to the skin in a neonatal unit: Fact or fiction. There are pressure injuries in the NICU, they do not tend to be on bony prominences (except the occiput), most are equipment related (NCPAP, lines, etc. . .)

Pressure injuries to the skin in a neonatal unit: Fact or fiction - ScienceDirect

Small Japanese study on incidence of pressure sores in a NICU. Basically, most were on the nose, one on the occiput. All the articles have a decent review of the literature you can mine for additional information:

https://pdfs.semanticscholar.org/6b09/5e17eb2b062cfb8a872cf80d7941745148f7.pdf

While paper on pressure ulcers by the National Pressure Ulcer Advisory Panel. They address how it's inappropriate to use adult guidelines on neonates because of the whole "touch me not" phenomenon.

http://www.npuap.org/wp-content/uploads/2012/01/peds_white_paper.pdf

Your unit needs to write their own age and developmentally appropriate skin guidelines. Perhaps propose a study to retrospectively (and prospectively) track skin breakdown and focus your interventions on the actual injuries documented.

It is beyond irresponsible to implement interventions designed for adults on infants.

THANK YOU so much for the articles you posted! Very valuable/helpful information to pass along.

[TeenyTinyBabyRN, BSN, RN]

Your NICU already turns preemies every 2 hours? What's the evidence based good practice for this??

We had not started implementing this policy, but we were told that we would have to start soon.

There was no evidence based practice that supported this (for neonates). It was something that they were trying to push for the whole hospital, not taking into account how specialized our patients are.

Thank goodness, we were able to put a stop to it, before it started !

[fulitarn, BSN, RN]

As a developmental care specialist I would say this sort of blanket policy is very contra indicated in NICU. The most fragile and sick babies should not be touched, let alone turned, but minimally. It also doesn't line up with clustered care times.

Rather than refuse to do it, I suggest trying to change the policy to be NICU specific. State that infant will be turned and repositioned with care times, skin and pressure points will be assessed and massaged as tolerated, always back to sleep in open crib, etc.

My hospital also tried to enforce blanket hospital wide policies and we have to gently remind them that we are a very specialized unit and do things differently.