Family Involvement in Quality Improvement: From Bedside Advocate to System Advisor

Decreasing Invasive Urinary Tract Infection Screening in a Pediatric Emergency Department to Improve Quality of Care

OBJECTIVES

Obtaining urine samples in younger children undergoing urinary tract infection (UTI) screening can be challenging in busy emergency departments (EDs), and sterile techniques, like catheterization, are invasive, traumatizing, and time consuming to complete. Noninvasive techniques have been shown to reduce catheterization rates but are variably implemented. Our aim was to implement a standardized urine bag UTI screening approach in febrile children aged 6 to 24 months to decrease the number of unnecessary catheterizations by 50% without impacting ED length of stay (LOS) or return visits (RVs).

METHODS

After forming an interprofessional study team and engaging key stakeholders, a multipronged intervention strategy was developed using the Model for Improvement. A urine bag screening pathway was created and implemented using Plan, Do, Study Act (PDSA) cycles for children aged 6 to 24 months being evaluated for UTIs. A urine bag sample with point-of-care (POC) urinalysis (UA) was integrated as a screening approach. The outcome measure was the rate of ED urine catheterizations, and balancing measures included ED LOS and RVs. Statistical process control methods were used for analysis.

RESULTS

During the 3-year study period from January 2019 to June 2022, the ED catheterization rate successfully decreased from a baseline of 73.3% to 37.7% and was sustained for approximately 2 years. Unnecessary urine cultures requiring microbiology processing decreased from 79.8% to 40.7%. The ED LOS initially decreased; however, it increased by 17 minutes during the last 8 months of the study. There was no change in RVs.

CONCLUSION

A urine bag screening pathway was successfully implemented to decrease unnecessary, invasive catheterizations for UTI screening in children with only a slight increase in ED LOS. In addition to the urine bag pathway, an ED nursing champion, strategic alignment, and broad provider engagement were all instrumental in the initiative's success.

Baby and Family-Centered Care in the Neonatal Intensive Care Unit: Changing Perspective

The goal of baby and family-centered care in the neonatal intensive care unit (NICU) is to recognize the baby's needs exhibited through the baby's individual behavior and communication and support parent education, engagement, and interaction with the baby to build a nurturing relationship. Health care providers and caregivers must guide rather than control the role of the parents from birth through NICU care, transition to home, and continuing care at home. Parents are health care team members, primary caregivers, and shared decision-makers in caring for their babies.

Next Steps for Health Care-Associated Infections in the Neonatal Intensive Care Unit

We discuss the burden of health care-associated infections (HAIs) in the neonatal ICU and the role of quality improvement (QI) in infection prevention and control. We examine specific QI opportunities and approaches to prevent HAIs caused by Staphylococcus aureus , multidrug-resistant gram-negative pathogens, Candida species, and respiratory viruses, and to prevent central line-associated bloodstream infections (CLABSIs) and surgical site infections. We explore the emerging recognition that many hospital-onset bacteremia episodes are not CLABSIs. Finally, we describe the core tenets of QI, including engagement with multidisciplinary teams and families, data transparency, accountability, and the impact of larger collaborative efforts to reduce HAIs.

Parent and interdisciplinary professional perceptions of family-centered care in Thai NICU: A qualitative study

BACKGROUND

Family-centered care (FCC) has been successfully incorporated into daily practice in many neonatal intensive care units (NICUs) worldwide. However, the implementation of FCC in lower-resourced settings, such as Thailand, can be challenging and needs to be further explored.

AIMS

To identify parents' and interdisciplinary professionals' perceptions of FCC and to describe the opportunities to improve FCC in a Thai NICU.

DESIGN

An exploratory qualitative approach was used.

METHODS

The data were collected through face-to-face, semi-structured, individual interviews based on an interview guide. This study was conducted before the outbreak of coronavirus disease 2019 (February 2020) in a hospital in southern Thailand. Inductive thematic analysis was used to analyse interview data.

RESULTS

Participants were parents (n = 9) and interdisciplinary professionals (n = 8). The results revealed four key themes: (a) Recognizing and responding to individual families' different readiness and their rights and values, (b) working in a parent-interdisciplinary partnership to provide care, (c) lacking resources and motivation and (d) understanding of care requirements and providing help/sympathy.

CONCLUSIONS

The interdisciplinary professionals accepted that FCC is necessary for clinical practice, but there are some challenges in the Thai NICUs context because of the system of health care delivery. The findings highlighted that interdisciplinary professionals often viewed parents' involvement as an obstacle to providing neonatal care.

RELEVANCE TO CLINICAL PRACTICE

Further research is recommended to investigate how FCC is operationalized by interdisciplinary professionals and how hospital administrators can be supported to implement the FCC approach into clinical practice in Thai NICUs.

Experience of care of hospitalized newborns and young children and their parents: A scoping review

INTRODUCTION

Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care.

METHODS

A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included.

RESULTS

The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents.

CONCLUSION

Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

Implementation Outcomes and Challenges of Partnerships between Resource Parents and Parents with Sick Infants in Intensive Neonatal Care Units: A Scoping Review

Parents with a sick child in a neonatal intensive care unit (NICU) usually experience stress, anxiety, and vulnerability. These precarious feelings can affect early parent–child interactions and have consequences for the child’s neurodevelopment. Parents who have had a sick child in an NICU (veteran parents) can offer helpful interventions for these vulnerable families. This article is a scoping review of parental interventions used with the families of NICU infants, and an overview of French perspectives. Two independent reviewers studied the scientific literature published in English between 2001 to 2021 using Covidence software. The databases used were MEDLINE, ISI Web of Science, the Cochrane Database, and Google Scholar. Themes were identified from the articles’ results using an open coding approach. The data are presented in a narrative format. Ten articles were included, and four major themes addressed: (1) description of activities, (2) recommendations, (3) impact, and (4) barriers (resulting from recruitment, training, remuneration, and organization). Activities were very diverse, and a step-by-step implementation was recommended by all authors. Peer-support interventions might be a potential resource for those anxious parents and improve their NICU experiences. These challenges are described by SOS Préma in France. This article brings together recent studies on partnership in the NICU. It is an innovative topic in neonatology with vast issues to explore.

Primary Care Implementation of Genomic Population Health Screening Using a Large Gene Sequencing Panel

To realize the promise of genomic medicine, harness the power of genomic technologies, and capitalize on the extraordinary pace of research linking genomic variation to disease risks, healthcare systems must embrace and integrate genomics into routine healthcare. We have implemented an innovative pilot program for genomic population health screening for any-health-status adults within the largest health system in Vermont, United States. This program draws on key research and technological advances to safely extract clinical value for genomics in routine health care. The program offers no-cost, non-research DNA sequencing to patients by their primary care providers as a preventive health tool. We partnered with a commercial clinical testing company for two next generation sequencing gene panels comprising 431 genes related to both high and low-penetrance common health risks and carrier status for recessive disorders. Only pathogenic or likely pathogenic variants are reported. Routine written clinical consultation is provided with a concise, clinical “action plan” that presents core messages for primary care provider and patient use and supports clinical management and health education beyond the testing laboratory’s reports. Access to genetic counseling is free in most cases. Predefined care pathways and access to genetics experts facilitates the appropriate use of results. This pilot tests the feasibility of routine, ethical, and scalable use of population genomic screening in healthcare despite generally imperfect genomic competency among both the public and health care providers. This article describes the program design, implementation process, guiding philosophies, and insights from 2 years of experience offering testing and returning results in primary care settings. To aid others planning similar programs, we review our barriers, solutions, and perceived gaps in the context of an implementation research framework.

Essentials of neonatal-perinatal medicine fellowship: innovations in medical education

Due to the changing complex healthcare environment, educational innovation is essential to meet the needs of current and future neonatal-perinatal medicine (NPM) leaders. Greater clinical demands, decreased academic funding, and expanded graduate medical education program requirements have negatively impacted time for teaching and educational scholarship potentially limiting innovation in the field. By focusing on adult learning principles, embracing technology, and promoting collaboration, today's educators are preparing the next generation of neonatologists. Current innovations include regionalizing simulation boot camps, leveraging virtual learning to increase accessibility, developing niche training opportunities, and incorporating population health principles within existing quality initiatives. Areas in need of additional innovation include faculty and fellow development for teaching skills, expansion of educational networks, and dissemination and financial support of educational scholarship. These efforts and future innovations will require medical institutions and national NPM organizations to further invest in the medical educator as part of their missions.

Engagement of Families in the Care of Hospitalized Pediatric Patients: A Scoping Review

This scoping review was conducted to examine the range, nature, and extent of the published family engagement literature specific to the pediatric acute care setting to highlight future research and practice development opportunities. Included studies (N = 247) revealed global relevance. Engagement strategies ranged from more passive such as allowing/encouraging families to be present at the bedside to more active strategies aimed at promoting mutual and reciprocal nurse-patient interactions. Family engagement is distinguished by a mutually beneficial partnership of families with health care team members and care organizations. Future research in the area of family engagement in pediatric nursing should focus on determining the core engaging health professional behaviors and engaged parent outcomes; extending the knowledge base related to mutually beneficial partnerships between families and health care teams; developing effectiveness studies to determine the optimal engaging actions by teams to achieve parent engagement; and measuring the influence of engagement on parent and infant/child outcomes.

Community, Hope, and Resilience: Parental Perspectives on Peer Support in Neonatology

OBJECTIVES

To describe the perspective of parents who participated in peer-to-peer support meetings with parents of children in a neonatal intensive care unit (NICU) and veteran resource parents with previous NICU experience.

STUDY DESIGN

During a longitudinal evaluation in a tertiary care NICU, participating parents were asked to evaluate meetings; with open-ended questions, they were asked about their perspectives. Results were analyzed using mixed methods.

RESULTS

Forty-five NICU parents participated over a 10-week study period. They were followed longitudinally after attending at least 1 of the 10 meetings offered; 95% of parents (43 of 45) reported that the meeting was useful to them and gave an overall evaluation of 8.7 out of 10 (average). For each meeting, all the subjects on the checklist of the moderators (veteran resource parents) were discussed with new parents. When describing why and how the meetings were useful to them in their answers to open-ended questions, NICU parents reported 3 major themes: (1) decreasing isolation and being a community (73%), (2) hope and resilience (63%), and (3) getting practical "parent" information (32%). Sharing stories with parents who also had experienced loss, sadness, and grief, NICU parents trusted that it was possible to adapt and thrive. The meetings normalized parents' emotions (92%), decreased negative emotions (eg, anger, sadness, guilt), empowered them in their parental role, and helped them communicate with loved ones and providers.

CONCLUSIONS

Peer support meetings are a unique and useful means to support parents. Future investigations will investigate whether and how this type of intervention can improve clinical outcomes.

Percepção dos pais sobre as práticas de educação em saúde na Unidade Neonatal

Resumo Objetivo analisar a percepção dos pais sobre as práticas de educação em saúde desenvolvidas pelos enfermeiros na Unidade Neonatal que facilitaram a aquisição de competências parentais para uma tomada de decisão fundamentada. Método estudo exploratório e descritivo, com abordagem qualitativa. Participaram 13 pais com filhos internados, pela primeira vez, em uma Unidade Neonatal portuguesa. Os dados foram colhidos entre fevereiro e agosto de 2020, por meio de grupos focais, processados no software Interface de R pour Analyses Multidimensionnelles de Textes et de Questionneires, através da Classificação Hierárquica Descendente e da Análise de Similitude. Resultados da Classificação Hierárquica Descendente, emergiram quatro classes: “Necessidades de informação”, “Lacunas na informação”, “Disponibilidade para informar”; “Práticas facilitadoras da educação em saúde”. Conclusão e implicações para a prática os pais consideraram como práticas facilitadoras da educação em saúde a tecnologia digital aliada à disponibilidade dos enfermeiros para informar e explicar, bem como propiciar um ambiente empático e informal. Tal resultado pode subsidiar o desenvolvimento de intervenções de enfermagem de educação em saúde para pais na Unidade Neonatal, com recurso à tecnologia digital.

Themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making in healthcare systems: a scoping review

OBJECTIVE

To identify the key themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making across the organisation and system domains of healthcare systems.

METHODS

We conducted a scoping review. Seven databases of journal articles were searched from their inception to June 2019. Eligible articles were literature reviews published in English and provided useful information for determining aspects of engaging patients and family caregivers in decision-making to evaluate. We extracted text under three predetermined categories: structure, process and outcomes that were adapted from the Donabedian conceptual framework. These excerpts were then independently open-coded among four researchers. The subsequent themes and their corresponding excerpts were summarised to provide a rich description of each theme.

RESULTS

Of 7747 unique articles identified, 366 were potentially relevant, from which we selected the 42 literature reviews. 18 unique themes were identified across the three predetermined categories. There were six structure themes: engagement plan, level of engagement, time and timing of engagement, format and composition, commitment to support and environment. There were four process themes: objectives, engagement approach, communication and engagement activities. There were eight outcome themes: decision-making process, stakeholder relationship, capacity development, stakeholder experience, shape policy/service/programme, health status, healthcare quality, and cost-effectiveness.

CONCLUSIONS

The 18 themes and their descriptions provide a foundation for identifying constructs and selecting measures to evaluate the quality of initiatives for engaging patients and family caregivers in healthcare system decision-making within the organisation and system domains. The themes can be used to investigate the mechanisms through which relevant initiatives are effective and investigate their effectiveness.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement

The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: A Quality Improvement Initiative

Implementation of neuroprotective and neuropromotive (NP²) strategies is essential to optimize outcomes for premature infants. Developmental care, once an addition to medical care, is now recognized by the NICU team as foundational to support long-term neurodevelopment of micropremature infants. A group approach to education and sharing implementation processes can result in collaborative and individual center improvements. This article includes examples of quality improvement (QI) education and tools inspired by implementation of NP² strategies in a consortium of 11 NICUs in the United States and Canada. Process change guided by potentially better practices are key; however, consistency of application must be included to ensure success. Assessment of NP² practices via use of surveys and practice audits are described. Increases occurred in family NP² education and provision of support during painful experiences. There were also increases in skin-to-skin holding, 2-person caregiving, and focus on reducing unnecessary painful procedures.

Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU

BACKGROUND

Quality improvement (QI) methods have been widely adopted in health care. Although theoretical frameworks and models for organizing successful QI programs have been described, few reports have provided practical examples to link existing QI theory to building a unit-based QI program. The purpose of this report is to describe the authors' experience in building QI infrastructure in a large neonatal ICU (NICU).

METHODS

A unit-based QI program was developed with the goal of fostering the growth of high-functioning QI teams. This program was based on six pillars: shared vision for QI, QI team capacity, QI team capability, actionable data for improvement, culture of improvement, and QI team integration with external collaboratives. Multiple interventions were developed, including a QI dashboard to align NICU metrics with unit and hospital quality goals, formal training for QI leaders, QI coaches imbedded in project teams, a day-long QI educational workshop to introduce QI methodology to unit staff, and a secure, Web-based QI data infrastructure.

RESULTS

Over a five-year period, this QI infrastructure brought organization and support for individual QI project teams and improved patient outcomes in the unit. Two case studies are presented, describing teams that used support from the QI infrastructure. The Infection Prevention team reduced central line-associated bloodstream infections from 0.89 to 0.36 infections per 1,000 central line-days. The Nutrition team decreased the percentage of very low birth weight infants discharged with weights less than the 10th percentile from 51% to 40%.

CONCLUSION

The clinicians provide a pragmatic example of incorporating QI organizational and contextual theory into practice to support the development of high-functioning QI teams and build a unit-based QI program.

Following through: Interventions to improve long-term outcomes of preterm infants

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.

Parents' Experiences With a Model of Integrated Maternity and Neonatal Care Designed to Empower Parents

OBJECTIVE

To explore the experiences of parents with an integrated maternity and neonatal ward designed to empower parents by providing family-integrated care (FICare) to mother-newborn couplets in single-family rooms.

DESIGN

A qualitative analysis with a contextual constructivist approach.

SETTING

An integrated maternity and neonatal level 2 ward designed to empower parents in a teaching hospital in Amsterdam, the Netherlands. Maternity and neonatal care, up to and including highly complex care, is provided to mother-newborn couplets in single-family rooms according to the principles of FICare.

PARTICIPANTS

Twenty-seven mothers and nine fathers of newborns who were hospitalized for at least 7 days.

METHODS

We held four focus group discussions and eight semistructured interviews 1 to 3 months after discharge of the newborn to explore which experiences (mechanisms) facilitated or impeded aspects of parent empowerment (outcomes) under which specific conditions of the integrated infrastructure (contexts). We used the realist evaluation model to analyze the data.

RESULTS

Our analysis revealed five themes of parent empowerment (outcomes): Feeling Respected, Gaining Self-Management Tools, Insights Into the Newborn's Condition, Perceived Control, and Self-Efficacy. For each theme, participants reported facilitating and impeding experiences (mechanisms) that were initiated and influenced by the combination of single-family rooms, couplet care, rooming-in, and FICare (contexts). Unrestricted physical proximity to their newborns, 24 hours per day, in a safe private environment offered parents intensive learning experiences through active participation in care. It helped them to achieve independent parenthood at the time of discharge, but it also generated challenges such as power conflicts with the staff; prioritizing care for themselves, siblings, or the newborn; feelings of isolation; and lack of sleep.

CONCLUSION

Providing FICare to mother-newborn couplets in single-family rooms offers parents an intensive learning context for independent parenthood at the time of discharge. Health care professionals should be aware of the challenges and facilitators experienced by parents in the context of close physical proximity to their newborns 24 hours per day in single-family rooms. This awareness will allow them to better support parents in their empowerment process toward independent parenthood at the time of discharge.

Understanding preparation for preterm infant discharge from parents' and healthcare providers' perspectives: Challenges and opportunities

AIM

To describe the facilitating/inhibiting factors of preparation for preterm infant discharge and recommendations for increasing discharge readiness from parents' and healthcare providers' perspectives based on Meleis's Transitions Theory.

DESIGN

A qualitative cross-sectional descriptive design.

METHODS

We selected a purposive sample of 17 parents (9 fathers and 8 mothers) and 13 healthcare providers (10 nurses and 3 clinicians) from the neonatal intensive care unit of a tertiary hospital in Eastern China. Data were collected between May -July 2018. Data from audio-recorded semi-structured individual interviews were coded with content analysis both inductively and deductively.

RESULTS

The analyses yielded four themes: personal conditions, community conditions, nursing therapeutics, and patterns of response. Parents and healthcare providers had unique opinions about the themes.

CONCLUSION

Meleis's Transitions Theory seems to be an applicable and practicable framework for understanding the discharge preparation of parents with preterm infants and may be used to help healthcare providers to develop appropriate interventions on discharge preparation practice.

IMPACT

To address the lack of discharge readiness of preterm infants in China and countries with a similar clinical context, healthcare providers should help parents play a more active role to promote their engagement in discharge preparation. In a wider global community, healthcare providers should consider parents' personal conditions and their practical needs in performing discharge preparation.

The Value of Family Advisors as Coleaders in Pediatric Quality Improvement Efforts: A Qualitative Theme Analysis

Engaging family advisors in pediatric quality improvement (QI) efforts is well-studied in intensive care but less understood in other settings. The purpose of this study was to assess the perceived impact of including a family advisor as a colead on a QI initiative that successfully improved the family-centered timing of routine morning blood tests performed on pediatric inpatients. Five structured written reflections from core QI team members were analyzed using inductive thematic analysis and 3 major themes were identified. The first found that a family advisor's presence from the beginning of a QI initiative helps inform project design. The second determined that family partners working with residents fostered a better shared understanding of the role of trainees and caregivers in improving the quality of care. The third found that a family partner is an effective change agent to enact practice improvement, support professional development, and enhance resident education. Our qualitative analysis showed that engaging a family advisor as a colead influenced the design, implementation, and post-intervention impact of the initiative and improved family-centered outcomes.

Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care

BACKGROUND

Family-centered care (FCC) in neonatal intensive care units (NICUs) was initiated in 1992 to promote a respectful response to individual family needs and support parental participation in care and decision-making for their infants. Although benefits of FCC have been reported, changes in the maternal experience in the NICU are unknown.

PURPOSE

The purpose of this study was to compare mothers' experiences in NICUs where FCC is the standard of care and to compare these with the experiences of mothers 2 decades ago.

METHODS

In this qualitative descriptive design, mothers of infants born under 32 weeks postconceptional age were asked to describe their experiences with their infant's birth and hospitalization. Open-ended probing questions clarified maternal responses. Saturation was reached after 14 interviews. Iterative coding and thematic grouping was used for analysis.

RESULTS

Common themes that emerged were: (1) visiting; (2) general caregiving; (3) holding; (4) feeding; and (5) maternal ideas for improvement. Findings indicated important improvements in privacy, mother-nurse relationship, ease of visiting, and maternal knowledge and participation in infant caregiving.

IMPLICATIONS FOR PRACTICE

Mothers suggested improvements such as additional comforts in private rooms, areas in the NICU where they can meet other mothers, and early information on back-transport. Better recognition and response for mothers without adequate social support would provide much needed emotional assistance.

IMPLICATIONS FOR RESEARCH

Future research addressing benefits of webcams, wireless monitors, back-transport, maternity leave, and accommodations for extended visiting for siblings would address other needs mentioned by mothers.

The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns

AIM

Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress.

METHODS

We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric).

RESULTS

A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one.

CONCLUSION

Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Vermont Oxford Network: a worldwide learning community

A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.

Bringing Depth and Meaning to Perinatal Quality Improvement by Partnering With Patients

The quality of maternal care in the United States has garnered attention as the public has been made aware of outcome data and stories of patients' experiences. Calls to action from national leaders include a focus on evidence-based clinical practice and on interventions that meaningfully include patients and their families in their own care and in identifying promising practices to fill existing gaps. This article provides a look at the methods to identify needs from the patient and family perspective to help improve the quality of maternal care.

An integrative review: maternal engagement in the neonatal intensive care unit and health outcomes for U.S.-born preterm infants and their parents

Hospitals and perinatal organizations recognize the importance of family engagement in the neonatal intensive care unit (NICU). The Agency for Healthcare Research and Quality (AHRQ) defines family engagement as "A set of behaviors by patients, family members, and health professionals and a set of organizational policies and procedures that foster both the inclusion of patients and family members as active members of the health care team and collaborative partnerships with providers and provider organizations." In-unit barriers and facilitators to enhance family engagement are well studied; however, less is known specifically about maternal engagement's influence in the NICU on the health of infants and mothers, particularly within U.S. social and healthcare contexts. In this integrative review, we examine the relationship between maternal engagement in the NICU and preterm infant and maternal health outcomes within the U.S. Results from the 33 articles that met inclusion criteria indicate that maternal engagement in the NICU is associated with infant outcomes, maternal health-behavior outcomes, maternal mental health outcomes, maternal-child bonding outcomes, and breastfeeding outcomes. Skin-to-skin holding is the most studied maternal engagement activity in the U.S. preterm NICU population. Further research is needed to understand what types of engagement are most salient, how they should be measured, and which immediate outcomes are the best predictors of long-term health and well-being.

Beyond a Seat at the Table: The Added Value of Family Stakeholders to Improve Care, Research, and Education in Neonatology

OBJECTIVES

To analyze activities involving veteran resource parents and patients in a family partnership program; their perspectives were also explored.

STUDY DESIGN

The multiple roles assumed by family stakeholders in neonatal initiatives were reviewed. Quality control questionnaires were distributed to resource parents and patients and providers who worked with them. Mixed methods were used to analyze results.

RESULTS

Thirty resource parents and patients were involved in a total of 653 activities related to clinical care (n = 413), teaching (n = 31), and research (n = 209); 7 initiatives were described to illustrate the positive impact of family stakeholders on clinical care, teaching, and/or research. Resource parents and patients had different degrees and intensity of involvement: all were involved in low-risk initiatives and 9 in more complex activities. In the questionnaire, family stakeholders all described positive impacts associated with their participation and benefits to themselves, such as meaning making. Three resource parents reported traumatic memories that occurred during medical simulations. The majority of providers report that resource parents and patients improved their projects, but some also report this new collaboration is complex.

CONCLUSIONS

Although stakeholder participation increasingly is recommended, practical knowledge and the impact of their participation is scarce. Having several resource parents and patients bring their contributions may be more valuable than a few "expert stakeholders." Recruiting and orienting resource parents and patients toward different types of activities should take into account the complexity and risks of the tasks. Family stakeholders are appreciated and have a positive impact on projects in which they are involved.

Aletheia-20 unconcealed observations from quality improvement and evidence-based medicine

Quality improvement (QI) and evidence-based medicine (EBM) activities ideally generate value (benefit/cost). Physicians and hospitals vary in ability to demonstrate efficiency despite common methodology available to all. Based upon our 60-some years of combined QI and EBM experience, we suggest reasoned consideration of meta-cognition-thinking about thinking. How do we observe, analyze, intuit, then share observations and learning with collaborative networks? The Greek word aletheia denotes disclosure of the essence of an object or event as its genuine nature, "unhidden, revealed, unconcealed". Aletheia is authenticity, not a claim or opinion, not an argument or hypothesis, nor an intervention-based assertion. QI and EBM have crucial features obscured by the lure and distraction of technology, economic conflicts, and inherent self-interests. We offer 20 QI and EBM observations in the spirit of aletheia. Enhancing the well-being of children is the foundation of a civilized society, a journey needful of shared QI understanding.

Parental Stress Experience and Age of Mothers and Fathers After Preterm Birth and Admission of Their Neonate to Neonatal Intensive Care Unit; A Prospective Observational Pilot Study

Background: Preterm birth is associated with increased stress of parents that might influence the parental-child interaction, thus potentially having influence on the neurobehavioral development of the preterm infants. However, little is known concerning the age dependency of parental stress after preterm birth. Objective: The aim of the present study was to examine the age dependency of stress in mothers and fathers after preterm birth and neonatal intensive care unit (NICU) admission of their infant. Methods: In a prospective observational pilot study 47 mothers and 47 fathers completed the parental stress scale:NICU (PSS:NICU) questionnaire within 72 h after delivery. This questionnaire measures parental stress after preterm birth with three subscales: "Looks and Behave" of the child, "Parental Role Alteration," and "Sights and Sounds." Stress levels of mothers and fathers were compared and correlated to the age of mothers and fathers, respectively. Results: Parental stress experience after preterm birth tended to be higher in mothers compared to fathers. Mothers showed a significant positive correlation of the "Sights and Sounds" scale and age, whereas fathers did not show any significant age dependency of stress. Conclusion: In mothers stress level increases with increasing maternal age after preterm birth and admission of their infant to NICU, whereas fathers did not show any significant age dependency of stress.

Patient and family members' perceptions of family participation in care on acute care wards

BACKGROUND

Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction.

AIM

The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care.

DESIGN AND METHODS

A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer-as-participant observation data and semi-structured interviews were undertaken. Following separate inductive content analysis, data were triangulated.

RESULTS

Thirty-two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality.

CONCLUSION

The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision-making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence-based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting.

Variation in Use by NICU Types in the United States

: media-1vid110.1542/5828370139001PEDS-VA_2018-0457Video Abstract BACKGROUND: Increased admissions of higher birth weight and less acutely ill infants to NICUs suggests that intensive care may be used inappropriately in these populations. We describe variation in use of NICU services by gestational age and NICU type.

METHODS

Using the Vermont Oxford Network database of all NICU admissions, we assessed variation within predefined gestational age categories in the following proportions: admissions, initial NICU hospitalization days, high-acuity cases ≥34 weeks' gestation, and short-stay cases ≥34 weeks' gestation. High acuity was defined as follows: death, intubated assisted ventilation for ≥4 hours, early bacterial sepsis, major surgery requiring anesthesia, acute transport to another center, hypoxic-ischemic encephalopathy or a 5-minute Apgar score ≤3, or therapeutic hypothermia. Short stay was defined as an inborn infant staying 1 to 3 days with discharge from the hospital.

RESULTS

From 2014 to 2016, 486 741 infants were hospitalized 9 657 508 days at 381 NICUs in the United States. The median proportions of admissions, initial hospitalized days, high-acuity cases, and short stays varied significantly by NICU types in almost all gestational age categories. Fifteen percent of the infants ≥34 weeks were high acuity, and 10% had short stays.

CONCLUSIONS

There is substantial variation in use among NICUs. A campaign to focus neonatal care teams on using the NICU wisely that addresses the appropriate use of intensive care for newborn infants and accounts for local context and the needs of families is needed.