The comprehensive care rounds: facilitating multidisciplinary communication among caregivers of complex patients in the neonatal intensive care unit

A Qualitative Study of Nurses' Perspectives on Neonatologist Continuity of Care

BACKGROUND

Families and staff in neonatal intensive care units (NICUs) value continuity of care (COC), though definitions, delivery, and impacts of COC are incompletely described. Previously, we used parental perspectives to define and build a conceptual model of COC provided by neonatologists. Nursing perspectives about COC remain unclear.

PURPOSE

To describe nursing perspectives on neonatologist COC and revise our conceptual model with neonatal nurse input.

METHODS

This was a qualitative study interviewing NICU nurses. The investigators analyzed transcripts with directed content analysis guided by an existing framework of neonatologist COC. Codes were categorized according to previously described COC components, impact on infants and families, and improvements for neonatologist COC. New codes were identified, including impact on nurses, and codes were classified into themes.

RESULTS

From 15 nurses, 5 themes emerged: (1) nurses validated parental definitions and benefits of COC; (2) communication is nurses' most valued component of COC; (3) neonatologist COC impact on nurses; (4) factors that modulate the delivery of and need for COC; (5) conflict between the need for COC and the need for change. Suggested improvement strategies included optimizing staffing and transition processes, utilizing clinical guidelines, and enhancing communication at all levels. Our adapted conceptual model describes variables associated with COC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Interdisciplinary NICU teams need to develop systematic strategies tailored to their unit's and patients' needs that promote COC, focused to improve parent-clinician communication and among clinicians. Our conceptual model can help future investigators develop targeted interventions to improve COC.

Management pathway for infants requiring chronic care in neonatal units-a scoping review of practices

Improvements in diagnostic and therapeutic modalities of antenatal care has meant that the neonatal intensive care units (NICU) need to care for infants with complex congenital conditions who need ongoing care post discharge. This, along with improved survival of the extreme preterm infants, provides the neonatal team with a cohort of infants who require long-standing multi-disciplinary input. However, provision of dedicated teams looking after infants with complex medical needs is not commonly reported in NICU workforce structure. The objective of this study is to perform a scoping review of literature on the presence of structured and dedicated complex care management teams in neonatal intensive care unit and their outcomes on care delivery. A scoping review was undertaken to identify all reported literature on existence of chronic care teams in NICU searching medical databases. A narrative synthesis of results was prepared.   Conclusions: The review identified very few clinical models reported with no robust data on clinical outcome measures. What is Known: • Neonatal units are increasingly providing care for infants who require chronic ongoing input from multiple specialties or allied health professionals. A majority of this cohort is formed by extreme preterm infants who require long term respiratory support or nutritional rehabilitation. • There are examples of dedicated clinical teams looking after complex patients in adult and pediatric intensive care outfits leading to improvements in outcome. What is New: • This is first literature review in the authors' knowledge on the use of complex care teams in neonatal intensive care unit. • This article provides a narrative synthesis of the clinical models that have been used by complex care teams in neonatal intensive care unit and whether they have demonstrated tangible benefits in patient outcome.

Interventions to reduce occupational stress and burn out within neonatal intensive care units: a systematic review

Occupational stress is an emerging problem among physician and nurses, and those working in intensive care settings are particularly exposed to the risk of developing burnout. To verify what types of interventions to manage occupational stress and burn out within neonatal intensive care units (NICUs) have been introduced so far and to verify their efficacy among caregivers. PsycINFO (PsycINFO 1967-July week 3 2019), Embase (Embase 1996-2019 week 29) e Medline (Ovid MEDLINE(R) without revisions 1996-July week 2 2019) were systematically searched combining MeSH and free text terms for "burn out" AND "healthcare provider" AND "NICU". Inclusion criteria were interventions directed to healthcare providers settled in NICUs. Only English language papers were included. Six articles were included in the final analysis. All the studies reported an overall efficacy of the interventions in reducing work-related stress, both when individual focused and organisation directed. The analysis revealed low quality of the studies and high heterogeneity in terms of study design, included populations, interventions and their evaluation assessment. There is currently very limited evidence regarding the management of occupational stress and burn out within NICUs. The quality of available studies was suboptimal. The peculiarities of the NICUs should be considered when developing strategies for occupational stress management. Training self-awareness of workers regarding their reactions to the NICU environment, also from the pre-employment stage, could be an additional approach to prevent and manage stress.

Why Are There So Few Ethics Consults in Children's Hospitals?

In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.

Improving care collaboration for NICU patients to decrease length of stay and readmission rate

Background

Medically complex patients in neonatal intensive care units (NICUs) typically require long hospitalisations and care from multiple subspecialists. Scheduled multidisciplinary discussions could improve collaboration and continuity of care and thereby improve patient outcomes. The specific aims of the project were to decrease the average length of hospitalisation by at least 1 day and improve parent satisfaction ratings on a standard questionnaire by the end of our project’s first year, and to maintain a stable (or decreased) cause-related (30-day) readmission rate.

Methods

We designed a quality improvement project to enhance collaboration and continuity of care for medically complex infants cared for in the NICU of Brenner Children’s Hospital. Weekly multidisciplinary team meetings were held to discuss the long-term plan for patients who met specific criteria. Attendees included attending neonatologists, paediatric surgeons, a physical therapist, an occupational therapist, a speech therapist, a social worker, a nurse coordinator for palliative care, a family support coordinator, the NICU Nurse Manager, a hospital chaplain, mid-level providers, bedside nurses, a nurse quality improvement leader and the leaders and database manager for the quality improvement project. When needed for specific patients, a bioethicist was included.

Results

One year after implementing the project, the average duration of hospitalisation had decreased by 6.5 days. Cause-related readmission rates decreased from 3.33% to 0.95%. Parent satisfaction scores did not change significantly.

Conclusions

Weekly multidisciplinary meetings to coordinate and provide continuity of care for medically complex neonates in our NICU was associated with improved patient outcomes.

How healthcare provider talk with parents of children following severe traumatic brain injury is perceived in early acute care

Healthcare provider talk with parents in early acute care following children's severe traumatic brain injury (TBI) affects parents' orientations to these locales, but this connection has been minimally studied. This lack of attention to this topic in previous research may reflect providers' and researchers' views that these locales are generally neutral or supportive to parents' subsequent needs. This secondary analysis used data from a larger descriptive phenomenological study (2005-2007) with parents of children following moderate to severe TBI recruited from across the United States. Parents of children with severe TBI consistently had strong negative responses to the early acute care talk processes they experienced with providers, while parents of children with moderate TBI did not. Transcript data were independently coded using discourse analysis in the framework of ethnography of speaking. The purpose was to understand the linguistic and paralinguistic talk factors parents used in their meta-communications that could give a preliminary understanding of their cultural expectations for early acute care talk in these settings. Final participants included 27 parents of children with severe TBI from 23 families. We found the human constructed talk factors that parents reacted to were: a) access to the child, which is where information was; b) regular discussions with key personnel; c) updated information that is explained; d) differing expectations for talk in this context; and, e) perceived parental involvement in decisions. We found that the organization and nature of providers' talk with parents was perceived by parents to positively or negatively shape their early acute care identities in these locales, which influenced how they viewed these locales as places that either supported them and decreased their workload or discounted them and increased their workload for getting what they needed.

Healthcare providers' perceptions of breastfeeding peer counselors in the neonatal intensive care unit

In this qualitative descriptive study we examined the perceptions of 17 neonatal intensive care unit (NICU) healthcare providers (nurses, neonatologists, lactation consultants, and dietitians) about the role of breastfeeding peer counselors who were mothers of former NICU infants and who provided primary lactation care in the NICU. Findings revealed that the healthcare providers respected the peer counselors' lactation expertise and identified three critical elements that contributed to the effectiveness of the peer counseling program: having a champion for the program, counselors being mothers of former NICU infants, and a NICU culture supportive of using human milk. Healthcare providers thought the peer counselors enhanced care of the infant by empowering mothers to provide milk and by facilitating and modeling positive patterns of maternal-infant interactions.