Journal of Neonatal Nursing (2017) xxx, xxxexxx

www.elsevier.com/jneo

ORIGINAL ARTICLE

Implementation of an evidence-based
non-invasive respiratory support (NIRS)
bundle in the NICU to decrease nasal
injury complications
Pamela S. Milligan, DNP, RNC-NIC, FNP-BC, NNP-BC, Neonatal
Nurse Practitioner, Assistant Professora,b,*,
Mitchell R. Goldstein, MD, Attending Neonatologist and
Associate Professorc

a
Loma Linda University Children’s Hospital, NICU, Loma Linda, CA, USA
b
Azusa Pacific University, School of Nursing, Azusa, CA, USA
c
Pediatrics, Loma Linda University Children’s Hospital, Division of Neonatology, Loma
Linda, CA, USA

KEYWORDS Abstract Background: Nasal skin breakdown is a common complication of non-

Non-invasive respira-
tory support (NIRS)
care;
Nasal injury;
Neonatal intensive
care unit (NICU);
Quality improvement
invasive respiratory support (NIRS) therapy. The objective of this quality improve-
ment project was to improve assessments and standardize care to infants receiving
NIRS to reduce iatrogenic nasal injury complications.
Methods: Nursing staff NIRS knowledge and action were assessed using a self-report
survey created for the project. A NIRS bundle was implemented to standardized
care provided to all infants receiving NIRS. Infant chart reviews were conducted
to determine incidence and severity of nasal injury before and after NIRS bundle
implementation.
Results: Twenty-six nurses completed pre and post survey assessments. Combined
NIRS care scores improved from an average of 16.81 (SD ¼ 1.569) to 17.57
(SD ¼ 1.287, p ¼ 0.058). NIRS knowledge scores slightly improved from an average
of 6.76 (SD ¼ 2.016) to 6.88 (SD ¼ 1.495, p ¼ 0.833). The incidence of nasal injuries

* Corresponding author. Azusa Pacific University, School of Nursing, 606 E. Huntington Drive, Monrovia, CA 91016, USA. Tel.: þ1 626
815 6350.
E-mail addresses: pmilligan@apu.edu, pmilligan@llu.edu (P.S. Milligan).

http://dx.doi.org/10.1016/j.jnn.2016.05.003
1355-1841/ª 2016 Published by Elsevier Ltd on behalf of Neonatal Nurses Association.

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
2 P.S. Milligan, M.R. Goldstein

from NIRS use was reduced by 15.8% (34.7% compared to 18.9%; p ¼ 0.086).
Conclusion: Improving staff NIRS knowledge and standardizing NIRS care is associ-
ated with decreased incidence of nasal injury. Implementing feasible evidence-
based interventions impact neonatal care by decreasing unintended treatment
complications and increasing NIRS success.
ª 2016 Published by Elsevier Ltd on behalf of Neonatal Nurses Association.

Introduction Newnam et al., 2013; Squires and Hyndman,

Dramatic medical advances in the past 20 years
have significantly increased the survival of
extremely premature babies and critically ill neo-
nates (Stoll et al., 2010; Webb et al., 2014). Sur-
vival of these infants parallel advances in prenatal,
obstetric, and neonatal care, in addition to
continuously improving medical technologies.
Respiratory distress syndrome (RDS) affects about
one percent of newborn infants and is the leading
cause of death in babies who are born prematurely
(Pramanik, 2015; Rodriguez et al., 2002). Approx-
imately 50% of premature infants born between 26
and 28 weeks of gestation develop RDS, which in
the United States affects approximately 20,000 to
30,000 infants each year (Pramanik, 2015; Whitsett
et al., 2005). Premature infants with RDS survive
with the help of improved ventilation methods and
surfactant use only to face long-term complica-
tions like chronic lung disease and broncho-
pulmonary dysplasia (BPD) (Bonner and Mainous,
2008; Sweet et al., 2013). Use of non-invasive
respiratory support (NIRS) mechanisms such as
nasal continuous positive airway pressure (NCPAP),
nasal intermittent mechanical ventilation (NIMV),
nasal intermittent positive pressure ventilation
(NIPPV), and nasal neurally adjusted ventilator
assist (NNAVA) has been shown effective in
providing respiratory support to neonates with RDS
and helps reduce barotrauma from mechanical
ventilation exposure (McCoskey, 2008; Sweet
et al., 2013). However, a significant and unin-
tended negative consequence associated with
widespread, prolonged use of NIRS is breakdown
and trauma to nasal skin mucosa.
Reported neonatal nasal injury rates from NIRS
use range from 20 to 60%. Negative consequences
suffered by neonates with nasal skin breakdown
include pain, infection, scarring, excoriation, loss
of nasal tissue requiring plastics interventions, re-
intubation to allow time for the nasal septum to
heal, and ultimately places affected neonates at
increased risk for chronic lung disease and BPD
(Bonner and Mainous, 2008; do Nascimento et al.,
2009; Fischer et al., 2010; Gunlemez et al., 2010;
2009; Xie, 2014; Yong et al., 2005).
Evidence-based literature
A review of the evidence was conducted to iden-
tify risks, causes of NIRS nasal injury complications
and to identify evidence-based strategies for pre-
vention. Cochrane Library, CINHAHL Plus, PubMed,
and Embase databases were searched for relevant
articles using combinations of the following search
terms: nasal CPAP, non-invasive respiratory sup-
port, skin breakdown, nasal trauma, nasal skin
breakdown, septum damage, premature infant,
neonate, preterm infant, nursing care, respiratory
pressure sources, and evidence-based practice.
Inclusion criteria included full text available in
English and publications released from 2003 to
2014. International studies were not excluded
from the search.
The search yielded 229 published articles from
2003 to 2014 representing disciplines of nursing,
neonatology, and pediatrics. Each article’s title
and abstract were briefly examined for applicable
content and included when criteria for subject
matter and identified population of interest were
met. This process yielded 24 articles. A manual
search of reference lists identified three additional
articles. Five articles were further excluded after
closer review due to general information about
NCPAP without specific reference to nasal skin
injury. Nineteen articles were fully evaluated
using the Johns Hopkins University Research
Appraisal Tool to grade each article’s quality and
strength.
Several effective interventions in the prevention
of nasal skin breakdown to neonates were evident in
the literature including: selection of appropriately
fitting interface device (Bonner and Mainous, 2008;
Buettiker et al., 2004; Davis et al., 2009; De Paoli
et al., 2008; do Nascimento et al., 2009), applica-
tion of a barrier layer or hydrocolloid dressing be-
tween skin and device (Gunlemez et al., 2010;
McCoskey, 2008; do Nascimento et al., 2009;
Newnam et al., 2013; Squires and Hyndman, 2009;
Xie, 2014), frequent monitoring and focused

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
Implementation of an evidence-based NIRS bundle
assessments (Askin, 2007; Davis et al., 2009;
Gunlemez et al., 2010; McCoskey, 2008; Newnam
et al., 2013), and optimal positioning and comfort
measures (Askin, 2007; Bonner and Mainous, 2008;
Davis et al., 2009; McCoskey, 2008; Newnam et al.,
2013). Some studies asserted that the success of
NIRS and prevention of nasal skin breakdown in-
creases in congruence with the experience and
knowledge of clinicians, nurses, and respiratory
practitioners who are administering the therapy
(Askin, 2007; Davis et al., 2009; McCoskey, 2008).
Several studies agree that length of time on NCPAP is
a significant factor in the prevalence of nasal trauma
(Bonner and Mainous, 2008; Fischer et al., 2010;
Jatana et al., 2010; do Nascimento et al., 2009;
Newnam et al., 2013; Yong et al., 2005). Frequent
evaluation to determine continued need for NIRS
therapy is necessary to determine effectiveness and
facilitate weaning to decrease risk and exposure
(Bonner and Mainous, 2008; Newnam et al., 2013).
Objective
The main objective of this quality improvement
(QI) project was to improve assessments and
standardize care provided to infants receiving
pulmonary support via NIRS technologies to reduce
iatrogenic nasal injury complications associated
with NIRS use. The aims of the project were to: (1)
improve nursing staff NIRS knowledge and care
practices, and (2) reduce the incidence of nasal
injuries to infants receiving NIRS.
Methods
Setting
This QI project was implemented at a large aca-
demic, 84-bed, regional, level III NICU in the
Western United States. The core NICU team is
comprised of attending neonatologists, neonatal
fellows, neonatal nurse practitioners, residents,
nurses, and respiratory care practitioners. Total
NICU nursing staff, comprised of full-time, part-
time, and per diem registered nurses, is 253. In
2015, there were a total of 2772 live births in the
hospital, with 674 (24.3%) of these infants being
admitted to the NICU. Additionally, 614 infants
were admitted from outside referring hospitals,
resulting in 1288 total admissions in 2015. The
average daily census was 79 and there were be-
tween eight to ten infants receiving pulmonary
support by NIRS on a daily basis.
Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
3
Design
A pretest-posttest study design using a cohort con-
venience sample was used to compare two separate
populations being studied, (1) the NICU nursing
staff and (2) infants receiving NIRS during the time
of the project. All NICU nurses working at the time
of project implementation were invited through
email to participate in a voluntary and anonymous
survey to assess NIRS knowledge and current care
practices. Inclusion criteria for neonatal partici-
pants were infants receiving pulmonary support
using NIRS, regardless of gestational age or
morbidity. All infants not receiving pulmonary
support using NIRS were excluded from the project.
NIRS EBP bundle
A NIRS EBP bundle was developed to combine ev-
idence-based clinical interventions from the liter-
ature, to standardize and improve the quality of
care for infants receiving NIRS therapy. The NIRS
EBP bundle contained six core interventions: (1)
the use of appropriately sized nasal interface de-
vice, (2) use of protective hydrocolloid dressing
barrier between skin and nasal interface device,
(3) visually observing the infant every hour to
check and maintain proper nasal interface posi-
tion, (4) briefly removing protective barrier and
nasal device once during a 12-h shift to conduct a
thorough nasal skin assessment, (5) repositioning
infant every three to 4 h using principles of
developmental care, and (6) obtaining pain scores
at least every three to 4 h (Table 1).
A nasal trauma classification tool (Fig. 1),
adapted with permission from publishing authors,
Table 1 Non-invasive respiratory support (NIRS)
bundle interventions.
1 Use of appropriately sized interface device per
manufacturer guidelines.
2 Protective barrier (hydrocolloid dressing) to be
used between skin and interface device.
3 Visually observe infant every hour to check and
maintain appropriate interface position.
4 Briefly remove protective barrier and interface
device once a shift to conduct focused nasal skin
assessment. (2-person procedure to minimize loss
of infant’s functional residual capacity (FRC)).
5 Reposition infant every 3e4 h using principles of
developmental care.
6 Obtain pain score at least every 3e4 h.
4 P.S. Milligan, M.R. Goldstein

Stage 0 Intact, non-compromised skin

Stage I Non-blanching erythema
Stage II Superficial erosion
Stage III Necrosis of full thickness of skin

Fig. 1 Classification of nasal trauma tool. Adapted from “Nasal trauma due to continuous positive airway pressure in
neonates,” Fischer et al. (2010). Archives of Disease in Childhood e Fetal and Neonatal Edition, (95) F447eF451.

was incorporated into the NIRS bundle to assure
consistent evaluation and documentation of nasal
skin assessments (Fischer et al., 2010). The nasal
trauma classification tool consisted of three
stages: Stage I for non-blanching erythema, Stage
II for superficial erosion, and Stage III for necrosis
of full thickness of skin (Fischer et al., 2010).
These stages were based on the United States
National Pressure Ulcer Advisory Panel classifica-
tion system, which was last revised in 2007
(National Pressure Ulcer Advisory Panel, 2007).
Consensus from two neonatologists, neonatal NP,
and RCP managers resulted in the addition of a
Stage 0 to the nasal trauma classification tool to
account for intact, non-compromised nasal skin.
Staff development
Staff education programs over a one-week period
were offered to NICU nursing staff in the unit.
Sessions lasted 15 to 20 min and were offered
during regularly scheduled work hours. Four
different sessions were held for both day and night
shifts to allow for scheduling options. The Power-
Point presentation content focused on general
NIRS knowledge, risk factors associated with
complications of nasal injuries from NIRS use, and
an in-depth discussion of the NIRS EBP bundle in-
terventions. Immediately following the presenta-
tion, nurses were given the opportunity to ask
questions, voice concerns, and seek clarification.
The NIRS education PowerPoint module was
uploaded into the hospital intranet education
portal and assigned to all NICU nursing staff to
ensure dissemination and adoption of practice
change. Department-wide participation in the NIRS
education module was mandatory as the NIRS
bundle was implemented as the standard of care
for all infants on NIRS support. NIRS education
module was likewise made available to all respi-
ratory care practitioners (RCP) in the NICU through
the hospital’s intranet education portal. Two NICU
educators and one neonatal nurse practitioner
provided support, reinforcement, and additional
education to nursing staff during the QI imple-
mentation period. A poster board presentation of
the NIRS EBP bundle was displayed in the staff
lounge for reference and availability.
Instruments
A 23-item survey, consisting of 5-point Likert scale
(strongly agree, agree, neutral, disagree, strongly
disagree), true/false, and multiple-choice ques-
tions, was developed purposefully for this study to
assess staff NIRS knowledge and current care
practices. Key elements of the survey included
general NIRS care, monitoring frequencies, and
extent of nasal assessments performed. Content
experts (1 neonatologist, 2 neonatal nurse practi-
tioners, 2 NICU educators) reviewed and revised
the survey. Staff demographic information
collected included age, gender, nursing education,
and years of nursing and NICU nursing experience.
Staff survey participation was strictly voluntary.
The survey was anonymous and sent electronically
to all NICU nurses using SurveyMonkey. Willing
participants acknowledged their consent by
completing the survey.
Data collection
Baseline measures were obtained during a three-
week period prior to staff NIRS education while
post intervention measures were collected during

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
Implementation of an evidence-based NIRS bundle 5

a three-week period, one month after staff edu-
cation and NIRS Bundle implementation. Re-
minders were sent through email and responses
were collected and analyzed using IBM SPSS Sta-
tistics version 23. Questions on a likert scale were
recoded to reflect yes for answers of strongly
agree and agree, and no for responses of strongly
disagree, disagree, or neutral. A paired samples t-
test or Wilcoxon non-parametric test was con-
ducted to analyze results as appropriate.
NICU infants receiving NIRS were identified
using the NICU Nursing Assignment List produced
by Charge RNs for each oncoming shift. Following
infant identification, medical record numbers
were retrieved using the NICU Daily Admission Log.
Pertinent data, including birth weight, gestational
age, gender, total days on NIRS, NIRS mode used,
and presence of nasal injury, were collected from
the patient’s electronic medical records (EMR).
Data for each individual was compiled once the
infant no longer required NIRS therapy. Data was
manually entered into IBM SPSS Statistics v23, and
independent t-test and chi-square test was con-
ducted to analyze results. Baseline data were ob-
tained from infants receiving NIRS from November
through December 2015. Post NIRS bundle data
collection began two weeks after implementation,
during the month of February 2016.
Ethical consideration
The hospital’s institutional review board (IRB)
granted an exemption for this quality improve-
ment project on December 18, 2015. Project
investigators reported no conflicts of interest. No
compensation or outside sources of funding were
received for this quality improvement project.
Results
Nursing outcomes
Baseline staff surveys were collected over a three-
week period from December 21, 2015 to January
11, 2016. Fifty-eight out of a possible 253 nurses
responded to the survey. Five responders did not
answer all survey questions. Missing values were
excluded for purposes of data analysis and results
were calculated based only on valid, non-missing
values for each variable measured. Table 2 dis-
plays a comparison of nursing staff demographics
grouped according to their pre- and post- survey
participation. There was no statistically significant
difference between staff that responded to both
pre- and post- surveys. Of the 58 nurses, 57 (98.1%)
were female and one (1.7%) was male. Staff age
ranged from 24 to 67 years old, with a mean age of
42.91. Twenty participants (34.5%) were associate
degree nurses, 36 (62.1%) were bachelor prepared,
and two (3.4%) were master prepared. Total years
of nursing experience ranged from 0.8 to 46 years,
with a mean of 16.19 years (SD ¼ 14.0). Years of
NICU specific nursing experience ranged from 0.4
to 41 years, with a mean of 14.26 years
(SD ¼ 12.78).
Twenty-one participants (36.8%) reported visu-
ally observing the baby’s nares hourly to check and

Table 2 Demographics of nursing staff participants.

Total (n¼58) Baseline survey Pre & Post survey p-value
responders responders (n¼26)
only (n¼32)
Gendera (%)
Male 1 (1.7%) 1 (3.1%) 0 0.387
Female 57 (98.3%) 31 (96.9%) 26 (100%)
Ageb
Mean (SD) 42.91 (13.45) 42.91 (11.13) 42.92 (16.19) 0.997
Nursing Educationa (%)
Associate Degree (ADN) 20 (34.5%) 9 (28.1%) 11 (42.3%) 0.385
Bachelor of Science (BSN) 36 (62.1%) 23 (71.8%) 14 (53.8%)
Master of Science (MSN) 2 (3.4%) 1 (3.1%) 1 (3.8%)
Years of Nursing Experienceb
Mean (SD) 16.19 (14.00) 14.99 (11.83) 17.77 (16.56) 0.459
Years of NICU Experienceb
Mean (SD) 14.26 (12.78) 14.29 (11.80) 14.21 (14.22) 0.982
Note: SD-standard deviation.
a
Based on Chi-square test.
b
Based on independent samples t-test.

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
6 P.S. Milligan, M.R. Goldstein
maintain proper prong position. Thirty-three par-
ticipants (57.9%) reported removing the interface
device once a shift to conduct a focused nasal skin
assessment. Twenty-nine participants (50.8%) re-
ported coordinating cares with RCPs when
removing and changing NIRS interface device.
Twenty-eight participants (48.3%) disagreed with
the statement that nasal injuries from NIRS use
were device related injuries that need to be re-
ported and tracked. Baseline NIRS care average
score was 16.472 (SD ¼ 1.70) out of 20. Baseline
general NIRS knowledge score average was 6.7
(SD ¼ 1.60) out of 10. Fig. 2 displays a comparison
of pre and post staff survey responses regarding
care practices provided to infants on NIRS therapy.
Post education nursing surveys were collected
over a three-week period from February 22, 2016
to March 14, 2016. A total of 26 (44.8%) of the
previous 58 participants, responded to the second
survey. As in previous analysis, missing values were
excluded and results were calculated based only
on valid, non-missing values for each variable
measured. Table 3 displays a comparison of all pre
and post staff survey results collected. Table 4
displays results only of participants who
completed both pre and post surveys. Comparative
statistical analysis was conducted only for partic-
ipants who completed both surveys. Although
overall NIRS care practice score improved from an
average of 16.81 (SD ¼ 1.569) to 17.57
(SD ¼ 1.287), results were not statistically signifi-
cant (p ¼ 0.058). NIRS knowledge scores slightly
100%
90% 84%
80%
70%
56.90%
60%
50.80%
50%
36.80%
40% 32%
30%
20%
10%
0%
Visually observes Removes Coordinates care ReposiƟons every Obtains pain
hourly interface once with RCP
per shiŌ
Pre (n=58)
Fig. 2 Comparison of pre- and post- staff survey responses regarding NIRS infant care.
Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
improved from an average of 6.76 (SD ¼ 2.016) to
6.88 (SD ¼ 1.495), but were likewise not statisti-
cally significant (p ¼ 0.833).
Infant outcomes
Table 5 displays a comparison of demographic data
between between pre and post infant groups.
There is no statistically significant difference be-
tween infant groups pertaining to gender, gesta-
tional age, and birth weight. From November 1,
2015 to December 31, 2015, 75 infants received
pulmonary support via NIRS therapy in the NICU.
The pre infant group comprised of 35 male and 40
female infants. The average gestational age was 32
3/7 weeks, average birth weight was 1921 g, and
average number of days on NIRS therapy was 12.25
days. Of the 75 babies in the pre infant group, 26
infants (34.7%) had complications of nasal injury
from NIRS use. There were 18 (24%) infants with
Stage I, non-blanching erythema injury and 8
(10.7%) infants with Stage II, superficial erosion
injury. No Stage III injury was identified.
NIRS EBP Bundle was implemented in the NICU as
the standard of care to all infants receiving pulmo-
nary support via NIRS on January 18, 2016. Post in-
fant group data was collected from February 01,
2016 to March 01, 2016. During this period, 37 in-
fants received NIRS therapy in the NICU. The group
comprised of 13 male and 24 female infants. The
average gestational age was 32 1/7 weeks, average
birth weight was 1948 g, and average number of days
100%
87.30%
81.80% 81.80%
75%
3-4 hours scores every 3-4
hours
Post (n=26)
Implementation of an evidence-based NIRS bundle 7

Table 3 Comparison of pre and post nursing education survey results.

Baseline survey (n ¼ 58) Post education survey
(n ¼ 26)
Nursing care practice
Visually observes baby’s 21 (36.8%) 8 (32%)
nares hourly to check and
maintain proper prong
position.
Removes interface device 33 (56.9%) 21 (84%)
once a shift to conduct a
thorough nasal skin
assessment.
Coordinates cares with 29 (50.8%) 18 (75%)
respiratory practitioner
when removing device from
nares for focused
assessment & nasal device
change.
Repositions infants on NIRS 48 (87.3%) 22 (100%)
every 3e4 h
Pain scores obtained every 45 (81.8%) 18 (81.8%)
3e4 h
NIRS knowledge score
Minimum 2 4
Maximum 10 9
Mean (SD) 6.7 (1.6) 6.9 (1.48)
Note: SD  standard deviation.

Table 4 Comparison of nursing care practice and knowledge scores pre and post NIRS staff education.
N Pre (SD) Post (SD) p-value
a
Nursing care practice 21 16.81(1.569) 17.57(1.287) 0.058
NIRS knowledge scoreb 17 6.76 (2.016) 6.88 (1.495) 0.833
Note: SD  standard deviation.
a
Based on Wilcoxon test.
b
Based on paired samples t-test.

Table 5 Comparison of infant demographic characteristics between pre and post groups.
Total (n ¼ 112) Retrospective group Prospective group p-value
(n ¼ 75) (n ¼ 37)
Gendera(%)
Male 53 (47.3%) 35 (46.7%) 13 (35.1%) 0.070
Female 59 (52.7%) 40 (53.3%) 24 (64.9%)
Completed gestational ageb
Mean age in 226.72 (32.99) 227.52 (32.5) 225.08 (34.38) 0.715
days (SD) w32 2/7 weeks w32 3/7 weeks w32 1/7 weeks
Birth weightb
Mean birth 1930.34 (1033.46) 1921.63 (1058.65) 1948.00 (994.45) 0.900
weight in grams
(SD)
Note: SD e standard deviation.
a
Based on Chi-square test.
b
Based on independent samples t-test.

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
8 P.S. Milligan, M.R. Goldstein

on NIRS therapy was 8.65 days. Of the 37 babies from
the post NIRS EBP bundle group, seven infants
(18.9%) had complications of nasal injury from NIRS
use. There were four (10.8%) infants with stage I,
non-blanching erythema injury and 3 (8.1%) infants
with stage II, superficial erosion injury. No Stage III
injury was identified.
Table 6 displays a comparison of NIRS variables
measured between pre and post infant groups. No
statistical difference was demonstrated between
groups on total length of time using NIRS support
and modes of NIRS used. Although there was a
15.8% decrease in nasal injury complications from
NIRS use between the retrospective and prospec-
tive group (from 34.7% to 18.9%), the improvement
was not statistically significant (p ¼ 0.086). Fig. 3
displays a comparison of nasal injury incidence
and severity between pre and post infant groups.

Table 6 Comparison of NIRS variables between pre and post infant groups.
Total (n ¼ 112) Retrospective group Prospective group p-value
(n ¼ 75) (n ¼ 37)
Days on NIRS supporta
Mean (SD) 11.06 12.25 (14.78) 8.65 (11.9) 0.200
(13.95)
NIRS mode usedb (%)
BCPAP 59 (52.7%) 43 (57.3%) 16 (43.2%) 0.239
NNAVA 2 (1.8%) 1 (1.3%) 1 (2.7%)
BCPAP, NIPPV 37 (33.0%) 21 (28.0%) 16 (43.2%)
BCPAP, NNAVA 3 (2.7%) 1 (1.3%) 2 (5.4%)
BCPAP, NIPPV, NNAVA 11 (9.8%) 9 (12.0%) 2 (5.4%)
Nasal injuryb (%)
With injury 33 (29.5%) 26 (34.7%) 7 (18.9%) 0.086
Without injury 79 (70.5%) 49 (65.3%) 30 (81.1%)
Nasal injury severityb (%)
Stage 0 e no injury 79 (70.5%) 49 (65.3%) 30 (81.1%) 0.199
Stage I e non- 22 (19.6%) 18 (24.0%) 4 (10.8%)
blanching erythema
Stage II e superficial 11 (9.8%) 8 (10.7%) 3 (8.1%)
erosion
Stage III - necrosis 0 0 0
Note: SD  standard deviation, NIRS e non-invasive respiratory support, BCPAP e bubble continuous positive airway pressure,
NNAVA e nasal neurally adjusted ventilatory assist, NIPPV e nasal intermittent positive pressure ventilation.
a
Based on independent samples t-test.
b
Based on Chi-square test.

Fig. 3 Nasal injury incidence and severity between retrospective and prospective groups.

Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
Implementation of an evidence-based NIRS bundle
Discussion
Risk factors associated with increased incidence of
nasal injuries during NIRS therapy are lower birth
weight, earlier gestational age, and duration of
therapy (Bonner and Mainous, 2008; McCoskey,
2008; Newnam et al., 2013). Inappropriately
fitted nasal interfaces and improper securing of
nasal interface and NIRS tubing causes irritating
friction and pressure to the nasal skin and septum
(Bonner and Mainous, 2008; De Paoli et al., 2008;
Gunlemez et al., 2010; Yong et al., 2005). These
gaps in practice are compounded by the lack of
standardized care provided to infants receiving
NIRS therapy. Monitoring frequencies, extent of
assessments, care, and documentation of nasal
skin conditions were greatly varied even among
staff in the same NICU (Askin, 2007; Davis et al.,
2009; Gunlemez et al., 2010).
Although statistical significance was not demon-
strated for decreasing the incidence of nasal in-
juries for infants receiving NIRS, the standard of
care for these infants has been clearly defined as a
result of this QI project. Detailed strategies for
bedside practice promote consistency of care be-
tween healthcare providers. In addition, introduc-
tion of the Nasal Trauma Classification Tool allowed
for a well-defined representation of nasal skin
condition with each nasal assessment. Bedside staff
NIRS knowledge and bundle compliance plays a key
role in the success of the NIRS EBD Bundle in
reducing nasal injury complications from NIRS.
Educational resources and annual staff develop-
ment plans are in place to sustain NIRS EBP bundle
use. NIRS online educational module is auto-
scheduled for annual review and completion,
while NIRS EBP bundle interventions will be incor-
porated in the unit’s yearly skills lab agenda.
Limitations
Several limitations to this QI project impacted
outcomes. First, it was conducted in one NICU
location which limits generalizability of results to
other settings. Second, the staff self-report survey
created for the project was not a validated tool,
affecting credibility of results due to the possibil-
ity of reporting bias. In addition, there was less
than desirable staff response for both the initial
and subsequent nursing surveys. For future sur-
veys, a paper version of the survey delivered to the
nurses’ NICU mailbox or distributed in the unit,
might result in better staff participation. Lastly,
both staff and infant sample sizes were small and
not powered.
Please cite this article in press as: Milligan, P.S., Goldstein, M.R., Implementation of an evidence-based non-invasive respiratory
support (NIRS) bundle in the NICU to decrease nasal injury complications, Journal of Neonatal Nursing (2017), http://dx.doi.org/
10.1016/j.jnn.2016.05.003
9
Conclusion
NIRS is an effective modality for the management
of RDS and respiratory distress in neonates. How-
ever, widespread NIRS use and the lack of stan-
dardized care to infants receiving NIRS therapy
resulted in complications of nasal skin injuries
among these infants. This preventable complica-
tion negatively impacts the positive benefits
reaped from NIRS therapy. This QI project exam-
ined the use of a NIRS EBP Bundle to standardize
care and reduce nasal injuries to infants receiving
NIRS. The project likewise evaluated the effec-
tiveness of the NIRS education module in increasing
general NIRS knowledge of the nursing staff.
Focus on prevention is key. Future studies
should concentrate on clearly identifying preven-
tive and therapeutic strategies aimed at reducing
iatrogenic complications of NIRS therapy use.
Acknowledgements
I would like to thank Loma Linda University Chil-
dren’s Hospital NICU, Division of Neonatology,
Respiratory Department, and the Loma Linda
Department of Nursing Research for their support
of this quality improvement project that helped
improve outcomes for our NICU patients.
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