Implementation of a Multi-disciplinary Practice
Project in the NICU
Laura Warner BSN, RNC-NIC, Morgan Pittman BSN, RNC-NIC, Darlene Fulinara BSN, Jan Thape MSN, RNC-NIC, Thomas Bass MD
Neonatal Intensive Care Unit, Children’s Hospital of The King’s Daughters, Norfolk, VA
Abstract
Bleeding in the brain or intra-ventricular
hemorrhage (IVH) in neonates can be devastating
and with lifelong effects. The NICU nursing staff is
collaborating with the neonatologists, neonatal
nurse practitioners, and residents on a quality
improvement project to decrease the rate and
severity of IVH by implementing a new bundle of
preventative measures.
Introduction
Neonatal intra-ventricular hemorrhage or IVH is
defined by bleeding in/ around the ventricles of the
brain. The smaller and more premature the infant,
the higher the risk for IVH. There are four types of
bleeds, called "grades" and are categorized by the
amount and location of bleeding. Grade 1 being
mild and grade 4 the most severe. Bleeding can
be one sided or bilateral. IVH is diagnosed by a
head ultrasound or "cranial sector scan".
Grade 1: bleeding occurs in just a small area of
around the ventricles (germinal matrix area)
Grade 2: bleeding occurs inside the ventricle
Grade 3: the ventricles are enlarged by the
bleeding
Grade 4: bleeding occurs into the brain tissue.
IVH is rarely present at birth, occurs most often
within the first few days of life and is multi-
factorial. Risk factors include:
Prematurity- inability to regulate cerebral
blood flow, immature blood vessels/
circulation, immature neurons,
Multiple gestations
Hypoglycemia
Thrombocytopenia
Respiratory Distress Syndrome, pneumothorax,
IVH Prevention Bundle
IVH prevention “bundle’ implementation is a
common strategy to decrease the rate and
severity of IVH in NICU patients. We
collaborated to develop our research – based,
multi- disciplinary interventions for infants < 28
weeks for the 1st 96 hrs of life . It expands our
“Golden Hour “ activities and includes changes
to medical care, nursing care , data collection,
additional monitoring of cerebral oxygenation
and use of a Transportle positioning device.
Procedure
Once the bundle was developed and a self-
learning packet was distributed , we developed
an “implementation folder” for the staff. It
includes a quick guide for staff education and
reference for the care of the < 28 week infants.
Signs were placed at the bedside to facilitate
minimizing stimulation and encourage
clustering of care among all the providers. It
emphasizes the “ Golden hour” of completing
all admission activities within 1 hr and having
the incubator “top down” and humidity
started.
Results
60
50
The bundle implementation has required on-going
40
collaboration/ education to fine tune the different
aspects of the bundle including the use of the 30
Goal
Overall IVH
transportle, NIRS monitor and strategizing the 20
clustering of care between all the disciplines.
10
Monthly activities include 0
Baseline 14-Nov 14-Dec 14-Jan 14-Feb 14-Mar 14-Apr
- Evaluation of the protocol progress to identify 25
areas for improvement
-Review of the data sheets for compliance to the 20
protocol, and areas for improvement
15
--Review of all the head ultrasound results by Dr. Goal
Bass. 10
Severe IVH
Our goals were to have compliance with the 5
protocol and to see a decrease in the overall IVH
rates to less than 29% and severe rates (grades 3 0
Baseline 14-Nov 14-Dec 14-Jan 14-Feb 14-Mar 14-Apr
and 4) to be less than 13%.
Our baseline for 2018 was 46% for overall IVH References
and 17% for severe IVH rates.
Over the past 5 months with the bundle in use,
we have had 2 months that exceed the severe
IVH goal rate and 3 months where the IVH rate fell
Ballabh P. Intraventricular hemorrhage in premature infants:
under the 13% goal.
mechanism of disease. Pediatr. Res. 2010 Jan;67(1):1-8
As you can see from the graphs we have seen
some decrease in overall IVH rates, but not Bass WT. (2019) Elevated midline head positioning of
consistently below our goal. However we have extremely low birth weight infants: ellects on cardio
had an overall decrease in severe IVH rates . pulmonary function and the incidence of P-IVH
J Perinatol. 2019 Mar;39(3):517-518..
We continue to work on the protocol
Carteaux, P, Cohen H et al (2003) Evaluation and
implementation between all the disciplines and
development of potentially better practices for the prevention
collect data about our results.
& treatment of brain hemorrhage/ Ischemic brain injury in
The protocol implementation has demonstrated very low birthweight infants. Pediatrics 2003 111e:489-496
the importance of a multi disciplinary approach
and ongoing focus on the protocol process and Gresens P, Rogido P et al (2002) The impact of neonatal
intensive care practices on the developing brain. The Journal
outcomes.
of Pediatrics Vol. 40 #6 pp 653-670
Malusky S, Donze A. ( 2011) Neutral head positioning in
premature infants for intraventricular hemorrhage prevention:
an evidence-based review. Neonatal Network. 2011 Nov-
Dec;30(6):381-96