Clinical Nurse III University of California Irvine Orange , California, United States
Background: Preterm infants in the NICU often undergo frequent painful and invasive procedures that are associated with altered white matter, reduced thalamus size and poor cognitive outcomes after discharge. Reducing the number of skin breaking procedures (SB) could result in a reduction in abnormal brain development, nosocomial infections, anemia, length of stay, and health care costs while increasing patient satisfaction. Objective: We aimed to reduce the number of skin breaking procedures (SB) in infants < 32 weeks. Design/Methods: IHI model for improvement with Plan Do Study Act (PDSA) cycles in a Level III Regional Center NICU.
Inclusion criteria: Gestational age < 32 weeks, admitted on day of birth, and with minimum of 7 days NICU stay. Specimens collected from a previous SB are not counted as a new SB. Patients on insulin were excluded. SBs were tallied per patient from birth until discharge.
SB audit forms are used to document SBs which are divided into categories: Heelsticks, PIV/PICCs, Venipuncture, IM/SQ injections, Arterial stick, and Others. Audit forms are collected weekly, analyzed and reviewed against the Electronic Health Record.
Baseline data collection started in December 2022 and included 17 patients. PDSA Cycle 1 Interventions included: education on the harmful effects of pain on the preterm brain, revision of the unit’s Accucheck screening protocols, promoting bundling of labs, and the use of add-on labs.
PDSA Cycle 2 Interventions included: Visual display of two graphs. SBs per month, per 1,000 patient days (PD) (Fig 1a), and Heelsticks performed for Accucheck screening only, per 100 PD (Fig 1b). Results: There was no significant difference in the total average SBs in the baseline cohort [N=17] vs PDSA 1 [N=30], 38 (SD 32.4) vs 38.9 (SD = 36.7) respectively. However, SBs per PD fell by 22% from 0.66 (0.3) in the baseline cohort, to 0.51 (0.3) in the PDSA 1 cohort.
The average number of SBs per month per 1,000 PD has decreased from 722 to 534 (Fig 1a). Our data shows that most SBs occur during the second week of life, post arterial line removal.
Conclusion(s): Focused interventions, including raising awareness, education and guideline development resulted in decreased number of unnecessary skin breaks in NICU patient population.
