Neonatal Rescue Improved by Nurse Status, Better Communication

An Expert Interview With Sheila Gephart, PhD(c), BSN, RN

Troy Brown

October 17, 2012

PALM SPRINGS, California — Editor's note: Many factors affect the ability of a neonatal intensive care unit (NICU) to successfully rescue an infant whose condition is rapidly deteriorating, but a common theme is the status of the nurse in the institution.

Having a low nurse/patient ratio, standard order sets, and more nurses with advanced degrees increases the odds of a successful rescue in the NICU, according to Sheila Gephart, PhD(c), BSN, RN, assistant professor at the College of Nursing at the University of Arizona in Tucson.

Gephart spoke about system actions and other steps that can improve neonatal rescue here at the National Association of Neonatal Nurses (NANN) 28th Annual Educational Conference. She discussed strategies to improve neonatal rescue in a telephone interview with Medscape Medical News.

Medscape: What is "failure to rescue" and why does it happen?

Gephart: Failure to rescue is a national patient safety indicator that is about not being able to rescue or save a patient's life when they develop a complication that is not present on admission. It's measured and reported in adult settings, but in the NICU, it's not measured or reported in that way, nor is it in perinatal settings.

We do save patients' lives...every time an infant is born and has a complication in delivery, such as a meconium aspiration, a prolapsed [umbilical] cord, or emergency cesarean section.

But if that rescue did not occur — say the mom had a prolapsed cord and they had to do an emergency cesarean delivery but the team wasn't available, or communication broke down, or there was some sort of inordinate delay and the infant died — that would be a failure to rescue.

Medscape: What is the role of nursing in improving rescue?

Gephart: There have been large multihospital national studies in adults that look at places that do and do not do a great job at rescue. Hospitals that really value the status of the nurse are generally better rescuing organizations.

Hospitals that have achieved magnet status or that have a larger percentage of nurses with advanced degrees (BSNs) have also been shown to more successfully save lives than those that do not.

Staffing ratios affect the ability to recognize complications in a timely way. A study that was done a few years ago...found that by going from a ratio of 5 patients to 1 nurse, to a ratio of 4 patients to 1 nurse, there was a difference in mortality of 30%.

Having extra expert staff available who actually float between patient assignments, like the charge nurse who has a span of control over a certain number of nurses, offers an extra layer of supervision and can help.

Medscape: How can surveillance, which is the first step in the rescue process, be improved?

Gephart: You need to have clear documentation...that's readable, that's transferable. One breakdown that affects rescue is when change of shift occurs and information about the patient is not transferred effectively across caregivers or across settings.

When information is not available or is not known, surveillance can break down, too, so making records complete and available is key.

Standardizing the handoff process can help. When the oncoming nurse or physician goes in and sees a deteriorating patient, [the clinician] already has a complete clinical picture of [the patient] because the handoff was effective.

Medscape: How can recognizing complications, the second step, be improved in NICUs?

Gephart: Advanced training to recognize complications helps. In the NICU, sometimes a hospital will decide to increase their level of care; for example, they might be caring for a patient population that goes from 32 weeks' gestation on, and then decide to beef up their services and take very-low-birthweight infants.

Very-low-birthweight infants are more prone to complications like necrotizing enterocolitis (NEC) and chronic lung disease. If [the infant has, for example], a pneumothorax, the outcome can be poor if you don't act on it immediately and [the patient] is likely to need prolonged ventilation. There are a lot of complications that nurses need to be looking for in that population that they wouldn't necessarily be as concerned about in a more physiologically mature population.

In electronic health records, having alerts and reminders or having systems set to alert if certain levels go below critical levels — whether they be lab values or physiologic parameters — can help.

Medscape: How does standardizing processes improve rescue?

Gephart: The model for rescue is really about reliable systems — things that work every time. Checklists have been used to dramatically reduce complication rates, specifically central-line infections, in NICUs in New York.

Standardizing routine processes can dramatically impact complication rates. Reliable systems affect the repeatability of quality within the NICU; eventually, that could affect rescue by creating less need for rescue.

Making a lot of things routine supports rescue because rescue is not routine. If we can make some of the things we do more predictable, it actually enables us to respond to the unpredictable better.

Medscape: How can taking action, which is the third step, be improved?

Gephart: One of the things that organizations have done to improve [response] is to use standard order sets. An example is a hypoglycemia protocol in a nursery: If a glucose level goes below a certain amount, the nurses know to do x. That is standard, so they can act immediately.

Teamwork training in a simulated environment can make action more effective. Practicing those skills in an interprofessional environment is very powerful because we act interprofessionally. In a very-high-risk rescue environment, we have at least 10 people in the room; practicing together makes it more effective when they actually have to do the rescue.

Practicing [team skills includes] practicing communication and nontechnical skills.

Medscape: Why is communication so important?

Gephart: One of the challenges in taking action is [when] the nurse recognizes a clinical deterioration and tries to initiate action, but is not able to get the orders to do so. One thing [the nurse] can do in that situation is to move up the chain of command. But before that, you need to really be clear about how you're presenting your message.

We wrote an article this summer about the PURE communication method, which is [about] making your messages purposeful, unambiguous, respectful, and effective (Newborn Infant Nurs Rev. 2012;12:109-114). That can be very powerful.

If that doesn't work, to actually use the words, "I'm concerned...I'm uncomfortable...this is a safety issue," can help.

One of the challenges with nursing is that we notice things because we're at the bedside, but without the standard order sets, sometimes we lack the power to act. That's really frustrating because of the way the structure is, and these situations are very hierarchical. If the [team] relationship isn't good, communication can break down and rescue doesn't happen.

The Joint Commission published their sentinel event alert a few years back about infant mortality and infants dying. In the root-cause analysis of those infant deaths, communication breakdown was implicated in about three quarters of the deaths.

Taking action implies effective communication. You cannot take action in an interdisciplinary, interprofessional environment without being able to clearly state your message and what you need. Maybe that's why the status of the nurse in the organization is so tightly tied to failure to rescue rates.

Medscape: How can activating the team response, which is the fourth step, be improved?

Gephart: Having rapid response teams and the ability to effectively communicate goes along with team response. About 30% to 40% of NEC cases are treated surgically...but a large number of NICUs do not have neonatal surgical services onsite. In that situation, the infant has to be transported to another NICU to get surgery or a surgical consult.

That team response involves not just the team within the NICU, but also the facilitated communication across 3 separate teams: the sending NICU team, the transport team, and the receiving NICU team.

Having clear communication and being able to work not just with your NICU team, but across centers, is important.

NEC develops fairly far into the clinical course, when an infant is a couple of weeks old, after the parents have bonded and perhaps even after a baby is off the ventilator. [The infant] seem[s] to be getting better, and then [he or she] deteriorate[s] quickly. It's just devastating to not be able to save that baby's life.

Medscape: How can neonatal nurses use professional guidelines to improve care?

Gephart: The power of a guideline is to empower to act, and challenge a status quo mentality. In many cases, guidelines set the standard of care and make action reliable and repeatable. Often, individual NICUs will have adopted guidelines for the management of common conditions like hypoglycemia, hypertension, hypotension, neonatal abstinence syndrome, and neonatal hyperbilirubinemia.

Less often, units will adopt guidelines for the prevention of neonatal complications (e.g., intraventricular hemorrhage, central-line infections, necrotizing enterocolitis, chronic lung disease, or retinopathy of prematurity). Internationally, guidelines are available for the management of hyperbilirubinemia, preferential use of human milk, and developmental care in the NICU.

To have an impact, guidelines need to be specific and somewhat prescriptive when symptoms of complications develop. My research is very focused on NEC, a costly and deadly complication in premature infants. Very strong evidence supports the adoption of standardized feeding guidelines (SFGs) as a preventive measure for NEC. However, a recent study reported that less than 30% of American NICUs have adopted [an SFG].

Within SFGs, very clear criteria are set for when feedings are initiated, advanced, and stopped. This empowers the bedside nurse and ultimately has been shown to reduce a complication not present on admission — NEC.

One of the less-standard guidelines is staffing. The neonatal staffing guideline is always a topic of discussion, because when you talk about staffing, you talk about dollars. The Association of Women's Health, Obstetric, and Neonatal Nurses has some staffing guidelines for NICU.

To improve care, one of the best defenses against poor outcomes is measurement and benchmarking. Neonatal nurses need to know that if they have complication rates outside of the median values, it is very likely that best practices are being used in other centers that may be transferable to their setting to improve care.

Furthermore, I strongly encourage nurses to trust their assessments and always [follow the adage]: "When in doubt, check it out." Seniority and experience are not substitutes for safety.

Gephart has disclosed no relevant financial relationships.