Skin‐to‐skin care in neonatal intensive care units in the Nordic countries: a survey of attitudes and practices

Aim: To investigate the application of skin‐to‐skin care (SSC) in the Nordic countries, the existence of guidelines for SSC and the attitudes of neonatal staff towards SSC. Methods: One questionnaire was distributed at unit level and one at staff level in all Nordic neonatal intensive care units (n = 109). Results: The unit questionnaire was answered by 95 (87%) units and the staff questionnaire by 1446 staff members (72%). All units offered SSC to various degrees, but guidelines only existed at 47% of them. Units in Denmark, Norway and Sweden seemed to use SSC earlier, longer and in more medically complicated situations than units in Finland and Iceland. Seventy‐seven per cent of the units had private rooms where parents and infants could stay together, still the physical environment of the units limited the use of SSC. Medical risks were considered the main barrier for further implementation of SSC, while general development and early interaction were the most frequently mentioned benefits. Conclusion: Skin‐to‐skin care is implemented in all Nordic neonatal units, but offered to various degrees, to various populations and to varying extents. Danish, Norwegian and Swedish units are offering SSC more extensively than units in Finland and Iceland.     

Multicentric study on neonatal medical pain management in the Nord-Pas-de-Calais]

The aim of this study was to describe pain management for newborn infants in neonatal intensive care units and neonatal units in the Nord-Pas-de-Calais. PATIENTS AND METHODS: A questionnaire was distributed to the 52 physicians practising in the six neonatal intensive care units and six neonatal units. The questions were in reference to pain assessment, treatment and prevention. RESULTS: Forty questionnaires were completed (77%). Eleven units proclaimed an interest in neonatal pain management. The tool for assessing pain was the EDIN scale (Echelle Douleur Inconfort Nouveau-né, neonatal pain and discomfort scale). Analgesic treatment was administered in 100% of cases for the insertion of chest tube, in 92% of cases for the insertion of percutaneous central catheter in a ventilated newborn infant and in 91% of cases for necrotizing enterocolitis requiring a mechanical ventilation. Prescribed analgesic drugs were propacetamol, nalbuphin or fentanyl; a sedation by midazolam or diazepam was occasionally associated. Emla cream was used before lumbar puncture in 80% of cases in the neonatal intensive care units and in 92% of cases in the neonatal units. Three neonatal intensive care units and four neonatal units administered a sucrose solution for blood samples. CONCLUSION: At the time of study, the interest in the pain of the physicians working in neonatal intensive care units and neonatal units was inadequate to guarantee an optimum management of pain in newborn infants. Physicians' approach remained heterogeneous.     

Ethical issues in neonatal intensive care and physicians' practices: a European perspective

An international project (EURONIC) was carried out to explore the end-of-life decision-making process in a large, representative sample of neonatal intensive care units (NICUs) in eight western European countries: France, Germany, Great Britain, Italy, Luxembourg, the Netherlands, Spain and Sweden. Structured questionnaires were used to record data on NICU organization and policies, and to survey staff views and practices regarding ethical decision-making. One hundred and twenty-two NICUs were recruited by census or random sampling (response rate 86%); 1235 physicians and 3115 nurses completed the staff questionnaire (response rates 89 and 85%, respectively). This paper focuses on the physicians' answers. In all countries but Italy, most physicians reported having been involved at least once in setting limits to intensive care because of a baby's incurable condition and/or poor neurological prognosis. Adopted strategies varied between countries. Practices such as the continuation of current treatment without intensifying it and the withholding of emergency manoeuvres appeared widespread. In contrast, the frequency of doctors reporting withdrawal of mechanical ventilation was highest in the Netherlands (93%), Sweden (91%) and the Great Britain (88%), intermediate in France and Germany, and lowest in Spain and Italy (34 and 21%, respectively). CONCLUSION: Ethically problematic clinical cases are approached differently in the various countries. The findings of this study may provide an opportunity for physicians to review their practices critically, in light of how other colleagues proceed, and foster an open discussion about these difficult issues.     

Ethical issues in neonatal intensive care and physicians' practices: A European perspective

An international project (EURONIC) was carried out to explore the end-of-life decision-making process in a large, representative sample of neonatal intensive care units (NICUs) in eight western European countries: France, Germany, Great Britain, Italy, Luxembourg, the Netherlands, Spain and Sweden. Structured questionnaires were used to record data on NICU organization and policies, and to survey staff views and practices regarding ethical decision-making. One hundred and twenty-two NICUs were recruited by census or random sampling (response rate 86%); 1235 physicians and 3115 nurses completed the staff questionnaire (response rates 89 and 85%, respectively). This paper focuses on the physicians' answers. In all countries but Italy, most physicians reported having been involved at least once in setting limits to intensive care because of a baby's incurable condition and/or poor neurological prognosis. Adopted strategies varied between countries. Practices such as the continuation of current treatment without intensifying it and the withholding of emergency manoeuvres appeared widespread. In contrast, the frequency of doctors reporting withdrawal of mechanical ventilation was highest in the Netherlands (93%), Sweden (91%) and the Great Britain (88%), intermediate in France and Germany, and lowest in Spain and Italy (34 and 21%, respectively).
Conclusion: Ethically problematic clinical cases are approached differently in the various countries. The findings of this study may provide an opportunity for physicians to review their practices critically, in light of how other colleagues proceed, and foster an open discussion about these difficult issues.     

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

AIM: Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. METHODS: A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. RESULTS: Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. CONCLUSION: Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.     

Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units

BACKGROUND: The Centers for Disease Control and Prevention, Atlanta, Ga, recommend use of waterless alcohol hand products in lieu of traditional handwashing for patient care, but there are few data demonstrating the impact of this recommendation on health care-associated infections. OBJECTIVE: To compare the effect of 2 hand hygiene regimens on infection rates and skin condition and microbial counts of nurses' hands in neonatal intensive care units. DESIGN, SETTING, AND PARTICIPANTS: Clinical trial using a crossover design in 2 neonatal intensive care units in Manhattan, NY, from March 1, 2001, to January 31, 2003, including 2932 neonatal hospital admissions (51 760 patient days) and 119 nurse participants. INTERVENTION: Two hand hygiene products were tested: a traditional antiseptic handwash and an alcohol hand sanitizer. Each product was used for 11 consecutive months in each neonatal intensive care unit in random order. RESULTS: After adjusting for study site, birth weight, surgery, and follow-up time, there were no significant differences in neonatal infections between the 2 products; odds ratios for alcohol compared with handwashing were 0.98 (95% confidence interval [CI], 0.77-1.25) for any infection, 0.99 (95% CI, 0.77-1.33) for bloodstream infections, 1.61 (95% CI, 0.57-5.54) for pneumonia, 1.78 (95% CI, 0.94-3.37) for skin and soft tissue infections, and 1.26 (95% CI, 0.42-3.76) for central nervous system infections. The skin condition of participating nurses was significantly improved during the alcohol phase (P = .02 and P = .049 for observer and self-assessments, respectively), but there were no significant differences in mean microbial counts on nurses' hands (3.21 and 3.11 log(10) colony-forming units for handwashing and alcohol, respectively; P = .38). CONCLUSIONS: Infection rates and microbial counts on nurses' hands were equivalent during handwashing and alcohol phases, and nurses' skin condition was improved using alcohol. However, assessing the impact on infection rates of a single intervention is challenging because of multiple contributory factors such as patient risk, unit design, and staff behavior. Other practices such as frequency and quality of hand hygiene are likely to be as important as product in reducing risk of cross-transmission.     

新生儿重症监护病房医护人员对新生儿疼痛评估和镇痛管理的认知现状调查

目的 了解新生儿重症监护病房（neonatal intensive care unit，NICU）医护人员对新生儿疼痛评估和镇痛管理的认知现状。 方法 根据《新生儿疼痛评估与镇痛管理专家共识（2020版）》自制量表，采用此量表对江苏省新生儿科医疗质量控制中心成员单位的NICU医护人员发放问卷调查表，分析其对新生儿疼痛的基本知识、评估和管理的掌握水平。 结果 共收回有效问卷957份，其中医生383份，护士574份。医生与护士对新生儿疼痛基本知识的答题正确率的均值分别为38%和39%；对新生儿疼痛评估的答题正确率的中位值分别为0%和50%；对镇痛管理的答题正确率的均值分别为73%和68%。接受过疼痛相关培训的医护人员对新生儿疼痛基本知识和疼痛评估的答题正确率较未接受相关培训的医护人员显著增高（P<0.05）。三级医院医护人员对新生儿疼痛基本知识和疼痛评估的答题正确率较二级医院医护人员显著增高（P<0.05）。 结论 NICU医护人员对新生儿疼痛的认识不足，需开展有关新生儿疼痛知识的专项培训，建议侧重对《新生儿疼痛评估与镇痛管理专家共识（2020版）》的推广和临床应用，以提高医护人员对新生儿疼痛评估和镇痛管理的水平。     

Factors associated with hand hygiene practices in two neonatal intensive care units

OBJECTIVE: To determine whether hand hygiene practices differ between levels of contact with neonates; to characterize the hand hygiene practices of different types of personnel; and to compare hand hygiene practices in neonatal intensive care units (NICUs) using different products. METHODS: Research assistants observed staff hand hygiene practices during 38 sessions in two NICUs. Patient touches were categorized as touching within the neonates' environment but only outside the Isolette (Level 1), touching within the Isolette but not the neonate directly (Level 2) or directly touching the neonate (Level 3). Hand hygiene practices for each touch were categorized into five groups: cleaned hands and new gloves; uncleaned hands and new gloves; used gloves; clean hands and no gloves; uncleaned hands and no gloves. RESULTS: Research assistants observed 1472 touches. On average each neonate or his or her immediate environment was touched 78 times per shift. Nurses (P = 0.001), attending physicians (P = 0.02) and physicians-in-training (P = 0.03) were more likely to use appropriate practices during Level 3 touches, but only 22.8% of all touches were with cleaned and/or newly gloved hands. The mean number of direct touches by staff members with cleaned hands was greater in the NICU using an alcohol-based hand rub than in the NICU using antimicrobial soap (P < 0.01). CONCLUSIONS: Hand hygiene was suboptimal in this high risk setting; administrative action and improved products may be needed to assure acceptable practice. In this study use of an alcohol-based product was associated with significantly improved hand hygiene and should be encouraged, as recommended in the new CDC hand hygiene guideline.     

Outbreaks of influenza A virus infection in neonatal intensive care units

BACKGROUND: Outbreaks of nosocomial influenza virus infections have been described rarely during childhood and even less so in the neonatal period. METHODS: We report 30 neonates admitted to 2 neonatal intensive care units with nosocomial influenza A virus infection, which occurred in 2 outbreaks during 1999. Risk factors for infection were evaluated, and control measures were adopted. Virus was detected by indirect immunofluorescence antibody screen. Any infant with nasopharyngeal aspirate positive for influenza A virus was considered infected. RESULTS: Of 95 infants screened 30 were positive for influenza A virus (31.5%). Mean birth weight was 1622 g, and mean gestational age was 31 weeks in the infected group. In the noninfected group mean birth weight was 2594 g and mean gestational age was 36.4 weeks. Low birth weight, short gestational age, twin pregnancy and mechanical ventilation were identified as risk factors for infection. Clinical symptoms were seen in 22, and 8 were asymptomatic. Clinical features were predominantly respiratory and digestive. The outcome was favorable in all cases. CONCLUSIONS: Infection by influenza virus has to be considered as a possible cause of nosocomial infection in the neonatal period. Control measures and prevention are important.     

Barriers to neonatal care in developing countries: Parents' and providers' perceptions

Aim: Hospital care and advanced medical technologies for sick neonates are increasingly available, but not always readily accessible, in many countries. We characterised parents' and providers' perceptions of barriers to neonatal care in developing countries. Methods: We interviewed parents whose infant was hospitalised within the first month of life in Cambodia, Malaysia, Laos and Vietnam, asking about perceived barriers to obtaining newborn care. We also surveyed health-care providers about perceived barriers to providing care. Results: We interviewed 198 parents and 212 newborn care providers (physicians, nurses, midwives, paediatric and nursing trainees). Most families paid all costs of newborn care, which they reported as a hardship. Although newborn care is accessible, 39% reported that hospitals are too distant; almost 20% did not know where to obtain care. Parents cited lack of cleanliness (46%), poor availability of medications (42%) or services (36%), staff friendliness (42%), poor infant outcome (45%), poor communications with staff (44%) and costs of care (34%) as significant problems during prior newborn care. Providers cited lack of equipment (74%), lack of staff training (61%) and poor infrastructure (51%) as barriers to providing neonatal care. Providers identified distance to hospital, lack of transportation, care costs and low parental education as barriers for families. Conclusions: Improving cleanliness, staff friendliness and communication with parents may diminish some barriers to neonatal care in developing countries. Costs of newborn care, hospital infrastructure, distance to hospital, staffing shortages, limited staff training and limited access to medications pose more difficult barriers to remedy.     

Census of neonatal transfers in London and the South East of England

OBJECTIVES: To determine the number and characteristics of inter-hospital transfers of newborn infants in London and the South East of England. DESIGN: Prospective census of neonatal transfers over a three month period. SETTING: Transfers between the 53 hospitals that provide care for newborn infants within the former Thames regions. DATA SOURCES: Census returns from participating neonatal units. MAIN OUTCOME MEASURES: Number, timing, and hours of staff time spent on transfers. Gestation, birth weight, and reason for transfer of the baby. Time elapsed between request and retrieving team departing and arriving with patient. RESULTS: A daily average of 2.7 urgent, 3.5 elective, and 0.7 short term transfers took place during the census period. The most common reason for urgent transfer was neonatal surgery. Neonatal unit staff spent an average of 21 hours a day off their units accompanying transfers each day. It took over four hours for 90% of ambulances to set off with the retrieving team and over six hours for 90% of teams to reach the baby. CONCLUSIONS: During the census period, services for the transport of neonates in London and the South East of England involved long delays and used appreciable amounts of staff time. It is likely that a small number of dedicated neonatal transfer teams could meet the needs identified in this census more effectively than the 53 hospitals currently involved.     

The use of mechanical ventilation protocols in Canadian neonatal intensive care units

OBJECTIVES:To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols.METHODS:A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013.RESULTS:Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]).CONCLUSION:Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.     

An international survey of EEG use in the neonatal intensive care unit

Objective: To examine the extent of EEG monitoring in neonatal intensive care units (NICUs), and to survey the level of experience and training of those using it. Study design: A web‐based survey, the link to which was circulated via e‐mail, personal contact, specialist societies and professional groups. Survey data were exported to SPSS for analysis. Results: In total 210 surveys were analysed; 124 from Europe, 54 from the US. Ninety percent of respondents had access to either EEG or aEEG monitoring; 51% had both. EEG was mainly interpreted by neurophysiologists (72%) whereas aEEG was usually interpreted by neonatologists (80%). Only 9% of respondents reported that they felt ‘very confident’ in their ability to interpret aEEG/EEG with 31% reporting that they were ‘not confident’. Half had received no formal training in EEG. Conclusion: Both aEEG and conventional EEG were used extensively in the NICUs surveyed for this study. Most of the survey respondents were not confident in their ability to interpret EEGs despite the fact that they used monitoring routinely. There is an urgent need for a structured and appropriately targeted training programme in EEG methodologies and EEG interpretation for neonatal intensive care unit staff.     

Disinfection with 10% povidone-iodine versus 0.5% chlorhexidine gluconate in 70% isopropanol in the neonatal intensive care unit

AIM: The finding that 10% povidone-iodine skin disinfectant may compromise thyroid function in premature infants prompted its replacement with 0.5% chlorhexidine gluconate solution in 70% isopropanol. The objective of this study was to compare the incidence rates of true infection and contamination associated with the use of these two disinfectants in the neonatal intensive care unit. METHODS: The study population comprised two cohorts of infants admitted to our neonatal intensive care unit: 1) in 1992-1993 when only 10% povidone-iodine was used as a skin disinfectant, and 2) in 1995-1996 when only 0.5% chlorhexidine gluconate solution in 70% isopropanol was used. A retrospective chart review was conducted to determine whether all documented positive blood, CSF and suprapubic aspirate cultures indicated true infection or contamination. True infection was defined as clinical symptoms and/or laboratory abnormalities suggestive of sepsis, with positive blood, CSF or suprapubic aspirate cultures. RESULTS: 1146 infants were admitted during the study periods, 507 during the first period and 639 during the second. In the early group, 17.6% of infants had major malformations, 72.0% were premature and 25.2% had weights of < 1500 g. Corresponding percentages for the latter group were 16.0%, 80.6% and 32.9%, respectively. No statistically significant differences were found between the two research periods in rate of infants with positive blood cultures, true infections, or contamination. CONCLUSION: The use of 0.5% chlorhexidine gluconate solution in 70% isopropanol as a skin disinfectant is justified in neonatal intensive care units because it is not associated with an increased incidence of infections as opposed to 10% povidone-iodine and is devoid of detrimental effects.     

Pain assessment and procedural pain management practices in neonatal units in Australia

OBJECTIVE: To identify current pain assessment and procedural pain management practices in neonatal units in Australia. METHODS: Postal survey conducted during December 2003 and January 2004. The survey comprised questions relating to pain assessment scores, pain reduction strategies for minor painful procedures and the use of articulated policies relating to procedural pain management. Participants were the Nurse Unit Managers or their nominees of neonatal intensive care units, special care units and newborn emergency transport services in Australia. RESULTS: Surveys were sent to 181 eligible organizations, and 105 of these were returned (58%). Six units (6%) used pain assessment scores on a regular basis, and 16 units (15%) had an articulated policy directing pain management practices during painful procedures. Non-nutritive sucking and various nursing comfort measures were the pain reduction strategies most frequently used during minor painful procedures. Twenty-four units (23%) used sucrose or other sweet-tasting solutions during procedures; however, the reported frequency of their usage was low. Breast-feeding during venepuncture, heel lance and intramuscular or subcutaneous injection was infrequently practised and topical anaesthetic agents were rarely used. CONCLUSION: This survey demonstrates that the majority of Australian neonatal units have no articulated policy to guide pain management during painful procedures and do not regularly undertake pain assessments. Current evidence-based strategies to reduce procedural pain in hospitalized infants are used infrequently.     

UK neonatal intensive care services in 1996. On behalf of the UK Neonatal Staffing Study Collaborative Group

A census of activity and staff levels in 1996 was conducted in UK neonatal units and achieved a 100% response from 246 units. Among the 186 neonatal intensive care units, the median (interquartile range) number of total cots was 18(14-22); level 1 intensive care cots 4(2-6); total admissions 318(262-405); very low birthweight admissions 40(28-68); and the number ventilated or given CPAP by endotracheal tube 52(32-83). Forty six (25%) intensive care units lacked the recommended minimum of one consultant with prime responsibility for neonatal medicine. As a conservative estimate 79% of intensive care units had a lower nursing provision than that recommended in previously published guidelines. There was substantial variation in activity and staffing levels among units.     

Impact of resident duty hour limits on safety in the intensive care unit: A national survey of pediatric and neonatal intensivists*

OBJECTIVE:: Resident duty-hour regulations potentially shift the workload from resident to attending physicians. We sought to understand how current or future regulatory changes might impact safety in academic pediatric and neonatal intensive care units. DESIGN:: Web-based survey. SETTING:: U.S. academic pediatric and neonatal intensive care units. SUBJECTS:: Attending pediatric and neonatal intensivists. INTERVENTIONS:: We evaluated perceptions on four intensive care unit safety-related risk measures potentially affected by current duty-hour regulations: 1) attending physician and resident fatigue; 2) attending physician workload; 3) errors (self-reported rates by attending physicians or perceived resident error rates); and 4) safety culture. We also evaluated perceptions of how these risks would change with further duty-hour restrictions. MEASUREMENTS AND MAIN RESULTS:: We administered our survey between February and April 2010 to 688 eligible physicians, of whom 360 (52.3%) responded. Most believed that resident error rates were unchanged or worse (91.9%) and safety culture was unchanged or worse (84.4%) with current duty-hour regulations. Of respondents, 61.9% believed their own work-hours providing direct patient care increased and 55.8% believed they were more fatigued while providing direct patient care. Most (85.3%) perceived no increase in their own error rates currently, but in the scenario of further reduction in resident duty-hours, over half (53.3%) believed that safety culture would worsen and a significant proportion (40.3%) believed that their own error rates would increase. CONCLUSIONS:: Pediatric intensivists do not perceive improved patient safety from current resident duty-hour restrictions. Policies to further restrict resident duty-hours should consider unintended consequences of worsening certain aspects of intensive care unit safety.     

How clinicians in neonatal care see the introduction of neonatal nurse practitioners

The aim of this study was to investigate the views of UK clinicians in neonatal care who were working with nurses trained as neonatal nurse practitioners (NNPs). A questionnaire survey was used with a total sample of senior clinicians in the 66 neonatal units with one or more qualified NNPs. The main outcome measures were type and frequency of response, and similar data from NNPs were used to make comparisons. Data were returned from 57 of the 66 clinicians contacted (86%). NNP clinical practice as perceived by them was largely similar to that recorded by NNPs, though the clinicians expected more NNP involvement in some procedures (inserting central venous lines, umbilical arterial catheters, chest drains and peripheral arterial cannulae) than was actually found. Perceptions of the NNP role were similar, though the clinicians were significantly less likely to see taking a case-load, conducting a ward round, accepting outside referrals and taking charge of emergency transfers as integral elements. Reflections on the utilization of NNPs in neonatal care and the impact on junior medical staff education referred to NNPs filling gaps, a reduction in the intensity of work, improvements in training and in the quality of care.

Conclusion : The introduction of NNPs is seen positively from the perspective of clinicians working alongside them in neonatal care. The development of similar models of care in countries where the introduction of NNPs is being considered is likely to be similarly supported.