Working together: neonatal nurse practitioners in practice

The aim of this study was to examine the relatively new role of neonatal nurse practitioners (NNPs) in the United Kingdom, comparing practice in different types of neonatal units and work undertaken by junior medical staff (JMS). Diary checklists sent to the total population of qualified NNPs in neonatal units (NNUs) and JMS in six regional centres with qualified NNPs were returned from 68 out of 109 qualified NNPs (62%), working in 50 different NNUs and from 25 out of 48 JMS (52%). Direct observations (totalling 263.5 h) were made by an experienced neonatal nurse researcher on 30 different NNPs. Frequencies of activities and specific procedures were compared between groups. Observational measures included type and duration of activity and interactions with other members of staff. NNPs were found to be undertaking a range of activities: in the NNU, which usually involved blood sampling, siting of intravenous cannulae, presenting at ward rounds and teaching. Outside the unit, NNPs attended the delivery suite and the postnatal ward. Significant differences were found in the nature and organization of their work in different types of NNUs. A comparison between NNPs and JMS showed similar activities, with greater direct involvement by NNPs in the NNU and in teaching. The diary data were supported by observations and together these are evidence of current NNP practice. CONCLUSION: To a large extent there is an overlap in the work of JMS and NNPs in neonatal units, but although the clinical work and areas of activity are similar, there are differences in emphasis and in work organization.     

Evaluation of graduating neonatal nurse practitioners

To compare the knowledge and problem-solving, communication, and clinical skills of graduating neonatal nurse practitioners (NNPs) and pediatric residents, a cohort study was conducted in a 33-bed tertiary-level neonatal intensive care unit in a 400-bed teaching hospital affiliated with a faculty of health sciences. Participants were all (n = 10) NNP graduates from the first 3 years of the educational program and 13 (87%) of 15 second-year pediatric residents. One hundred multiple-choice questions and 20 radiographic slides were used to test knowledge; a semistructured oral examination tested problem-solving skills; three simulated interactions with parents tested communication skills; and seven simulated procedures tested clinical skills. Graduating NNPs scored similarly to the pediatric residents on the multiple-choice questions (difference -3.4%; 95% confidence interval [CI] around difference -9.7, 2.9), radiographs (difference -1.4%; 95% CI -11.5, 8.7), oral examination (difference 2.8%; 95% CI -11.1, 16.7), communication skills (simulated parents assessment: difference 0.8%; 95% CI -4.2, 5.7; expert observer assessment: difference 5.8%; 95% CI -2.8, 14.3), and clinical skills (difference 7.4%; 95% CI -5.5, 20.2). The NNPs about to graduate from their educational program showed knowledge and problem-solving, communication, and clinical skills equivalent to those of second-year pediatric residents and are thus likely to deliver comparable care in the clinical setting. The results support the adoption of the NNP role.     

Comparison of neonatal nurse practitioners' and pediatric residents' care of extremely low-birth-weight infants

OBJECTIVE: To compare outcomes and charges of health care delivery to extremely low-birth-weight infants by neonatal nurse practitioners (NNP) and pediatric residents. DESIGN: Retrospective cohort study. SETTING: A 56-bed neonatal intensive care unit (NICU) in a university teaching hospital. METHODS: Study population included all infants with birth weights less than 1000 g who were admitted to the NICU during the 2-year period between September 1, 1994, and August 31, 1996. Infants who died earlier than 12 hours of age, or who were admitted after 1 week of age or with major malformations, chromosomal abnormalities, or congenital infections were excluded. There were separate teams of NNPs and residents providing care around the clock. The study group included 201 infants with birth weights of less than 1000 g. The NNP team cared for 94 infants and the resident team cared for 107 infants. MAIN OUTCOME MEASURES: Survival, length of stay, and total charges. RESULTS: Survival to discharge occurred for 71 NNP team infants (76%) and 82 resident team infants (77%) (P =.87). The median total length of stay was 87 days (range, 39-230 days) for NNP team infants and 88 days (range, 41-365 days) for resident team infants (P =.54). There were no significant differences between NNP infants and resident team infants in the prevalence of severe intracranial hemorrhage, threshold retinopathy of prematurity, or chronic lung disease at 36 weeks postconceptual age. Median total NICU hospital charges were $141,624 (range, $52,020-$693,018) for NNP team infants and $139,388 (range, $50,178-$990,865) for resident team infants (P =.89). There were no significant differences between NNP team infants and resident team infants in NICU charges for laboratory, radiology, or pharmacy services. CONCLUSION: Neonatal nurse practitioners and pediatric residents provided comparable patient care to extremely low-birth-weight infants, with similar outcomes and similar charges.     

The role of the neonatal nurse practitioner in the community hospital level I nursery

Neonatal nurse practitioners (NNPs) have played a significant role in providing medical coverage to many of the country's Level III neonatal intensive care units (NICUs). Extensive education and experience are required for a nurse practitioner (NP) to become competent in caring for these critically ill newborns. The NNP can take this competence and experience and expand her role out into the community Level I nurseries. Clinical care of the infants and close communication with parents, pediatricians, and the area tertiary center provide a community service with the goal of keeping parents and babies together in the community hospital without compromising the health of the baby. The NNP service, with 24-hour nursery and delivery coverage, supports an ongoing obstetric service to the community hospital. The NNP's experience enables her to provide a neonatal service that encompasses a multitude of advanced practice nursing roles.     

Ethical dilemmas and the nurse practitioner in the NICU

With the emergence of advanced practice roles for nurses, including the role of the neonatal nurse practitioner (NNP), nurses are increasingly being placed in the position of making difficult decisions, especially in acute or emergency situations. NNPs, therefore, must have a working knowledge of the ethical decision-making process in order to make appropriate decisions at the bedside.     

The history of the neonatal nurse practitioner: reflections from "under the looking glass"

The neonatal nurse practitioner (NNP) emerged in the 1970s. During the first two decades, nurses who functioned in this new advanced-practice role were forced to overcome interprofessional isolation, variable educational preparation, underutilization, and title ambiguity. However, after nearly 30 years of evolution influenced by the changing health care environment, technological advancements in newborn care, medical personnel shortages, and the advanced-practice nurse movement, the NNP is now a recognized member of the neonatal health care team nationwide. The NNP has achieved the level of provider status, but only after successfully overcoming many practice restrictions and restraints over the decades. This article chronicles the history of the NNP and recounts the external and internal elements that contributed to the development of this profession.     

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.     

Stress and work relationships in the neonatal intensive care unit: Are they worse than in the wards?

Objective : To compare working conditions, sources of stress and professional relationships between a group of nurses working in neonatal intensive care units (ICU) and those working in general paediatric teaching hospital wards. Methodology : Surveys were sent to 96 nurses working in general paediatric wards in three Sydney paediatric teaching hospital centres and to 291 nurses working in six major neonatal ICU in Sydney. The survey asked about work environment, patient care, decision-making, sources of stress and professional relationships. Thirty-one questions were identical in each survey. The survey also included the General Health Questionnaire (GHQ) as a measure of emotional health. Results : The response rate was ward nurses 86% and neonatal intensive care nurses 66%. Of the 31 identical statements, nine were significantly different between the two groups. Neonatal nurses were more likely to feel that their ward work areas were overcrowded and poorly laid out with little patient-free space. They had more concerns about inadequate staffing and conflict between nurses and doctors. The general ward nurses were more likely to feel that adequate priority was given to patient pain relief and that they had more influence in such decisions but experienced more stress in keeping up to date and were more likely to feel that communication problems between doctors and nurses were a major source of conflict. Forty per cent of general ward nurses and 32% of neonatal nurses had GHQ scores indicating possible psychological impairment, a significantly higher proportion than would be expected in the population. Conclusions : Paediatric nurses perceive a variety of stresses in their work, with problems in communication between doctors and nurses being a prominent perception. The high GHQ scores may be a reflection of some of those problems. Attention to problems of under-staffing, better work environment and improved communication may help resolve some of these issues and may have implications for improving patient care.     

Cause-specific stillbirth and neonatal death in Sweden: a catchment area-based analysis

A register-based study of the impact of obstetric and neonatal care on stillbirth and neonatal death rate was performed on all births in Sweden in 1983-1995. Each birth was assigned to a primary delivery hospital where the mother with a term singleton pregnancy was most likely to have been delivered (not possible for 25% of the deliveries), and the catchment areas of each hospital were classified according to the level of care of that hospital. Only small differences in total mortality existed between the different levels of care of the primary hospital: areas served by primary hospitals with obstetric service and resources for neonatal intensive care including continuous positive airway pressure but without facilities for ventilator treatment for prolonged periods showed a 7% excess risk of stillbirth or neonatal death.     

Pain management in Swedish neonatal units – a national survey

Aim: The aim of this study was to investigate the degree to which Swedish neonatal units have adopted the national guidelines for prevention and treatment of pain in newborn infants.
Method: A survey was sent to all units in Sweden that provide neonatal care. For a list of potentially painful procedures, compiled from the national neonatal pain guidelines, the units were asked if they would use pharmacological and/or behavioural interventions, and in each case to specify the treatment.
Results: The response rate was 80.4%. Eighty-eight percent of the units had written guidelines for pain management, and 59% of these had been updated within the last 2 years. For almost every presented case, all units reported that they used either pharmacological or behavioural treatment or both. The survey showed a wide variation in morphine and paracetamol dosing and the absence of a paracetamol loading dose in a fourth of the units.
Conclusions: This study suggests that a majority of Swedish neonatal units have adopted pain management guidelines in concordance with the Swedish national guidelines, and kept them up-to-date. For most painful situations a variety of behavioural and pharmacological interventions are used, often in combination.     

Diagnostic management of neonatal stroke

In this paper the clinical presentation of neonatal arterial ischaemic stroke (NAIS) and neonatal cerebral sinovenous thrombosis (NCSVT) is briefly summarised; then a structured hierarchical diagnostic flow is proposed to discern clinical phenotypes underlying neonatal (ischaemic as well as haemorrhagic) stroke. The diagnostic flow proposed following clinical detection or chance imaging finding is an initial step towards standardisation of the mechanisms leading to stroke. For NAIS the sequence is: infection, trauma, embolism, arteriopathy, other, primary thrombosis and unclassified; for NCSVT the sequence is: infection, trauma, venopathy, other, primary thrombosis and unclassified. Such standardisation should guide attempts at prevention and treatment. The analysis of a retrospective personal cohort of 134 newborn infants with stroke, suggest that–for stroke in general–embolism is the most common identifiable mechanism (25%), preceding trauma (10%) and infection (8%). For NAIS the presence of an embolic phenotype is 33% in this cohort. The designation unclassifiable scored 34% for the entire stroke group, 25% for neonatal arterial ischaemic stroke. Complex arterial stroke, with multiple arteries involved–is regularly seen following embolism, infection and cranial trauma.     

Perinatal Morbidity of Infants of Diabetic Mothers

Along with the recent progress in controlling the diabetic state during pregnancy, the number of diabetic pregnancies in our country has been increasing. It is not appropriate to apply White's classification to Japanese pregnant women, because more than two-thirds are NIDDM and it is not easy to clarify their duration of illness. Neonatal complications were analyzed in 160 infants of diabetic mothers (IDMs) who were admitted to Tokyo Women's Medical College over the past five years. All were inborn except four. Neonatal outcomes of IDDM and NIDDM were not statistically different. The overall incidence of neonatal complications in IDMs was 66%, and there were no neonatal deaths. Offspring whose mothers had been suffering from retinopathy were likely to be premature and light-for-date infants. A planned pregnancy in diabetic women is likely to decrease neonatal complications. The cooperative total care of diabetic mothers and their offspring by respective specialists, namely endocrinologists, obstetricians and neonatologists is essential for the better prognosis of infants of diabetic mothers.     

灾害背景下NICU的应急准备方案

由于对仪器设备的特殊需求,新生儿在灾害中极易受到更大伤害。新生儿重症监护病房(NICU)应尽可能为各种灾害做好准备。应急准备方案可保证NICU高效的灾害应对能力。新生儿灾害救援应根据实际情况做决策,如现有设备、药物、人员配备等。灾害应急准备中应包括伦理问题的解决方案,还应考虑灾害后家属及救援人员的心理需求。     

腹腔镜治疗新生儿卵巢囊肿

目的探讨新生儿卵巢囊肿的治疗方法。方法对腹腔镜手术治疗的13例新生儿及小婴儿卵巢囊肿进行了回顾性总结。7例年龄小于1个月,单侧12例,双侧1例,产前B超发现12例;单纯型6例,复杂型7例。结果手术证实单纯型均无并发症发生,其中5例为新生儿。复杂型中6例并发扭转,其中1例病理诊断双侧卵巢颗粒细胞瘤;另1例复杂型实为卵巢囊性畸胎瘤。所有患儿无术中和术后并发症。结论产前B超发现的卵巢囊肿,复杂型及囊肿大于5cm的单纯型应及时腹腔镜手术。     

Transcutaneous blood gas monitoring during neonatal intensive care

Aim: To evaluate the accuracy in transcutaneous (Tc) blood gas monitoring in newborn infants, including extremely low birth weight infants, during neonatal intensive care. Methods: Tc PO₂/PCO₂ was monitored in the neonatal intensive care unit (NICU) during stable infant conditions. In comparison, simultaneous arterial PO₂ and PCO₂ was measured. Sixty measurements were taken in 46 infants with median (range) birth weight of 0.93 (0.53–4.7) kg and at median (range) age of 8.5 (1–44) days. Comparison of measurements was performed using Bland–Altman plots, and the mean (95% CI) of the difference was calculated. Comparison was also performed in relation to body weight, postnatal age and oxygen requirement. Results: The mean (95% CI) difference in PO₂ (TcPO₂–aPO₂) was 0.3 (?0.2–0.9) kPa, and the corresponding difference in PCO₂ (TcPCO₂–aPCO₂) was 0.4 (0.03–0.8, p < 0.05) kPa. Some differences were related to body weight, age and oxygen requirement, but these differences were small. Conclusion: There was good agreement between TcPO₂/TcPCO₂ and corresponding arterial measurements. The mean difference between the methods was small and clinically acceptable in a current NICU. Tc blood gas monitoring could be recommended as a valuable complement for blood gas monitoring also in extremely low birth weight infants.     

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.     

Maternal perceptions of neonatal care

In a large-scale study of neonatal care in England, hospital and questionnaire data were collected on the experiences of an unselected group of 420 mothers whose babies had recently been admitted for neonatal care to one of 23 widely distributed hospitals. Perceptions of their infant while in the neonatal unit differed in relation to gestational age, whether or not the baby required assisted ventilated, the mother's own health and if she had previously had a baby cared for in this way. This investigation of how mothers see and adjust to their small, sick baby in the neonatal unit confirmed the crisis nature of the birth and admission, and provides insights for staff and other health professionals about the salient issues for parents at this time.     

珠江三角洲新生儿转运网络工作报告

目的　评价珠江三角洲新生儿转运网络（ｎｅｏｎａｔａｌｔｒａｎｓｐｏｒｔｎｅｔｗｏｒｋ, ＮＴＮ） 十年工作及其效果。方法　介绍新生儿转运网络方法及分析有关效果的资料。结果　转运网络现有８７ 家医院;１０ 年共转运急危重症新生儿８ １２４ 例,转运途中死亡３５ 例,病死率为０．４３％ ;第三级新生儿监护病房（ＮＩＣＵ）收容８ ０８９ 例,共死亡３６４ 例,病死率为４．５０ ％ ,ＮＴＮ 医院中总死亡率为２．０７‰。结论　该ＮＴＮ 所实行的运转机制合理适用;促进了网络单位包括三级ＮＩＣＵ 的发展与提高;建立ＮＴＮ是降低新生儿死亡率的重要措施。     

Fetal and neonatal mortality of small-for-gestational age infants

Fetal and neonatal mortality of small-for-gestational age (SGA) infants in 1968–1982 were studied in the region of the University Central Hospital of Turku, Finland. During the study period, there were 254 fetal and 127 neonatal deaths in SGA infants. The fetal mortality rate of SGA infants declined from 49.9/1000 to 14.0/1000. The neonatal mortality rate of SGA infants declined from 23.8/1000 to 8.3/1000. The severely SGA infants with a birth weight below the 2.5th percentile had three times higher neonatal mortality rates than SGA infants with a birth weight between the 2.5th and the 10th percentiles. The main causes of fetal deaths were maternal diseases, placental and cord complications and fetal malnutrition, even though there was a decline in all these groups. Malformations remained the main cause of neonatal death during the study period, while there was a decline in deaths due to asphyxia and respiratory distress syndrome (RDS). The high mortality rates of SGA infants emphasize the need for early diagnosis and special attention during pregnancy, delivery and the neonatal period.Abbreviations SGA small-for-gestational age - AGA appropriate-for-gestational age - UCHT University Central Hospital of Turku - RDS respiratory distress syndrome     

重症监护病房新生儿皮肤管理指南(2021)

新生儿皮肤屏障功能弱,极易受损而导致局部或全身感染,增加死亡风险.保护新生儿皮肤完整性、预防皮肤损伤是新生儿重症监护病房管理的重要内容之一.该指南基于国内外相关证据,采用证据推荐分级的评估、制定与评价方法进行证据分级,制定新生儿重症监护病房新生儿皮肤管理指南,对皮肤常规管理、医源性皮肤损伤的预防及处理给出推荐意见,旨在...