Primary nursing care key to successes in one NICU

By Sandy Keefe, MSN, RN

Day in and day out, nurses in the NICU at Driscoll Children's Hospital (DCH) in Corpus Christi, TX, care for the most critically ill babies from 33 counties in South Texas.

"We get the sickest of the sick, with babies coming to us after referring facilities have done everything they can," said Roxana Reyna, RN, clinical coordinator. "Here at Driscoll Children's, we provide surgical interventions and intensive care the outlying hospitals within the area are unable to provide since our specialty is pediatrics."

Trish Carr, BSN, RN,C, nurse manager, described the role the unit plays within the neonatology network of South Texas.

"Driscoll supports a 24/7 dedicated transport team that provides transport services for the surrounding hospitals of South Texas via ground or air ambulance," she said. "Even though these hospitals may have neonatologists on staff, our NICU receives babies who require intensive services only provided at DCH. We are a 43-bed unit that handles level II, III and IV patients. We provide care for babies with problems such as respiratory distress, sepsis, extreme prematurity, congenital heart disease, retinopathy of prematurity, necrotizing enterocolitis, gastrointestinal disorders and other anomalies that require surgical interventions. Driscoll partners with families to offer the best care in a safe and nurturing environment."

24/7

The NICU supports open family visitation 24 hours a day, and relatives and friends are encouraged to visit and offer support to the family. Knowing it's hard for siblings to develop relationships with a tiny brother or sister who is in the unit for months, the staff encourages sibling visits whenever possible.

Parents are encouraged to participate in rounds and provide care for their babies, such as bathing, feeding, assisting with weights and measurements, dressing changes, kangaroo care and any other special care their baby may need.

A neonatologist is physically present in the NICU 24 hours a day, 7 days a week. By providing around-the-clock in-house coverage, the neonatologist is able to closely monitor the baby's progress and provide immediate intervention should a patient's condition suddenly deteriorate. This coverage provides support for the nursing staff and facilitates communication between other caregivers. A neonatologist is always available to the families to answer questions and explain the baby's plan of care.

Family-Centered Care

Even in the high-tech environment of the NICU, DCH's family-centered philosophy of care is ever-present.

"We know from the literature babies have better outcomes when parents have been interacting with their infant in the NICU," Carr said. "Family-centered care not only improves and enhances clinical outcomes, but it provides more support for the families as they cope with the stress of caring for their new baby in the NICU."

Families may face formidable obstacles visiting their babies in the NICU and learning to care for these complex infants at home can be challenging. Many don't speak English and resources often are limited.

"Many families who are illegal citizens are unable to travel to Corpus Christi due to immigration laws," Reyna said. "We work with Social Services and Immigration to help bring these families to DCH. Unfortunately, due to circumstances, some families are unable to come here and be at their baby's bedside.

"Once the families are here, we are able to provide them with housing at the Ronald McDonald House or in hospital guest rooms, assist with obtaining meal tickets and support breastfeeding mothers. We encourage the families to participate in the care of their baby; and when the baby is more stable, they can assist with feedings, bathing and total care. Families also receive special instruction for babies with special needs."

Surgical Interventions

When patients in the NICU are too unstable to transport to the OR, surgeons may decide to perform certain surgical procedures at the bedside. For a baby with hydrocephalus, the surgeon may perform a subgaleal shunt, which temporarily bypasses the normal cerebrospinal fluid pathway until the baby is ready for a ventriculoperitoneal shunt.

"We do PDA ligations [repair of the opening between the aorta and pulmonary artery], insert peritoneal drains for babies with necrotizing enterocolitis, and perform laser surgery for retinopathy of prematurity," Reyna said. "It is awesome to be a part of the healthcare team that provides a continuum of care for the critically ill neonate. What a joy it is to produce positive outcomes for the patient and family!"

Primary Nursing

The NICU supports primary care nursing, which allows for continuity in nursing care. The patients are cared for by a core group of nurses on a daily basis. The primary nurse assigned to each patient is responsible for establishing a plan of care, ensuring the plan stays current throughout the patient's stay. The primary nurse coordinates with staff members, respiratory therapists and physicians to ensure every transition is as comfortable as possible for the patient. The primary nurse, as well as the core group, works with families teaching them about medication administration, answering questions about possible procedures and, most important, being an advocate for the baby.

"Primary nursing is especially helpful for our families who cannot travel to the hospital due to transportation issues," Reyna said.

Parent Education

Pam Watson, RN, staff nurse, loves the parent education component of her role. "I particularly enjoy working with first-time moms who really don't know what they've gotten into," she said. "It's a privilege to educate them so they can care for their very tiny premature babies with special needs. We make a big deal out of every tiny milestone with these babies!"

Pat Walker, APN, begins discharge planning the moment the baby comes into the unit.

"Many of our babies require multispecialty follow-up and may have six specialists following the baby, in addition to the regular pediatrician," she explained. "I'll make sure the baby has follow-up appointments at cardiology, gastroenterology, ophthalmology, pulmonary, nephrology, urology or whatever else is indicated. We make sure the family meets with a dietitian to ensure they know how to mix and prepare formula, mix additives with expressed breast milk and properly feed their baby."

Rooming-in offers the perfect opportunity for parents to care for their babies independently, with backup from the hospital staff as needed.

"We have a room set up like a home environment and, prior to discharge, the social worker orders the necessary home health equipment for the baby. The equipment is placed in the rooming-in room so parents can become knowledgeable and comfortable in utilizing the equipment before discharge. This process gives parents a chance to develop confidence in their ability to care for their baby," Walker said.

Laurie Beck, MSN, RN, IBCLC, lactation coordinator, offers both formal and informal parent education within Mom's Place (see accompanying article). "Depending on who attends and where their baby is in the discharge process, my regular classes vary a great deal," she noted. "Moms of sick, sick babies may want very basic information about breastfeeding and how to start pumping milk, while individuals closer to discharge might benefit from learning how to continue to provide breast milk to their infants after discharge. We continue follow-up at home as long as the family needs us."

Orientation & Continuing Education

The NICU staff goes through extensive orientation and training, as well as ongoing continuing education. New grads go through the hospital's 22-week Clinical Pathways program, with a NICU-based didactic day each week. Teaching occurs daily during rounds, and there is a monthly educational focus as well. The nurses at DCH are required to achieve certification specific to their area of practice within 2 years of beginning employment.

Arvilla Johnson, RN, who has worked in the NICU since it opened 32 years ago, spoke about the changes she's seen.

"I've always been excited about the advances in technology, the new treatments and the nursing care," she said. "While so much has changed with ventilators and monitors, the basic nursing assessment and teaching are still the core of what we do. We've always been the advocates, speaking up for our patients."

Sandy Keefe is a regular contributor to ADVANCE.

Mom's Place

As visitors step out of the elevator on their way to the NICU at Driscoll Children's Hospital (DCH), they glimpse beautiful glass doors featuring an etching of a woman holding a baby and a sign saying "Mom's Place." Established in May 2004 to promote the use of breast milk for the critically ill babies within the NICU, Mom's Place provides a welcoming environment under the direction of Laurie Beck, MSN, RN, IBCLC.

Along with handwashing supplies, breast pumps and containers and a refrigerator, Mom's Place offers a refuge.

"It's a warm and inviting place, with chocolate and candies out for visitors, and decorated with pictures of babies," Beck said. "We play soft music and there are televisions with VCRs and short videotapes in both Spanish and English. Moms can bring in food and beverages, relax and be by themselves for a bit."

Beck offers lactation consultation, parent teaching and emotional support Monday through Friday and is available by phone at other times. Mom's Place is staffed around the clock with technicians who can prepare the breast milk according to the orders for each NICU baby.

"About 70 percent of the moms of our NICU babies initiate breastfeeding, supplying their babies with something only they can give," Beck said. "In the past 8 months alone, we've logged in more than 584,000 mL of breast milk pumped here."

Very ill babies may receive breast milk by tube feeding until they're stable. "Once they've developed a good suck and coordinated swallowing, they may breastfeed 2 or 3 times a day while mom is still pumping for the other feedings," Beck explained. "More stable babies may be breastfed by mom right at the bedside in the NICU. We'll monitor the baby's weight before and after the feeding to estimate the amount of milk consumed, which provides a safety net to establish successful breastfeeding before the baby goes home."

DCH also is designated by the state of Texas as an employee-friendly work site, so female employees who are breastfeeding can use Mom's Place as well. In addition, the center serves as a drop-off site for the Mother's Milk Bank in Austin.

"If the mom of one of our preemies is pumping for 2-3 months before the baby can start full feeds, there's no way the baby will ever drink all that milk," Beck explained. The mother can choose to donate the milk to the milk bank to be processed and distributed to other babies.

"Healthy babies do best with breast milk, but babies like ours who are off to a rough start need breast milk even more. Once I get a mom pumping, she realizes how simple and quick it is, and she's confident in her own ability to provide milk for her baby."

– Sandy Keefe, MSN, RN