Developing a design-based concept to improve hand hygiene in the neonatal intensive care unit

BackgroundHand hygiene (HH) is the most critical measure in the prevention of nosocomial infections in the neonatal intensive care unit (NICU). Improving and sustaining adequate HH compliance rates, however, remains a significant challenge. Using a behavioral change framework and nudge theory, we developed a design-based concept aimed at facilitating and stimulating HH behavior.MethodsConcept development was initiated by selecting a theoretical framework after which contextual field studies aimed at discovering causes for poor compliance were conducted. Potential solutions were brainstormed upon during focus group sessions. Low-fidelity prototypes were tested regarding feasibility, usability, and acceptability. A final concept was crafted drawing from findings from each design phase.ResultsComplying with recommended HH guidelines is unrealistic and infeasible due to frequent competing (clinical) priorities requiring HH. The concept "Island-based nursing," where a patient room is divided into two geographical areas, namely, the island and general zone, was created. HH must be performed upon entering and exiting the island zone, and after exposure to any surface within the general zone. Reminding of HH is prompted by illuminated demarcation of the island zone, serving as the concept's nudge.ConclusionsIsland zone demarcation facilitates and economizes HH indications in an innovative and intuitive manner.ImpactAlthough hand hygiene (HH) is the single most important element in the prevention of nosocomial infections in neonates, improving and sustaining adequate HH compliance rates remains a significant challenge.Complying with recommended HH guidelines was found to be unrealistic and infeasible due to the significant amount of time required for HH in a setting with a high workload and many competing (clinical) priorities.The concept of "Island-based nursing," under which the primary HH indication is upon entering and exiting the island zone, facilitates and economizes HH indications in an innovative and user-friendly manner.Developmen

Repetitive versus standard tactile stimulation of preterm infants at birth - A randomized controlled trial

Development and application of statistical models for medical scientific researc

Comparison of two devices for automated oxygen control in preterm infants: a randomised crossover trial

Objective To compare the effect of two different automated oxygen control devices on target range (TR) time and occurrence of hypoxaemic and hyperoxaemic episodes.Design Randomised cross-over study.Setting Tertiary level neonatal unit in the Netherlands.Patients Preterm infants (n=15) born between 24+0 and 29+6 days of gestation, receiving invasive or non-invasive respiratory support with oxygen saturation (SpO(2)) TR of 91%-95%. Median gestational age 26 weeks and 4 days (IQR 25 weeks 3days-27 weeks 6 days) and postnatal age 19 (IQR 17-24) days.Interventions Inspired oxygen concentration was titrated by the OxyGenie controller (SLE6000 ventilator) and the CLIO2 controller (AVEA ventilator) for 24 hours each, in a random sequence, with the respiratory support mode kept constant.Main outcome measures Time spent within set SpO(2) TR (91%-95% with supplemental oxygen and 91%-100% without supplemental oxygen).Results Time spent within the SpO(2) TR was higher during OxyGenie control (80.2 (72.6-82.4)% vs 68.5 (56.7-79.3)%, p<0.005). Less time was spent above TR while in supplemental oxygen (6.3 (5.1-9.9)% vs 15.9 (11.5-30.7)%, p<0.005) but more time spent below TR during OxyGenie control (14.7 (11.8%-17.2%) vs 9.3 (8.2-12.6)%, p<0.05). There was no significant difference in time with SpO(2) <80% (0.5 (0.1-1.0)% vs 0.2 (0.1-0.4)%, p=0.061). Long-lasting SpO(2) deviations occurred less frequently during OxyGenie control.Conclusions The OxyGenie control algorithm was more effective in keeping the oxygen saturation within TR and preventing hyperoxaemia and equally effective in preventing hypoxaemia (SpO(2) <80%), although at the cost of a small increase in mild hypoxaemia.Developmen

High variability in nurses' tactile stimulation methods in response to apnoea of prematurity: a neonatal manikin study

Aim: Neonatal intensive care unit (NICU) nurses provide tactile stimulation to terminate apnoea in preterm infants, but guidelines recommending specific methods are lacking. In this study, we evaluated current methods of tactile stimulation performed by NICU nurses.Methods: Nurses were asked to demonstrate and explain their methods of tactile stimulation on a manikin, using an apnoea scenario. All nurses demonstrated their methods three times in succession, with the manikin positioned either prone, supine or lateral. Finally, the nurses were asked how they decided on the methods of tactile stimulation used. The stimulation methods were logged in chronological order by describing both the technique and the location. The nurses' explanations were transcribed and categorised.Results: In total, 47 nurses demonstrated their methods of stimulation on the manikin. Overall, 57 different combinations of technique and location were identified. While most nurses (40/47, 85%) indicated they learned how to stimulate during their training, 15/40 (38%) of them had adjusted their methods over time. The remaining 7/47 (15%) stated that their stimulation methods were self-developed.Conclusion: Tactile stimulation performed by NICU nurses to terminate apnoea was highly variable in both technique and location, and these methods were based on either prior training or intuition.Developmen

Increased end-expiratory pressures improve lung function in near-term newborn rabbits with elevated airway liquid volume at birth

Approximately 53% of near-term newborns admitted to intensive care experience respiratory distress. These newborns are commonly delivered by cesarean section and have elevated airway liquid volumes at birth, which can cause respiratory morbidity. We investigated the effect of providing respiratory support with a positive end-expiratory pressure (PEEP) of 8 cmH(2)O on lung function in newborn rabbit kittens with elevated airway liquid volumes at birth. Near-term rabbits (30 days; term = 32 days) with airway liquid volumes that corresponded to vaginal delivery (similar to 7 mL/kg, control, n = 11) or cesarean section (similar to 37 mL/kg; elevated liquid (EL), n = 11] were mechanically ventilated (tidal volume= 8 mL/kg). The PEEP was changed after lung aeration from 0 to 8 to 0 cmH(2)O (control, n = 6; EL, n = 6), and in a separate group of kittens, PEEP was changed after lung aeration from 8 to 0 to 8 cmH(2)O (control, n = 5; EL, n = 5). Lung function (ventilator parameters, compliance, lung gas volumes, and distribution of gas within the lung) was evaluated using plethysmography and synchrotron-based phase-contrast X-ray imaging. EL kittens initially receiving 0 cmH(2)O PEEP had reduced functional residual capacities and lung compliance, requiring higher inflation pressures to aerate the lung compared with control kittens. Commencing ventilation with 8 cmH(2)O PEEP mitigated the adverse effects of EL, increasing lung compliance, functional residual capacity, and the uniformity and distribution of lung aeration, but did not normalize aeration of the distal airways. Respiratory support with PEEP supports lung function in near-term newborn rabbits with elevated airway liquid volumes at birth who are at a greater risk of suffering respiratory distress.NEW & NOTEWORTHY Term babies born by cesarean section have elevated airway liquid volumes, which predisposes them to respiratory distress. Treatments targeting molecular mechanisms to clear lung liquid are ineffective for term newborn respiratory distress. We showed that respiratory support with an end-expiratory pressure supports lung function in near-term rabbits with elevated airway liquid volumes at birth. This study provides further physiological understanding of lung function in newborns with elevated airway liquid volumes at risk of respiratory distress.Developmen

Increasing Respiratory Effort With 100% Oxygen During Resuscitation of Preterm Rabbits at Birth

Background: Spontaneous breathing is essential for successful non-invasive respiratory support delivered by a facemask at birth. As hypoxia is a potent inhibitor of spontaneous breathing, initiating respiratory support with a high fraction of inspired O2 may reduce the risk of hypoxia and increase respiratory effort at birth. Methods: Preterm rabbit kittens (29 days gestation, term ~32 days) were delivered and randomized to receive continuous positive airway pressure with either 21% (n = 12) or 100% O2 (n = 8) via a facemask. If apnea occurred, intermittent positive pressure ventilation (iPPV) was applied with either 21% or 100% O2 in kittens who started in 21% O2, and remained at 100% O2 for kittens who started the experiment in 100% O2. Respiratory rate (breaths per minute, bpm) and variability in inter-breath interval (%) were measured from esophageal pressure recordings and functional residual capacity (FRC) was measured from synchrotron phase-contrast X-ray images. Results: Initially, kittens receiving 21% O2 had a significantly lower respiratory rate and higher variability in inter-breath interval, indicating a less stable breathing pattern than kittens starting in 100% O2 [median (IQR) respiratory rate: 16 (4–28) vs. 38 (29–46) bpm, p = 0.001; variability in inter-breath interval: 33.3% (17.2–50.1%) vs. 27.5% (18.6–36.3%), p = 0.009]. Apnea that required iPPV, was more frequently observed in kittens in whom resuscitation was started with 21% compared to 100% O2 (11/12 vs. 1/8, p = 0.001). After recovering from apnea, respiratory rate was significantly lower and variability in inter-breath interval was significantly higher in kittens who received iPPV with 21% compared to 100% O2. FRC was not different between study groups at both timepoints. Conclusion: Initiating resuscitation with 100% O2 resulted in increased respiratory activity and stability, thereby reducing the risk of apnea and need for iPPV after birth. Further studies in human preterm infants are mandatory to confirm the benefit of this approach in terms of oxygenation. In addition, the ability to avoid hyperoxia after initiation of resuscitation with 100% oxygen, using a titration protocol based on oxygen saturation, needs to be clarified

Automatic tactile stimulation: Improving the treatment of Apnea of Prematurity

Apnea of prematurity is one of the most common diagnoses in the Neonatal Intensive Care Unit. Frequent breathing pauses occur in almost all infants born at <28 weeks gestational age or with a birth weight of <1000g and can result in serious brain damage. Medicines are used to suppress the apnea but are not able to eliminate it. Manual tactile stimulation is currently used to terminate apneas that occur despite the preventative treatment. However, the duration of apnea is dependent on the reaction of the nurse. A direct automatic response could significantly shorten the apnea hence reducing hypoxia and bradycardia and reduce the chance of infection due to cross-contamination. In addition, detecting imminent apnea could potentially prevent it. The goal of this graduation project was to find out the best way of preventing and terminating apnea in premature infants by automatic tactile stimulation. During this project three studies were performed. The first study was a literature review. The purpose of this review was to verify what is known about the effects of (automatic) tactile stimulation on the termination and prevention of apnea in preterm infants. This was done by systematically reviewing available literature. The results showed that the effects of touch, oscillation, pulsation and vibration were studied. In conclusion, although the big variations in study design, amount of subject etc., the majority of studies show positive results of tactile stimulation on the termination and prevention of apnea. However, it is not known which receptors are stimulated by specific stimuli and what their neuronal pathways are. Therefore it is currently hard to tell which stimulation mode and stimulation characteristics are most optimal for the termination and/or prevention of AOP. The second study focused on the design of a vibrotactile actuator that was suitable for comparing stimulation with different (stochastic) frequencies. Voice coils, linear resonant actuators and piëzo elements appeared to be most suitable for studies comparing the responses of vibrations with different frequencies. The selection of the right specific actuator is dependent on the frequencies and strokes that it should generate. In the final study the effect of stimulation stroke and stimulation spot on the regularity of breathing (experiment 1) and on the termination of apnea (experiment 2) in preterm rabbits were compared. The results the first experiment show that stochastic vibrations of 490-980Hz applied at the chest cause an increase in the variability of the breathing pattern compared with the same stimulation at the sole of the foot. However, statistical significance was only reaches for low stroke stimulation. The results of the second part of the experiment show that, in contrast with earlier performed studies, the vibratory stimulation does not reinitiate breathing following apnea provoked by hypoxia. This might be caused by the high frequency. However, it seems very likely that apnea caused by severe hypoxia requires more vigorous stimulation. All in all, automatic tactile stimulation seems to be able to improve the current treatment of AOP. However, more research is required to select the most optimal stimulus.Mechanical, Maritime and Materials EngineeringBiomedical Engineerin

Technology in the delivery room supporting the neonatal healthcare provider's task

Very preterm infants are a unique and highly vulnerable group of patients that have a narrow physiological margin within which interventions are safe and effective. The increased understanding of the foetal to neonatal transition marks the intricacy of the rapid and major physiological changes that take place, making delivery room stabilisation and resuscitation an increasingly complex and sophisticated activity for caregivers to perform. While modern, automated technologies are pro-gressively implemented in the neonatal intensive care unit (NICU) to enhance the caregivers in providing the right care for these patients, the technology in the delivery room still lags far behind. Diligent translation of well-known and promising technological solutions from the NICU to the delivery room will allow for better support of the caregivers in performing their tasks. In this review we will discuss the current technology used for stabilisation of preterm infants in the delivery room and how this could be optimised in order to further improve care and outcomes of preterm infants in the near future.Developmen

Sensory stimulation for apnoea mitigation in preterm infants

Apnoea, a pause in respiration, is ubiquitous in preterm infants and are often associated with physiological instability, which may lead to longer-term adverse neurodevelopmental consequences. Despite current therapies aimed at reducing the apnoea burden, preterm infants continue to exhibit apnoeic events throughout their hospital admission. Bedside staff are frequently required to manually intervene with different forms of stimuli, with the aim of re-establishing respiratory cadence and minimizing the physiological impact of each apnoeic event. Such a reactive approach makes apnoea and its associated adverse consequences inevitable and places a heavy reliance on human intervention. Different approaches to improving apnoea management in preterm infants have been investigated, including the use of various sensory stimuli. Despite studies reporting sensory stimuli of various forms to have potential in reducing apnoea frequency, non-invasive intermittent positive pressure ventilation is the only automated stimulus currently used in the clinical setting for infants with persistent apnoeic events. We find that the development of automated closed-looped sensory stimulation systems for apnoea mitigation in preterm infants receiving non-invasive respiratory support is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form. Impact This review examines the effects of various forms of sensory stimulation on apnoea mitigation in preterm infants, namely localized tactile, generalized kinesthetic, airway pressure, auditory, and olfactory stimulations. Amongst the 31 studies reviewed, each form of sensory stimulation showed some positive effects, although the findings were not definitive and comparative studies were lacking. We find that the development of automated closed-loop sensory stimulation systems for apnoea mitigation is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form.Developmen

Effect of Tactile Stimulation on Termination and Prevention of Apnea of Prematurity: A Systematic Review

Developmen