Dissertations / Theses on the topic 'Neonatal intensive care units'

Background: Neonates who require specialized care and life-saving therapies in neonatal intensive care units (NICUs) and neonatal special care units (NSCUs) can be exposed to separation from their parents and families. Consequently, establishing a parental-neonate bond can be difficult. However, addressing this problem of separation through involving parents and families in neonatal care to improve parent-professional collaboration can result in positive outcomes for neonates and their families. Family-centred care (FCC) has developed over decades and is broadly recommended as an ideal model of care in daily clinical practice in NICUs. However, FCC implementation is challenging at individual, organizational, cultural, and healthcare system levels. In particular, developing countries are challenged by the lack of material resources, infrastructure, and staff shortages. In Thailand, the practical incorporation of FCC into daily clinical practice in neonatal care units is difficult, and it has not been sustainably achieved. Furthermore, there has been minimal research reporting on the development, implementation, and evaluation of FCC in the neonatal critical care context within Thailand. Aim and Objectives: The aim of this PhD study has been to develop, implement and evaluate innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. It had three objectives, each representing a distinct phase in the study: (1) to identify perceptions, current practices and FCC strategies; (2) to develop and implement an innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU; and (3) to evaluate the FCC innovation developed in Phase 2. Methods and Results Design: The multistage, mixed-methods study design applied the Participatory Intervention Model (PIM) to guide the innovation’s development, implementation, and evaluation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. Setting and context: This study was conducted in a tertiary care hospital in southern Thailand (February 2020-January 2021). Ethics approval was obtained from the Research Ethics Committee of Hatyai Hospital and Griffith University. Phase 1: Identification of perceptions, current practices, and FCC strategies Phase 1 was planned to include data collection over 3 months. Due to the COVID-19 pandemic, it was reduced to 2 months during the very early stages of the pandemic (February to March 2020). This phase consisted of two parts, including surveys and interviews with parents and the interdisciplinary professionals. Participants: Participants consisted of two groups: parents of neonates (all gestational ages with no life-threatening or life-limiting diagnosis) who had an expected NICU stay of at least 72 hours and visited the study NICU at least once, and interdisciplinary professionals with a permanent position for at least 1 year in the study unit. Part A: Survey of parents and interdisciplinary professionals Surveys of parents and interdisciplinary professionals were conducted using the validated Perceptions of Family Centred Care – Parent (PFCC-P) and Perceptions of Family Centred Care – Staff (PFCC-S) instruments which were translated into Thai. Sample size: Sample size was based on availability of parents and interdisciplinary professionals over the planned 3-month Phase 1 period. Recruiting parent participants in Phase 1 was prior/during the very early stages of the COVID-19 pandemic and needed to be stopped prior to pre-determined sample size of 100 parents due to visitor restriction (n = 85). Eighty-five parents and 20 interdisciplinary professionals completed the surveys. Data analysis: Demographic characteristics of parents, interdisciplinary professionals, and neonates are reported using descriptive statistics. The subscale scores for parents and interdisciplinary professionals were not normally distributed, so medians were calculated for each of the three sub-scales (respect, collaboration, and support). Parents’ and interdisciplinary professionals’ perceptions of FCC (PFCC-P & PFCC-S) were compared using the Mann-Whitney U test to examine differences in medians in the preimplementation phase because they were unpaired groups. Part B: Semi-structured interviews with parents and interdisciplinary professionals Face-to-face, semi-structured, individual interviews were planned to gain information from extended family members and parents and interdisciplinary professionals; however, given the visitation restrictions, only parents and interdisciplinary professionals were recruited to participate (during the first half of February 2020). Sample size: The sample size was determined when data saturation was identified. Eight interdisciplinary professionals and nine parents participated in face-to-face interviews. Data analysis: Thematic analysis was used to analyse the transcribed Thai language interviews. Results: The survey results across the median of three subscales demonstrated that parents and interdisciplinary professionals’ perceptions on the FCC strategies in current practice were 2-3/4 (Interquartile range [IQR] 1.7-3.8) and 3-4/4 (2.85-3.55), respectively. Considering the median subscale scores, the interdisciplinary professionals had significantly higher subscale scores for respect (median 3.00 (95% CI, 2.91-3.24) vs 2.50 (2.37-2.81)), collaboration (median 3.22 (3.10-3.37) vs 2.33 (1.9-2.62)), and support (median 3.20 (3.03-3.39) vs 2.60 (2.03-2.61)) (all p ≤ 0.001). The interview findings highlighted that the interdisciplinary professionals in this study accepted that the three critical elements of FCC (respect, collaboration, and support) were necessary to be implemented into clinical practice. However, they believed that in reality it was not easy in the Thai NICUs context. This finding identified that the challenge to promote parent-healthcare professional partnerships was associated with the structure and processes of the healthcare delivery system. In addition, the individuality of families' readiness and healthcare providers' perceptions of parents’ involvement as obstacles to providing care were found to be challenges to current practices of FCC. Phase 2: Development and implementation of innovation to facilitate FCC This phase was achieved by two different methods: strategy development working group and implementation of the FCC innovation. Strategy development working group: The development of FCC innovations by the strategy development working group (June to August 2020) was based on Phase 1 findings and the reported integrative literature review. In addition, the FCC innovations were considered within the policies and practices of the NICU in the context of COVID- 19 in Thailand. The development working group members were key and high-level stakeholders in the NICU. Educational activities for the healthcare professional team to incorporate the FCC innovations into their clinical practice in NICU were provided. Implementation of the FCC innovation: The FCC innovations were then implemented over 2 months (September to October 2020), during a period of restrictions on parents and staff arising from COVID-19. Results: The working group identified the gaps in the three key elements (respect, collaboration, and support) to providing FCC in a Thai NICU through the analysis of Phase 1’s results in consort with the findings from the integrative review. A preliminary protocol for the FCC innovations and implementation plan were developed consistent with the challenges associated with COVID-19 in Thailand. FCC practice innovations associated with improving communication were established, including changes and updates to the material within the parent booklet with specific material related to COVID- 19, neonatal updates at bedside or conducted via telephone calls, interdisciplinary family meeting for complex care situations, structured communication checklists, and documentation templates. In addition, although visiting restrictions were limiting, parents were provided with more flexibility as to when they could visit based on individual circumstances. The majority of the healthcare providers in this setting (80%) attended the educational activities to incorporate the FCC innovations into their clinical practice in the NICU. The FCC innovations were incorporated into daily NICU practice by nurses in cooperation with other healthcare providers and ancillary support staff during the pandemic. Phase 3: Evaluation of the FCC innovation Phase 3 (post-implementation) was conducted over 3 months (November 2020-January 2021), and it focused on evaluating the FCC innovations. This phase repeated the collection of data from the validated PFCC-P and PFCC-S surveys of parents and interdisciplinary professionals' perceptions, as per Phase 1, to assess respect, collaboration, and support changes after implementing the FCC innovations in the Thai NICU during the pandemic. Sample size: One hundred parents and 20 interdisciplinary professionals completed the surveys. Data analysis: As per Phase 1 for demographic characteristics. The Mann-Whitney U test was used to analyse parents' perceptions of the items of the PFCC-P pre- and postimplementation given they were two independent groups. Wilcoxon signed-rank test was used to compare the perceptions of the interdisciplinary professionals pre- and postimplementation using the PFCC-S given they were matched samples. Results: The participants consisted of 83 pairs of parents (i.e., mother and/or father of neonate participated) (35 pre; 48 post), which represented 102 neonates (50 pre; 52 post). There were 185 parents; 85 pre-implementation and 100 post-implementation. For the NICU health care team, 20 participated. The median scores of parents' perceptions post-implementation significantly improved for respect (2.50 to 3.50; 95%CI, 3.02-3.53), collaboration (2.33 to 3.33; 2.90- 3.40), support (2.60 to 3.60; 2.84-3.62), and the overall score (2.50 to 3.43) (p < 0.001, 95%CI 2.93-3.51). There was an absolute difference of at least 0.3 in the pre- and postimplementation scores for three subscales and overall score, where 0.3 corresponds to 10% of the rating scale. Comparatively, interdisciplinary professionals' perception of FCC did not significantly change pre- and post-implementation for respect ([median] 3.00 to 2.92; 95%CI, 2.87-3.16), collaboration (3.22 to 3.33; 3.16-3.47), support (3.20 to 3.20; 2.96-3.28) and overall (3.15 to 3.20; 95%CI, 3.10-3.25). Conclusions:Results from this study indicate that incorporating FCC innovations in the NICU appeared to be successful, despite the challenges of COVID-19. The key finding was that the innovations incorporated in the NICU were primarily based on communication strategies, a simple means to support, collaborate with, and respect parents that required low investment within the complex situation arising from COVID-19. These innovations were essential to engage collaborative working between parents and healthcare providers to promote parents as partners in a neonatal critical care team. To successfully implement FCC innovations in different settings, further innovations associated with communication methods need to target the specifics of individuals involved, healthcare settings, and available resources.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing & Midwifery
Griffith Health
Full Text

Comparisons of the incidence of blood stream infection (BSI) between neonatal intensive care units (NICUs) can promote sharing of potentially better practices for infection control. Comparisons should take into account differences in babies’ vulnerability and the invasive procedures which can introduce infection. I carried out a systematic review of methods reported in the literature, or used by regional monitoring systems, for comparing the incidence of BSI among NICUs. I found substantial variation, especially in the risk factors used to adjust incidence estimates. The use of routinely recorded administrative data would minimize and accelerate staff workload for BSI monitoring. I investigated which risk factors recorded in routine data should be adjusted for when comparing BSI incidence between NICUs. I linked microbiology laboratory records with administrative records collected over four years for three London NICUs. I analysed rates of BSI using various methods, including Poisson regression and logistic regression assuming a matched case control design. With both approaches, National Health Service level of care was the strongest predictor for BSI incidence. Using Poisson regression models, the rate ratio for BSI, adjusted for birth weight, inborn/outborn status and postnatal age, was 3.15 (95% confidence interval (CI) 2.01, 4.94) for intensive care and 6.58 (95% CI 4.18, 10.36) for high dependency care, relative to special care. The case control study gave slightly larger estimates of effect than the Poisson regression models. Total parenteral nutrition was significantly associated with BSI incidence but explained less of the variance among babies than level of care. Using the results from the risk adjustment model, I demonstrated how routine data can be integrated into a method for prospective, risk adjusted monitoring. This method involved standardised infection ratios and a sequential probability ratio test. The method can evaluate changes in BSI rates over time and between NICUs. It could also be used to quantify improvements following infection control interventions.

Magister Curationis - MCur
Parents undergo negative experiences that include parental anxiety, depression, and posttraumatic stress when their new-born babies are hospitalised in neonatal intensive care unit. During this stressful period, parents need assistance from staff in order to cope. A quantitative, descriptive survey design was used to describe parents’ perception of nursing support during their baby’s admission in neonatal intensive care units (NICU) at three selected private hospitals in the city of Cape Town in the Western Cape Province. A structured existing 21- item Likert type questionnaire, the Nurse-Parent Support Tool (NPST) was used to collect data from an all-inclusive sample of 85 parents with a response rate of 78.8% (n=67). The purpose of the questionnaire was to determine their perception of information giving and communication by nurses; emotionally supportive behaviours by nurses; care given support or instrumental support and to identify parents’ perception of esteem or appraisal support while in the NICU environment. The data was analysed using Statistical Package for Social Sciences (SPSS) version 24. The findings of this study suggested that the overall mean score for parents’ perception of nursing support was high 4.6 (±0.5) out of a possible of 5. There was no significant difference in the overall mean perceived support score between the different facilities. No significant differences were found in terms of all the demographics characteristics with regard to perceptions of the support that was received, thus indicating that there was no relationship between the demographic variables and perception of support. The findings suggested that though high parental support was reported, the area of involving parents in the care of their babies i.e. letting them decide whether to stay or leave during procedures need improvement.

A neonatologia é uma subespecialidade da pediatria relativamente nova iniciando-se como uma área altamente tecnológica e que tende a ser cada vez menos invasiva. Foram vários os avanços que permitiram uma redução da mortalidade do recém-nascido prematuro: o transporte in utero, os corticóides prenatais, o "milagre" do surfactante, cuidados regionalizados (de que Portugal é um bom exemplo), ... Com a evolução dos tempos a preocupação dos neonatologistas "transferiu-se" da mortalidade para a morbilidade, os cuidados passaram de centrados no doente a centrados na família, a ventilação tornou-se não invasiva, a maior importância da nutrição, sono, redução da infecção, luz, ruído e dor, variáveis conjuntas influenciando o neurodesenvolvimento.

Les nouveaux-nés prématurés sont vulnérables à des complications comme l’hyperbilirubinémie néonatale et le sepsis tardif (LOS), posant des défis importants dans les unités de soins intensifs néonatals (USIN). Malgré les avancées en matière de soins, la détection précoce et la gestion efficace de ces affections restent complexes. Cette thèse, basée sur l’étude CARESS-Premi (NCT01611740), vise à développer des techniques avancées de traitement des données et des modèles interprétables d’apprentissage automatique afin d’améliorer la prise de décision en USIN, via des systèmes de surveillance non invasifs, continus et en temps réel. Les principales contributions comprennent : (i) une chaîne optimisée de traitement des signaux pour l’analyse ECG en conditions réelles, adaptée aux USIN; (ii) un modèle mathématique patient-spécifique pour la caractérisation de la dynamique postnatale de la bilirubine, avec des paramètres comme biomarqueurs potentiels pour détecter les comorbidités associées ; (iii) une estimation non invasive de la bilirubine utilisant des modèles d’apprentissage automatique à effets mixtes intégrant l’analyse de la variabilité de la fréquence cardiaque (HRV) et des informations physiologiques ; (iv) des modèles pour la détection précoce du LOS via l’analyse de la HRV ; (v) la conception, le déploiement et l’évaluation préliminaire d’un système d’aide à la décision clinique (CDSS) on-the-edge, intégrant du traitement des signaux en quasi-temps réel et des modèles d’inférence dans un contexte USIN. Ces résultats démontrent le potentiel du traitement avancé des signaux physiologiques combiné à l’apprentissage automatique pour optimiser les soins néonatals
Preterm infants are highly vulnerable to complications such as neonatal hyperbilirubinemia and late-onset sepsis (LOS), which pose significant challenges in Neonatal Intensive Care Units (NICU). Despite advancements in neonatal care, early detection and effective management of these conditions remain difficult. Based on the CARESS-Premi project (NCT01611740), the dissertation aims to develop advanced data processing techniques and interpretable machine learning (ML) models to enhance NICU decision-making and neonatal outcomes, by leveraging non-invasive, continuous and real-time monitoring systems. The main contributions include: (i) an optimized automatic signal processing pipeline for real-life ECG analysis tailored to NICU; (ii) a patient-specific mathematical model for postnatal bilirubin dynamics characterization in preterm infants, with model parameters serving as potential biomarkers for detecting associated comorbidities; (iii) the knowledge-based non-invasive bilirubin estimation using mixed-effects ML integrating heart rate variability (HRV) analysis and physiological insights; (iv) ML models for LOS early detection using HRV analysis, proving timely alerts before clinical suspicion; (v) the design, deployment and preliminary evaluation of an on-the-edge clinical decision support system (CDSS) integrating quasi-real-time signal processing and ML models in a NICU setting. These results demonstrate the potential of combining advanced physiological signal processing with ML to optimize neonatal care

Kangaroo care (KC) is a cost-efficient method to increase infant-parent bonding and neonatal health outcomes worldwide. Despite evidence supporting KC in critically ill infants, nursing perceptions regarding patient safety and interrupted work flow continued to impede practice in the local high-tech neonatal intensive care unit (NICU). Their current policy failed to address the 2-person transfer method recommended for safe practice. In addition, both staff and parents lacked training and education regarding the benefits and feasibility of KC. This doctoral project aimed to decrease practice barriers and promote earlier and more frequent KC by developing and integrating an evidence-based clinical pathway within a multifaceted champion-based simulated educational training program for NICU staff and parents. Published outcomes and generated organizational data for program synthesis connected the gap in practice. Kolcaba's comfort theory served as the guiding framework to ensure a partnership in care. This quasi-experimental quantitative study used the generalized liner model for data analysis. Study findings indicated that KC occurred 2.4 more times after the intervention compared to before (p = 0.001). Descriptive data revealed that KC episodes for intubated patients nearly doubled after implementation (11.1% from 6.2%). Post-survey scores for nursing knowledge and comfort level also improved after the intervention. Although earlier KC practice was non-conclusive (p = 0.082), future trials should control groups for day of life since admission. Disseminating the KC pathway can have a positive social change on family-centered care by increasing NICU nurses' knowledge, comfort, and adoption of this evidence-based practice as an expected routine standard of care.

This descriptive comparative and correlational study was designed to determine the degree of environmental stress perceived by mothers and fathers during the first week of their infant's admission to a Special Care Nursery (SCN) and to determine the differences in their perceptions. In addition, the variables of gestational age, birth weight and paternal attitude toward caregiving were investigated for their relationship to the perceived degree of environmental stress. A convenience sample of 31 sets of parents was selected from a tertiary level SCN in a large urban children's hospital. Both parents completed the Neonatal Intensive Care Unit Parental Stress Scale and an information sheet; fathers also completed the Paternal Attitude Scale. Overall, mothers and fathers perceived the SCN environment as a low source of stress. Mothers were moderately stressed by their altered parental role. In addition, mothers were significantly more stressed by the environmental aspects of SCN and the total SCN experience than were fathers. Environmental stress arising from staff communications and relations was significantly negatively related to birth weight and gestational age. No significant relationship was found between paternal attitude toward care giving and the fathers' perception of environmental stress.
Applied Science, Faculty of
Nursing, School of
Graduate

Kangaroo Mother Care (KMC) is an alternative model of care that prevents parent-infant separation when preterm infants need neonatal intensive care by skin-to-skin contact between infants and their parents. KMC is also a strategy that involves parents in their infants’ care and enables them to assume the responsibility for the care. Furthermore, KMC promotes parent-infant bonding and attachment. The overall aim of this thesis was to gain a deeper understanding and knowledge about parents’ capacity, willingness, and experiences of KMC and to which extent parents choose to use KMC throughout their infants' hospital stay. These studies were conducted in the NICUs at two Swedish university hospitals (NICU A and NICU B). Mothers of infants cared for at NICU A (n=17) answered a questionnaire about their experiences of KMC (Paper I). Twenty parents of infants cared for at NICU A recorded the duration of each KMC session during a period of 24 hours and the identity the KMC provider (Paper II). Seven fathers were interviewed about their experiences of KMC (Paper III) and 76 mothers and 74 fathers completed a questionnaire about what facilitated or rendered it difficult to perform KMC (Paper IV). The time of initiation of KMC and duration in minutes, and the identity of the KMC providers was recorded continuously during the infants’ (n=104) hospital stay: 83 mothers and 80 fathers also completed a questionnaire during their infants’ hospital stay (Paper V). This thesis provides new knowledge about parents’ practice of KMC, also continuously day and night, in a high tech NICU in an affluent society, with good resources for infant care in an incubator by trained staff. The accuracy of parents’ records of KMC were comparable to nurses’ records. The results indicate that parents want to be together with their infant in the NICU and be actively involved in the infants’ care. Although parents may experience KMC as exhausting and uncomfortable, they still prefer KMC to conventional neonatal intensive care as it supports their parental role. Early initiation of KMC after birth appears to result in a longer total duration of KMC during the infants’ hospital stay.

BACKGROUND: Physical therapists (PTs) may care for full-term or premature newborns in all levels of hospital nurseries. There is some endorsement in the published physical therapy literature for restricting practice in the nursery setting to only those PTs with specialized training.1-4 PURPOSE: The purpose of this study was to understand the experiences of becoming and being a physical therapist in a special care nursery (SCN) or neonatal intensive care unit (NICU) from the therapists’ perspective. METHODS: The participants were physical therapists who have practiced in a SCN or NICU in the United States. A phenomenological approach was used and data was collected through interviews. The constant comparative method was used to analyze the data and identify common themes to describe therapists’ beliefs about becoming and being a physical therapist in a hospital nursery. RESULTS: These four themes include: 1) Never Alone, which reflects the unique collaborative culture of the NICU; 2) Families First, which speaks to the need to focus on the family, avoid judgment, and facilitate their involvement in the care of their child; 3) Take a Deep Breath, which reflects the need to be mindful and cautious because of the potential to do harm due to the extreme fragility of the infant; and 4) Know What You Don’t Know, which reflects the depth and breadth of knowledge necessary to work in the NICU/SCN. CONCLUSIONS: This project was the first to systematically research practicing therapist’s beliefs and perspectives regarding PT practice in the SCN and NICU. It is evident that current practice does not align with the adopted statements from APTA and APPT, as well as other professional associations. Much evidence draws attention to the fragility of premature neonates, yet our PT practice and education does not appropriately address these concerns.

The literature review highlighted the continuing problem of hospital acquired infection. This study examined this problem in depth, in a high-risk area, the Neonatal Intensive Care Unit. A multi-centre study was conducted using multi-methods in order to capture data regarding nurses' infection control practices in neonatal units. Ninety nurses/ nursery nurses from six neonatal units were included in the study. Non-participant observation was used to investigate nurses' existing infection control practices, interviews were used to explore nurses' opinions of infection control, questionnaires were used to collect demographic data about the sample and assess nurses' knowledge of infection control issues and a Likert-type scale was developed to investigate the unit atmosphere/environment. Microbiological laboratory work was undertaken to compare the efficacies of three products (soap, alcohol hand rub and chlorhexidine) at removing/reducing the numbers of bacteria found on the hands. The effectiveness of gloves at preventing contamination of the hands was also assessed. Finally, the numbers of bacteria recovered from the hands of university administrative staff and nurses were compared to determine whether or not nurses had higher numbers of bacteria on their hands due to the number of organisms they are exposed to and their increased frequency of hand hygiene. Overall, nurses' hand hygiene practices were found to be relatively poor. However, there was some evidence that length of shift, as a proxy indicator of fatigue, and unit atmosphere/environment may influence nurses' infection control practices. Opinions and knowledge were not associated with observed practice. Nursery nurses had lower hand hygiene scores and knowledge scores than nurses and increased experience in the neonatal unit was associated with increased infection control knowledge. The number of bacteria recovered from the hands of nurses was significantly higher than the numbers of bacteria recovered from the hands of administrative staff. In the clinical setting, chlorhexidine was found to be the only product that consistently removed significant numbers of bacteria from the hands. Indeed, the alcohol hand rub was found to increase the numbers of bacteria on the hands. The number of bacteria recovered from the hands did not differ when gloves were worn. This suggests the inside of gloves may be providing a medium for the multiplication of bacteria. However, the number of bacteria recovered from the surface of used gloves was significantly lower than the numbers of bacteria recovered from nurses' hands after nursing activities. The use of gloves for all procedures on the neonatal unit may be advantageous.

The purpose of this study was to describe the phenomenon of maternal attachment as it specifically relates to moderate premature delivery. The study investigated the impact of educational, counseling and therapeutic interventions on mothers who delivered premature infants. Research hypotheses were that mothers who participated in the treatment group would demonstrate significant increases in the independent variables of self esteem, social networking and family function strategies. This study also hypothesized that there would be a significant positive relationship between treatment and the dependent variable of maternal attachment. The sample consisted of 30 mother-infant dyads between the ages of 15 and 38 years of age. Infants' gestational age ranged from 32 to 36 weeks. Data were gathered using three measures: (1) a demographic profile of the subjects; (2) a questionnaire including the Tennessee Self Concept Scale, Sarason's Life Event Survey, Norbeck's Social Support Questionnaire, Feetham's Family Function Index; and (3) Barnard's Nursing Child Assessment Feeding Scale (NCAFS). The research study consisted of a field experiment. Fifteen subjects were assigned to the experimental and control group via a modified randomized block procedure. A questionnaire was issued during infant's hospitalization and at 4 months post infant discharge from the hospital to measure the independent variable. The dependent variable was measured at 1 month, 2-1/2 months and 4 months using the NCAFS. Treatment consisted of a minimum of seven sessions during the infant's hospitalization and discharge to home. Statistical analyses were conducted in the form of frequency distributions, means, standard deviations, t-tests and correlation scores. Stepwise multiple regression techniques were used for predictor variables. Results indicated that mothers who participated in the treatment group demonstrated significantly improved maternal attachment processes than those mothers who did not receive intervention. The results did not indicate that there was a significant difference between the two groups on self esteem, social support, life events or family function. Implications for the study were noted. Recommendations for medical and mental health practitioners and future areas of research were discussed.

Thesis (MScMedSc (Interdisciplinary Health Sciences. Speech-Language and Hearing Therapy))--University of Stellenbosch, 2007.
Noise is a noxious stimulus with possible negative physiological effects on the infant, especially in the Neonatal Intensive Care Unit (NICU). The present study conducted a detailed noise assessment in a NICU of a state hospital in the Cape Metropole and documented 6 infants’ physiological responses to noise levels. Noise levels ranged from 62.3-66.7dBA (LAeq), which exceed all American and British standards (50dBA -60dBA) for a NICU. Continuous exposure to noise of these levels is potentially harmful to the infants’ auditory system and health stability. The general well-being of the staff working in the NICU may also be compromised. Analysis of the noise events revealed that staff conversations were the largest single contributor to the number of noise events, while the largest single non-human contributor was the alarm noise of the monitors. No significant correlations were found between the heart rates and noise levels and the respiratory rates and the noise levels for any of the participants in either room. The NICU was found to be an extremely reverberant environment, which suggested that the NICU noise levels were largely a result of reverberant noise reinforcements. NICU nursing staff’s most common suggestion for noise abatement strategies was reduction of staff conversation. Results of this study highlight the need for NICU noise abatement to optimise newborn patient care, reduce the risk of acoustic trauma and to improve the neonate’s quality of life, thus enhancing the infant’s physiologic stability, growth and health.

Lo scopo di questa tesi consiste nello sviluppo e nella costruzione di nuovi metodi di misura senza contatto per la valutazione di parametri fisiologici (saturazione del sangue, frequenza cardiaca, frequenza respiratoria, e temperatura) molto importanti all’interno di un reparto di terapia intensiva neonatale (NICU). In questo ultimi anni, come dimostrato in letteratura, è aumentato l’ interesse sui dispositivi senza contatto. La principale motivazione è quella di eliminare i rischi biologici, chimici ed elettrici, che sono sempre presenti quando un dispositivo medicale viene applicato su un paziente. Ciò è particolarmente evidente in pazienti ricoverati in un’unità di terapia intensiva; specialmente se nati pre-termine e perciò con l’apparato cardiaco/respiratorio non ancora del tutto formato e con le difese immunologiche basse. Le tesi è stata organizzata per esplorare e proporre soluzioni fattibili per misure senza contatto di parametri fisiologici nei pazienti pre-termine, quali: • Saturazione del sangue (SaO2) • Frequenza Cardiaca (HR) • Frequenza Respiratoria (RR) • Temperatura superficiale del paziente (T) SaO2 è generalmente affetta da numerosi falsi positivi dovuti all’errato posizionamento del pulso ossimetro oppure agli artefatti da movimento. Nel capitolo 4 è descritto ed implementato un metodo consolidato per l’eliminazione di dati saturimetrici erronei, l’algoritmo è stato applicato a 24 pazienti con un’acquisizione di 483 giorni, di cui più del 12% (equivalente a 58 giorni) sono risultati falsi e quindi da scartare. L’HR e la RR sono state misurate senza contatto su 8 pazienti, senza che questi fossero spostati dalle isole neonatali o dalle incubatrici. I dati raccolti sono stati rielaborati e validati con ECG e ventilatori, mostrando un’accuratezza della misura di ± 43 ms e ± 150 ms. Infine è stato progettato un nuovo metodo senza contatto per la misura della temperatura superficiale di pazienti NICU. Lo strumento usato è una termo camera IR che ha permesso di ottenere mappature termiche del soggetto in modo da avere un riscontro indiretto della termogenesi e dei parametri metabolici del paziente. Inoltre è stato costruito un modello per valutare e quantizzare i parametri vitali del paziente. I metodi descritti, permettono misure molto accurate e continue di parametri vitali, eliminando il contatto paziente-dispositivo biomedicale (fatta eccezione del pulso ossimetro), diminuendo significativamente il rischio biologico, chimico ed elettrico ritenuti molto gravi in pazienti presenti in NICU.
The main aim of this thesis is to design and develop novel measurement methods for the non-contact assessment of physiological quantities (oxygen saturation, heart rate, respiration rate and temperature) of importance in neonatal intensive care units (NICU). During the last decade, a growing interest on non-contact medical devices was testified by the literature; the reason is mainly due to the importance to eliminate the possible biological, chemical and electrical hazards always present when a medical device is used on a patient. This is particularly true on patients recovered in intensive care unit; especially if such patients are pre-born babies with low cardiac/respiration apparatus efficiency or reduced immunological defense systems. The work has been organized in order to explore and propose feasible solutions for the non-contact measurements of the following vital signs in pre-term patients: • Oxygen saturation (SaO2) • Heart rate (HR) • Respiration rate (RR) • Patient skin temperature (T) Oxygen saturation (SaO2) is typically affected by numerous fake values due to the non-optimal placement of the pulse oximeter or to movement artifacts. In chapter 4, a robust method for the rejection of the fake/erroneous values of SaO2 is described and implemented on 24 patient over 483 days period of time. More than 12% of erroneous data (equivalent to a 58 days period of time) have been individuated and rejected. Heart rate (HR) and respiration rate (RR) without any physical contact have been implemented on 8 patients maintained into thermal cribs or incubators. Data have been recorded, processed and compared with ECG and patient ventilator, showing an uncertainty of ± 43 ms and ± 150 ms. Finally a novel non-contact method for the measurement of the patient skin temperature (T) was designed and implemented for the use on NICU patients. An IR thermo-camera was used for determination of multi-point temperature determination with special attention on the indirect determination of thermogenesis and metabolic parameters of the patient. A specially devoted algorithm has been developed for the assessment and quantization of the patient parameters. The studied methods allow to perform the continuous and accurate measurement of important physiological parameters eliminating (a part from the pulse oxymeter) the contact between the patient and the medical devices and consequently reducing significantly the biological and electrical hazards risks which are particularly severe for NICU patients.

Neonatal abstinence syndrome (NAS) is a public health concern that is increasing in the United States due to the use of illicit drugs by pregnant women, which exposes the fetus to these substances. NAS results in increased infant morbidity and prolonged stay in the hospital, which can lead to increased cost of care. The inability of the nurses to care for at-risk infants can lead to inconsistent NAS scores, which can affect the infant's care treatment. The project examined the effectiveness of educating the neonatal intensive care unit (NICU) nurses on the correct use of the modified Finnegan Neonatal Abstinence Tool (FNAST) and implementing a practice protocol in the management of infants experiencing NAS, thereby reducing inconsistencies in NAS scores. Implementing clinical guidelines and proper use of the modified FNAST can lead to early intervention and treatment of infants exhibiting withdrawal symptoms. An educational session was conducted, pretests and posttests were used to evaluate the NICU nurses' baseline knowledge of the correct use of the modified FNAST and their acquired knowledge after the educational intervention on the correct use of the modified FNAST. The goal of the project was met with the NICU nurses experiencing knowledge gain evidenced by a 30% increase between the pretests and posttests and obtaining consistent NAS scores by applying the correct technique of scoring. The mastery of the use of the modified FNAST brought about social change by impacting positive attitudes and behaviors among the NICU nurses and enhancing collaboration between the physicians and nurses.

Hospital treatment environments have become a major concern in recent years. Noise and illumination are potential stress sources in hospitals. The purpose ofthis study was to examine the effects of hospital noise levels and ambient illumination on newborn infants (neonates). Noise levels and lighting were varied and the effect upon neonatal heart rate, respiration rate, blood pressure, and oxygen consumption were measured. These measures are sensitive tosympathetic nervous system reactivity such as that brought about by stressful environments. In addition, noise and lighting levels were measured to determine if differences existed across conditions. Psychophysiological responses to various noise and lighting levels varied within and across neonates with some changes in the expected direction. Some unexpected results of Quiet Time were noted among neonatal intensive care staff and hospital personnel.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior
Hospitalization of the newborn is necessary when health conditions require immediate assistance for their recovery. Humanized actions in the neonatal unit have been developed in order to make it less painful separation parent-child when it needs technological support and team of trained professionals. It was aimed to analyze the perception and knowledge of the nursing team on the promotion of humanized care for newborn in a Neonatal Intensive Care Unit . It is a qualitative study conducted in a public hospital, large, tertiary level, in Fortaleza, Brazil, in the months October and November 2015, after approval by the Research Ethics Committee, under Protocol N. 1,191,339. The subjects were 14 nurses and 20 nursing technicians working in neonatal care. The data collected through semi-structured interviews consist identification data and five guiding issues that permeate the knowledge of the nursing team about the care and promotion of humanized care in the UTIN. In addition, we used no-participant observation and field diary. For analysis, we sought to Bardin technique that extracted the three categories lines: âTaking care of the human personâ, ânursing contributions to the humane careâ and âFactors that affect the quality of humanized care.â The results showed that the nursing team understands humanization as an indispensable element for the comprehensive care to the baby and family, which was observed from the speeches of welcome, restoring health and disease of the newborn process. The professionals had knowledge of the humanized care, played their actions conscious, oriented and appreciative way about the quality of neonatal care and parents who face the challenges inherent in the admission process. We conclude that the performance of these professionals permeates compliance with the regulations of the National Humanization Policy regarding humanized care to the newborn, family and neonatal ambience. It is believed that such actions minimize the impact caused by the characteristics of the disease treatment as well as stressors.
A hospitalizaÃÃo do recÃm-nascido faz-se necessÃria, quando as condiÃÃes de saÃde requerem assistÃncia imediata para o seu restabelecimento. As aÃÃes humanizadas na unidade neonatal tÃm sido desenvolvidas, a fim de tornar menos dolorosa à separaÃÃo pais-filho, quando este necessita de suporte tecnolÃgico e equipe de profissionais capacitados. Objetivou-se analisar a percepÃÃo e conhecimentos da equipe de enfermagem sobre a promoÃÃo do cuidado humanizado ao recÃm-nascido internado na Unidade de Terapia Intensiva Neonatal (UTIN). Trata-se de estudo qualitativo, realizado em hospital pÃblico, de grande porte, nÃvel terciÃrio, em Fortaleza-CE-Brasil, nos meses outubro e novembro de 2015, apÃs aprovaÃÃo pelo Comità de Ãtica em Pesquisa, sob Protocolo n 1.191.339. Os sujeitos foram 14 enfermeiros e 20 tÃcnicos de enfermagem atuantes na assistÃncia ao neonato. Os dados coletados, por meio de entrevista semiestruturada, consistem dados de identificaÃÃo e cinco questÃes norteadoras, que permeiam o conhecimento da equipe de enfermagem acerca do cuidado e a promoÃÃo da assistÃncia humanizada na UTIN. Ademais, utilizou-se observaÃÃo nÃo participante e diÃrio de campo. Para anÃlise, sÃntese e descriÃÃo, buscou-se a tÃcnica de Bardin, que se extraÃram das falas trÃs categorias: âCuidar do ser humanoâ, âContribuiÃÃes de enfermagem para o cuidado humanizadoâ e âFatores que interferem na qualidade do cuidado humanizadoâ. Os resultados revelaram que a equipe de enfermagem compreende a humanizaÃÃo como elemento indispensÃvel para o cuidado integral ao bebà e famÃlia, o que se observou desde as intervenÃÃes de acolhimento, ao restabelecimento do processo saÃde-doenÃa do neonato. Os profissionais apresentaram conhecimentos acerca do cuidado humanizado, desempenharam suas aÃÃes de forma consciente, orientada e sensibilizada, quanto à qualidade da assistÃncia ao neonato e aos pais que enfrentam os desafios inerentes ao processo de internaÃÃo. Percebe-se, portanto, que a atuaÃÃo desses profissionais permeia o cumprimento aos regulamentos da PolÃtica Nacional de HumanizaÃÃo. Conclui-se que o cuidado humanizado aplicado nessa ambiÃncia à essencial ao recÃm-nascido e famÃlia, uma vez que minimiza o impacto causado pelas caracterÃsticas da doenÃa, tratamento, bem como os fatores estressantes da UTIN.

Alarm fatigue is a practice problem that applies to hospitalized patients and the nurses who care for them. Addressing alarm fatigue is important to promote alarm safety and to decrease the risk of patient harm or death. The purpose of this study was to decrease alarm fatigue and improve alarm safety in a regional neonatal intensive care unit (RNICU). Guided by the conceptual model for alarm fatigue and alarm safety, this study addressed whether or not alarm management protocols designed to decrease false and nuisance alarms in the physiological monitoring of neonates improve alarm safety via decreased alarm burden and alarm fatigue as evidenced by statistically significant reductions in false and nuisance alarms. A quantitative, time series quasi-experimental design was used with 4 waves of data collection. One wave was baseline data collected preintervention, and 3 waves of data were postprotocol implementation to obtain an initial indication of sustainability. Alarm observation data collection sheets were developed and used to track numbers and types of alarms pre- and post-protocol implementation. The data analysis showed statistically significant decreases in both false alarms and nuisance alarms related to the physiological monitoring protocol and lead changing protocol. Overall, high protocol adherence was noted, and the total number of alarms per hour per bed was reduced by 42% (p < .001), 46% (p < .001), and 50% (p < .001) from baseline at Weeks 2, 4, and 6, respectively. Implications from this study include impact on practice and policy, direction for future study, and a call for social change to promote alarm safety in the care of neonates.

Thesis (MCur)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Burnout is one of the challenges that nurses are faced with in their stressful and rapidly changing work environment. The vulnerability of nurses to burnout remains a major concern which affects both the individual and institution. Knowledge about burnout and associated risk factors which influence the development of burnout is vital for early recognition and intervention. The research question which guided this study was: “What are the factors influencing the degree of burnout experienced by nurses working in neonatal intensive care units?” The objectives included determining which physical, psychological, social and occupational factors influenced the degree of burnout experienced by nurses. A descriptive, explorative research design with a quantitative approach was applied. The target population consisted of (n=105) permanent nursing staff members working in the neonatal units of two different hospitals. A convenience sampling method was used. Participants (n=102) who gave voluntary consent to participate was included in the study. Validity and reliability was supported through the use of a validated questionnaire, Maslach Burnout Inventory – General Survey including a section based on demographical information and a section based on physical, psychosocial, social and occupational factors. Validity of the questionnaire was supported by the use of a research methodologist, nurse expert and a statistician in the particular field. A pilot study was done to test the feasibility of the study and to test the questionnaire for any errors and ambiguities. Ethics approval was obtained from Stellenbosch University and permission from the Heads of the hospitals where the study was conducted. The data was analyzed with the assistance of a statistician and these are presented in histograms, tables and frequencies. The relationship between response variables and nominal input variables was analysed using analysis of variance (ANOVA). Various statistical tests were applied to determine statistical associations between variables such as the Spearman test, using a 95% confidence interval. Results have shown that participants experienced an average level of emotional exhaustion, a high level of professional efficacy and a low level of cynicism. Further analyses have shown that there is a statistical significant difference between emotional exhaustion and the rank of the participant (p=<0.01), highest qualification (p=0.05) and a high workload (p=0.01). Furthermore a statistical significant difference was found between professional efficacy and rank of participants (p=<0.01). In addition a statistical significant difference was found between cynicism and the number of years participants were in the profession (p=0.05). Multiple factors were determined in this study that influences the degree of burnout nurses experience. The majority of participants (n=56/55%) experienced decreased job satisfaction and accomplishment, (n=52/51%) of participants experienced that their workload is too much for them and (n=63/62%) participants received no recognition for their work. Recommendations are based on preventative measures, because preventing burnout is easier and more cost-effective than resolving burnout once it has occurred. In conclusion, the prevention strategies, early recognition of work stress and appropriate interventions are crucial in addressing the problem of burnout.
AFRIKAANSE OPSOMMING: Uitbranding is een van die uitdagings waarmee verpleegsters te kampe het in hulle stresvolle en vinnig veranderende werkomgewing. Die kwesbaarheid van verpleegsters vir uitbranding bly ’n kritieke bekommernis wat beide die individu en die inrigting affekteer. Kennis omtrent uitbranding en verwante risiko faktore wat die ontwikkeling van uitbranding beïnvloed, is deurslaggewend vir vroeë opsporing en intervensie. Die navorsingsvraag wat hierdie studie gelei het, is: “Wat is die faktore wat die mate van uitbranding beïnvloed wat deur verpleegsters ondervind word wat in neonatale intensiewe sorgeenhede werk?” Die doelwitte wat ingesluit is, is om te bepaal watter fisiese, sielkundige, maatskaplike en beroepsfaktore die mate van uitbranding wat deur verpleegsters ervaar word, beïnvloed. ’n Beskrywende, ondersoekende navorsingsontwerp met ’n kwantitatiewe benadering is toegepas. Die teikengroep het bestaan uit (n=105) permanente verpleegpersoneel wat in die neonatale eenhede van twee verskillende hospitale werk. ’n Gerieflikheidsteekproef metode is gebruik. Deelnemers (n=102) wat vrywillige toestemming gegee het om deel te neem, is ingesluit in die navorsingstudie. Geldigheid en betroubaarheid is ondersteun deur die gebruik van ’n geldige vraelys van “Maslach Burnout Inventory – General Survey”, asook ’n afdeling gebaseer op demografiese inligting en ’n afdeling gebaseer op fisiese, sielkundige, maatskaplike en beroepsfaktore. Geldigheid van die vraelys is ondersteun deur ’n navorsingsmetodoloog, ’n verpleegspesialis en ’n statistikus op die navorsingsgebied. ’n Loodsondersoek is gedoen om die haalbaarheid van die studie te toets en om die vraelys te toets vir enige foute en dubbelsinnighede. Etiese goedkeuring is verkry van die Universiteit van Stellenbosch en goedkeuring van die Hoofde van die hospitale waar die studie uitgevoer is. Die data is geanaliseer met die hulp van ’n statistikus en is aangebied in histogramtafels en frekwensies. Die verwantskap tussen responsveranderlikes en nominale insetveranderlikes is geanaliseer deur gebruik te maak van die analise van variansie (ANOVA). Verskeie statistiese toetse is toegepas om statistiese assosiasies tussen veranderlikes te bepaal, soos deur van die Spearmantoets gebruik te maak, met ’n 95% betroubaarheidsinterval. Resultate het bewys dat deelnemers ’n gemiddelde vlak van emosionele uitputting, ’n hoë vlak van professionele effektiwiteit en ’n lae vlak van sinisme ervaar. Verdere analise het bewys dat daar ’n statistiese beduidende verskil tussen emosionele uitputting en die rang van die deelnemers (p=<0.01) is, hoogste kwalifikasie (p=0.05) en ’n hoë werklading (p=0.01). Verder is ’n statistiese beduidende verskil gevind tussen professionele effektiwiteit en rang van deelnemers (p=<0.01). Saam hiermee is ’n statistiese beduidende verskil gevind tussen siniesheid en die aantal jare wat deelnemers in die beroep is (p=0.05). Voorts, is veelvuldige faktore bepaal in hierdie studie wat die mate van uitbranding beïnvloed wat verpleegsters ervaar. Die meeste van die deelnemers (n=56/55%) het ’n afname in werksbevrediging en -verrigting ervaar, (n=52/51%) deelnemers het ervaar dat hul werklading te veel is vir hulle en (n=63/62%) deelnemers het geen erkenning vir hulle werk ontvang nie. Aanbevelings is gebaseer op voorkomende maatreëls, want om uitbranding te voorkom, is makliker en meer koste-effektief as om uitbranding te probeer oplos as dit alreeds begin het. Ten slotte, die voorkomende strategieë, vroeë identifisering van werkstres en geskikte intervensies is deurslaggewend om die probleem van uitbranding aan te spreek.

The psychometric properties of this Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) were assessed, before using the scale to describe stress experienced by parents in a Neonatal Intensive Care Unit (NICU). The extent to which parental stress from the parent-infant relationship in the unit was linked to parenting they received as a child, and adjustment to their couple relationship, was also examined. The sample consisted of 182 mothers and 183 fathers, who were in a cohabitating relationship, of infants from the NICU at Christchurch Women's Hospital. The self-report questionnaires included the PSS:NICU, Parental Bonding Instrument, and the Dyadic Adjustment Scale, and were administered to parents within 2-3 weeks of their infant's birth. This study extends the finding of satisfactory psychometric properties of the PSS:NICU (Franck, Cox, Allen & Winter, 2005; Miles, Funk & Carlson, 1993; Reid & Bramwell, 2003) to this New Zealand sample. Mothers experienced significantly higher stress from the unit compared to fathers (p < .01). A previous finding, for mothers, of the parent-infant relationship being the most stressful aspect of the unit (Franck et al., 2005; Reid & Bramwell, 2003; Shields-Poe & Pinelli, 1997) extends to the New Zealand sample. The most stressful aspect of the unit for fathers was sights and sounds. Lack of evidence was found for associations between parental stress from the parent-infant relationship in the unit and parenting received as a child, or adjustment to their couple relationship. A weak but significant negative correlation was, however, found between stress from the mother-infant relationship and maternal care received in childhood. It is unnecessary to provide all parents with intervention further to what is already being practiced in the unit, as overall low levels of stress were reported. Some parents, however, did find the unit more stressful, and they may benefit from increased intervention.

The hospitalization of one's infant is a stressful situation that can lead to decreased bonding and poor health outcomes. This longitudinal comparative design study examined the effects of neonatal palliative care (PC) consultation on stress levels and satisfaction scores of parents of neonatal intensive care unit (NICU) infants. Clinical data was abstracted from the medical record. Demographic data, stress scores, and satisfaction reports were obtained via self-report.

Mean stress scores indicated most parents experienced moderate stress due to NICU hospitalization. Some parents met diagnostic criteria for acute stress disorder. While all parents expressed satisfaction with care received; PC parents were extremely satisfied with care. No statistically significant differences in stress or satisfaction scores were noted between parents who received PC consultation and those who did not. Study conclusions validate previous research regarding NICU parent stress and show that additional quantitative and qualitative research regarding NICU palliative care is warranted.

This survey research explores neonatal intensive care unit speech-language pathologists’ perceptions of infants with neonatal abstinence syndrome; specifically, how NAS affects infants’ feeding skills, along with structural and oral-motor characteristics. The findings of this research will contribute to this population’s information base. The results are expected to inform the field and current evidence-based practice care for infants with NAS.Learner Outcome(s): Explain Neonatal Abstinence Syndrome (NAS) Describe infants with NAS and how NAS affects the infants’ feeding skills from the perspective of Neonatal Intensive Care Unit (NICU) Speech-Language Pathologists (SLPs) Identify how SLPs in the NICU participate in intervention for infants with NAS and their families

Neonatal abstinence syndrome (NAS) refers to the withdrawal infants exposed to opioids in utero may experience following birth. In recent years, the number of infants born who present with NAS has grown exponentially. This increase in the number of infants with NAS has led to a new population within the caseloads of speech-language pathologists (SLPs) who work in neonatal intensive care units (NICUs). SLPs’ knowledge base and skill set of assessment and treatment of swallowing and feeding disorders in infancy play a vital role in the treatment of infants with NAS in the NICU. A dearth of research exists regarding the specific nature of the feeding problems and skills of infants with NAS and whether SLP intervention for infants with NAS needs to differ from that of other infant NICU populations. Identifying how SLPs can best serve infants with NAS in the NICU is essential to their immediate well-being as well as the development of these infants. The purpose of this survey-based research study was to examine NICU SLPs’ perceptions of infants with NAS, and more specifically, how NAS affects the infants’ feeding skills, structural, and oral-motor characteristics. A questionnaire was developed based on an in-depth literature review to collect information on NAS, caseloads, treatment environment, and respondent demographics. The survey consisted of three sections: NAS (further divided into Assessment, Treatment, and Education), Environmental Description, and Respondent Demographics. The secure web-based questionnaire was distributed through SurveyMonkey™, an online survey platform. Survey research was conducted, and hospital-based speech-language pathologists within the USA acted as respondents. The findings will contribute to establishing a preliminary base of information on this topic. The results are expected to further inform the field as well as current practices in evidenced-based practice care for infants with NAS.

Objective: The purpose of this study was to determine the characteristics, assessment, and treatment of infants with Neonatal Abstinence Syndrome (NAS) as perceived by Speech-Language Pathologists (SLP) and whether it differed from those of other Neonatal Intensive Care Unit populations. Methods: A secure web-based questionnaire with 62 questions collected information on NAS, caseloads, treatment environment, and demographics. Twenty-six respondents initiated the survey; 42% completed most or all questions. Response analyses included descriptive and nonparametric inferential statistics. Results: Infants with NAS were on the caseloads of 73% of respondents. The majority (79%) only saw infants with NAS and feeding problems. Primary problems included incomplete or increased time to complete feeds, increased/excessive/irregular sucking rates, and reflux. Working on teams, respondents provided assessment, treatment, and education of infant feeding and state. Conclusion: Growing demand for SLP intervention with infants with NAS is likely to persist if opioid use continues to increase as projected.

The research objective was: to determine (a) the extent of the present involvement of neonatal intensive care nurses in technology assessment, (b) their perceptions of the technologies with which they worked, and (c) their perceptions of requirements for improvements in the technology assessment process. Nurses and senior staff (nursing s.u perv.i sors, NICU consultants and training officers) ln the neonatal intensive care units (NICUs) of five hospitals in London were included in the study sample. They completed questions regarding new medical technologies in general and NICU technologies in particular. Nurses and senior does not prepare Further, in some training regarding staff believed that nurses' training them adequately for new technologies. instances, nurses had not received a new technology prior to using it. Neither nurses nor senior staff were fully aware of formal processes for technology assessment in their hospitals, but did identify informal processes. While a small minority of the nurses had been directly involved in decisions regarding the new technologies, more than half had made recommendations. The nurses considered their level of involvement unsatisfactory, and believed (as did the senior staff) that their hospital could improve its procedures for purchasing, introducing and using new technologies. Most of the nurses who were planning to remain in neonatal intensive care were dissatisfied with their involvement and with their hospital's methods for adopting new technologies. One-third of the nurses and most of the senior staff identified examples of nurses' having contributed to the development and adaptation of new equipment and procedures, either formally or informally. The impacts considered most significant by nurse participants were: job stress, increased ethical, legal or social concerns, and decreased reliance on clinical judgment or skills of nurses.

Para citação, referenciar também o artigo: Adaptação cultural e validação para a língua portuguesa da Parental Stress Scale: Neonatal Intensive Care Unit (PSS:NICU) (http://repositorio.unifesp.br/handle/11600/6920) conforme determinação da autora.
Made available in DSpace on 2015-07-22T20:50:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-06-24
Introdução: a internação de um recém-nascido na Unidade de Terapia Intensiva Neonatal (UTIN) é um acontecimento inesperado e assustador com o qual os pais não estavam preparados para lidar.Esse evento, que gera sofrimento na família, traz para os profissionais da saúde uma demanda de cuidado, cujo intuito é amenizar as repercussões dessa hospitalização no cotidiano da família. Como enfermeira neonatologista, a autora percebe o estrese dos pais no ambiente neonatal e a necessidade de instrumentos objetivos para identificá-lo e para elaborar as intervenções de enfermagem. No Brasil não encontramos um instrumento para avaliar este tipo de estresse. A escala Parenteral Stress Scale Neonatal Intensive Care Unit(PSS:NICU) é um instrumento desenvolvido por Margaret S. Milles nos Estados Unidos, cuja finalidade é avaliar esse tipo de estresse, tem sido utilizado em vários países. Objetivo: fazer a tradução, a adaptação cultural e a validação da PSS:NICU na língua portugues. Método: fora, utilizadas as etapas de tradução e adaptação cultural proposta Guillemin et al.(1993) que incluem tradução, retradução, análise por um comitê de revisores e preteste da escala. Foi reaizada também análise da confiabilidade por meio do teste e reteste e da consistência interna. Foi feita a validação clínica da versão da escala PSS:NICU na língua portuguesa a uma amostra de 163 país em dois hospitais no Estado de São Paulo.Resultados: a escala na língua portuguesa foi prestada e o nível de compreensão dela foi considerado adequado. A investigação da confiabilidade mostrou boa consistência interna na aplicação a pais brasileiros.Os valores obtidos dos coeficientes de correlação intraclasse ficaram em torno de 0,70, mostrando-se uma boa estabilidade entre as duas avaliações. A análise fatorial pelo método de componentes principais utilizou os mesmos critérios da escala original, com rotação Varimax, que apresentaram grau de variância adequado de 57,9%.Os escores de estresse dos pais foram de 2,3(pouco estressante) na subescala "sons e imagens"; 2,9(moderadamente estressante)na subescala "aparência e comportamento do bebê" e 3,7(muito estressante) na subescala "alteração papel de pais" na métrica 1(Nível de Ocorrência de Estresse")e 2,2; 2,6 e 3,4(pouco, moderadamente e muito estresse) respectivamente na métrica 2(Nível Geral de Estresse").Conclusão: a PSS:NICU na versão em português é uma ferramenta válida e confiável para avaliar o estresse de pais na Unidade de Terapia Intensiva Neonatal.
TEDE
BV UNIFESP: Teses e dissertações

Introdução: A dor neonatal merece atenção diferenciada pelos profissionais de saúde, uma vez que os recém-nascidos (RNs) não se expressam verbalmente. A grande dificuldade existente para avaliar e tratar a dor em RNs internados em Unidades de Terapia Intensiva Neonatal (UTIN) continua sendo uma preocupação para profissionais e pesquisadores da área. Nesse sentido, essa pesquisa tem como pergunta: Como se dão as práticas de avaliação e tratamento da dor em RNs internados em UTINs de Curitiba (PR) e Região Metropolitana? Objetivo geral: Descrever o conhecimento e as práticas de manejo da dor do RN, empregadas por enfermeiros que atuam em UTINs. Objetivos específicos: Verificar o conhecimento dos enfermeiros sobre o manejo da dor de RNs internados; caracterizar as estratégias não farmacológicas e farmacológicas adotadas pelos enfermeiros para o controle da dor de RNs internados; verificar a forma de registro da avaliação e do tratamento da dor realizada pelos enfermeiros. Metodologia: Estudo transversal realizado em seis hospitais de Curitiba (PR) e Região Metropolitana que possuem UTIN com atendimento pelo Sistema Único de Saúde (SUS), a amostra do estudo foi constituída por 51 enfermeiros. A coleta de dados se deu por meio de questionários contendo informações a respeito da caracterização das unidades, um questionário referente ao perfil dos enfermeiros, formação, atuação e qualificação profissional e outro sobre conhecimentos e práticas do manejo da dor neonatal. A análise dos dados ocorreu pelo Statistical Package for Social Sciences (SPSS versão 21.0) e o nível de significância adotado foi de 5%. Resultados: A maioria dos enfermeiros era mulheres com idade entre 20 e 30 anos e tempo de formação de 1 a 5 anos. Os profissionais responsáveis pela avaliação da dor do RN eram em sua maioria enfermeiros (84,3%), seguidos por técnicos (62,7%) e auxiliares de enfermagem (11,8%). A maioria dos enfermeiros concordou que os RNs são capazes de sentir dor, porém 34,7% afirmaram nunca utilizar escalas para avaliar a dor do RN. 98% dos enfermeiros concordaram que é importante registrar a dor no prontuário do RN, sendo a evolução e anotação de enfermagem os locais mais mencionados em que ocorre o registro. As medidas não farmacológicas para alívio da dor neonatal assinaladas pelos enfermeiros foram: glicose oral, sucção não nutritiva, posicionamento, ninho, diminuição de estímulos auditivos, método canguru, toque, diminuição de estímulos visuais, contenção, aleitamento materno, massagem e musicoterapia. O Paracetamol e o Fentanil foram as medidas farmacológicas mais assinaladas pelos enfermeiros, seguidos pela Morfina, Codeína, Midazolam, Hidrato de Cloral e Lidocaína. Conclusões: Os enfermeiros conhecem as medidas farmacológicas e não farmacológicas para alivio da dor neonatal, porém a prática difere dos conhecimentos apresentados por não utilizarem estas medidas para alívio da dor em RNs.
Introduction: The neonatal pain needs special attention by health professionals, because newborns dont verbalize. The large difficulty to assess and treat pain in newborns admitted in Neonatal Intensive Care Units (NICU) is a big concern for professionals and researchers. For this reason, this research has the question: What are the evaluation practices and treatment of pain in newborns admitted to NICUs in Curitiba (PR) and metropolitan area? General aim: To describe the knowledge and practices about newborns pain relief employed by nurses that work in NICUs. Specifics aims: To verify the knowledge of nurses on the management of hospitalized newborns pain, to characterize the pharmacological and non-pharmacological strategies used by nurses to control hospitalized newborns pain and identify the ways of registration of the evaluation and treatment of pain held by nurses. Methodology: Cross-sectional study that occurred in six hospitals in Curitiba, Paraná State and metropolitan area that have NICU with care by the Unified Health System. The study sample consisted of 51 nurses. The data collection was through questionnaires containing information about the characterization of the units, a questionnaire relating to the profile of nurses, education, experience and professional qualifications and another questionnaire about knowledge and practices of management of neonatal pain. Analysis of the data was the Statistical Package for Social Sciences (SPSS - version 21.0) and the significance level was 5%. Results: The majority of nurses are women, the ages are between 20 and 30 years and 1-5 years of graduation. The professionals responsible for newborns pain assessment are mostly nurses (84.3%), followed by technicians (62.7%) and nursing assistant (11.8%). Most of the nurses agree that newborns are capable of feeling pain, but 34.7% reported never using scales to assess newborns pain. 98% of the nurses agree that is important to register the pain on newborn s chart record, being the evolution and nursing note the most mentioned places where the registration takes place. The non-pharmacological measures to relieve neonatal pain marked by nurses were: oral glucose, non-nutritive sucking, positioning, nest, decreased auditory stimuli, kangaroo method, touch, decreased visual stimuli, containment, breastfeeding, massage and music therapy. Paracetamol and Fentanyl were the pharmacological measures more marked by nurses, followed by Morphine, Codeine, Midazolam, Chloral Hydrate and Lidocaine. Conclusions: The nurses know the pharmacological and non-pharmacological measures to relief neonatal pain, but the practice differs from the knowledge shown because they do not use these measures to relief pain in newborns.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
INTRODUÃÃO: O Brasil, acompanhando a tendÃncia mundial, experimentou uma reduÃÃo marcante na mortalidade infantil, mas uma forÃa de declÃnio de igual valor nÃo foi percebida na taxa de mortalidade neonatal, sugerindo falhas na qualidade da assistÃncia obstÃtrica e neonatal. As desigualdades nacionais e regionais, o acesso limitado aos cuidados necessÃrios, a iniquidade na distribuiÃÃo de leitos intensivos neonatais e a fragilidade dos serviÃos prestados, contribuem como fatores associados ao risco de morte infantil no perÃodo neonatal. OBJETIVOS: Avaliar os fatores associados à mortalidade intra-hospitalar no perÃodo neonatal, utilizando como variÃveis explicativas as caracterÃsticas individuais relacionadas à mÃe e aos recÃm-nascidos internados em Unidades Neonatais de Alto Risco (UTIN) integrantes da RENOSPE no Nordeste do Brasil e caracterizar as UTIN em relaÃÃo aos indicadores de qualidade no atendimento obstÃtrico e neonatal. METODOLOGIA: Delineou-se estudo longitudinal, multicÃntrico de base hospitalar entre recÃm-nascidos, cujas unidades de anÃlise foram as UTIN dos estados do Nordeste brasileiro. A populaÃÃo do estudo compreendeu 3.623 nascidos vivos internados em UTIN das instituiÃÃes hospitalares das nove Unidades Federadas do Nordeste do Brasil e integrantes da RENOSPE. Os dados individuais do modelo hierarquizado foram obtidos do formulÃrio: Pesquisa: DiagnÃstico da Qualidade da AtenÃÃo Perinatal em InstituiÃÃes de SaÃde Participantes da RENOSPE. Para a anÃlise foi utilizado modelo hierÃrquico em trÃs nÃveis: nÃvel distal (caracterÃsticas sociais, econÃmicas e demogrÃficas), nÃvel intermediÃrio I(caracterÃsticas maternas) e II (assistÃncia prÃ-natal e ao parto) e nÃvel proximal (condiÃÃes de saÃde do nascido vivo e da atenÃÃo neonatal - uso de tecnologias). Foram selecionados sete indicadores de qualidade do atendimento obstÃtrico e neonatal: Iniciativa Maternidade Segura; Iniciativa Hospital Amigo da CrianÃa; Programa atendimento da gestante de alto risco; UTIN interditada nos Ãltimos 12 meses; UTIN superlotaÃÃo nos Ãltimos 12 meses; AdoÃÃo do MÃtodo Canguru na assistÃncia ao recÃm-nascido; Estabelecimento de saÃde com Protocolo de IntervenÃÃo MÃnima para Prematuro com peso inferior a 1.250g. RESULTADOS: ApÃs o ajuste para os trÃs nÃveis hierÃrquicos do modelo de determinaÃÃo do Ãbito ocorrido em UTIN, as variÃveis que compuseram o modelo hierarquizado final da regressÃo logÃstica multivariada foram: i) parto cesÃrea (OR ajustada=0,72; IC95% 0,56-0,95; p=0,019); ii) nÃo utilizaÃÃo de corticÃide antenatal entre recÃm-nascidos com peso inferior a 1.500g (OR ajustada=1,51; IC95% 1,01-2,25; p=0,041); iii) prÃ-eclampsia (OR ajustada=0,73; IC95% 0,56-0,95; p=0,020); iv) oligodramnia (OR ajustada=1,57; IC95% 1,17-2,10; p=0,002); v) peso inferior a 2500g (OR ajustada=1,40; IC95% 1,03-1,90; p=0,027); vi) escore de Apgar 5 minuto de vida inferior a sete (OR ajustada=2,63; IC95% 2,21-3,14; p<0,001); vii) uso de tubo endotraqueal (OR ajustada=1,95; IC95% 1,31-2,91; p=0,001); viii) nÃo uso de surfactante entre recÃm-nascidos com peso inferior a 1.500g (OR ajustada=0,54; IC95% 0,43-0,69; p<0,001). A relaÃÃo entre a variÃvel independente uso de surfactante, apesar de apresentar associaÃÃo protetora entre aqueles que nÃo utilizaram a referida tecnologia, esse significado nÃo nos pareceu com caracterÃsticas espÃrias, haja vista que os que utilizaram, o fizeram por apresentarem-se mais gravemente enfermos. Em relaÃÃo aos sete indicadores de qualidade das instituiÃÃes hospitalares e UTIN, destaca-se um cenÃrio de superlotaÃÃo e interdiÃÃo, em meio Ãs iniciativas positivas de incentivo ao aleitamento materno exclusivo e mÃtodo MÃe Canguru. Esses dados reforÃam que as causas de morte intra-hospitalar ocorrido no perÃodo neonatal, sÃo determinadas principalmente pela qualidade e condiÃÃes de assistÃncia à gestaÃÃo e ao parto e ao recÃm-nascido, dependendo de fortalecimento na organizaÃÃo da rede assistencial.
INTRODUCTION: Brazil, following the global trend, experienced a marked reduction in infant mortality, but a force of equal value decline was not seen in the neonatal mortality rate, suggesting gaps in the quality of obstetric and neonatal care. National and regional inequalities, limited access to care, inequity in the distribution of beds and the fragility of neonatal intensive services, contributing factors associated with the risk of infant death in the neonatal period. OBJECTIVES: To evaluate the factors associated with in-hospital mortality in the neonatal period, using as explanatory variables individual characteristics related to the mother and the newborns hospitalized in High Risk Neonatal Units (NICU) members RENOSPE in northeastern Brazil and characterize NICU for indicators of quality in obstetric and neonatal care. METHODOLOGY: The design of this study was longitudinal, multicenter hospital-based among newborns, the units of analysis were the NICU states of the Brazilian Northeast. The study population comprised 3,623 live births admitted to NICU of hospitals from nine federal units of Northeast Brazil and members of RENOSPE. Individual data were obtained from the hierarchical model of the form: Search: Diagnostic Quality of Care in Perinatal Health Care Participants RENOSPE. For the analysis model was used in three hierarchical levels: the distal level (social, economic and demographic), intermediate I (maternal characteristics) and II (prenatal care and childbirth) and the proximal (health conditions live birth and neonatal care - use of technologies). We selected seven indicators of quality of obstetric and neonatal: Safe Motherhood Initiative, the Baby Friendly Hospital Initiative; Program attendance of high risk pregnancies; NICU banned in the past 12 months; NICU overcrowding in the last 12 months; Adoption of Kangaroo Care assistance the newborn; health establishment with Protocol Minimal Intervention for Premature weighing less than 1.250g. RESULTS: After adjustment for the three-level hierarchical model for the determination of death occurring in the NICU, the variables that compose the hierarchical model of the final multivariate logistic regression were: i) cesarean delivery (adjusted OR = 0.72, 95% CI 0, 56 to 0.95, p = 0.019), ii) non-use of antenatal corticosteroids among infants born weighing less than 1,500 g (adjusted OR = 1.51, 95% CI 1.01 to 2.25, p = 0.041) iii) pre-eclampsia (adjusted OR = 0.73, 95% CI 0.56 to 0.95, p = 0.020), iv) oligohydramnios (adjusted OR = 1.57, 95% CI 1.17 to 2.10; p = 0.002), v) weighing less than 2,500 g (adjusted OR = 1.40, 95% CI 1.03 to 1.90, p = 0.027); vi) Apgar score 5 minutes of life less than seven (adjusted OR = 2.63, 95% CI 2.21 to 3.14, p <0.001), vii) endotracheal intubation (adjusted OR = 1.95, 95% CI 1.31 to 2.91, p = 0.001), viii) no surfactant use among newborns weighing less than 1,500 g (adjusted OR = 0.54, 95% CI 0.43-0.69, p <0.001). The relationship between the independent variable surfactant use, despite a protective association among those who did not use such technology, meaning that it did not seem to spurious features, given that they have used, did they present themselves more seriously ill. Concerning the seven indicators of quality in hospitals and NICU, there is a scenario of overcrowding and interdiction, amid positive initiatives to encourage exclusive breastfeeding and kangaroo mother method. These data reinforce the causes of in-hospital death occurred in the neonatal period, are primarily determined by the quality and conditions of care during pregnancy and childbirth, and the newborn, depending on strengthening the organization of health care network.

Aims: Since 1990 data have been collected by the Trent Neonatal Survey (TNS) on neonatal intensive care activity within the area of the former Trent Regional Health Authority. While TNS is a unique data set, no systematic investigation had previously been undertaken to ensure that the most appropriate statistical methods were applied to its analysis. In this thesis, methods for the analysis of in unit mortality rates were reviewed, critically appraised and, where appropriate, developed in order to identify the most suitable methods. Methods: Statistical methods were illustrated using data from infants born in the years 2000 to 2002, at 32 completed weeks gestational age or less, admitted to one of the sixteen neonatal intensive care units (NICUs) within the area. The methods were discussed and risk adjustment methods were explored to allow for differences in disease severity between the units. Results: Simple descriptive approaches and statistical models are presented. In particular, summary statistics derived from logistic regression models were explored, including odds ratios and statistics from both direct and indirect standardization. In the final approach, logistic regression models were applied to obtain estimated standardized mortality ratios (SMRs) for each NICU. Proposed methods to estimate confidence intervals for the SMR were investigated through a simulation study and by application to the TNS data, with the method proposed by Hosmer and Lemeshow (1995) applied in the final models. The use of Bayesian methods was proposed and a model developed allowing the appropriate estimation of all uncertainty. Conclusions: The use of SMRs was proposed for the reporting of mortality in future TNS annual reports. The advantages of a Bayesian approach, with the ability to make probability statements about the SMR, were also emphasised. Further work is required into the effect of specification of prior distributions before this method can be recommended routinely.

Le sepsis tardif, défini comme une infection systémique chez les nouveaux nés âgés de plus de 3 jours, survient chez environ 7% à 10% de tous les nouveau-nés et chez plus de 25% des nouveau-nés de très faible poids de naissance qui sont hospitalisés dans les unités de soins intensifs néonatals (USIN). Les apnées et bradycardies (AB) spontanées récurrentes et graves sont parmi les principaux indicateurs précoces cliniques de l'infection systémique chez les prématurés. L'objectif de cette thèse est de déterminer si la variabilité du rythme cardiaque (VRC), la respiration et l'analyse de leurs relations aident au diagnostic de l'infection chez les nouveaux nés prématurés par des moyens non invasifs en USIN. Par conséquent, on a effectué l'analyse Mono-Voie (MV) et Bi-Voies (BV) sur deux groupes sélectionnés de nouveau-nés prématurés: sepsis (S) vs. non-sepsis (NS). (1) Tout d'abord, on a étudié la série RR non seulement par des méthodes de distribution (moy, varn, skew, kurt, med, SpAs), par les méthodes linéaire: le domaine temporel (SD, RMSSD) et dans le domaine fréquentiel (p_VLF, p_LF, p_HF), mais aussi par les méthodes non–linéaires: la théorie du chaos (alphas, alphaF) et la théorie de l'information (AppEn, SamEn, PermEn, Regul). Pour chaque méthode, nous étudions trois tailles de fenêtre 1024/2048/4096, puis nous comparons ces méthodes afin de trouver les meilleures façons de distinguer S de NS. Les résultats montrent que les indices alphaS, alphaF et SamEn sont les paramètres optimaux pour séparer les deux populations. (2) Ensuite, la question du couplage fonctionnel entre la VRC et la respiration nasale est adressée. Des relations linéaires et non-linéaires ont été explorées. Les indices linéaires sont la corrélation (r²), l'indice de la fonction de cohérence (Cohere) et la corrélation temps-fréquence (r2t,f) , tandis que le coefficient de régression non-linéaire (h²) a été utilisé pour analyser des relations non-linéaires. Nous avons calculé les deux directions de couplage pendant l'évaluation de l'indice h2 de régression non-linéaire. Enfin, à partir de l'ensemble du processus d'analyse, il est évident que les trois indices (r2tf_rn_raw_0p2_0p4, h2_rn_raw et h2_nr_raw) sont des moyens complémentaires pour le diagnostic du sepsis de façon non-invasive chez ces patients fragiles. (3) Après, l'étude de faisabilité de la détection du sepsis en USIN est réalisée sur la base des paramètres retenus lors des études MV et BV. Nous avons montré que le test proposé, basé sur la fusion optimale des six indices ci-dessus, conduit à de bonnes performances statistiques. En conclusion, les mesures choisies lors de l'analyse des signaux en MV et BV ont une bonne répétabilité et permettent de mettre en place un test en vue du diagnostic non invasif et précoce du sepsis. Le test proposé peut être utilisé pour fournir une alarme fiable lors de la survenue d'un épisode d'AB tout en exploitant les systèmes de monitoring actuels en USIN
Late-onset sepsis, defined as a systemic infection in neonates older than 3 days, occurs in approximately 10% of all neonates and in more than 25% of very low birth weight infants who are hospitalized in Neonatal Intensive Care Units (NICU). Recurrent and severe spontaneous apneas and bradycardias (AB) is one of the major clinical early indicators of systemic infection in the premature infant. Various hematological and biochemical markers have been evaluated for this indication but they are invasive procedures that cannot be repeated several times. The objective of this Ph.D dissertation was to determine if heart rate variability (HRV), respiration and the analysis of their relationships help to the diagnosis of infection in premature infants via non-invasive ways in NICU. Therefore, we carried out Mono-Channel (MC) and Bi-Channel (BC) Analysis in two selected groups of premature infants: sepsis (S) vs. non-sepsis (NS). (1) Firstly, we studied the RR series not only by distribution methods (moy, varn, skew, kurt, med, SpAs), by linear methods: time domain (SD, RMSSD) and frequency domain (p_VLF, p_LF, p_HF), but also by non-linear methods: chaos theory (alphaS, alphaF) and information theory (AppEn, SamEn, PermEn, Regul). For each method, we attempt three sizes of window 1024/2048/4096, and then compare these methods in order to find the optimal ways to distinguish S from NS. The results show that alphaS, alphaF and SamEn are optimal parameters to recognize sepsis from the diagnosis of late neonatal infection in premature infants with unusual and recurrent AB. (2) The question about the functional coupling of HRV and nasal respiration is addressed. Linear and non-linear relationships have been explored. Linear indexes were correlation (r²), coherence function (Cohere) and time-frequency index (r2t,f), while a non-linear regression coefficient (h²) was used to analyze non-linear relationships. We calculated two directions during evaluate the index h2 of non-linear regression. Finally, from the entire analysis process, it is obvious that the three indexes (r2tf_rn_raw_0p2_0p4, h2_rn_raw and h2_nr_raw) were complementary ways to diagnosticate sepsis in a non-invasive way, in such delicate patients.(3) Furthermore, feasibility study is carried out on the candidate parameters selected from MC and BC respectively. We discovered that the proposed test based on optimal fusion of 6 features shows good performance with the largest Area Under Curves (AUC) and the least Probability of False Alarm (PFA). As a conclusion, we believe that the selected measures from MC and BC signal analysis have a good repeatability and accuracy to test for the diagnosis of sepsis via non-invasive NICU monitoring system, which can reliably confirm or refute the diagnosis of infection at an early stage

The goal of this project was to explore mothers’ experiences of caring for infants in the Neonatal Intensive Care Unit (NICU) using a microsystem perspective. This perspective focuses on the structure, processes and people and in so doing allows for a critical exploration of how these elements work together to influence mothers in the NICU. The research framework involved an institutional ethnography to explore care delivery, relationships, and discourses in the NICU. Data was collected using nonparticipant-observations, interviews, and collection of discourse artifacts. There is clear evidence that caring for an infant in the NICU can result in significant increases in maternal stress and associated outcomes. Results from triangulation of the data indicated that being separated from the infant and learning to mother in the unit were particularly salient experiences retold by the mothers. These experiences were affected – either positively or negatively – by different elements of the microsystem including consistency in communications, increased opportunities for mothers’ inclusion in decision-making and infant care and lastly, access to more support resources. Implementing improvements to the microsystem could better empower mothers adjusting to parenthood within the NICU context.

The American Academy of Pediatrics (AAP) delineated four criteria for management of perinatal care and discharge (DC) of high-risk neonates: 1) physiological stability, 2) tracking and surveillance of growth and development for each infant, 3) active parental involvement with the infant's care, and 4) follow-up care arranged with experienced primary care provider. Registered Nurses in California Neonatal Intensive Care Units (NICUs) were surveyed about NICU DC transitioning programs to 1) identify current common standards of care used in DC transitioning and 2) define the nature and extent of additional criteria and procedures used in DC transitioning. Useable surveys were obtained from 32 of the 79 facilities queried (41%): 17 (53%) Level II, 10 (31%) Level III, and 5 (16%) Level IV. All responding facilities were located in communities of 100,000 people or more. All but one of the facilities (97%) used all four AAP criteria for determining readiness for DC. Facilities differed in whether they also used weight, corrected gestational age, or both as criteria for DC. They differed in the definition of active parental involvement with care, the degree to which parents participated in DC planning, who arranged for post-DC primary care, and how outcomes of DC planning practices were evaluated. Profiles derived from these data can be used to expand procedures, guidelines, and policies for DC transitioning of the NICU graduate.

Magister Scientiae (Physiotherapy) - MSc(Physio)
Background: The role of the physiotherapist in the neonatal intensive care unit is unclear. How other neonatal healthcare professionals and physiotherapists themselves perceive their role in the management of neonates, their practice patterns and services, their role in the neonatal intensive care multidisciplinary team, their use of evidence-based practice and awareness of the profession in this setting has not been well explored. This information is lacking in the South African healthcare context as well. Therefore, the aim of the study was to explore and describe the perception of doctors, nurses and physiotherapists of the role of the physiotherapist in public and private sector neonatal intensive care units in South Africa. Methods: A qualitative exploratory research design was used. All medical practitioners (paediatricians and neonatologists), nurses and physiotherapists working in the neonatal intensive care units in two private sector and two public sector hospitals in the Cape Metropole region in the Western Cape South Africa who provided consent to participate were included. An inclusive (total population) sampling method was used where all healthcare professionals working in these units were invited to an individual face-to-face audiotaped interview using a semi-structured interview guide and conducted by the researcher at a time and place convenient to the participants following informed consent. Data was transcribed verbatim and analysed using both deductive and inductive thematic content analysis to develop codes, categories and themes. Trustworthiness was ensured by ensuring credibility, conformability, dependability and transferability of data. Ethics was obtained from the relevant Institutional Review Board. Results: Twenty-one healthcare professionals participated, including doctors (n=5), nurses (n=6) and physiotherapists (n=10). The mean age in years of the participants was 41+/–11 years with the physiotherapists having the lowest mean age. The participants had various years of general and neonatal intensive care experience and physiotherapists in specific only had basic undergraduate qualifications with minimal specialised training in neonatal intensive care. Five major themes emerged namely: i) the role of the physiotherapists in the management of the neonatal ICU patient, ii) practice patterns and services iii) teamwork iv) training and qualifications including evidence-based practice, v) awareness of and exposure to neonatal intensive care physiotherapy. Conclusion: Physiotherapists working in this neonatal intensive care setting need to promote their profession through education of other neonatal healthcare professionals in order to improve awareness, referral patterns and integration into the multidisciplinary team. Evidence-based practices and improving training and skills development in the area of neonatal physiotherapy can be further explored in this setting.

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Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG
Hospitalization at Neonatal Intensive Care Units (NICU) is commonly related to many invasive and painful procedures. It has been reported that painful experiences in infancy can be associated with pain perception in the future. Little is known about the relation between the history of NICU care and children’s pain behavior during the dental exam. This study aimed to compare the occurrence of pain during the dental exam of children with/out history of previous admission to a NICU. This case-control study enrolled 42 children, 5.7±0.4 years-old, 24 girls, with (n=21) and without (n=21) history of NICU care, exploring other medical/dental features potentially related to this association. Children’s pain perception was evaluated by the Brazilian versions of two scales: the observational measure “Faces, Legs, Activity, Cry, Consolability (FLACC) Pain Assessment Tool”, and the self-report Faces Pain Scale–Revised (FPS-R)”. Data were analyzed by descriptive statistics, Chi-square (likelihood ratio) and Mann-Whitney tests. Findings showed that 5 children (23.8%) with history of NICU care showed pain during the dental exam (FLACC≥1), compared to none from the control group (P=0.006). Most of the 42 children (90.0%) did not perceived pain during the dental exam (FPS-R), with no difference between case and control groups (P=0.238). NICU children had more hospitalization later in childhood (81.0%) than the control group (25.0%, P<0.001). Groups did not differ regarding chronic diseases (P=0.141). History of dental pain, dental treatment experience and negative behavior at the dentist did not differ between the 5 children with FLACC≥1 and the others (P>0.05). It was concluded that children with history of NICU care present more pain during dental exam than those who did not have this experience.
O comportamento infantil pode ser influenciado por diversos fatores, como experiências médicas traumáticas. A internação em Unidades de Terapia Intensiva Neonatal (UTIN) é necessária para algumas crianças prematuras e pode ser caracterizada por numerosos procedimentos invasivos e dolorosos. Evidências ressaltam que os temores da infância podem ser exacerbados na vida futura; as experiências dolorosas no início da vida podem ser fatores associados ao comportamento. Poucos estudos buscaram relacionar o comportamento no consultório odontológico de crianças ao histórico de hospitalização emUTIN. Esta pesquisa de abordagem quantitativa, observacional transversal, caso-controle, analisou o comportamento durante exame odontológico, de 42 crianças de 5 a 6 anos de idade com e sem história de cuidados intensivos neonatais, aspectos relacionados ao nascimento e saúde bucal. A coleta de dados envolveu exame odontológico e avaliação do comportamento, utilizando-se versão brasileira das escalas Faces, Legs, Activity, Cry, Consolability (FLACC) eFaces Pain Scale – Revised(FPS-R). Os dados foram analisados por estatística descritiva e teste Qui-quadrado (razão de verossimilhança). Cárie dentária estava presente em 73,8%% da amostra Os resultados evidenciaram que 90% das crianças não mostraram sinais de dor durante o exame odontológico, segundo a escala FPS-R. Cinco crianças (23,8%) com história pregressa de internação em UTIN demonstraram dor durante o exame odontológico (escore FLACC≥1) (p-valor=0,006). Houve associação estatisticamente significante entre dor no exame odontológico e internação em UTIN.

Background Hyperbilirubinemia is a condition that affects most infants, but typically self-resolves and is not harmful. However, if bilirubin levels exceed neuroprotective defenses, the compound can cross the blood-brain barrier and have neurotoxic and potentially fatal effects. Treatment of neonatal hyperbilirubinemia with phototherapy is necessary for the prevention of kernicterus. Guidelines for the use of phototherapy in infants born at ≥ 35 weeks’ gestation were published by Bhutani et al. and endorsed by the American Academy of Pediatrics. Consensus-based recommendations for phototherapy treatment and exchange transfusion of premature infants were published in 2012 by Maisels, et al. However, there are no published recommendations for the timing of screening for hyperbilirubinemia in NICU patients. In 2012, the Kapʻiolani Medical Center for Women & Children Neonatology Division implemented internal guidelines for phototherapy with recommendations for the timing of screening serum bilirubin levels, based on the group’s opinion. Five years later, the current study queried whether these guidelines for screening were appropriate. Objective The present study sought to describe current practices of obtaining serum bilirubin levels and the use of phototherapy in the NICU during the first five days of life. It was hypothesized that many bilirubin levels obtained at ≤ 48 hours of life are below published recommended treatment thresholds and are potentially unnecessary. Methods Retrospective chart review was performed on all infants admitted to the NICU at < 24 hours of life, from July 2016-June 2017. Eligible infants were divided into three gestation age groups: ≤ 28, 29-35, and ≥ 36 weeks at birth. Patient demographics, bilirubin levels, and phototherapy treatment were noted. The primary outcome of interest was the percent of serum bilirubin levels obtained during the first 48 hours of life that did not meet phototherapy treatment criteria. Results 931 charts were reviewed. Infants born at ≤ 28, 29-35 and ≥ 36 weeks’ gestation made up 10%, 51% and 39% of the cohort. Overall mortality was 3%, and no exchange transfusions were performed during the study period. At least one serum bilirubin level was obtained for 96% of the patients, but only 55% were treated with phototherapy within the first five days of life. Phototherapy was rarely prescribed on day of life (DOL) 1 (0.7%). By DOL 2, a total of 563 bilirubin levels were obtained, but only 108 infants (19%) were treated with phototherapy. However, one-third of these patients’ bilirubin levels did not meet published criteria for treatment. The timing of phototherapy treatment varied by gestational age. Ninety percent of infants born ≤ 28 weeks’ gestation who received phototherapy were treated starting between DOL 2-3. In contrast, eighty-five percent of infants born ≥ 29 weeks’ gestation who received phototherapy, started on DOL 3-5. Discussion Far more bilirubin levels were obtained than courses of phototherapy prescribed. Given the distinct patterns of phototherapy for infants of varying gestational age, there is ample opportunity to improve resource utilization with targeted recommendations for obtaining screening bilirubin levels in the neonate without early jaundice.

The transition to motherhood is not easy for any new parent but it is especially difficult for the mother of an infant in the Neonatal Intensive Care Unit (NICU). There may be instances in the NICU where the nurses' perception of maternal needs may be incongruent with the mother's perception. Many NICU nurses focus on the physical needs of infants such as cardiorespirartory monitoring, mechanical ventilator support, and I.V. therapy. Mothers may instead be focused on their own need for emotional and psychological support. This study investigated the differences and similarities regarding maternal needs as perceived by the mothers and NICU nurses. A 30 item questionnaire called the Perceived Needs of Family Members of Critically Ill Patients (Norris and Grove, 1986) was given to a group of mothers and a group of NICU nurses. The instrument consists of "needs" statements which are ranked on a Likert Scale from "very important" to "not important". The rankings by mothers and the rankings by nurses were compared. The results of this study demonstrated that the mothers' perceptions and the nurses perceptions of maternal needs were similar in most instances, althought there were some differences. Therefore, it is important that the mothers' needs are accurately identified so that nursing interventions can be developed to meet them.

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MudanÃas que aconteceram no sÃculo XX, permitiram que avanÃos tecnolÃgicos aumentassem a sobrevida diante de doenÃas anteriormente incurÃveis e processos patolÃgicos irreversÃveis. No entanto, a busca incessante pela cura, alÃm de levar ao aumento da sobrevida, tambÃm gerou a obstinaÃÃo terapÃutica, ou seja, medidas terapÃuticas fÃteis diante de evoluÃÃo inexorÃvel para a morte, impactando em indicadores como Ãndice de satisfaÃÃo do cliente e cuidadores, tempo mÃdio de permanÃncia, elevaÃÃo de custos, bem como em prejuÃzo na distribuiÃÃo equitativa de recursos. No inÃcio dos anos 90, a limitaÃÃo do suporte de vida (LSV) comeÃou a ser estudada e considerada, em paÃses da Europa, Estados Unidos, Canadà e Austrlia, como forma de assistir os pacientes nesses casos, uma vez que as medidas terapÃuticas nÃo mais trariam benefÃcios, mas gerariam prolongamento do sofrimento e do processo de morrer. No Brasil, contudo, os estudos sÃo limitados e os dados referentes ao Nordeste do paÃs sÃo ainda muito escassos. O objetivo do estudo foi caracterizar as condutas mÃdicas que antecederam o Ãbito de pacientes em UTI pediÃtrica e neonatal em um hospital de referÃncia do Nordeste Brasileiro. Foram estudados 86 prontuÃrios de pacientes que morreram nas referidas UTIs no perÃodo de dezembro/09 a novembro/10. Apenas 3,5% dos Ãbitos ocorreram apÃs LSV registrada em prontuÃrio, destes 33,7% tinham doenÃa crÃnica associada, sendo as neoplasias as mais comuns. As causas de Ãbito mais comuns foram sepse (23,5%), falÃncia de mÃltiplos ÃrgÃos (18,8%), insuficiÃncia respiratÃria (12,9%), cardiopatias congÃnitas (8,2%) e as outras causas somaram 36,6%. A maior parte dos pacientes morreu apÃs aumento das medidas de suporte avanÃado de vida, considerando as ultimas 24h antes do Ãbito: drogas vasoativas (59,3% 24h antes e 70,9% no momento do Ãbito); VentilaÃÃo mecÃnica (89,5% 24h antes e 95,2% no momento do Ãbito). Enquanto as medidas de cuidados e conforto nÃo tiveram a mesma expressÃo, tendo um aumento irrelevante: sedaÃÃo (39,5% 24h antes e 43% no momento do Ãbito); analgesia (60% 24h antes e 60,5% no momento do Ãbito). As manobras de ressuscitaÃÃo cardiopulmonar foram registradas em 4,7% 48h antes do Ãbito, 29,1% 24h antes e 69,4% no momento do Ãbito. O uso de adrenalina foi registrado em 55,4% antes do Ãbito. Conclui-se que a LSV ainda nÃo à frequentemente considerada como uma alternativa de assistÃncia de final de vida a pacientes pediÃtricos e neonatais no Estado do CearÃ, onde as condutas mais prevalentes incluem o incremento do suporte avanÃado de vida em detrimento das medidas de conforto e cuidados paliativos. Comparando-se com estudos do Sul e Sudeste do paÃs, evidencia-se uma grande diferenÃa, onde se observam uma maior prevalÃncia de LSV e cuidados paliativos para pacientes em fase terminal, o que denota prÃticas mais humanas e de maior qualidade na assistÃncia.
Changes around the world at the XX century allowed new technologies to improve the possibilities of surviving in so many cases of sickness that were incurable before. Besides the benefits it brought, other consequences have come together specially futility, in other words futile therapeutic measures when the cure is impossible and the death is inevitable. These facts have influence in client satisfaction, lengh of stay and costs elevation. Since 1990 life support limitation (LSL) started to be considered in Europe, United States, Canada and Austrlia to assist patients in terminal conditions to whom curative practices wouldnât bring any benefit. In Brazil there is a limited number of studies and the data from the Northeastern are even less. The aim of this study was to describe the medical practices before death in patients in PICU and NICU at a reference pediatric hospital in Brazilian Northeastern. Data were collected from 86 medical charts. Only 3.5% of LSL was registered. 33.7% of patients had some chronic disease and neoplasic ones were more comons. The main causes of death were: sepsis (23.5%), MDOS (18.8%), respiratory failure (12.9%), congenital heart disease (8.2%) and the other causes 36.6% together. Most of patients died after increment in vasoatives administration, considering the final 24 hours before death (59.3% 24h before, 70.9% at the momento of death). Mechanical ventilation (89.5% 24h before, 95.2% at the moment). In the other hand palliative care and pain control were not so frequent as could be expected: sedative (39.5 24h before, 43% at the moment) analgesic (60% 24h before, 60.5% at the moment). CPR was offered in 4.7% of patients 48h before death, 29.1% 24h before and 69.4% at the moment of death. Adrenaline was used in 55.4% at the moment of death. These data show that LSL is not a frequente alternative to assist terminal patients at PICU and NICU in Brazilian Northeastern, where more prevalent practices are to maintain life support instead of offer palliative care and pain control. At Southern and Southeastern practice include LSL and palliative care more frequently, what suggests better practices of the end-of-life care.