Dissertations / Theses on the topic 'Neonatal intensive care'

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
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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.

The vital signs monitoring data of an infant receiving intensive care are a rich source of information about its health condition. One major concern about the state of health of such patients is the onset of neonatal sepsis, a life-threatening bloodstream infection. As early signs are subtle and current diagnosis procedures involve slow laboratory testing, sepsis detection based on the monitored physiological dynamics is a clinically significant task. This challenging problem can be thoroughly modelled as real-time inference within a machine learning framework. In this thesis, we develop probabilistic dynamical models centred around the goal of providing useful predictions about the onset of neonatal sepsis. This research is characterised by the careful incorporation of domain knowledge for the purpose of extracting the infant’s true physiology from the monitoring data. We make two main contributions. The first one is the formulation of sepsis detection as learning and inference in an Auto-Regressive Hidden Markov Model (AR-HMM). The model investigates the extent to which physiological events observed in the patient’s monitoring traces could be used for the early detection of neonatal sepsis. In addition, the proposed approach involves exact marginalisation over missing data at inference time. When applying the ARHMM on a real-world dataset, we found that it can produce effective predictions about the onset of sepsis. Second, both sepsis and clinical event detection are formulated as learning and inference in a Hierarchical Switching Linear Dynamical System (HSLDS). The HSLDS models dynamical systems where complex interactions between modes of operation can be represented as a twolevel hidden discrete hierarchical structure. For neonatal condition monitoring, the lower layer models clinical events and is controlled by upper layer variables with semantics sepsis/nonsepsis. The model parameterisation and estimation procedures are adapted to the specifics of physiological monitoring data. We demonstrate that the performance of the HSLDS for the detection of sepsis is not statistically different from the AR-HMM, despite the fact that the latter model is given “ground truth” annotations of the patient’s physiology.

The observed physiological dynamics of an infant receiving intensive care contain a great deal of information about factors which cannot be examined directly, including the state of health of the infant and the operation of the monitoring equipment. This type of data tends to contain both common, recognisable patterns (e.g. as caused by certain clinical operations or artifacts) and some which are rare and harder to interpret. The problem of identifying the presence of these patterns using prior knowledge is clinically significant, and one which is naturally described in terms of statistical machine learning. In this thesis I develop probabilistic dynamical models which are capable of making useful inferences from neonatal intensive care unit monitoring data. The Factorial Switching Kalman Filter (FSKF) in particular is adopted as a suitable framework for monitoring the condition of an infant. The main contributions are as follows: (1) the application of the FSKF for inferring common factors in physiological monitoring data, which includes finding parameterisations of linear dynamical models to represent common physiological and artifactual conditions, and adapting parameter estimation and inference techniques for the purpose; (2) the formulation of a model for novel physiological dynamics, used to infer the times in which something is happening which is not described by any of the known patterns. EM updates are derived for the latter model in order to estimate parameters. Experimental results are given which show the developed methods to be effective on genuine monitoring data.

We have assessed the introduction of a commercially available computerised physiological trend monitoring network into a neonatal intensive care area. The attitudes of staff and parents were on the whole favourable, with the majority feeling that infant care benefited from the introduction of computers. A detailed study of the effects of computerised physiological monitoring on patient outcome in both short and medium term, showed no significant benefits. The computers improved both the quality and accuracy of the stored infant physiological data. Artefact was predominantly predictable; it could be ignored in real time trends and removed from recorded data prior to statistical analysis. Neonatalogy is a relatively new science, and a continuously expanding physiological data source could help to improve patient care through research. Three areas were explored: (a) Reference blood pressures ranges were established for very low birth weight infants, using more detailed information on a larger group of infants than previously possible. (b) Infants with retinopathy of prematurity compared to those without the disease, did not differ significantly in the amount of time they spent with a continuously monitored transcutaneous oxygen greater than 12 kPa. (c) Previously undescribed blood pressure waves were identified. Associated with hypoxia, they may help improve understanding of fetal autonomic development. Although unable to demonstrate an improvement in patient outcome resulting from the introduction of a computerised physiological network (possibly due to poor outcome measurements), we have demonstrated improved staff confidence, better physiological record and the opportunity for improvement in care through research.

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.

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.

The aim of this thesis was to establish methods of measuring the mechanical properties of the respiratory system in small infants while they were being ventilated in the intensive care unit. A double pneumotachograph system which fitted in the ventilator bias flow-circuit was used to measure flow, overcoming the problems of adding resistance or dead space to the infant's breathing circuit. Two methods for measuring compliance in infants (< 1500 g) breathing spontaneously through endotracheal tubes were assessed. The traditional measurement of dynamic lung compliance (Cdyn) using oesophageal pressue was compared with a technique for measuring total respiratory compliance (Crs) based on the utilisation of the Hering-Breuer reflex (Olinsky 1976) and using airway pressure. Values of Cdyn were poorly reproducible and correlated poorly with Crs and this was due to variability and inaccuracy of oesophageal pressure measurement in infants with chest wall distortion. Total respiratory compliance was reliably measured in intubated infants both when breathing spontaneously and when fully ventilated. Another approach based on the passive expiratory flow-volume relationship (Zin 1982) was developed for use in ventilated infants. The expiratory time constant (Trs) was measured and total respiratory resistance (Rrs) calculated from the relationship Trs = Rrs.Crs. This technique was validated by adding resistive loads and deriving new volumes for Rrs from the altered Trs. The first measurements of the time constant and respiratory resistance of preterm infants during the acute stage of illness were made using this technique. Representative mean values from 12 infants < 1500 g with hyaline membrane disease were Crs = 0.41 ml.cmH₂O^-1; Trs = 0.073 s; Rrs = 219 cmH₂O.ℓ-1.s. A computerised technique was developed to enable these measurements to be made at the cotside. This provided a preliminary model for a lung function monitor to assess mechanical lung function continuously during neonatal ventilation.

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.

The purpose of this study was to describe maternal coping effort. The sample was composed of 30 mothers of infants hospitalized in the neonatal intensive care unit. Descriptive and correlational statistics were used to determine maternal coping effort and the maternal factors that may be associated with coping effort. Results of the study showed that a majority of the mothers exerted a great amount of effort to cope with situations encountered in the NICU. Maternal age, marital status, gravidity and parity, mode of delivery and ethnicity did not prove to associate significantly with coping effort. The results of this study are significant to nursing practice in the confirmation of the high degree of maternal coping associated with the hospitalization of an infant in the NICU.

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 (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.

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 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.

Having an infant admitted to the neonatal intensive care unit (NICU) can be stressful and overwhelming for parents and families. Parents have developed anxiety and depression disorders, as a result of their experience from having their infant in the NICU. The stress and anxiety can also affect the parent-child attachment, as well as putting the infant/child at risk of abuse and neglect. A licensed clinical social worker will facilitate a support group using the strength based perspective to empower individuals and families. The support group goals are: to reduce the amount of stress that parents and/or caregivers encounter, as a result of their infant being in the NICU, to empower parents and/or caregivers to advocate for their infant who has been in the NICU, and to increase the parents and/or caregivers' ability to appropriately respond to the infant's needs. In selecting, Health Trust, as a funder, it values enhancing the well-being of individual and families in Santa Clara County. An actual submission to the funder was not a requirement of this project.

Neonatal intensive care units (NICU) aim not only to reduce mortality and morbidity but also to promote babies' future well-being and health. Baby-led (evidence-based) practices take into account babies' physical and emotional needs. They also consider parents' needs and, when possible, encourage parental participation. Based on ethnographic field work over the course of ten months, the study examined interactions among healthcare professionals, parents and babies in two Mexican NICUs. Dialectic critical realism underpinned the analysis of data while ideas taken from the new sociology of childhood contributed to an investigation about babies as service users of healthcare facilities in their own right. This thesis contributes to an understanding of why preterm babies in Mexico are cared for as they are and opens ways forward towards changes in practice. Three overarching themes, moral and physical hygiene, dignity and well-being, illuminated discussion of results. I identify theory/practice inconsistencies that arise when discourses about sanitation, breastfeeding and babies' best interests are used to control and oppress service users of public hospitals (babies and their parents) rather than to protect them. I have found evidence that relationships between healthcare staff and service users were influenced by prejudices about social class, gender and ethnicity, which resulted in deficient care and disrespect of basic human rights. I consider how wider structures such as neoliberal policies, Catholic practices, poverty, corruption and violence influenced the day-to-day life in these hospitals. The thesis concludes by identifying three ways in which practice might be improved: a) to consider nurses as agents of transformational change; b) to create multi-disciplinary teamwork, including parents and babies, in order to enhance communication at all levels; and c) to develop routine procedures and practices in the NICU informed by research evidence of high standards of care. Finally, I identify implications and steps for further research.

The number of babies that require care in the Neonatal Intensive Care Unit continues to rise in the UK and parents who have a baby who is born sick or prematurely find themselves adapting to this stressful and often unexpected event whilst also trying to establish their role as a new parent. With no current large British studies, this study explores the experiences of both mothers and fathers in the NICU in relation to adaptation and parental role development and how their experience changes over time. In total 76 parents were interviewed using semi structured interviews 7-10 days following the birth to capture their early experiences of the NICU and then again beyond 28 days to explore any changes in their views and feelings over time. Interviews were tape recorded, transcribed verbatim into the written word and imported into WINMAX PRO. Data analysis revealed nine major sections. These are preparation prior to birth, labour and delivery, first sight of infant, support from the partner, family, friends and other parents, support from and communication with staff, adaptation to the NICU experience, development of the parental role, changes with time and the experiences of fathers. Findings show differences in what mothers and fathers find stressful about their NICU experience, how they adapt to the birth of a sick or premature infant and in their development of the parental role. With the passage of time the events surrounding the birth became less significant as parents start to look to the future. Their role as a parent continued to develop with feelings that their baby needed and recognised them, but many parents felt that they were unable to influence what happened to their baby in the NICU. Recommendations are made for further research and for changes to NICU practice.

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.

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.

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

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.

Very premature infants often experience high blood sugar levels as a result of incomplete metabolic development, illness, and stress. High blood sugar levels have been associated with a range of worsened outcomes and increased mortality, but debate exists as to whether high blood sugar levels are a cause of, or marker for, these worsened outcomes. Insulin can be used to lower blood sugar levels, but there is no standard protocol for its use in neonates, and the few clinical studies of insulin use in neonatal intensive care are relatively small and/or have resulted in high incidence of dangerously low blood sugar levels. Hence, there is a need for a safe and effective protocol for controlling blood sugar levels to a normal range in order that potential clinical benefits can be successfully studied in this clinical cohort. This thesis adapted a glucose-insulin model successfully used in adult intensive care for the unique physiology and situation of the very premature infant. The model aims to reflect known physiology. As such, sources and disposal of glucose and insulin within the body are examined using both published data and unique data sets from a study here in New Zealand. In addition, the absorption of glucose from milk feeds is examined. This glucose-insulin physiological model is then used alongside statistical forecasting to develop a protocol for selecting an appropriate insulin dose based on targeting of likely outcomes to a specified target normal range. The protocol is tested in silico using virtual trials, and then clinically implemented, with results showing improved performance over current clinical practice and other published studies. In particular, ~77% of blood glucose is observed within the specified target range across the cohort, and there has been no incidence of dangerously low blood glucose levels. This protocol is thus safe and effective, accounting for inter- and intra- patient variability, and thus enabling patient-specific care.

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.

The peer-reviewed journal articles comprising this thesis were published during the modern era of neonatal intensive care from 1973 through 2017. The published work is novel, original, and eclectic because it concerns the neonatal intensive care unit populace: sick newborns, bereaved parents, parents of sick newborns, neonatal nurses, and neonatologists. The types of study and examples of research results are as follows. First, studies of sick newborns that include: (1) clinical case reports, such as the treatment of refractory neonatal seizures with lamotrigine, (2) case series, such as the clinicopathological features of newborns with severe congenital tricuspid incompetence, (3) cohort studies showing, for example, (i) the lack of correlation between blood pressure and blood volume and the negligible beneficial effects of albumin infusion in hypotensive preterm newborns and (ii) the high mortality rate following cardiopulmonary resuscitation for cardiac arrest in a neonatal intensive care unit, and (4) reports of novel procedures and treatments showing, for example, (i) the practicality of peripheral artery cannulation and (ii) the efficacy of dexamethasone in weaning term newborns with pulmonary barotrauma from mechanical ventilation. Second, cohort studies of personality and psychological health showing, for example, (1) proneness to negative self-conscious emotion (guilt and shame) predicts grief in perinatally bereaved parents, (2) proneness to ‘problematic emotions’ (guilt, shame, envy, and jealousy) and fear of death predict grief in reproductively bereaved mothers, (3) proneness to guilt, shame, and fear of death, other facets of personality (e.g., adult attachment styles, assumptive world view schemas, and ways of coping with stress) and neonatal intensive care unit parent stressors predict posttraumatic growth, changes in outlook, and psychological health in parents of sick newborns. Third, a cohort study showing work role stress and perceived social support predict neonatal nurses’ professional quality of life (burnout, secondary traumatic stress, and compassion satisfaction). Fourth, cohort studies of neonatologists showing, for example, neonatologists’ personal fear of death and dying correlates with their care of newborns at the end-of-life.

Introduction - Gastrointestinal tonometry has been widely used in adult practice for the early detection of shock and multi-organ failure. Its application in paediatrics has been limited by unsuitably large tonometers and doubt about the accuracy of measurements when saline is used as a tonometric fluid / vehicle for carbon dioxide (CO₂) equilibration. Objective - To evaluate the accuracy and reliability of the newly developed saline 5 French (5F) neonatal gastric tonometer. Study Design - (a) Direct in-vivo comparison of the 5F 0.9%saline tonometer (NST) with the recirculating gas tonometer (RGT) [the current reference standard in adult practice] in 10 Paediatric intensive care unit (PICU) patients, measuring tonometric PCO₂ (PtCO₂) and gastric intramucosal PCO₂ (PiCO₂). (b) In-vivo comparison of PiCO₂ measurements from two 5F tonometers in 10 PICU patients in unfed and fed state. (c) In-vitro comparison of reference PCO₂ to PtCO₂ values obtained using 0.9%saline and phosphate buffered saline in SF tonometers, and the RGT. Results - (a) Comparing the SF NST to RGT in 50 paired simultaneous measurements over PtCO₂ range 3.0 - 9.7kPa, the mean bias was -1.44kPa; limits of agreements (LOA) ±1.45kPa. The mean values of PtCO₂- derived gastric intramucosal pH (pHi) and PiCO₂-PaCO₂ difference differed significantly by -.11 and + 1.1kPa respectively (p<0.0001). (b) 100 paired 5F NST measurements (50 fed/ 50 unfed) over PtCO₂ range 2.48-11.1kPa were assessed. No significant difference was observed in PtCO₂: mean difference (standard deviation) - unfed 0.05kPa (0.36) (p=0.36); fed 0.05kPa (0.42) (p=0.43). (c) 20 consecutive measurements of PtCO₂ were obtained from the 5F NST, 5F phosphate buffered saline tonometer (PBST) and RGT at constant reference PCOi's of 2.5, 5.0, 7.5, 10.0kPa. The 5F NST underestimated the reference PCO₂ by a mean bias of 58% (LOA ±20%); the 5F PBST by 6% (LOA ±26%); while the RGT performed best with a mean bias of 5.7% and tight LOA ±1.5%. Conclusion - There are inherent problems in the methodology of the saline tonometry utilised in the 5F neonatal gastric tonometer. The use of the saline SF neonatal gastric tonometer to monitor gut perfusion in neonates and children should be interpreted with caution. Recirculating gas tonometry is the most accurate method of tonometry studied.

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.

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.

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.

Thesis (MCUR)--University of Stellenbosch, 2003.
ENGLISH ABSTRACT: South Africa has a proud history of a high standard of health care delivery in State funded hospitals. This implies that high standards of education and care in both medical and nursing training have been achieved. The care of sick and premature newborn infants by nurses is a speciality that has evolved worldwide over the last forty years as a result of various technological developments. In order to ensure the standard of care delivered, protocols of care should be available for nurses to refer to and to measure their work against. There were no protocols of care available in the two Neonatal Units (NICUs) used in this study. Using a non-experimental, exploratory descriptive design, the researcher set about measuring the quality of nursing care in the NICUs. Standards (structure, process and outcome) were written by the researcher, and validated. The results showed that the standards were not met at an acceptable level in various areas. One of the areas of great concern was the lack of effective hand washing. Outcome standards which reflect the consequences of care indicated serious shortages of staff in some cases and insufficient staff training. Recommendations are that a Quality Assurance Program should be introduced with training and education of the nurses working in the NICUs and the introduction of evidencebased practice. Future research should aim at showing the way to improve the service delivered.
AFRIKAANSE OPSOMMING: Suid-Afrika het ‘n trotse geskiedenis van ‘n hoë standard van gesondheidsorgdienslewering in Staatsbefondsde hospitale. Dit impliseer dat hoë standaarde in mediese en verpleegopleiding bereik is. Die versorging van siek en premature pasgebore babas deur verpleegkundiges is ‘n spesialiteit wat oor die afgelope veertig jaar wêreldwyd ontwikkel het as gevolg van verskeie tegnologiese ontwikkelings. Ten einde te verseker dat ‘n hoë standard van sorg gelewer word, moet protokolle beskikbaar wees vir verpleegkundiges om te gebruik en hulle werkverrigting teen te meet. Daar was geen protokolle beskikbaar in die twee neonatale eenhede wat in hierdie studie gebruik is nie. ‘n Nie-eksperimentele, verkennende, beskrywende ontwerp is deur die navorser gebruik om die gehalte van verpleegsorg in die neonatale eenhede te evalueer. Standaarde (struktuur, proses en uitkoms) is deur die navorser opgestel en gevalideer. Die resultate toon aan dat die standaarde in verskeie areas nie aanvaarbaar nagekom word nie. ‘n Kommerwekkende bevinding was die afwesigheid van effektiewe was van hande. Uitkomsstandaarde wat die resultaat van sorg weerspieël, het aangedui dat daar ernstige tekorte aan personeel in sommige gevalle bestaan het asook onvoldoende opleiding van personeel. Aanbevelings is dat ‘n Gehalteversekeringsprogram ingestel behoort te word en met die opleiding van verpleegkundiges werksaam in die neonatale eenhede en evidence-based practice aangespreek moet word. Toekomstige navorsing behoort aan te dui hoe om die diens wat gelewer word, te verbeter.