Authors (including presenting author) :
Chan SY(1), Chau Janita(2), Siu KL(1), But Betty(1), Yeung, YM Iris(1), Cheung SY(1), Ng CP Janice(1), Chau, KY Doris(1), Leung MY(1), Yung YT(1), Chu Tommy(1)
Affiliation :
(1) Department of Paediatrics, Queen Elizabeth Hospital, (2) The Nethersole School of Nursing, The Chinese University of Hong Kong
Introduction :
Most of the preterm infants admitted to a neonatal intensive care unit (NICU) have respiratory distress and need different level of respiratory supports including supplemental oxygen and mechanical ventilation. Recently, noninvasive ventilation (NIV) becomes the mainstay of the ventilation strategy in NICUs, especially for the preterm infants. NIV provides similar invasive ventilation backup to infants but minimises the complications of ventilation-induced lung injury arisen from invasive ventilation. Nevertheless, complication of NIV device-related pressure injury was common, the incidence of nasal injury ranged from 20% to 60%. The smaller the gestation age of the infants, the higher risk for occurrence of the complications.
Previous studies focus on evaluating the efficacy of NIV in managing respiratory problems such as respiratory distress syndrome and apnea of prematurity in infants. Limited studies were found evaluating the nursing care of preterm infants receiving NIV.
Objectives :
This study aims to develop an evidence-based clinical practice guideline for preterm infants receiving NIV, implement the guideline in a NICU of a regional hospital, and evaluate infant outcomes including comfort, incidence of NIV device-related pressure injury in NICU. The objectives of the study were as the followings:
1. to assess any change in the incidence of NIV device-related pressure injury and comfort level (in term of calm time, pain score and haemodynamic data) in infants whilst receiving NIV before and after implementation of the guideline
2. to assess any change in nurse's NIV knowledge and their practice in caring of preterm infants receiving NIV after received a nurse training program on the new clinical practice guideline
Methodology :
A before and after study design was adopted and included the pre-implementation phase (before group) and post-implementation phase (after group). Prior to the pre-implementation phase, an integrative review was conducted to identify relevant studies from eight electronic databases. All studies meeting the inclusion criteria were appraised using the Johns Hopkins University’s evidence appraisal tool to assess the level of evidence level and its quality. The workgroup discussed and reviewed the evidence, then developed the evidence-based clinical practice guideline (the guideline) applicable to NICU.
A nurse training program regarding the care in the guideline was provided to all nurses working in the NICU for a month after the guideline was established. This program included 3 parts as face-to-face small group lecture on care bundle in the guideline, a video demonstration on application of selection and application of NIV devices, and a scenario-based practice related to common causes for pressure injury or discomfort in infants whilst receiving NIV. After completion of the training, the guideline was commenced to implement in the NICU.
Infants receiving NIV in NICU were recruited to the study whereas infants had severe clinical conditions including congenital heart disease, respiratory failure, congenital crano-facial abnormalities, and skin problems were excluded to the study. Written consent from parent of the eligible infants was obtained after explanation of the study's details and given an information leaflet to them. After that, data collection on infants regarding their demographic information, clinical information and intervention provided during NIV was begun.
Moreover, nurses' NIV care knowledge was tested before, immediate after the lecture and 12-week after the training. In addition, NIV care bundle audit was conducted before, 12-week and 24-week after implementation of the guideline in NICU.
Ethical approval from the University and the hospital were obtained before the study.
Result & Outcome :
The guideline was established including six core elements: choice of nasal interfaces; regular alternating the interfaces; use of skin protective dressing; regular positioning infant in non-prone positions; regular skin assessment on the nasal areas and pain level; and other supportive care in keeping ventilator circuit warm and humid; drying up condensate inside the interfaces, and decompressing the stomach regularly.
A total of 74 infants of mean gestation age at 31.7 weeks (SD 2.74 weeks), mean birth weight in 1613.92 grams (SD 502.81 grams) were recruited in before group, and 67 infants of mean gestation age at 32 weeks (SD 2.96 weeks), mean birth weight in 1717.61 grams (SD 529.96 grams) were recruited in after group.
There were 50% of infants in before group and 19.4% of infants in after group found with NIV device-related pressure injury. Between group comparison of incidence was performed by using logistic regression model, and infants in after group had a decreased odds of acquiring pressure injury (odds ratio=0.149 (95% CI 0.045, 0.495), p=0.002) after adjusted for all covariates found with significant differences between groups. Infant’s calm state in the two groups was compared by generalized linear model, and the mean difference of calm state in infants in after group decreased to 3.53 hours (95% CI: -5.15, -1.92) less than infants in before group. As N-PASS was only used in after group that subgroup comparison between infants with and without pressure injury in the after group was performed by independent t-test, and pain score in infants without pressure injury was clinically found less than the infants with pressure injury (p=0.624). Therefore, improvement in comfort level in infants of after group was not determined.
Regarding nurses’ NIV knowledge: mean scores of pretest (8.68), immediate posttest (9.32), and 12-week posttest (9) were compared by paired t-test (adjusted with Bonferroni correction), and found significant differences in scoring between pretest and immediate posttest (p< 0.001), and significantly declined in mean score between immediate and 12-week posttest (p=0.024).
Mean compliance rate of audits performed in Pre-implementation phase (0.82), and 12-week (0.97) and 24-week (0.93) after the guideline implementation were compared by one-way ANOVA (adjusted with Bonferroni correction), and significant differences were found at 12-week (p< 0.001) and 24-week (p< 0.001) in comparison with the baseline compliance rate in the pre-implementation phase.
