OUT WITH THE OLD TERM-INOLOGY
Perinatal healthcare professionals have traditionally used the word “term” to apply to infants born from 3 weeks before until 2 weeks after the 40-week gestation mark. Infants born during this 5-week span were generally thought to have the same good outcomes. However, the evidence increasingly shows that lumping all of these infants together is not appropriate, because the outcomes of infants born 3 weeks before “term” (37 weeks) can be significantly different from those born at 40 weeks.
The American College of Obstetricians and Gynecologists Committee on Obstetric Practice and the Society for Maternal-Fetal Medicine convened a workgroup to consider the definition of the term pregnancy.1 This group recommends that the label “term” be replaced with the following designations:
- Early term: 37 weeks through 38 weeks and 6 days;
- Full term: 39 weeks through 40 weeks and 6 days;
- Late term: 41 weeks through 41 weeks and 6 days; and
- Postterm: 42 weeks and older.
The full committee opinion, “Definition of Term Pregnancy,” is available on the American College of Obstetricians and Gynecologist's Web site at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Definition_of_Term_Pregnancy.
For the best possible care and communication between neonatal, obstetric, and pediatric providers, it is important to have uniformity in the terminology used to characterize our patients. Use of the same language will also improve conformity in clinical research and public health reporting of birth statistics and outcomes. Neonatal nurses should endeavor to adopt the new, more specific terminology when speaking or documenting the care of the newborn.
1. American College of Obstetricians and Gynecologists. Definition of term pregnancy: committee opinion no. 579. Obstet Gynecol. 2013;122:1139–1140.
RETHINKING PRIVATE NEONATAL INTENSIVE CARE UNIT ROOMS
Private rooms for infants in the neonatal intensive care unit (NICU) have become common, almost becoming a standard of care. Many benefits for infants and families were anticipated, such as reduced exposure to noise and light, more privacy, more space, and improved infection control. We did not necessarily need a lot of studies to tell us that private rooms were better for the babies.
Or, did we? A recent study1 calls into question the commonsense view that private rooms are better for infants than the traditional ward-style NICU. This particular study evaluated associations between NICU room type (open ward and private room) and medical outcomes; neurobehavior, electrophysiology, and brain structure at hospital discharge; and developmental outcomes of the infants at 2 years of age.
This prospective longitudinal cohort study enrolled 136 preterm infants (<30 weeks' gestation) from an urban, 75-bed level III NICU from 2007 to 2010. Each infant was admitted to a bed space in an open ward (containing 8-12 beds) or private room (according to space and staffing availability) and remained in that room for the duration of hospitalization. It was standard practice in the NICU to dim overhead lights, cover incubators, and attempt to minimize noise. The primary outcome was developmental performance at 2 years of age (86 infants returned for testing, which was 83% of the survivors). Secondary outcomes included neurobehavior and cerebral maturation assessed by magnetic resonance imaging and amplitude-integrated electroencephalography.
They found that at term equivalent age, the private room infants showed reduced normal hemispheric asymmetry and a trend toward lower amplitude-integrated electroencephalography cerebral maturation scores (P = .02). At the age of 2 years, private room infants had lower language scores (P = .006), a difference that was even more pronounced in infants with moderate-severe cerebral injury. Private room infants also exhibited a trend toward lower motor scores (P = .02) and significantly higher arousability scores than open ward infants.
The investigators concluded that their findings highlight the need for further research into the potential adverse effects of different amounts of sensory exposure in the NICU environment. They raise the possibility that the relative “sensory deprivation” of a private room might explain the differences in the study groups. They acknowledge that parental visiting and holding in their urban NICU might have been below average, although controlling for parental visitation and holding in the NICU, did not alter the findings. Still, it is impossible to know from this study whether higher levels of parental interaction, particularly vocalization, might be able to counteract the relative sensory deprivation of a private room.
Pineda RG, Neil J, Dierker D, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments [published online ahead of print October 9, 2013]. J Pediatr.
PEDIATRIC PALLIATIVE CARE
Pediatric palliative care programs are becoming more common in children's hospitals, a positive development. A recent survey1 found that approximately 70% of children's hospitals have pediatric palliative care programs, although there is marked variation in how the programs operate, suggesting a need for formal guidance on how to deliver high-quality pediatric palliative care.
A new guideline from the American Academy of Pediatrics2 is a timely and welcome response to this need. The goal of pediatric palliative care is to relieve suffering, improve quality of life, facilitate informed decision-making, and assist in care coordination. It should be patient-centered and family engaged, respecting and partnering with patients and families. Among the principles of high-quality pediatric palliative care outlined in the guidance document are the following:
- Hospitals and health care organizations that frequently care for children with life-threatening illness and routinely provide end-of-life care should have dedicated interdisciplinary specialty teams to address physical, psychosocial, emotional, practical, and spiritual needs of the child and family.
- Palliative/hospice care should involve various modes of integrated care: cure-seeking, life-prolonging (when in the child's best interest), and comfort-enhancing.
- Specialists should facilitate clear, compassionate discussions with patients and families and support them through the process.
- Psychological and bereavement counselors should be available to help siblings express their thoughts and emotions.
- All health care professionals should be supported via peer-to-peer discussions, debriefings, and other counseling and educational programs.
- Institutional policies should address ethical considerations on topics such as withdrawal of life-sustaining medical treatment and the relief of severe symptoms.
1. Feudtner C, Womer J, Augustin R, et al. Pediatric palliative care programs in children's hospitals: a cross-sectional national survey [published online ahead of print November 4, 2013]. Pediatrics. 2013;132:1063–1070.
2. Section on Hospice and Palliative Medicine and Committee on Hospital Care. Pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatrics. 2013;132:966–972.
WHAT IS A CLINICAL NURSE LEADER?
The clinical nurse leader (CNL) is a master's educated nurse, prepared for practice across the continuum of care within any health care setting in today's changing health care environment. According to the American Association of Colleges of Nursing, which originally developed the role, a CNL oversees the care coordination of a distinct group of patients and actively provides direct patient care in complex situations. The CNL puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery. The CNL evaluates patient outcomes, assesses cohort risk, and has the decision-making authority to change care plans when necessary. The CNL is a leader in the healthcare delivery system, and the implementation of this role will vary across settings.
A new document from the American Association of Colleges of Nursing, Competency and Curricular Expectations for Clinical Nurse Leader Education and Practice, delineates the entry-level competencies for all CNLs. The document also includes a curriculum framework and clinical/practice expectations for CNL programs. These components provide the basis for the design and implementation of a master's or postmaster's CNL education program and prepare the graduate to sit for the Commission on Nurse Certification CNL Certification Examination.
PREVENTING CLABSI: TAKE OUT THE PICC
A new study1 suggests that a good strategy to prevent central line–associated bloodstream infections (CLABSIs) in neonates is to remove the catheter after no longer than 2 weeks, if possible.
To assess the daily risk for CLABSIs associated with catheter dwell time, Milstone and colleagues1 conducted a multicenter retrospective cohort study looking at 3967 patients who had a total of 4797 peripherally inserted central catheters (PICCs) placed between 2005 and 2013. Of 89,946 catheter-days, 149 CLABSIs were diagnosed (incidence 1.66 per 1000 catheter-days).
In adjusted analysis, the average predicted daily risk for CLABSI after PICC insertion increased during the first 2 weeks after PICC insertion and remained elevated for the dwell time of the catheter. Dwell times longer than 2 weeks were associated with a higher risk for CLABSI than shorter dwell times. CLABSI risk was increased in neonates with concurrent PICCs, and the incidence of gram-negative CLABSIs was higher in PICCs with dwell times greater than 50 days.
The researchers recommend that clinicians should review PICC necessity daily, optimize catheter maintenance practices, and investigate novel CLABSI-prevention strategies in PICCs with prolonged dwell times.
1. Milstone AM, Reich NG, Advani S, et al. Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study [published online ahead of print November 11, 2013]. Pediatrics. 2013;132:e1609–e1615.