Kangaroo care (KC), or skin-to-skin care, occurs when an infant is dressed in a diaper and held to a parent's bare chest. This form of holding has been shown to have many benefits for hospitalized infants, including enhanced physiologic stability, increased weight gain, decreased length of stay, and decreased risk of hospital-acquired infection (Gazzolo, Masetti, & Meli, 2000; Harrison & Brown, 2017; Moore, Bergman, Anderson, & Medley, 2016). Kangaroo care has also been shown to improve outcomes for mothers including decreased postpartum depression, increased maternal milk production, and improved parent–infant attachment (Ludington-Hoe, 2011; Moore et al.). Children's Hospital of Philadelphia has a predominant strong human milk and breastfeeding culture that includes KC as routine care in all units caring for infants (Martino, Wagner, Froh, Hanlon, & Spatz, 2015; Spatz, 2004, 2018). Children's Hospital of Philadelphia has had a procedure and instructional DVD in place for skin-to-skin transfer of the intubated infant since 2005. Despite availability of resources and our hospital's strong human milk and breastfeeding culture, routine KC was not integrated into standard care for hospitalized infants with congenital heart disease (CHD) in our cardiac center, which is composed of a cardiac intensive care unit (CICU) and a cardiac step-down unit (CCU). Research in our cardiac center has found almost all parents initiate pumping for their infants and the majority of infants receive human milk through a feeding tube or a bottle (Torowicz, Seelhorst, Froh, & Spatz, 2015). Experts have called for integration of family-centered, developmental care interventions, such as KC, into standard care for infants with CHD (Harrison, 2019; Lisanti et al., 2019; Peterson, 2018; Torowicz, Lisanti, Rim, & Medoff-Cooper, 2012). In a survey of 28 CICUs in North America, all sites reported allowing infant holding during the infant's CICU admission and 57% reported they encouraged KC (Sood et al., 2016). Several pilot studies have established feasibility and safety of KC as an intervention for infants with CHD after cardiac surgery (Gazzolo et al.; Harrison & Brown; Harrison & Ludington-Hoe, 2015). Although emerging evidence suggests KC promotes cognitive development and autonomic functioning of infants with CHD (Harrison & Brown; Harrison, Chen, Stein, Brown, & Heathcock, 2019), we did not find published evidence of feasibility of unit-based integration of KC in cardiac centers.
Infants born with critical CHD are often separated from their parents immediately after birth to receive life-saving care in our CICU, including cardiac surgery in the first few days of life (Lisanti, Golfenshtein, & Medoff-Cooper, 2017). A critical window is missed for early initiation of parental bonding and breastfeeding. Fragility of infants with CHD who need surgery in the first few weeks of life requires intensive care in the pre- and postoperative periods, with the use of a multiple lines, tubes, wires, medications, interventions, and technologies (Lisanti et al., 2019). Intensity of care creates many barriers hindering initiation of KC between infants and parents (Sood et al., 2016). Nurses may not be comfortable identifying patients to safely implement KC at the bedside or understand the process or method to perform the intervention. Infant holding via KC may increase risk of dislodgement of lines (Torowicz et al., 2012). Nurses in our cardiac center created holding and mobility guidelines to support a more consistent and standard approach to infant holding (Torowicz et al.). The guidelines provide specific information about which lines, tubes, and wires are considered safe for infant holding in the cardiac center. Although our team was able to demonstrate safe holding of infants after cardiac surgery, we were unable to examine KC documentation in the electronic health record because no field existed for nurses to enter these types of data. However, our team anecdotally witnessed much less frequent KC after cardiac surgery than infant holding in the other units.
In January 2018, the lead author (AJL) launched a KC research project in our cardiac center for infants undergoing cardiac surgery. This provided a unique opportunity to have the unit-based nurse scientist partner with staff nurses to launch a separate quality improvement (QI) initiative to address barriers, provide education, and foster increased translation of KC into practice in the cardiac center. Nurses from the CICU and CCU formed a KC QI committee under the mentorship of the lead author to create strategies to support use of KC as a nursing intervention for infants and their parents before and after cardiac surgery. The committee met monthly, over 6 months, to launch the following initiatives:
- Create an additional nursing policy and procedure on KC for infants with a natural airway to provide more general guidelines for infants in the cardiac center.
- Adapt the electronic health record (EHR) to facilitate KC documentation.
- Educate nurses about KC through formal group presentations and peer-to-peer, in-person education by members of the KC committee.
- Encourage translation into practice through the cardiac center's Kangaroo-A-Thon, giving nurses a chance to win a prize basket for initiating and documenting KC with an infant and parent.
This project followed Squire 2.0 guidelines and did not overlap, disrupt, or impact the KC research study that was ongoing in the cardiac center during the same time frame (Ogrinc et al., 2016).
A nursing standard and procedure on KC was created in July of 2018 that added to the procedure and resources in place at Children's Hospital of Philadelphia (Table 1). The procedure directly linked to the cardiac center's holding guidelines to help nurses determine KC eligibility, safety considerations, and best practices for patients. The EHR was updated to include specific fields in the holding and positioning nursing flowsheets for documentation of KC, including fields to note who participated in KC and for how long. Nursing education on the new standard and EHR documentation was completed between August and September 2018. Nurses were provided with slide presentations via email and in person, and just-in-time teaching was done at the bedside by members of the KC committee. The lead author modeled KC practice to the staff nurses as she personally facilitated KC between infants and mothers in the cardiac center through her separate KC research project in the cardiac center. The unit-based nurse scientist oversaw KC intervention occurring for her study and used this opportunity to teach staff nurses about benefits of KC. This was an opportunity to reinforce to the nurses all of the policies and procedures that are available on our internal Web site (Froh & Spatz, 2016).
A Kangaroo-A-Thon was initiated for 8 weeks from October to November 2018 to promote the translation of KC into practice through an exciting and novel nursing engagement strategy. The Kangaroo-A-Thon gave nurses from each unit a chance to win a prize basket for initiating KC with their patient and parent and documenting it in the EHR. Each time nurses in the units independently supported KC on their own (and not for the lead author's research), they could enter the unit's raffle. The more times nurses initiated KC, the greater their chances of winning. Education was repeated often and frequent emails were sent reminding and encouraging nurses to participate. Members of the KC committee helped bedside nurses identify candidates for KC and provided just-in-time teaching for KC as needed. Data were collected from the raffle to identify the number of nurses and patients who participated in the Kangaroo-A-Thon and documentation was confirmed in the EHR. After the conclusion of the Kangaroo-A-Thon, nurses who entered the raffle were approached by members of the KC QI committee and asked an open-ended question about how they felt their experience was participating in the Kangaroo-A-Thon. Responses were collated by the KC QI committee.
Safety is continuously monitored in our cardiac center through adverse event reporting. Adverse events are any unplanned event occurring with a patient, such as line or tube dislodgements. These events were monitored after the institution of the new policies as well as during the Kangaroo-A-Thon.
Results of the Kangaroo-A-Thon
Twenty-six nurses initiated KC 43 times with 14 patients over the 8-week period for the Kangaroo-A-Thon (Table 2). Three patients were held in both the CICU and the CCU after being transferred out of critical care. Kangaroo care was initiated more times on day shift (n = 29) than on night shift (n = 14). Kangaroo care was initiated more times in the CCU (n = 28) than the CICU (n = 15). No adverse events were reported as a result of infants being held by their parents in KC.
Nurses who participated in the Kangaroo-A-Thon provided positive feedback. Nurse comments included It was amazing to see how my patient's vitals really did improve with skin-to-skin! My patient was a pre-operative critical coarctation who was having hypotension earlier in the morning. When doing skin-to-skin his blood pressure was as robust as it had been all day (CICU nurse). Nurses from the CCU offered these responses The Kangaroo-a-Thon shed light on a tool we as nurses had in our back pockets all along. Skin-to-skin is medicine our babies need to promote healing... I will definitely be using this tool in my everyday practice and I think in all the hustle and bustle of the hospital, it's so important to take the time to nurture and cuddle an infant in need, in pain, or just in general to help them grow. And the Kangaroo-A-Thon promoted that skin-to-skin that all babies need.
This project describes our unit-based initiative to support KC for infants admitted to the cardiac center for CHD who require cardiac surgery. Similar to recent studies on KC in infants after cardiac surgery (Harrison & Brown, 2017; Harrison & Ludington-Hoe, 2015), the project found KC is safe and feasible in this patient population, but highlighted that standards and procedures are needed to support translation of KC into practice in a cardiac center. Nurses in the CCU had more opportunities to place patients in KC with their parents than in the CICU, most likely due to increased physiologic stability and less invasive lines present (Sood et al., 2016). In the CICU, infants are more often unstable hemodynamically and frequently have multiple tubes, lines, and wires present (Lisanti et al., 2019). Infants in our CICU are often in open bay-style rooms where parents are unable to sleep overnight at the bedside. This may have contributed to KC occurring more frequently on day shift than night shift.
Nurses who participated in the Kangaroo-A-Thon in both the CICU and CCU described positive experiences. Although we did not directly measure patient outcomes or hemodynamic stability for this QI project, nurses commented on the physiologic benefits that they noticed while their patients were in KC and no adverse events occurred. Nurses found the Kangaroo-A-Thon to be a helpful event to increase awareness of KC, the new standards and procedures, and to remind nurses in the cardiac center to promote KC between their neonatal patients and parents.
Our hospital has had a nurse researcher in lactation (senior author DLS) in place since 2001. Nurses at Children's Hospital of Philadelphia have the opportunity to take a 2-day intensive course on human milk and breastfeeding, The Breastfeeding Resource Nurse course (Spatz, Froh, Flynn-Roth, & Barton, 2015), which addresses importance of KC for critically ill infants. This model has published research outcomes on the impact of nurses providing care to families including KC (Spatz et al.). Breastfeeding Resource Nurses articulated the importance of the course in empowering them to be able to provide evidence-based lactation care and support including the provision of KC. For nurses in the Neonatal Intensive Care Unit and the Special Delivery Unit, the Breastfeeding Resource Nurse course is mandatory. The cardiac center cares for pediatric patients across all age ranges from infancy to young adults, which creates a unique challenge to ensure that all nurses have expertise in mother–baby care, which is a main focus in the Neonatal Intensive Care Unit and Special Delivery Unit. Both CICU and CCU nurses need to be adept at caring for a wide range of populations; therefore, the orientation needs and priorities are different.
This QI project was led by a unit-based nurse scientist (lead author). With the lead author conducting research in the cardiac center, it created a unique opportunity to reengage nurses about importance of KC. The study served as a catalyst for practice change in the unit. The launch of the research study allowed the unit-based nurse scientist to engage staff nurses in a mentoring relationship. This led to the local QI initiative that facilitated unit-based procedure development, education, and grassroots interventions. Hospital-based nurse scientists who are embedded within a clinical practice setting are well positioned to support reduction of the research-to-practice gap and enhance implementation of evidence-based practice (Brant, 2015).
This local project was conducted in one cardiac center, with a small sample, limiting generalizability to other hospitals. We did not gather data on incidence of KC prior to the Kangaroo-A-Thon because of inability to extract data from charts, because a place for EHR documentation did not exist. Therefore, results should be interpreted with caution because they only reflect the amount of KC that occurred during the period of the Kangaroo-A-Thon. The small sample does not allow wide inferences about safety in infants with CHD before and after corrective surgery; however, our findings are consistent with other studies about safety of KC for newborns in general. More QI data are needed to determine whether the interventions for this project will support sustainable culture change and increased frequency of KC in the cardiac center. We acknowledge that the ongoing research project being conducted by the lead author most likely enhanced the educational opportunities of nurses and their exposure to KC. We cannot separate the impact of the nurse scientist's study from the efforts of this QI project. However, we believe the synergistic effect of a unit-based nurse scientist conducting research while modeling, mentoring, and supporting staff to lead a QI project is a novel model to support inquiry and innovation in our current era.
Our initiative provided preliminary evidence that KC can be safely integrated into standard care in cardiac centers that care for infants with CHD. More data with larger samples are needed to confirm these results. Formal standards and procedures, combined with nursing education and creative initiatives such as a Kangaroo-A-Thon, can foster translation of KC into practice for this patient population. These standards and procedures can serve as an example to other cardiac centers and provide additional evidence of feasibility of integrating KC as a nursing care standard for infants with CHD. Future QI initiatives can also evaluate whether the consistent provision of KC according to standards improve patient outcomes such as reducing hospital length of stay or rates of hospital-acquired infections, as has been shown in other neonatal populations. Experience of parents of infants with CHD as well as pediatric cardiac nurses caring for this fragile population should be examined in future studies.
Dr. Lisanti was supported by NINR T32NR007100 as a Ruth L Kirschstein Postdoctoral Fellow at the University of Pennsylvania School of Nursing during this work. The Skin to Skin Holding study referred to in this manuscript was funded by a grant to Dr. Lisanti from the American Nurses Foundation, Association of periOperative Registered Nurses, and Stryker.
- Kangaroo care has been shown to have many benefits and to improve outcomes for hospitalized infants and their parents; thus for these fragile infants with congenital heart disease, the therapy may be especially valuable.
- Even with multiple lines, tubes, wires, medications, and interventions, kangaroo care can be accomplished in the context of a clinical protocol and care guidelines.
- We found kangaroo care to be a feasible intervention to support infants with congenital heart disease before and after cardiac surgery and their parents.
- Development of formal standards and procedures for KC of infants with congenital heart disease is essential to support translation of KC into practice in cardiac centers.
- Creative strategies to engage nurses, such as a Kangaroo-A-Thon, may be effective to enhance awareness of KC as an intervention and increase its use in a cardiac center.
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