JOGNN. Safe Use of Opioid Analgesics for Chronic Pain in Pregnancy. Newborn Care. Poster Presentation

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1 Newborn Care Laura McKay, MSN, CNM, Memorial University Medical Center, Savannah, GA Ursula A. Pritham, PhD, WHNP-BC, FNP-BC, Georgia Southern University, Statesboro, GA Sharon Radzyminski, PhD, JD, RN, Georgia Southern University, Statesboro, GA Melissa Garno, EdD, RN, Georgia Southern University, Statesboro, GA chronic pain in pregnancy opioid analgesics neonatal abstinence syndrome Safe Use of Opioid Analgesics for Chronic Pain in Pregnancy To identify safe practices for management of chronic pain in pregnancy. Retrospective chart review. We studied three commonly used opioid analgesics, compared neonatal outcomes for each of the agents, and identified potential contributing factors to the incidence of neonatal abstinence syndrome (NAS). Neonatal outcomes were evaluated for all singletons delivered full term during a 42-month period, whose mothers met inclusion criteria and were taking codeine, hydrocodone, or oxycodone at any dosage three or more times per week. The first phase was the retrospective chart review. Charts for every patient delivered by the perinatology practice for the specified time frame were individually reviewed for appropriateness for the study. Data were manually gathered onto an individual data sheet and de-identified. Once all charts were reviewed and data collected, data were coded and entered into a spreadsheet and analyzed for trends in neonatal outcomes using descriptive statistics. The second phase was to use the information collected combined with available data from other studies to create practice guidelines. Outcomes examined included gestational age at delivery, birth weight, APGAR score, admission to the neonatal intensive care unit (NICU), diagnosis of NAS, length of stay, and treatment required. Maternal demographics were evaluated for any potential impact on neonatal outcome trends. Thirty-one charts met criteria for the study. Nine neonates required a NICU admission. Length of NICU stay ranged from 2 to 10 days with an average NICU stay of 5 days. Two neonates required medical management with methadone. They were the only two with a diagnosis of NAS. Six of the nine were admitted for transient tachypnea of the newborn (TTN) and one was diagnosed as a poor feeder. Baseline data indicated that there is no association between NICU stay and agent used or between specific dosages or use of more than one agent. The study was limited by small sample size and multiple potential contributing factors to observed neonatal outcomes. Obstetric and neonatal nurse and practitioners must become knowledgeable about the use of opioid analgesics in pregnancy. The findings of this study indicate the need for further research but support the judicious use of opioid analgesics at minimum effective doses. Thorough evaluation of the neonate at delivery for signs of NAS and TTN is warranted, and supportive care in a NICU environment can ease the transition to extrauterine life without opioid exposure. JOGNN S74 C 2013 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses

2 Ainsworth, R. M., Maetzold, L., Mog, C., and Summerlin-Long, S. E VIDENCE-BASED Q UALITY I MPROVEMENT R ESEARCH P ROJECTS Ethnically Distinct Ways of Describing Breast Milk Newborn Care Emily M. Olson, University of Pennsylvania School of Nursing, Philadelphia, PA Cindy Sooeun Wee, University of Pennsylvania School of Nursing, Philadelphia, PA Marilyn Stringer, PhD, WHCNP-BC, RDMS, University of Pennsylvania School of Nursing, Philadelphia, PA breastfeeding language education Newborn Care To determine which words or phrases women from three different age groups (12 21, 22 45, 46 and greater) and four different ethnicities (African American, Hispanic, Asian, White) use to describe breast milk. Women greater than the age of 12 and of African American, Asian, White, or Hispanic ethnicity. Through a survey, a total of 216 women were individually asked, How would you complete the following sentence to describe the value of breast milk and breast feeding. Breast milk is like... The women were also asked how they would describe their ethnicity and their age group. Qualitative descriptive design with a survey of women in the maternity ward and outside of the hospital of the University of Pennsylvania, on streets in West Philadelphia, and through an anonymous online survey. We used qualitative descriptive data analysis to identify seven themes for words or phrases that describe breastfeeding: priceless gift, health, nutrition, protection, natural, bonding, and other. The responses were separated by race and then by the response s theme. Within each race, the percentage of responses in each theme varied. Among the Asian and Hispanic respondents, the most popular theme was natural. The most popular theme among White respondents was priceless gift and among African American respondents was nutrition. To effectively communicate the value of breast milk to new mothers, nurses should emphasize that breastfeeding is natural and nutritious. It is also effective to refer to breast milk as a priceless gift, such as liquid gold. The results of this study indicate that it would be ineffective to encourage new mothers to breastfeed by describing the low cost of breastfeeding or by explaining how breastfeeding can help a new mother lose weight. Based on these results, it is apparent that women of different ethnicities use different language to describe the value of breast milk. However, no parallel pattern was identified among women of differing age groups. The implications of this study will be useful to health providers as they teach new mothers about breastfeeding. Minimizing Mother-Baby Separation to Promote Breastfeeding Exclusivity: Closing the Gap in Nursing Practice To implement strategies to increase the time mothers and newborns spend together during postpartum hospitalization and ultimately increase the rate of breastfeeding exclusivity. This project was implemented in a regional perinatal and neonatal referral center of a Magnet designated community teaching hospital. Care is provided to more than 3,000 mother newborn dyads per year. Roxlyn E. Maugans, MSN, RN, NE-BC, Wellspan Health, York, PA Barbara L. Buchko, DNP, RN, York Hospital, York, PA Connie H. Gutshall, MS, RN, NE-BC, York Hospital, York, PA A pre- postintervention design was used to measure rate of breastfeeding exclusivity, breastfeeding immediately following birth, and time newborns spent in the nursery before and after implementation of strategies to minimize mother baby separation. Nursery census was monitored during the hours of 11 p.m. and 7 a.m. pre- and postimplementation to determine progress toward nonseparation. Breastfeeding exclusivity and time to first feeding were also evaluated for improvement pre- and postimplementation. JOGNN 2013; Vol. 42, Supplement 1 S75

3 A multidisciplinary perinatal team used Lean Six Sigma methodology to decentralize newborn care: (a) portable equipment was purchased for assessing newborns at mother s bedside; (b) change in documentation providing more detail about newborn feeding methods; and (c) mandatory education was provided to nurses about the change in clinical practice. There has been an overall increase (54%) in rooming-in during hospitalization. Newborns breastfeeding within 1 hour postvaginal birth has steadily increased to 96%. Breastfeeding exclusivity rate has shown an increase of 38%. Research evidence supports that newborns who room-in with their mothers are more likely to be exclusively breastfed at discharge compared to newborns that have been separated from their mothers. Rooming-in of mothers and newborns has been found to improve breastfeeding, produce milk sooner and in more abundance, and improve mother s attention to their newborn needs resulting in less newborn crying. Professional organizations and regulatory agencies worldwide recognize breast milk as the ideal food for newborns recommending exclusive breastfeeding for its health benefits. Research has identified that hospital practices affect breastfeeding duration and exclusivity throughout the first year of life. At our hospital, mothers and newborns were separated during the first 2 hours of birth, for newborn assessments and procedures, and at mother s request. Separating mothers from their newborns creates missed opportunities for recognizing feeding cues in which a nurse could be readily available to teach and provide support for breastfeeding. Decentralizing newborn care to support nonseparation provides the opportunity for nurses to close the gap and champion breastfeeding exclusivity during hospitalization. breastfeeding rooming-in nonseparation Protecting Our Littlest Patients: A Newborn Falls Prevention Strategy To reduce and prevent newborn falls at Huntsville Hospital for Women and Children. Mother/baby patients and staff. There were seven newborn falls during a 7-month time period on the hospital s postpartum unit. After the first falls, the unit formed a committee to create a policy on newborn fall prevention and to develop education and tools for family members and staff to decrease the incidence of infant falls/drops. Committee members used information from review of the seven falls events, from a comprehensive literature review on newborn falls, and from information collected by the unit s Nurse Manager from other hospitals with similar numbers of deliveries. As a result of the committee s work, the following interventions targeting family members have currently been implemented: information on newborn falls added to safety instruction sheet read to, given to, and signed by parents at admission: new crib cards with information on falls prevention; room posters and mirror clings with falls information created; and falls information to be added as a crawl on unit s Newborn Channel. Parents are also educated on newborn falls during childbirth classes. Strategies targeting staff members include staff education on falls through a mandatory class, s, staff meetings, and unit flyers; a new Fall Risk Assessment Tool added to charting system; and a Newborn Post-Fall Debriefing Form created for use after fall events. The Newborn Falls Policy is now in use and includes protocol for parental education, infant transport, placement of infant for sleeping, review of maternal medications, assessment of environment and mother s level of consciousness, and actions for preventing falls during infant feedings. In addition, Falls Committee staff members are meeting with pediatricians who see patients at Huntsville Hospital to plan a unified protocol for physician response to newborn falls. No newborn falls have occurred in the time period since the implementation of this comprehensive falls prevention strategy. The issue of newborn falls (drops) in the hospital is one that has only been recognized as a problem in recent years. With little in the literature to provide evidence-based guidelines for a uniform healthcare policy response, hospitals are developing their own strategies to reduce and prevent Rose Mary Ainsworth, RN, MSN, Huntsville Hospital for Women and Children, Huntsville, AL Linda Maetzold, RNC, MS, LCCE, Huntsville Hospital for Women and Children, Huntsville, AL Cathy Mog, RN, Huntsville Hospital for Women and Children, Huntsville, AL Shelley Summerlin-Long, RN, MPH, MSW, Huntsville Hospital for Women and Children, Huntsville, AL newborn falls patient safety staff and patient education Childbearing S76 JOGNN, 42, S74-S78; DOI: /

4 Bailey, B. A., McGrady, L., McCook, J. G., and Greenwell, A. E VIDENCE-BASED Q UALITY I MPROVEMENT R ESEARCH P ROJECTS newborn falls. Other hospitals seeking to reduce and prevent newborn falls may learn from the experience of Huntsville Hospital in its newborn falls initiative. Nursing Sensitive Quality Indicators in the Perinatal Setting Professional Issues Christina S. Wical, MS, RN, WHNP-BC, VCU Medical Center, Richmond, VA HeatherL.Hable,RNC,VCU Medical Center, Richmond, VA Brenda Baker, PhD, RNC, CNS, Virginia Commonwealth University Health System, Richmond, VA dashboard quality indicators labor and delivery perinatal To develop a nursing sensitive quality indicator in the perinatal setting. Random sampling of patients from a labor and delivery (L&D) unit at a large urban teaching hospital. A review of literature on nursing sensitive quality indicators revealed limited recommendations specific to L&D. Indicators were identified from a review of hospital wide indicators, Institute for Health Improvement (IHI) evidenced-based care bundles, national trends, and event reports with relevance to L&D. The unit-based Nursing Quality Committee developed the following dashboard of indicators for the perinatal setting: retained material after vaginal or cesarean deliveries, perinatal falls, maternal and neonatal hypothermia, placement of newborns skin-to-skin following vaginal and cesarean deliveries, induction/augmentation safety, surgical safety, assessment of risk for skin breakdown, and management of tachysystole associated with the use of oxytocin. Data are collected monthly through retrospective chart reviews. Benefits of perinatal specific indicators include transformational leadership; engagement of staff in data collection that is meaningful to practice; and data-driven decision making. Data included in the L&D Quality Dashboard have been used to guide the purchase of new equipment for the unit, facilitate design of a new L&D Suite, develop interdisciplinary simulation training, and initiate a nursing research project related to falls in the perinatal population. Perinatal areas have struggled to identify nursing sensitive indicators that are meaningful and representative of the care provided in this specialty. National indicators and benchmarks have primarily focused on topics common in the medical/surgical and critical care areas of nursing. In an effort to measure and improve the valuable care provided in L&D, the unit based Nursing Quality Committee at an urban teaching hospital developed an L&D Quality Dashboard of indicators that are specific to perinatal nursing care. The L&D Quality Dashboard is a dynamic tool that has improved communication between staff, leadership, and administration. It has empirically guided decision making and promoted accountability at the bedside and in the boardroom to transform practice in the perinatal setting. Educating Nursing Students on Issues Related to Smoking during Pregnancy to Improve Regional Intervention Efforts Beth A. Bailey, PhD, East Tennessee State University, Johnson City, TN Lana McGrady, MS, East Tennessee State University, Johnson City, TN Judy G. McCook, PhD, CNS, RN-BC, East Tennessee State University, Johnson City, TN Audry Greenwell, PhD, APRN, East Tennessee State University, Johnson City, TN To implement and evaluate training session related to smoking during pregnancy for baccalaureate nursing students in rural Southern Appalachia. Nursing students attended training on dangers and intervention techniques related to smoking during pregnancy. Third year students beginning clinical rotations in obstetrics. One and one half hour training including pre- and post tests. Four months later, a follow-up survey assessed gains in knowledge, skill, comfort, and willingness to address smoking during pregnancy. During seven semesters, 659 nursing students were trained. Substantial gains in knowledge of issues related to smoking during pregnancy were seen from pre- to post testing, and knowledge JOGNN 2013; Vol. 42, Supplement 1 S77

5 was retained at 4-month follow-up. The percentage of students who felt they lacked skills to intervene with pregnant smokers dropped from 39% at pretest to 6% at same day post test. In addition, the percentage who reported they would be uncomfortable talking with pregnant women about smoking dropped from 10% to 1%; the percentage who indicated they would always make time to address smoking with pregnant women increased from 54% to 87%. While most students did address smoking with multiple pregnant patients during clinicals, and more than half felt the patients benefited from their actions, only 58% were confident in their intervention skills at 4-month followup. Finally, 83% felt the training had been beneficial, and more than 90% committed to addressing smoking with pregnant patients once they graduated. Rates of smoking during pregnancy in the rural South are twice as great as national averages and contribute to poor birth and long-term outcomes for affected women and children. Efforts to intervene during prenatal care with pregnant women have been hampered by lack of knowledge, skill, comfort, and commitment from prenatal providers and their nursing staff. Regional community providers and staff have been reluctant to participate in available trainings, and even those who do seldom exhibit attitude and practice change long term. Therefore, efforts to educate healthcare professionals on the dangers of smoking during pregnancy and to provide necessary skills for intervention efforts may need to occur before students enter practice, and ongoing education may be needed to promote skills and confidence long term. In the rural South, where smoking rates are high and provider efforts to address pregnancy smoking are inconsistent, educating future nurses could have substantial impact on rates of smoking during pregnancy and birth outcomes into the future. smoking during pregnancy nursing student training pregnancy intervention Professional Issues S78 JOGNN, 42, S74-S78; DOI: /