Transcript Slide 1

Keeping Mother
and Baby Together:
Make it Simple
Cynthia A. Eckert, RN-C, MSN, CNS
May, 2011
Goal
The overall goal is to keep the
baby and the mother together
at all times unless there is a
medial reason for separation
Why is there a problem?
We are all aware of the literature
concerning need to keep the mother
and baby together to increase the
facilitation and success of breast
feeding.
Problem
So, what is the problem?
Why can’t we manage to accomplish
that one little goal of keeping the
mother with the baby?
Process
In 1997, our management team made
the decision to change from the
traditional practice model to the
family centered care model based on
the work of Celeste Phillips.
We did all the normal things one would do when making such a big
change.
•We brought administration on board
•We brought in Celeste Phillips’ management group to assist us.
•We conducted staff attitude and knowledge surveys
•We taught everyone about change theory
•We educated staff members to teach the didactic classes to the
nursery, post partum and labor and delivery staff.
• We held LOTS of classes and educated staff
• We had a model unit where we partnered the
postpartum nurse and the nursery nurse together to
care for a couplet
• We prepared the L&D nurses to care for the newborn
at delivery
• We worked with the pediatricians to answer their
concerns and questions
• We redeveloped staffing grids and scheduling
patterns.
In 1998, we officially became a Mother/Baby unit that
practiced couplet care.
We had the usual problems:
Push back from physicians, nurses, and mothers.
We held firm and kept up with the latest evidence based
practices and continued to EDUCATE-everyone.
It is now 2005,and many evidence based articles
were appearing in the literature stressing the
importance of early breast feeding, prevention of
hypothermia by initiating skin to skin contact, and
keeping the infant with the mother to promote
bonding and successful breast feeding.
The leadership team started looking at the reality of
what we said was Family Centered Care.
Reality Check
• Nursery and mother baby units were chaotic,
with babies coming and going and constant
crying.
• Babies were admitted to the nursery on
admission to the mother baby unit. Baths
were done under the warmer in the nursery
• Transitioning of newborns who were having
initial medical problems was done in the busy
nursery with little privacy for visiting parents
• Babies were separated from their mothers
most of the night, every night
Action Plan
In the summer of 2006, the Director of
Women’s and Children’s services and
Perinatal Clinical Nurse Specialist held
discussions with the managers concerning the
need to reexamine the current Maternity
Practice model which had been put into place
in 1997. The management team made the
decision to initiate a PDSA cycle to examine all
current nursing practices as they related to
the care of the mother and infant.
The Project Team, which consisted of staff
from all units of Maternity Services, met for a
kick-off meeting on August 28, 2006 and
again on September 25, 2006. During these
initial meetings, the team discussed the
Mission, Vision and Values of the team and
brainstormed a number of issues.
The team discussed the concept of principles
or values, rather than policies, guiding our
day to day decisions to create a seamless,
high-quality experience for our patients.
Team Mission/Purpose:
• To enhance the patient experience, using
a systems approach, to improve
processes and increase teamwork within
maternity services.
Vision:
• To provide safe, compassionate,
exceptional, family-centered care by
efficient, highly skilled, committed team.
Our Desired Values
Patient Focused Care
Vs
Staff or department focused
processes
Principle driven decision making
Policy driven decision making
Flexibility
Rigidity, tunnel vision
Trusting relationships
The 3 “Bs”: Bickering, Backbiting,
Blaming
Teamwork
Silos, protecting, self/unit
interests
Individual Growth and Development No growth of skill, knowledge or
leadership
What we believe about Patient Care…
•It’s the patient’s experience, not ours
•Every patient deserves an excellent experience
•Every patient is as important as any other
•There should be as few handoffs as possible
What we believe about ourselves…
•If it’s legal and you’re able, it’s your job
•If you see it, you own it.
•Everyone owes her co-workers a cooperative, positive
attitude.
•Everyone should be willing to learn new skills.
In addition the team discussed challenges and
ideas to enhance teamwork and learned about
their “circle of influence”
So, did we go forth and change the world?
NOT YET!!!!!!!!!
What Happened Next
The following year (2007) the management
team continued to have discussions
concerning our current Mother Baby Model
which included interested staff members. It
became evident that each unit was
representing their own concerns. Care was
being defined as “location centered” rather
than “patient centered”.
Meetings were changed to include just
the Patient Care Coordinators (PCCs)
and managers and presentations
were made to this group about the
change process, teamwork, trust,
dissolving silos and use of evidencebased practice.
• On October 1, 2007, the PCCs were
brought together in a workshop to gain
consensus and buy-in from the group.
• Beginning in November, 2007, weekly
Meetings were held with the PCCs and
other interested staff members.
These meetings focused on three priorities:
• Best Practice
• Patient Preference
• Departmental Situation
Small teams composed of staff from
each unit were assigned to map the
process of care from the moment of
birth until the patient left L&D and
from the moment the patient arrived
on the Mother/baby unit until
discharge; recording every instance
when the baby was removed from
the mother.
Labor and Delivery
In labor and delivery, most babies were
removed to the warmer after the mother had
viewed the infant. Assessments, medications,
measurements and weights were done. The
baby was dressed and swaddled in a blanket
and handed back to the mother when the
delivery was complete. Breast feeding might
be initiated, but was not the routine. Many
infants were sent to the nursery due to
hypothermia, hypoglycemia or respiratory
concerns.
Mother/Baby Unit
Many babies were transported to the mother/baby
unit with the mother, but were left at the nursery on
the way to the mother’s room. The infants were
routinely placed in the warmer and bathed in the
nursery when the infant’s temperature had
stabilized. It might be several hours before the
infant went to the mother’s room. Infants were
routinely removed from the mother’s room for blood
testing, weights, injections, sleep and RN
assessments.
NICU
In the NICU, the unit was closed for report
twice a day, visitation was limited.
Rounds were done without the parent’s
participation; skin to skin was not
routinely practiced and breast feeding
support was limited.
• Each of these groups were then assigned
to apply the evidence for best practice
they had researched to design and create
care plans to eliminate these periods of
separation based on our priorities.
• Notebooks were created with the
research articles and staff was encouraged
to read the research for themselves.
• As plans were created, many issues and
questions arose about the proposed
changes.
These concerns included:
•parents desires over best practice
• increased nursing time,
• lack of knowledge to adequately support
breast feeding,
•parental reaction to procedures done at the
bedside that involved pain to the infant, i.e.,
blood draws and immunizations
• staffing issues if a parent requested the infant
to go to the nursery;
•staff retention due to the changes.
Action plans were developed to address each
of these concerns, again, based on our
priorities
In subsequent meetings, the PCCs discussed the feedback from a
previous assignment to list all the issues that were keeping
them up at night. These issues were classified under the
headings of
• no nursery
• staffing
• critical situations/abnormal (rare occasions, what ifs)
• staff satisfaction/retention
• patient satisfaction; patient preference
• facilities
• efficiency
• change
• transition nursery
The next meeting was devoted to developing the
educational agenda for staff to move the maternity
center from plans to action!
The sessions were scheduled for 4 hours with the
following agenda:
• Video of support from the Vice President of Nursing
• Discussion of the vision/values/principles and why the change
was necessary by the Director of Women’s and Children’s
services
• Philosophy of family centered care presented by the Clinical
Nurse Specialist
• Education on process details using skill stations/hand-on
demonstrations (Staff/PCCs)
• Problem solving session (mixed groups of 5 staff from the
different units) “What will keep you up at night about this”
and “What are the solutions?”
Train the trainer sessions were held for the
staff volunteers in December of 2007.
• While the training was occurring, aspects
of the plan were being discussed between
staff members and some principles were
being put into place by the early adopters
on the staff.
• Their success and the parents’ positive
reaction were instrumental with later
adoption by the entire staff.
In January of 2008, the PCCs met to finalize
educational session plans.
• Eight sessions were planned for 25 staff
members for each session.
• Staff members involved in the training
created all the posters, skills stations,
lesson plans, post tests and competency
skills check lists that were utilized during
the training.
• They also developed scripts that could be
utilized by staff to explain the new
practices to the parents.
In February, 2008, the entire plan was
presented to the staff during a week
of Maternity Center retreats that
were held off campus.
These retreats were organized to
generate knowledge, enthusiasm and
acceptance of the new ideas.
Skills Fairs were presented in March,
2008 with mandatory attendance by
all staff.
• Staff were scheduled by their
managers to include groups from
each of the different maternity
center nursing units.
• The educator or CNS was present
at every presentation to ensure
uniformity of the information
presented and to answer questions
as needed.
• The Staff nurses who made the
presentations were professional and
well organized. They presented the
research behind the changes and
discussed ways these changes would
be incorporated into practice. Their
enthusiasm was contagious and the
staff voiced agreement that they
benefited from being taught by their
peers.
The practice change was officially
initiated in March of 2008.
Multiple celebrations were held by the
managers.
The Director later held a Celebration“Cinco de Mayo Party” at her home
for all the project team and staff
leaders.
After the Change
•The nursery is usually empty. Patients are educated on the
importance of keeping the baby with them in the room
•The neonatal observation unit (NOU) is now located in the
NICU where parents have privacy and the environment is
conducive to recovery. With the assistance of the new NICU
high risk team, more babies are transitioned in the L&D unit on
the mother’s chest, eliminating the need to be admitted to the
NOU.
•At the request of patients, Quiet Time was initiated in the
department with no interruptions for the patients from 2pm to
4pm and 2am to 4am. Patients are rounded on prior to quiet
time and instructed to call the nurse for any needs. All
interruptions are limited to promote time with the just the
baby, his mother and significant other.
• All procedures are done at the bedside with parental education
describing what is being done and why and includes methods
to comfort their infant during the procedures.
• In labor and delivery, patients are educated about the benefits
of skin to skin and immediate breast feeding after delivery.
Babies are delivered to the mother’s abdomen, dried and
placed skin to skin with the mother and covered with a warm
blanket. Assessments are done on the mother’s chest. Breast
feeding is initiated. Weighing and medications are delayed for
up to an hour post delivery.
• Transfers are delayed based on the mother and infants needs.
They are transferred together and taken to their room.
Mothers are encouraged to keep their infants skin to skin.
• Bathes are delayed for at least 6 hours. This allows the mother
to rest and recover and the family to participate in the bathing
process that is done in the room.
•In the NICU, parents can bring any adult they wish to visit the
infant, whenever they wish.
•Very young siblings can visit with their parents weekly
•The unit does not close during rounds.
•Kangaroo Care-skin to skin, is used more often and earlier
•Reports are done at the bedside and include parents
•A new parent support group meets weekly.
Results
•
•
•
•
•
•
Initiation of Skin to Skin at time of delivery improved from
13% to 82% for all deliveries
Initiation of breast feeding in the first 60 minutes has risen
from 37% to 60% for all deliveries
Newborn baths performed at the bedside increased from
51% to 96%.
Newborn Hearing referral rates decreased from 8% to 3%
Patient satisfaction with overall quality of nursing care
increased from the 60th percentile to the 100th percentile.
The mother/baby unit improved from a Tier II to a Tier I on
the Morehead Employee Engagement Survey
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80%
70%
60%
50%
40%
30%
20%
10%
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NICU infants removed from total beginning Aug
2009
Carolinas Medical Center-NorthEast
Family Centered Care Practice Change
Initiation of Skin to Skin Post Delivery
100%
90%
All Deliveries
Vaginal Delivery
Cesearean Delivery
Carolinas Medical Center-NorthEast
Family Centered Care Model Practice Changes
Breast Feeding Initiation within 60 Minutes in L&D
100%
90%
80%
70%
NICU infants excluded from total
starting Aug, 2009
60%
50%
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Carolinas Medical Center-NorthEast
Family Centered Care Practice Change
Percent of Infant Baths Performed at the Bedside
Jan 2008-Nov 2009
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
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Jan- Feb Mar
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Carolinas Medical Center-NorthEast
Family Centered Care Project
Hearing Screen Referral Rates
9.0%
8.0%
7.0%
6.0%
Goal Referral
Rate less than
4%
4.0%
3.0%
2.0%
1.0%
0.0%
What did we learn
• Leadership must make the initial
decision:
Ours was the goal of keeping the
mother and baby together at all
times unless medically
countraindicated.
What did we learn
Developing and carrying out the plan must be a joint effort between
management and staff.
• Management team members must be in agreement and look at the
overall needs of the patient. Care must be given in a patient
centered manner rather than a location centered manner.
• This has to happen before staff can be brought together. There is
nothing more counterproductive than having a divided
management team.
• Staff needs to research and read the evidence themselves. It is
much more meaningful than if it is handed to them by the CNS or
educators.
• Involvement of key players is essential, including physicians.
What did we learn
You must carefully mange the perception of “NO Nursery”
We do have a nursery and mothers can use it if they want to after we
have provided the education on which they base their decision.
Sometimes, things slide and it takes data and persistent follow up to
prevent slipping back into old ways.
Gather baseline data BEFORE you start talking about changes
Include the nursing students and instructors on the planning
Though keeping moms and babies together is a
common problem in perinatal nursing practice,
the Family Centered Care model used at CMC-NE
was achieved using an innovative approach to
solving this problem. Evidence-based practice
was combined with value-based and principlecentered care to create the model. Change
management theories were used along with
organizational behavior techniques to promote
the improvement process. By bridging the gap
between clinical practice and human behavior, all
aspects of change management were addressed
and led to the successful implementation of our
model.
How do we make it simple ?
We keep our goal in mind through every step of the process
Keep mother and baby together
References
Beal, Judy. (2005). Evidence for Best Practices in the Neonatal Period. Maternal
ChildHealth,10 (6), 397-403.
Behring, A., Vezeau, T., Fink, R., (2003). Timing of the Newborn Bath: A
Replication. Neonatal Network,
22(1),39-46.
Crenshaw, Jeanette (2007). Care Practice #6: No Separation of Mother and
Baby. Lamaze® Institute for Normal
Birth. Lamaze® International.
Dabrowski, Gretchen A. (2007). Skin to Skin Contact-Giving Birth Back to Mothers and
Babies. Nursing
for Women's Health, 11(1), 61-71.
Galligan, Maura. (2006). Proposed Guidelines for Skin-to Skin Treatment of Neonatal
Hypothermia. Maternal Child Nursing, 31 (5), 298-304.
Harmon, K., Sey, R., Hiner, J, Faron,S. and McAdam, A. (2010). Successful Nurse
Engagement. Nursing for Women’s Health, 14 (1), 42-48.
International Lactation Consultant Association (June, 2005). Clinical Guidelines for the
Establishment of Exclusive Breastfeeding.
O’Neal, H.; Manley, K. (2007). Action Planning: Making change happen in clinical
practice. Nursing Standard pp 21, 35, 36-39.
Ramono, A. & Lothian, J. (2008). Promoting, Protecting, and Supporting Normal Birth:
A look at the Evidence. JOGNN (37)1, 94-104.
Walters, M.W, Boggs, K.M., Ludington-Hoe, S., Price, K., and Morrison, B. (
2007). Kangaroo care at birth for full term infants: a pilot study. Maternal
Child Nursing (32)6, 375-381