7 Core Measures of Neuroprotective Family-Centered Developmental Care.docx

**7 Core Measures of Neuroprotective Family-Centered Developmental Care** **Neonatal Integrative Developmental Care (IDC) Model** The IDC model (Altimier & Phillips, 2016) is a complementary approach to NIDCAP, without the necessity of undergoing a certification process for implementation. This mo...

**7 Core Measures of Neuroprotective Family-Centered Developmental Care** **Neonatal Integrative Developmental Care (IDC) Model** The IDC model (Altimier & Phillips, 2016) is a complementary approach to NIDCAP, without the necessity of undergoing a certification process for implementation. This model, originally described by Coughlin et al. (2009) as the "universe of developmental care model," has been expanded to include seven core measures, each with guidelines for intervention aimed at providing neuroprotective, developmentally supportive, and family-centered care in the NICU. These approaches can be applied to the care of any NICU patient and family who are on the continuum of developmental risk. The seven core measures described in the IDC model include: 1\. healing environment, 2\. partnering with families, 3\. positioning and handling, 4\. safeguarding sleep, 5\. minimizing stress and pain, 6\. protecting skin, and 7\. optimizing nutrition. The IDC model is depicted in Fig. 22.3 as overlapping petals of a lotus, demonstrating the integrative nature of developmental care. Altimier and Phillips (2016) provided specific goals and corresponding interventions for each of the core measures (Table 22.2) for implementation by NICU staff, and recommended approaches for effective integration of these core measures into the existing NICU culture. Adoption of this or a similar model of care into a NICU culture always requires extensive planning, administrative buy-in, a comprehensive approach to staff education, and a related quality improvement process. In the case of the IDC framework, acceptance by administration and staff may be facilitated by the fact that the specific core measures: (1) are congruent with those generally recommended by the Joint Commission for hospital services/settings, (2) can be measured, and thus (3) lend themselves to quality improvement initiatives. **Table 22.2 - Advanced Clinical Applications of Neuroprotective Interventions Related to the Seven Core Measures of Neuroprotective Family-Centered Developmental Care** **Core Measure \# 1: Healing Environment:** Standard: A policy/procedure/guideline on the healing environment including physical space and privacy as well as the protection of the infant's sensory system exists and is followed throughout the infant's stay. - ***Infant Characteristics:*** - Stability of the infant's autonomic, sensory, motoric, and state regulation systems. - ***Goals:*** - An environment will be maintained that promotes healing by minimizing the impact of the artificial extrauterine NICU environment on the developing infant's brain. - ***Neuroprotective Interventions:*** - General: - Educate, coach, and mentor parents on the importance of creating a healing environment that protects the developing sensory system of the preterm infant. Emphasize the central role of parents in the healing environment. - Skin-to-skin Contact: - Facilitate early, frequent, and prolonged skin-to-skin contact (SSC) - Encourage zero-separation between parents and infant - Provide comfortable and safe reclining chair or adult bed for early, frequent, and prolonged SSC. - Space: - Maintain a private and safe environment for the infant and family that consists of minimum of 120 sq. ft. per patient. - Provide organized, non cluttered space for the family to support comfortable and private caregiving - When renovations are planned, advocate for single family rooms (SFR) And promote utilization of the latest standards from the "recommended standards of newborn ICU designs" at: http://www3.nd.edu/\~nicudes - Tactile: - Provide a neutral thermal environment for the infant incorporating the following factors: - Facilitate early, frequent, and prolonged skin to skin contact. - Fe LBW, provide humidity during the first 1 - 2 weeks after birth - Provide care and incubator or SSC until infant can maintain old temperature - Vestibular: - Change infants position gently and slowly without sudden movements - Eliminate moving infants to different bed-space to accommodate staffing patterns. - Olfactory: - Maintaining a scent-free and fragrant-free unit - Minimize exposure to noxious odors - Expose infant to mother's sense when possible via breast pad or soft cloth - Gustatory: - Position infant with hands near face - Provide call colostrum of expressed breast milk - Provide positive oral feeding experiences as outlined in "Optimizing Nutrition" section - Auditory: - support infants with consistently calm, relaxing environment with muted sounds during caregiving interactions - Be mindful of own voice and other sounds produced in the NICU - Monitor sounds levels to maintain average sound levels of 45 dB - Silence alarms as quickly as possible and avoid unnecessary alarms - Comfort crying infants as quickly as possible - Expose infant to audible maternal/parental voice - Visual: - Provide adjustable light levels up to a maximum of 60 fc - Gently shield infant's eyes during cures of overhead light is needed - Be mindful of structuring an infant's visual field to support alert wakefulness as appropriate, transition to sleep, or quiet, restful sleep - Minimize purposeful visual stimulations until 37 weeks gestation - Overall healing environment: - Consider all sources of light, sound, movement, smell and taste confronting an infants during here, and eliminate all inappropriate or unnecessary sources of stimulation - Create an implement an individualized developmental care plan for each infant - Provide guidance to parents on how to create and sustain a healing environment with respect to sensory exposures and experiences - When renovating the nick you environment, advocate for optimal family support spaces and resources **Core Measure \#2: Partnering with Families:** Standard 1: A policy/procedure/guideline on partnering with families to include unlimited access to ensure around-the-clock-information and access to their baby exists and is followed throughout the NICU Standard 2: There is a specific mission statement addressing partnering with families. Standard 3: NICU staff are competent in educating, coaching, and mentoring parents in infant caregiving skills and in providing psychosocial support to NICU families. - Infant Characteristics: - Infant's response to parental interactions - Goals: - Family centered care is supported from birth or as soon as a NICU stay is anticipated (antenatally if possible) - Parents will NOT be viewed as "visitors" but as equal & vital members of the caregiving team with zero-separation supported and encouraged 24 hrs/d - Parents will be supported & encouraged as the primary and most important caregivers for their infant, incorporating them as full participatory, essential healing partners within the NICU caregiving team - Infant will develop emotional connection & secure attachment with parents - Parents who lose a baby before, during, or shortly after birth, or later in the nick you will be supported at all points of care - Neuroprotective Interventions: - facilitate early, frequent, and prolonged skin-to-skin contact - Encourage zero-separation between parents and infant - Educate, coach, and mentor parents and becoming active participants in their baby's care in supporting their infants developmental goals - Support families with a warm, respectful, and welcoming manner - Acknowledge where the family is in regards to stages of grief and loss and provide individualized and appropriate resources as needed - Actively listen to families' feelings and concerns (both verbal and non-verbal) - Incorporate parents as full participants in parenting their baby in the NICU - Encourage families to personalize their infant's bed space and make the NICU environment more home-like - Encourage participation in medical rounds and nursing hands-offs - Share information with families in a tone of voice that preserves confidentiality - Honor both Health Insurance Portability and Accountability Act (HIPAA) And safety concerns while in the NICU - provide parents with full access and input to both written and electronic medical records - Accommodate the presence of families in the NICU and seek ways to ensure their comfort - Include and support siblings and extended family participation as desired by parents - Communicate the infants medical, nursing, and developmental needs in a culturally appropriate and understandable way, avoiding acronyms and medical jargon - Educate parents on infant attachment, language development, developmental and safety issues and infant behavioral cues (appropriate for their infants gestational age) - Support breast milk expression and breastfeeding - Provide social networking opportunities for parents of infants in the NICU - Provide peer-to-peer support with parents who have gone through similar nick you experiences - Encourage and empower parents as they develop confidence in their own abilities to continue caring for their baby when going home - Provide anticipatory guidance regarding grieving and risk/symptoms of postpartum depression and PT St. To mothers and fathers, and other family members, recognizing they all may process the NICU experience differently - Provides um psychosocial support for all members of the family, including grandparents and the babies siblings - Provides staff education related to principles of family-centered care and how to support parents' caregiving rules **Core Measure \#3 -- Positioning & Handling:** Standard A: A policy/procedure/guideline on Positioning & handling exists and is followed throughout the infants stay that includes education, coaching and mentoring parents on how to position and handle their infant - Infant Characteristics: - Autonomic stability during handling - Ability to maintain tone and flex postures with and without supports - Goals: - Autonomic stability will be maintained throughout positioning change and handling activities as well as during periods of rest sleep. - Parents will be educated, coach, and mentored in how to position and handle their infants. - Preventable positional deformities will be eliminated or minimized by maintaining infants in a midline, flex, contained, and comfortable position throughout their NICU stay - - Neuroprotective Interventions: - Facilitator early, frequent, and prolonged skin-to-skin contact - Educate, coach, and mentor parents and how to position, contain and handle their infants in a developmentally appropriate manner. - Provide infants with positioning supports needed to maintain optimal tone and position and to remain either in a quiet, restful sleep or a relaxed, comfortable wakefulness. - Utilize a validated & reliable positioning assessment tool \[i.e. Infant Positioning Assessment Tool (IPAT)\] routinely to ensure appropriate positioning and encourage accountability. - Maintain a midline, flex, contain, and comfortable position at all times utilizing appropriate positioning aids and boundaries. - Provide appropriate ventral support to ensure flex shoulders/hips. - Provide swaddling when bathing and weighing. - Avoid doing procedures with infant in a prone position where he/she is unable to use self-comforting abilities. - Anticipate, prioritize, and support the infants individualized needs during caregiving interaction to minimize stressors known to interfere with normal development. - Engage with the infant and let behavior of infant guide care. Do cheers "with" the infant, rather than "to" the infant. - Assist infant sleep-wake cycle to evaluate appropriate timing of positioning and care. - Reposition infant with care and minimally every 4 hours. - Provide 4-handed support during positioning and caring activities - Promote hand to mouth/face contact - When providing caregiving activities: - Collect all supplies prior to approaching infants so infant is not left unattended or unsupported once hands-on care has begun - Seek another person to support infant care during a potentially stressful experience, including bathing and weighing. - Include parents and providing support when available and willing. - The caregiver sees her or himself in partnership "with" the baby so that caregiving procedures are performed "with" the infant rider then "to" the infant. - Infants will be provided developmentally appropriate stimulation/play as they mature (i.e. Mobiles, swings, etc.) **Core Measure \#4 -- Safeguarding Sleep:** Standard 1: A policy/procedure/guideline on safeguarding sleep exists and is followed throughout the infant stay. Standard 2: A policy/procedure/guideline on back-to-sleep practices exists and is followed prior to discharge. - Infant Characteristics: - Infant sleep-wake states, cycles, and transitions - infants maturity and readiness for back-to-sleep protocol - Goals: - Infants sleep-wake states will be assessed before initiating all caregiving activities - Prolonged periods of uninterrupted sleep will be protected - Infants will be transitioned to back to sleep when developmentally appropriate - Neuroprotective Interventions: - facilitate early, frequent, and prolong skin-to-skin contact - Educate, coach, and mentor parents on sleep-wake states and how to safeguard their babies sleep, recognizing the importance of sleep for healing, growth and brain development - Utilize a validated & reliable scale to assess sleep wake states to promote sleep - Recognize and protect sleep cycles, especially REM sleep - Promote a quiet environment to ensure uninterrupted sleep - Avoid sleep interruptions from bright lights, loud noises, and unnecessary disturbing activities. - Protect quiet sleep states by providing flexibility and timing of care - Encourage with infant and lip behavior of infant guide care - Individualize all caregiving activities by clustering cures based on infant sleep wake states. - Take care not to over-stress infants with too many clustered cures at once. - If necessary to arouse a sleeping infant, approach using a soft voice/whisper followed by gentle touch - Supports smooth transitions back to restful sleep before stepping away from bedside - Protect infant's eyes from direct light exposure and maintain low levels of ambient light new line use incubator covers to protect the infant from direct light - When developmentally appropriate, provide some daily exposure to light, preferably including shorter wavelengths, for entertainment of the circadian rhythm. - Avoid (when possible) high doses of sedatives and depressing drugs which can depress the endogenous firing of cells thus, interfering with visual development, REM, and NREM Sleep cycle, and thus optimal brain development. - Provide developmental care appropriate for the age and maturation of the infants including supportive positioning to promote restful sleep period new line Assure and then is able to maintain normal sleep pattern during back-to-sleep well before discharge and role model this behavior in the NICU. - Provide tummy-time/prone-to-play time routinely for infants that are Back-to-Sleep - Coach, educate, and mentor parents about the importance and rationale for back-to-sleep and tummy-time. **Core Measure \#5: Minimizing Stress & Pain** Standard: A policy/procedure/guideline on the assessment and management of pain exists and is followed throughout the infant stay. - Infant Characteristics: - Behavioral cues indicating stress or self-regulation - Goals: - Promote self-regulation and neurodevelopmental organization. - Reduce excessive stress and pain in the neck you - Neuroprotective Interventions: - Facilitate early, frequent, and prolonged skin-to-skin contact - Educate, coach, and mentor parents on infants cues related to stress and pain and how to provide their infant with non-pharmaceutical support during stressful or painful procedures - provide individualized care in a manner that anticipates, prioritize, and supports the needs of infants to minimize stress and pain. - Utilize a validated & reliable pain assessment tool to evaluate the need for formal logic support - Regularly evaluate the clinical need for frequent labs and procedures, and reduce the excessive number of stressful/painful procedures whenever possible. - Provide non pharmacologic support (breastfeeding, skin-to-skin contact, sucrose, pacifier) prior to/with all minor invasive interventions. - Provide midline, flexion, and containment with all positioning (whenever possible) to promote comfort. - Provide therapeutic and positioning aids to maintain supportive positioning - Provide guidance to parents on how to collaborate with NICU staff to minimize their baby's stress and pain. - Invite parents to help support their baby during painful procedures if they are available and willing to participate - Reserve parenting activities for parents (feeding, diapering,etc.) **Core Measure \#6 -- Protecting Skin** Standard: A policy/procedure/guideline on skin care exists and is followed throughout the infant's stay. - Infant Characteristics: - Maturity and integrity of infant skin - Goals: - Reduce trans epidural water loss of ELBW infants - Maintain skin integrity of the infant from birth to discharge - Provide developmentally appropriate and fit massage - Neuroprotective Interventions: - Facilitate early, frequent, and prolonged skin-to-skin contact - Educate, coach, and mentor parents on skin care, swaddling bathing, and delivery of developmentally appropriate infant massage. - Utilize a validated & reliable skin assessment tool on emission and routinely according to hospital protocol. - Provide humidity for ELBW infants during the first one - two weeks after birth (50% humidity is provided when infant is in skin to skin contact) - Provide appropriate positioning support utilizing gel products and other positioning aids to prevent skin breakdown. - Examine position of nasal prongs per protocol to protect against breakdown of nasal septum - Minimize use of adhesives and use caution when removing adhesives to prevent epidural stripping - Avoid soaps and routine use of emollients - Use only water for bathing b1000g infants - Use pH neutral cleansers for bathing N1000 grams infants - when bathing, do swaddled bathing in bed or tub (to reduce stress and promote relaxation) with overhead warmer (to prevent skin from hypothermia). - Provide bathing no more than every 72 to 96 hours - Priority should be given to parents to bathe their own infant whenever possible - Provide parents guidance on how to protect their baby's skin and its many functions, including its roles as a conduit of neurosensory information to the brain - Teach parents how to give developmentally appropriate infant massage to promote relaxation, bonding and attachment. **Core Measure \# 7: Optimizing Nutrition:** Standard 1: A policy/procedure/guideline on Optimizing nutrition using cue-based/infant-driven breasts or bottle feeding (which includes infant readiness, quality of feeding and caregiver techniques) is followed throughout the infant's stay. Standard 2: A policy/procedure/guideline on skin-to-skin contact (kangaroo care) exists and is followed throughout the infants stay. - Infant Characteristics: - physiologic stability what feeding & handling - Feeding readiness cues - Coordinates suck/swallow/breathing (SSB) Throughout breasts or bottle feeding - endurance to maintain nutritional intake and support growth - Goals: - feeding will be safe, functional, nurturing, and developmentally appropriate - Optimize nutrition will be enhanced by individualizing all feeding care practices - Oral aversions will be prevented by assuring feeding is a positive experience for the infant - First oral feeds will be at the breast for babies whose mothers are pumping their milk - Infants of breastfeeding mothers will be competent at breastfeeding prior to discharge - Neuroprotective Interventions: - Facilitate early, frequent, and prolonged skin-to-skin contact - Educate, coach, and mentor parents about positive oral stimulation, infant feeding cues, and feeding techniques. - Promote positive oral/olfactory stimulation during early skin-to-skin contact by letting infant lick, nuzzle and smell the nipple if interested - Minimize negative perioral stimulation (adhesives, suctioning, etc.) - Utilize in dwelling gavage tubes rather than intermittent tubes - Hold infinite and use NS with appropriate size pacifier during gavage feedings when mother is not available. - Provide taste and smell of breast milk, if available, with gavage feedings. - Utilize validated & reliable Feeding-Readiness and Infant-Driven Feeding tools, and involve parents in assessments of feeding readiness and quality of feedings. - Ensure every feeding experience is a positive, pleasant, and nurturing experience. - Educate parents about the medical importance of breast milk for most infants, especially for ELBW infants. - Support and encourage mother's expressed breast milk (EDM) supply. - Provide donor human milk for ELBW infants (whenever possible) if mother's milk is not available or is contraindicated. - Ensure first oral feeding is at the breast for babies who mothers have been pumping their breast milk. - Support and encourage competent breastfeeding well before discharge. - Promote side-lying position close to parent/caregiver when bottle-feeding. - Provide guidance to parents on how to provide supportive oral feeding experience for their infant, including positioning and pacing **Teamwork & Collaboration** Standard 1: An interdisciplinary team of caregivers work together collaboratively to support the medical, developmental and psychosocial needs of infants and families. Standard 2: Hospital leadership facilitates staff education and training related to new productive Family-Centered Developmental Care principles and practices, including how to educate, coach and mentor parents in the care of their infants during NICU hospitalization. Standard 3: A policy/procedure/guidance on roles and responsibilities of team members and collaboration thereof exists and is followed. - Infant Characteristics - Infant and family are central to each team member's plans, decision and caregiving - Goals: - An individual elite individual individualized developmentally appropriate environment is provided for every infant and family - Each parents is viewed as an active member of the caregiving team - All staff members are equipped with the knowledge and skills they need to care for babies and support parents and families - All staff members are supported in self-care to prevent burnout and compassion fatigue. - Neuroprotective Interventions. - Support parents are the primary caregivers by educating, coaching, and mentoring them and parenting their babies in the NICU. - Support parents and be getting it active members of the caregiving team. - Include parents in all medical decision making. - Provide as much space and comfort as possible for family caregiving, keeping charts and equipment well organized and avoiding clutter. - Consistently share information about infant's behavior competencies common vulnerabilities, thresholds and parental involvement when communicating with colleagues during medical rounds or staff shift change. - Prior to performing a procedure, cure, or exam on an infant under the care of a another team member (or parent), discuss the needs of that team member to mutually agree on the timing. - Respect and support the roles of other individuals and disciplines when caring for infants - support each other through mentoring relationships. - Willy and proactively assist colleagues to provide support for infants in their care during potentially stressful procedures. - Ensure all infants and families are treated consistently with support, dignity, and respected by all team members, and constructively confronts team members if discrepancies are noted. - Educate and train staff in all disciplines on neuroprotective family-center developmental care principles and practices. - Educate staff about methods for improving and expanding family-centered developmental care in NICU. - Staff on the differences and value of cultural practices other than their own. - Educate staff on active listening skills and other optimal methods of communication with parents in distress. - HP staff about stages of grief and risk of postpartum depression and PTSD in the NICU parents and staff. - Educate and support staff and elements of self-care to proactively prevent and minimize burnout and compassion fatigue. - Have a program to regularly acknowledge and appreciate the NICU staff and the work they do for babies and families.