Implementing a Neuro-Bundle in a

Level III Neonatal Intensive Care Unit

Item Type DNP Project

Authors Steiner, Itta

Publication Date 2019-05

Abstract Background: Intraventricular hemorrhage (IVH) is a complication

primarily associated with preterm birth, specifically those born
before 32 weeks gestation and weighing less than 1500 gram.
With increasing survival rates for the most premature infant...

Keywords Cerebral Intraventricular Hemorrhage--prevention & control;

Intensive Care Units, Neonatal; Patient Care Bundles

Download date 21/12/2023 [Link]

Link to Item [Link]

Running head: IMPLEMENTING A NEURO BUNDLE 1

Implementing a Neuro-Bundle in a Level III Neonatal Intensive Care Unit

by:

Itta Steiner

Under Supervision of

Carmel McComiskey, DNP, CRNP, FAANP, FAAN

Second Reader

Claire Bode, DNP, RN, CRNP

A DNP Project Manuscript

Submitted in Partial Fulfillment of the Requirements for the
Doctor of Nursing Practice Degree

University of Maryland School of Nursing

May 2019
IMPLEMENTING A NEURO BUNDLE 2

Abstract

Background: Intraventricular hemorrhage (IVH) is a complication primarily associated with

preterm birth, specifically those born before 32 weeks gestation and weighing less than 1500
gram. With increasing survival rates for the most premature infants, IVH rates have remained
stagnant at approximately 20% with severe IVH at approximately 5%. The incidence of IVH is
highest within the first 24 hours of life and approximately 90% of cases occur within the first 3
days of life. IVH is associated with long term neurologic consequences such as hydrocephalus,
seizures, and cerebral palsy. Midline positioning and minimal handling as part of a bundle-
intervention have been proven to decrease the incidence of IVH.
Local Problem: This Level III NICU recognizes the risk IVH poses to its patients and wants to
put in place all measures that will improve their outcomes. Prior to Implementation the unit did
not utilize a neuro-bundle for IVH prevention. The purpose of this project was to implement a
neuro bundle consisting of midline positioning and minimal handling for the first 72 hours of life
for preterm infants born before 32 weeks and weighing less than 1500 grams.
Interventions: A quality improvement project measuring nursing education and utilization of a
neuro-bundle was implemented in a Level III NICU in a community hospital in Baltimore,
Maryland. The project took place over a 14 week period. The first 2 weeks consisted of a pre-
survey and nursing education module to be completed via the hospital’s online education system.
This was followed by the implementation of the neuro-bundle during weeks 3-13 and concluded
with a post-implementation survey during week 14 to evaluate the change in practice. During
implementation, a checklist was completed for each infant meeting criteria for the neuro-bundle.
The checklist documented midline positioning, minimal handling, reasons for not adhering to the
bundle, and other pain/stress reducing techniques that were used.
Results: The bundle was utilized for 94% of babies admitted to the NICU meeting inclusion
criteria. For those whom the neuro-bundle was utilized, midline position was maintained
97.59% of the time and minimal handling was used 86.4% of the time with pain/stress
minimizing measures used 100% of the time. Only a single baby in the project had an IVH.
Conclusion: Use of a neuro-bundle has been proven to decrease IVH rates. The neuro-bundle
was successfully implemented and during this time the IVH rate was low. More information is
needed to quantify the benefits since the sample size and duration of the project were small. The
unit should continue to monitor the use of the neuro-bundle and its associated outcomes.
IMPLEMENTING A NEURO BUNDLE 3

Implementing a Neuro Bundle: A Quality Improvement Project in a Level III NICU

Introduction

Background

Intraventricular hemorrhage (IVH) is a complication primarily associated with preterm birth,

specifically babies born before 32 weeks gestation and with a weight less than 1500 grams

(Crowell, 2017; Kenet, Kuperman, Strauss, & Brenner, 2011; Soul, 2017). IVH is a brain bleed

that originates in the germinal matrix. The germinal matrix is an active site of cell proliferation

and as a result it is highly vascularized (Inder, Perlman, & Volpe, 2018). This cellular activity

peaks at approximately 28 weeks gestation and then rapidly declines with complete involution of

the germinal matrix by 36 weeks gestation. Additionally, the vasculature of the germinal matrix

consists of large, endothelial lined vessels which are fragile and likely to hemorrhage (Ballabh,

2014; Inder et al., 2018; Soul, 2017). The development of IVH can be linked to fluctuations in

cerebral blood flow, with infants displaying a fluctuating pattern of cerebral blood flow more

likely to develop an IVH than an infant with a stable cerebral blood flow pattern (Inder et al.,

2018). Preterm infants do not have the ability to regulate cerebral blood flow and increases and

decreases can be seen in response to a variety of factors including pain and stress, routine

handling, hypoglycemia, and respiratory distress syndrome (Ballabh, 2014; Inder et al., 2018).

The severity of the IVH is graded based on the presence of blood; including how much and

where (Inder et al., 2018). A grade I bleed is a hemorrhage in the germinal matrix alone. In a

grade II bleed, the hemorrhage extends to the lateral ventricles without dilation of the ventricles.

A grade III bleed involves a hemorrhage occupying more than 50% of the ventricle with

ventricular dilation. A grade IV IVH is a periventricular hemorrhagic infarction with bleeding in

the parenchyma. Grade III and IV bleeds are collectively referred to as severe IVH. The
IMPLEMENTING A NEURO BUNDLE 4

incidence of IVH is highest within the first 24 hours of life and progression may occur within the

first 72 hours; approximately 90% of cases occur within the first 3 days of life. (Allen, 2013;

Szpecht, Szymankiwicz, Nowak, & Gadzinowski, 2016).

Significance of Problem

With increasing survival rates for the most premature infants, IVH rates have remained at

approximately 20% with severe IVH at approximately 5% (Inder et al., 2018). The more

premature infants have a higher risk of developing more severe grades of IVH, with a ten-fold

higher risk of grade III-IV. IVH is associated with long term neurologic consequences such as

hydrocephalus, seizures, and cerebral palsy; the more severe the IVH the higher the risk of

neurologic deficits (Ballabh, 2014; Malusky & Donze, 2011). Furthermore, the development of

IVH is associated with an additional cost of $53,600 for the initial hospitalization of a preterm

infant (Malusky & Donze, 2011).

The national rate for preterm birth in 2015 was 9.6% with 1.6% being <32 weeks

gestation (National Center for Health Statistics, 2018). Maryland’s premature birth rates are

above the national average at 10% and 1.8% and Baltimore City’s rates are higher than the State

average at 13% and 2.7%. This project was implemented in a level III NICU in a community

hospital. This hospital is a member of the Vermont Oxford Network (VON), a nonprofit

collaboration of healthcare professionals working together to change the landscape of neonatal

care (VON, 2018). The VON collects data on very low birth weight infants from its participating

centers and analyzes it to facilitate quality improvement projects. IVH rates are one of the

datasets collected and analyzed by the VON. The national rate of IVH in 2016 among VON

participating centers was 25.3% and the rate of severe IVH was 8.1%. This unit’s rates were

below the national average at 21.3% for any IVH and 4.3% for severe IVH. While this NICU
IMPLEMENTING A NEURO BUNDLE 5

has low IVH rates, the neonatologists, neonatal nurse practitioners (NNP), and nursing staff

recognize that IVH is a significant problem for the population they treat and wish to do anything

that is in their control to minimize the risks.

Neuro-bundles consisting of midline positioning and minimal handling have been shown to

decrease the incidence and severity of IVH (Chiriboga, Cortez, Pena-Ariet, Makker,

Smotherman, Gautam,…Hudak, 2019; Christ, Barber, Murray, Dunleavy, Stoller,

Taha,…Posencheg, 2015; Schmid, Reister, Mayer, Hopfner, Fuchs, & Hummler, 2013). Midline

positioning requires the baby’s head to remain midline at all times; the baby can be in a supine or

side lying position. Minimal handling consists of clustering cares as well as minimizing painful

and stressful interventions. Clustering care does not apply to emergency interventions. If

clustering of cares cannot be achieved due to medical necessity, measures should be used to

minimize pain and stress. This can be achieved through swaddling, maintaining boundaries, and

shielding eyes from light.

Project Purpose

The purpose of this DNP project was to implement a neuro-bundle consisting of midline

positioning and minimal handling in a level III Neonatal Intensive Care Unit (NICU). The short

term goal of this project was for the nurses to implement the neuro-bundle. In order for this to be

achieved, the nurses completed an on-line education module with the desired goal of an 80%

completion rate by the end of week 2. The remainder of the healthcare team including

neonatologists, nurse practitioners, respiratory therapists, occupational therapists, and physical

therapists were educated about the neuro-bundle prior to its implementation. The desired

outcome for this project was for the nurses to utilize the neuro-bundle for 75% of preterm infants

who met the inclusion criteria. The long term goals of this project are for documentation to
IMPLEMENTING A NEURO BUNDLE 6

transition to the Electronic Health Record (EHR) and to see a decrease in the IVH rate; overall

and severe.

Theoretical Framework

The implementation of the neuro-bundle was guided by the Knowledge to Action (KTA)

Framework. The KTA framework is comprised of two components: knowledge creation and the

action cycle. Knowledge creation involves utilizing research findings and synthesizing and

recommending practice change. The action cycle is a seven phase guide to implementing an

evidence based program (EBP) (Graham & Tetroe, 2010; Straus, Tetroe, & Graham, 2013).

The two components of the KTA framework can either take place sequentially or

simultaneously (Graham & Tetroe, 2010). In the case of implementing this neuro-bundle in the

NICU the two phases took place sequentially. The problem was identified that preterm infants

less than 32 weeks and weighing less than 1500 grams are at an increased risk for developing

IVH. Interventions were then identified through a literature review supporting the

implementation of a neuro-bundle consisting of midline head positioning and minimal handling

to prevent IVH.

The action cycle provides a step by step guide of how to successfully implement the

neuro-bundle. The 7 steps of the action cycle are: i) identify a problem ii) adapt knowledge use

to local context iii) assess barriers to knowledge use iv) select, tailor, and implement

interventions v) monitor knowledge use vi) evaluate outcomes vii) sustain knowledge use

(Graham & Tetroe, 2010). In order to address the problem, a neuro-bundle was be implemented

in a Level III NICU to reduce the incidence of IVH. This was accomplished with the help of

stakeholders and unit champions. The project leader utilized site visits and phone calls to

monitor adherence to the neuro-bundle and implemented changes in real time to maximize
IMPLEMENTING A NEURO BUNDLE 7

implementation. Outcomes were evaluated by monitoring neuro-bundle usage for short term

goals and looking at the VON data on IVH incidence for long term goals. As a way to sustain

the program, a staff nurse has agreed to take over the program after implementation and met with

the project leader to discuss her role and possible changes that need to take place.

Literature Review

The focus of this literature review was the evidence that supported the implementation of

a neuro bundle consisting of midline positioning and minimal handling in a Level III NICU.

First, a brief analysis of the literature presented. This is followed by a synthesis of the data

supporting midline positioning and minimal handling. The data that supports the use of this

neuro bundle varies in study design and outcomes. See Table 1 for the complete evidence table.

Analysis

Christ and Colleagues (2015) implemented a quality improvement project to reduce the

incidence of severe IVH in preterm infants less than or equal to 30 weeks gestation. They

implemented a bundle including midline positioning and minimal handling for the first week of

life. The authors found that following implementation the monthly rate of severe IVH decreased

from 8.3% to 5.1%. A disadvantage of this study is that only the abstract is published and it does

not list the sample size or if the decrease in IVH is statistically significant.

In a quality improvement project in a Level III NICU, Chiriboga and Colleagues (2019)

sought to decrease their unit’s severe intracranial hemorrhage (ICH) rate. They implemented an

ICH bundle addressing admission temperature, delivery room resuscitation, and minimizing

excessive stimulation with clustered care and midline positioning. The project took place over

four years and included 281 infants and resulted in a significant decrease in severe ICH from

24% to 9.7%.
IMPLEMENTING A NEURO BUNDLE 8

Coughlin (2011) developed five core measures for providing age appropriate

developmental cares. These recommendations were based on a comprehensive evidence review

and a successful implementation in two pilot studies. These studies demonstrated that with

consistent implementation of these core measures neonatal morbidity can be reduced. Building

on these core measures Coughlin (2015) provided evidence-based recommendations and

guidelines that when implemented have been proven to reduce morbidity and mortality. Included

in these recommendation are midline positioning for infants less than 32 weeks gestation and

minimal handling for all NICU babies.

Davis, Berger, & Chock (2016) reviewed obstetrical and neonatal practices that have

been shown to have a neuroprotective effect on the developing brain, including midline head

positioning and minimal handling. The authors found that midline head positioning maintains a

constant cerebral blood flow by not impeding venous blood flow and minimal handling and

avoidance of stressful situation may be beneficial in decreasing IVH rates.

In an evidence based expert opinion Kaspar & Rubart (2016) recommend the

implementation of neuroprotective strategies such as midline head positioning to prevent IVH

and other brain injuries. A review of neonatal literature shows that midline head positioning

prevent elevations in cerebral blood flow and other head positions are associated with fluctuation

in cerebral blood flow that contribute to the risk of IVH development.

Malusky & Donze (2011) performed a systematic review to evaluate the current evidence

supporting midline head positioning in infants less than 32 weeks gestation to prevent IVH. The

existing literature shows no negative adverse effects noted when midline positioning was used.

The authors recommend midline head positioning for the first 72 hours of life.
IMPLEMENTING A NEURO BUNDLE 9

In a repeated measure research design, Peng, Bachman, Jenkins, Chen, Chang, Chang, &

Wang (2009) studied the relationship between environmental stress and stress response in 37

preterm infants. The authors found there was a statistically significant relationship (p<0.05)

between environmental stress and a change in vital signs as well as specific stress behaviors. A

disadvantage of this study is that it did not mention the specific gestational age of the infants

studied, just that they were premature.

Romantsik, Calevo, & Bruschettini (2017) performed a Cochrane review that evaluated

midline head positioning in preterm infants less than or equal to 32 weeks gestation. The results

demonstrated no difference between midline and other positioning.

Schmid, Reister, Mayer, Hopfner, Fuchs, & Hummler (2013) performed an interventional

cohort study on 454 infants less than 30 weeks gestation or weighing less than 1500 grams. A

bundle of measures including minimal handling and midline positioning was evaluated to

determine the efficacy of reducing IVH in general and specifically to impact severe IVH (grade

3-4). The authors found that the incidence of IVH decreased from 22.1% to 10.5% (p=0.002)

and the incidence of severe IVH decreased from 9.1% to 3.7% (p=0.037) supporting the use of

midline positioning and minimal handling.

Synthesis

Midline positioning is recommended for infants <32 weeks gestation for the first 72

hours of life (Davis et al., 2016; Malusky & Donze, 2011). Midline head positioning has been

shown to maintain constant cerebral blood flow by not impeding jugular blood flow (Davis et al.,

2016; Kaspar & Rubarth, 2016). Other head positions are associated with fluctuations in

cerebral blood flow contributing IVH. Midline positioning and minimal handling as part of a
IMPLEMENTING A NEURO BUNDLE 10

bundle-intervention has been proven to decrease the incidence of IVH (Chiriboga et al., 2019;

Christ et al., 2015; Schmid et al., 2013).

Routine care is associated with circulatory fluctuations that can lead to IVH; by providing

neuroprotective care such as minimal handling, we can decrease the incidence of IVH (Kaspar &

Rubarth, 2016). With minimal handling and the avoidance of stressful and painful situations the

neurologic outcomes of preterm infants can be improved (Coughlin, 2011,2016; Davis et al.,

2016; Peng et al., 2009).

Implementation Plan

Design, Sample, and Setting

A quality improvement project measuring the effectiveness of nursing education and

implementation of a neuro-bundle was implemented in a Level III NICU in a community

hospital in Baltimore, Maryland. A neuro-bundle consisting of midline positioning and minimal

handling (see Appendix A for neuro-bundle guideline) was utilized in the first 72 hours of life for

all preterm infants born prior to 32 weeks gestation and weighing less than 1500 grams. The

sample size for the project was 17. Eighteen infants were admitted to the NICU that met

inclusion criteria. The gestational age ranged from 23 3/7 to 30 3/7 weeks gestation. With birth

weights of 650 to 1610 grams. A single infant was excluded from the project since he was

transferred to this hospital at 2 days of life.

Procedures and Timeline

The project took place over a 14 week period and included a pre-implementation survey,

education, implementation, and a post-implementation survey. The pre-implementation survey

(Appendix B) was used to assess the nurses’ knowledge about IVH and neuro-bundles as well as
IMPLEMENTING A NEURO BUNDLE 11

their practice prior to implementation. The pre-implementation survey was linked to the

education module (Appendix C) and available to the nurses during weeks one and two.

The nursing education reviewed the pathophysiology of IVH and the purpose and

benefits of implementing a neuro-bundle. After completing the education, a completion report

was generated. Additionally, the remainder of the healthcare team, including neonatologists,

nurse practitioners, respiratory therapists, occupational therapists, and physical therapists learned

about the neuro-bundle including their role in its implementation.

At the conclusion of the nursing education, the neuro-bundle was implemented during

weeks three through thirteen. Each baby who met criteria for the neuro-bundle had a bundle at

his/her bedside containing the supplies needed to maintain midline positioning and aid in

minimal handling/stimulation as well as a copy of the guideline and paper checklists that were

completed for each set of cares (Appendix D). The bundles consisted of supplies that were used

in the NICU and were put together by the project leader to aid the nurses in implementing the

neuro-bundle. The nurses filled out the checklist documenting the gestational age and birth

weight of the baby as well as midline positioning, clustering of cares, and utilizing measures to

minimize pain and stress.

During week fourteen a post-implementation survey (Appendix E) was released via the

on-line education system. The nurses evaluated the process improvement by completing the

survey.

Data Collection and Analysis

Pre-implementation surveys were released with the education via the online education

system at the start of week one. A survey using a 5-point Likert scale was used to assess the

nurses’ knowledge about IVH and neuro-bundles. The project leader entered data from the surveys
IMPLEMENTING A NEURO BUNDLE 12

into an excel spreadsheet and central tendencies were calculated for each item. Following

completion of the education module, the project leader generated a completion report that provided

the number of as well as the percentage of nurses who completed the education. The data was

recorded in an excel spreadsheet.

Implementation took place from week three through thirteen. During implementation of

the neuro-bundle, checklists were completed by the nurses with cares. The data was entered into

an excel spreadsheet by the project leader. Demographic data about the infants was collected

including the infants’ gestational age and weight. Use of the neuro-bundle was measured by

calculating the number of babies admitted to the unit that met criteria compared to the number of

babies for whom nurses utilized the neuro-bundle. For babies whom the neuro-bundle was not

utilized, the use of pain/stress preventing measures was collected as well as factors that

contributed to lack of compliance.

At the completion of the QI project, a post-implementation survey using the same 5-point

Likert scale as in the pre-implementation survey was released via the on-line education system to

asses if there was a change in nurses’ knowledge as well as well as to get the nurses opinions on

the success of the project. The project leader entered data collected into an excel spreadsheet and

calculated central tendencies. Answers to the pre and post were compared using t-test to see if

there was an increase in perceived knowledge and if the increase was statistically significant.

Measures to Protect Human Rights

In the process of performing this quality improvement project, all efforts to protect

human subjects were made. All patient information was de-identified. All data collected was

stored in a locked file cabinet or in a password protected computer. Approval from the

University of Maryland Institutional Review Board for a non-human subject research

IMPLEMENTING A NEURO BUNDLE 13

determination was obtained and the proposal was reviewed and approved by the organization’s

review board.

Results

Prior to the initiation of this QI project, the unit did not utilize a neuro-bundle. A neuro-

bundle consisting of midline positioning and minimal handling was implemented in a Level III

NICU. The bundle consisted of midline positioning and minimal handling for the first 72 hours

of life for infants less than 32 weeks gestation and weighing less than 1500 grams. In order to

maximize the success of the project, a pre-implementation education module was utilized to

educate the nurses. The success of the education was measured using a pre and post survey.

The pre-survey, education module, and post survey were assigned to 56 full time and part

time nurses of the NICU. Nursing experience ranged from one year to 41 years with the mean

number of years of experience being 15.7 for the pre-survey and education module and 15.3

years for the post survey. The majority of the nurses had been in practice for >15 years and none

of the nurses had <1 year experience. See Table 2 for breakdown of years of experience. The

desired outcome was for 80% of the nurses to complete the surveys and education module. 49

nurses (87.5%) completed the pre-implementation survey and education module while only 31

nurses (55.4%) completed the post-implementation survey.

The pre and post surveys assessed nursing knowledge on IVH and neuro-bundles prior to

and after completing an education module. The survey was developed by the project leader for

the purpose of evaluating the bundle and was not tested for reliability and validity. The questions

were asked on a 5 point Likert scale which enabled the perceived knowledge of the nurses to be

measured. The answers were compared and the difference in the mean score analyzed using an

independent t-test with equal variance (α=0.05). The specific questions that were evaluated
IMPLEMENTING A NEURO BUNDLE 14

were: [Link] familiar are you with the pathophysiology of IVH? Pre-survey (M=2.98, SD=0.72)

and post-survey (M=3.68, SD=0.65); t= -4.37, P<0.001. 2. How familiar are you with the role

of the germinal matrix? Pre-survey (M=2.45, SD=0.84) and post-survey (M=3.23, SD=0.84); t= -

4.01, P=<0.001. 3. How familiar are you with why the germinal matrix is susceptible to

hemorrhage? Pre-survey (M=2.67, SD=0.80) and post-survey (M=3.71, SD=0.74); t= -5.81,

P=<0.001. 4. How often are you likely to use pain/stress minimizing measures when performing

routine cares or painful procedures? Pre-survey (M=4.22, SD=0.71) and post-survey (M=4.58,

SD=0.62); t= -2.28, P=0.013. 5. How often do you/likely are you to ask another nurse for help

when repositioning a baby? Pre-survey (M=2.43, SD=0.89) and post-survey (M=3.55,

SD=1.03); t= -5.16, P=<0.001. The change in mean score was statistically significant for all the

questions; the P-value was <0.05. (Table 3)

The implementation took place over 12 weeks. During this time, 18 babies were

admitted to the NICU that were less than 32 weeks gestation. A single baby was excluded from

the project due to the fact that he was a transfer from an outside hospital on day of life 2 and the

neuro-bundle is only utilized from birth until day of life 3. Six infants were male and 11 were

female with gestational age ranging from 23 3/7 weeks to 30 3/7 weeks and birth weight ranging

from 650 grams to 1610 grams. See Table 4 for a complete breakdown of demographic

information for the infants included in the QI project.

The project was successful with the neuro-bundle utilized for 16 of the 17 babies (94%)

admitted to the NICU during implementation. The neuro-bundle consisted of two parts; midline

positioning and minimal handling. For each set of cares that the checklist was completed,

midline positioning was maintained 97.6% of the time. The reasons given for not maintaining

the midline positioning were for IV placement and being on an Oscillator. It was recommended
IMPLEMENTING A NEURO BUNDLE 15

to utilize two nurses when repositioning infants, in order to maintain midline position. This was

done 56.03% of the time. The nurses reported they knew when they needed help repositioning

the baby.

Minimal handling was accomplished by clustering cares out to every 4 to 6 hours and

utilizing pain/stress minimizing strategies during handling. Minimal handling in the form of

cares every 4 to 6 hours was performed 86.4% of the time. The reasons for not performing

minimal handling were all related to the worsening status of the infant requiring immediate

intervention. During the time that minimal handling was unable to be achieved, the nurses’

utilized pain/stress minimizing interventions 100% of the time. The pain/stress minimizing

interventions included shielding eyes, maintaining boundaries, and administering pain

medication when appropriate.

As part of the unit’s protocol, infants born at <32 weeks receive screening head

ultrasounds to monitor for IVH. The IVH rate for the infants who participated in this project was

5.9% with a 0% rate of severe IVH. There was only a single case of grade II IVH and the

remainder of the babies had no IVH (Figure 1).

Discussion

The project was successful with a few unintended barriers identified along the way. The

pre and post surveys allowed for the comparison of knowledge and practice before and after

implementation. However, there was a lower response rate for the post-survey due to the high

census making it more difficult for nurses to take time to complete the survey.

The education module resulted in a better understanding of IVH and the benefits of

midline positioning and minimal handling. As a result, the nurses are more likely to use the
IMPLEMENTING A NEURO BUNDLE 16

different aspects of the neuro-bundle when caring for their patients. Additionally, the IVH rate

for the babies included in the project demonstrated a decrease in incidence of IVH.

The single baby for whom the neuro-bundle was not utilized was born when the hospital

went live with a new EHR. At the time of admission, the nurses were extremely overwhelmed

with the new charting system. With the help of the nurse educator and charge nurses, the project

continued without incident and all subsequent babies admitted to the NICU utilized the neuro-

bundle.

Of the babies for whom the neuro-bundle was utilized, only a single baby was not

maintained in midline position the entire 72 hours. This baby required respiratory support via

High Frequency Oscillatory Ventilation that prevented the baby from being in midline position.

This barrier was not anticipated, but at the same time was unavoidable. The nurses utilized the

neuro-bundle for this baby in the best way they could. They provided minimal handling when

appropriate and utilized pain/stress minimizing strategies at all times. This baby was also, the

only baby who developed an IVH over the course of implementation.

These results are consistent with the evidence presented in the literature review.

However, the decrease in IVH cannot be viewed as a cause and effect relationship as there are

many other factors that contribute to IVH risk. While the initial results of this project support the

utilization of a neuro-bundle, they are limited by the short timeline and small sample size.

Conclusion

The short term goals of this project were met with 87.5% (goal: 80%) of nurses having

completed the education module and the neuro-bundle being utilized for 94% (goal: 75%) of

infants meeting inclusion criteria. Furthermore, a low IVH rate was seen during implementation.
IMPLEMENTING A NEURO BUNDLE 17

The data supports the continued use of the neuro-bundle in the NICU. Through its

continued use, the neuro-bundle will enable a larger sample size to be followed and IVH rates to

be seen.

The long term success of the neuro-bundle would be aided by the addition of a single

location to document on all aspects of the neuro-bundle in one location. This will make it easier

for the nurses to document as well as for tracking compliance and outcomes. The unit may also

want to consider utilizing the education module as part of their new hire and yearly

competencies. This will enable the nurses to stay aware of the neuro-bundle and its benefits.
IMPLEMENTING A NEURO BUNDLE 18

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Running head: IMPLEMENTING A NEURO BUNDLE 21

Tables

Table 1

Evidence Review Table

Author, year Study Design Sample (n) Outcomes studied (how Results Level
objective/interv measured) and
ention or Quality
exposures Rating
compared
Chiriboga, Cortez, To reduce the Quality Preterm infants <30 Using a p-chart to compare A sustained reduction in ICH 4-A
Pena-Ariet, incidence of improvement weeks gestation the pre and post ICH rate was seen over 4 years from 24%
Makker, severe admitted to the to 9.7% (p<0.01).
Smotherman, intracranial NICU (n=281).
Gautam,…Hudak, hemorrhage
2019 (ICH) in infants
<30 weeks
gestation from
24% to 11%
Christ, Barber, To reduce the Quality Preterm infants <30 The number of severe and Average monthly rate of severe 4-C
Murray, Dunleavy, incidence of improvement weeks gestation overall IVH (%). IVH decreased from 8.3% to
Stoller, severe IVH in admitted to the Overall compliance with 5.1%
Taha,…Posencheg, preterm infants NICU. midline head positioning and Admission Huddle rate increased
2015 <30 weeks admission huddle (%). to 100%
gestation
Coughlin, 2016 To provide Evidence-Based All patients in the Guidelines and The implementation of evidence 1-A
evidence-based Practice NICU recommendation are based guidelines has been proven
practice Guidelines provided for each of the 5 to reduce morbidity and
guidelines to core measures included in mortality.
improve short trauma informed care. The latest evidence and
and long-term implementation strategies are
for infants and presented to assist in providing
families. age-appropriate, trauma-
informed care in the NICU.
IMPLEMENTING A NEURO BUNDLE 22

Coughlin, 2011 To provide Clinical Practice All patients in the There are 5 core measures in Consistent implementation 1-A
evidence based Guideline NICU providing age appropriate demonstrates a reduction in
clinical developmental care in the neonatal morbidities including
guideline for NICU. IVH.
age appropriate Recommendations are based The core measures meet the
care to on a comprehensive evidence requirements of the Joint
premature and review and two pilot studies. Commission to provide age-
critically ill specific care across the lifespan.
hospitalized
infants
Davis, Berger, & Review Literature Reduction of IVH rates to Midline head position has been 7-C
Chock, 2016 obstetric an Review/Expert improve neurologic outcomes shown to maintain a constant
neonatal Opinion cerebral blood flow by not
practices that impeding jugular venous blood
have been flow.
shown to have a Minimal handling and avoiding
neuroprotective stressful situations may be
effect on the beneficial.
developing More research is needed.
brain
Kaspar & Rubarth, The Expert Premature infants Circulatory fluctuations can By providing neuroprotective 7-B
2016 implementation opinion/evidence be seen in routine caregiving, care to prevent cerebral blood
of Based these fluctuations can lead to flow and blood pressure
neuroprotective IVH in critically ill preterm fluctuations we can decrease the
strategies are infants. incidence of IVH and have better
necessary to Overstimulation can increase outcomes for preterm infants and
prevent IVH blood pressure and increase their families.
and other brain cerebral blood flow leading
injuries to IVH.
Midline head position
prevents elevations in
cerebral blood flow and has
been shown to decrease
intracranial pressure.
Head positions other than
midline can be associated
with fluctuations in cerebral
blood flow contributing to
the risk of IVH.
IMPLEMENTING A NEURO BUNDLE 23

Malusky & Donze, Guideline for Systematic Preterm infants ,32 Evaluate the current evidence Implementation of midline head 1-B
2011 the institutional Review weeks gestation and determine if midline position recommended for
implementation head position for infants <32 infants <32 weeks gestation for
of weeks gestation prevents the first 72 hours of life – no
developmental IVH. adverse effects noted
care in the
Neonatal
Intensive Care
Unit
Peng, Bachman, The relationship Repeated measure Preterm infants Environmental stress There was statistically 3-B
Jenkins, Chen, between research design (n=37) (increased sound, light, significant (P<.05) relationship
Chang, Chang, & environmental nursing interventions)- between environmental stress
Wang, 2009 stressors and measured using a likert scale and change in vital signs.
stress responses Stress biobeahvioral There was a statistically
of preterm response: physiologic stress significant (P<.05) relationship
infants in the signals (HR, RR, and O2 between environmental stress
NICU sats), measured using and specific stress behavior
cardiorespiratory monitor;
and behavioral stress
response (sleep-wake states,
self-regulatory behaviors, and
behavioral stress cues),
Romantsik, To assess if Systematic Preterm infants born Is midline head positioning Not enough evidence to show a 1-C
Calevo, & midline head review (Cochrane at ≤32 weeks more effective in preventing positive or negative effect of
Bruschettini, 2017 position is Review) gestation. or extending IVH than any midline head position.
effective in other head position
preventing IVH
in infants <32
weeks gestation
IMPLEMENTING A NEURO BUNDLE 24

Schmid, Reister, To evaluate if a Interventional Preterm infants born The incidence of IVH and Incidence of IVH fell from 4-A
Mayer, Hopfner, bundle of cohort study <30 weeks gestation high grade IVH(%). 22.1% to 10.5% (p = 0.002)
Fuchs, & measures or weighing <1500 Incidence of severe IVH (grade
Hummler, 2013 including grams. 3-4) fell from 9.1% to 3.7% (p =
minimal Before intervention 0.037).
handling (n = 263)
(clustering Intervention (n=
cares, no baths, 191)
prevent noise,
etc.) and
midline head
positioning
would reduce
the incidence of
IVH
Running head: IMPLEMENTING A NEURO BUNDLE 25

Table 2

Years of Experience of Nurses

Pre Post
(n=49) (n=31)
Mean 15.7 16.3
Median 14 11
N (%) N (%)
<1 0 (0) 0 (0)
1-5 13 (26.5) 7 (22.5)
6-10 6 (12.2 8 (25.8)
11-15 7 (14.3) 4 (12.9)
>15 23 (46.9) 12 (38.7)
IMPLEMENTING A NEURO BUNDLE 26

Table 3

Pre and Post-Implementation Survey Results

Pre (n=49) Post (n=31)

How familiar are you with the pathophysiology of IVH?
N (%) N (%)
Mean 2.98 3.68
1 0 0
2 11 (22.45) 0
3 30 (61.22) 7 (22.58)
4 6 (12.22) 21 (67.74)
5 2 (4.08) 2 (6.45)
How familiar are you with the role of the germinal matrix?
N (%) N (%)
Mean 2.45 3.23
1 7 (14.29) 1 (3.26)
2 17 (34.70) 4 (12.90)
3 21 (42.86) 14 (45.16)
4 4 (8.16) 11 (35.48)
5 0 1 (3.26)
How familiar are you with why the germinal matrix is susceptible to hemorrhage?
N (%) N (%)
Mean 2.67 3.71
1 4 (8.16) 0
2 14 (28.57) 0
3 25 (51.02) 14 (45.16)
4 6 (12.22) 12 (38.71)
5 0 5 (16.13)
How often do you/ likely are you to use pain/stress minimizing measures when performing
routine cares or painful procedures?
N (%) N (%)
Mean 4.22 4.58
1 0 0
2 1 (2.04) 0
3 5 (10.20) 2 (6.45)
4 25 (51.02) 9 (29.03)
5 18 (36.73) 20 (64.52)
How often do you/likely are you to ask another nurse for help when repositioning a baby?
N (%) N (%)
Mean 2.43 3.55
1 8 (16.32) 0
2 17 (34.70) 6 (19.35)
3 19 (38.78) 8 (25.81)
4 5 (10.20) 11(35.48)
0 6 (19.35)
IMPLEMENTING A NEURO BUNDLE 27

Table 4

Infant Demographics (n=17)

N(%)
Sex
Male 6 (33.33)
Female 11 (61.11)
Gestational Age
<28 weeks 7 (41.18)
28-32 weeks 10 (58.82)
Birth Weight
<1000 grams 6 (33.33)
1000-1500 grams 9 (52.94)
>1500 grams 2 (11.76)
IMPLEMENTING A NEURO BUNDLE 28

IVH
18

16

14
Number of cases

12

10

0
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
IVH Grade

Figure 1. Number of cases of IVH by grade

IMPLEMENTING A NEURO BUNDLE 29

Appendix A: Neuro-bundle Guideline

Guideline for Implementing Neuro-Bundle

Targeted Population: Preterm infants <32 weeks and weighing <1500 grams, the first 72 hours of life

Practice Recommendations Rationale

Midline Positioning Prevent cerebral blood flow 1. Maintain head in midline

fluctuations, maintaining position, baby can be placed
jugular venous flow. supine or side-lying.
2. Head maintained in midline
position during position
changes: use 2 nurses to
reposition baby
3. Head maintained in midline
position for kangaroo care: use
2 nurses to transfer baby, have
baby in side lying position.

Minimal Handling Minimize pain and stress. 1. Cluster cares Q4-6 hours if
Routine care is associated with appropriate.
stress which is associated with 2. Healthcare team work together
increased cerebral blood flow. to minimize the number of
times the baby is handled.
3. Use swaddling and other non-
pharmacologic interventions
(boundaries; shield eyes from
light) when performing painful
procedures.
IMPLEMENTING A NEURO BUNDLE 30

Appendix B: Pre-implementation Survey

IVH Questionnaire

Pet’s name:_________________

# of years as a RN:____________________

All questions will be answered on a scale 1 to 5 with 1 meaning never/not at all and 5
meaning always/very.

1. How familiar are you with the pathophysiology of IVH?

1 2 3 4 5

2. How familiar are you with the role of the germinal matrix?

1 2 3 4 5

3. How familiar are you with why the germinal matrix is susceptible to hemorrhage?

1 2 3 4 5

4. How familiar are you with the use of neuro-bundles for IVH prevention?

1 2 3 4 5

5. How familiar are you with why midline positioning is thought to prevent IVH?

1 2 3 4 5

6. How familiar are you with why minimal handling/ pain and stress-minimizing is thought
to prevent IVH?
1 2 3 4 5

7. How often do you use pain/stress minimizing measures (swaddling, maintaining

boundaries, shielding eyes from light) when performing routine cares or painful
procedures?
1 2 3 4 5

8. How often do you ask another nurse for help when repositioning a baby?

1 2 3 4 5
IMPLEMENTING A NEURO BUNDLE 31

Appendix C: Education Plan

I. Powerpoint/online module

A. Background

1. IVH Pathophysiology

2. Significance of problem

B. Project Purpose

1. Short term goals

2. Long term goals

C. Implementation

1. Setting

2. Target population

3. Guideline/ evidence based practice

a) Midline positioning

b) Minimal handling

(1) Pain/stress minimizing measures

IMPLEMENTING A NEURO BUNDLE 32

Appendix D: Neuro-Bundle Checklist

Neuro-Bundle Checklist Patient Label

Date: _____________ Shift: □ day □ night

Gestational Age:____________ Birthweight:_________grams Day of Life:___________

Was midline positioning maintained? □Yes □No

Was the baby positioned with the help of a second nurse? □Yes □No

Was minimal handling utilized? □Yes □No

What interval was used between cares? ___________

What prevented the recommended interval from being used?

□ apnea/bradycardia event

□ acute worsening of respiratory status

□ other: __________________________________

What non-pharmacologic measures were utilized to minimize pain/stress?

□ swaddling

□ maintaining boundaries

□ shielding eyes from light

□ other: __________________________________________________

-----------------------------------------------------------------------------------------------------------------
For Project Leader
IVH □ yes □ no
IMPLEMENTING A NEURO BUNDLE 33

Appendix E: Post-implementation Survey

Neuro-Bundle Questionnaire
Pet’s name:_________________
# of years as an RN:____________________
All questions will be answered on a scale 1 to 5 with 1 meaning never/not at all and 5 meaning
always/very.

1. How helpful was the education module?

1 2 3 4 5
2. How familiar are you with the pathophysiology of IVH?
1 2 3 4 5
3. How familiar are you with the role of the germinal matrix?
1 2 3 4 5
4. How familiar are you with why the germinal matrix is susceptible to hemorrhage?
1 2 3 4 5
5. How often are you likely to use pain/stress minimizing measures (swaddling, maintaining
boundaries, shielding eyes from light) when performing routine cares or painful procedures?
1 2 3 4 5
6. How likely are you to ask another nurse for help when repositioning a baby?
1 2 3 4 5
7. How well did you think the implementation went?
1 2 3 4 5
8. What changes would you make? ____________________________________________
______________________________________________________________________