psychologist Boston Children's Hospital, Harvard Medical School Boston, Massachusetts, United States
Abstract:
Introduction: Neurodevelopmental deficits are noted throughout the lifespan for individuals with congenital heart disease (CHD). For the infant hospitalized with CHD, environmental challenges such as noxious stimuli, painful procedures, sleep deprivation, parental stress and reduced parental interaction leads to less optimal brain development and neurodevelopmental delay. Developmental care (DC) is an intervention designed to minimize the mismatch between the infant brain's expectations and the stressful experiences inherent within the Intensive Care Unit (ICU). Implementing DC practices in a Cardiac ICU (CICU) requires a well-planned process to ensure successful adoption of practice changes. Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is the only evidence-based, comprehensive, internationally recognized program of DC shown to improve outcomes for premature infants with enhanced brain structure and function and improved behavioral outcomes into school age. Resent literature calls for DC integration into the CICU; however, research shows it is rarely fully implemented into practice.
Methods: A multidisciplinary expert group (nursing, cardiology, surgery, respiratory therapy, child life, and psychology) were assembled to begin quality improvement (QI) (Key Driver Diagram, Figure 1) to increase the amount of DC in the CICU. DC was measured using the NIDCAP Organizational Structures Assessment (OSA) as a bedside audit. The OSA uses a 5-point rating scale (5= highest level of DC). Fifteen individual items measured the environment, infant bedspace, and caregiving along with background information including primary diagnosis, severity of illness, and discipline of caregiver observed. Audits were reviewed and PDSA cycles were implemented. Review of data led to interventions to improve care including multimodal multidisciplinary staff education, along with discussion at staff meetings and unit huddles.
Results: Bedside audits of DC were collected from 2017 to 2022 (n=358). Fifty-one percent of infants were under 30 days old and 22% of infants had single ventricle CHD. Most observations were with nursing (93%) and during routine caregiving (87%). Many infants were intubated (51%) and most had at least one invasive line or tube (98%). Most infants did not require sedation prior to caregiving (77%). The level of DC strategies provided improved over time including appropriate light and sound, therapeutic positioning, support for infant self-regulation, individualized bedspace and timing for caregiving, holding, and parent participation (Figure 2). Light and sound were challenging to sustain change in the most ill infants. Of note, changing practices during the COVID-19 pandemic challenged developmental care.
Conclusion: This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of DC improved overtime using a multimodal educational approach and bedside auditing in the CICU.
