Objective: Pediatric patients with complex congenital heart disease have delays in several key areas of neurodevelopment, notably motor skills, cognition, communication and language skills, visual/motor and visual/spatial integration, and executive functioning. Cardiac critical care unit (CCU) environmental factors, including monitor alarms, sleep interruptions, and diminished stimulation with sedation and paralysis, may contribute to these delays. We describe a nursing education model with a correlative case study integrating a neurodevelopmental model into routine medical care thereby improving neurodevelopment.
Methods: 41 RNs in our cardiac center underwent a 30-minute lecture and simulation session focusing on cue-based and four-handed cares. The education curriculum was developed utilizing a literature review of best practices for developmental care models in NICUs (Neonatal Integrative Care Model or IDC), as well as current and emerging practices on CVICUs (Individualized Family-Centered Developmental Care Model or IFDC) in addition to unit-specific recommendations based on therapists' discretion and observation. A locally developed pre- and post-lecture survey was administered to the CCU nursing staff to assess nursing awareness and comfort in providing the described cares. We continue to monitor how utilizing this model impacts various CCU environmental factors. For example, one patient with complex single ventricle congenital heart disease who required Berlin EXCOR ventricular assist device support was evaluated utilizing the practices communicated between the therapy and nursing staff.
Results: Pre-test average scores were 72% while post-test scores were 88%, showing a 16% improvement in nursing comfort with cue-based and four-handed cares. As an example of clinical correlate, a long-term patient before implementation had severe hyperactive delirium that required 75.2 morphine milligram equivalents (MME), daily exposure to 13 mg midazolam and 6 mg lorazepam, daily exposure to 302 mcg dexmedetomidine and 72 mcg clonidine, haloperidol, risperidone, and ketamine for baseline safety of the patient and cooperation with life-sustaining medical equipment as well as additional periodic exposure to opioids and ketamine for cares, dressing changes and wound vacuum changes. After implementation this exposure decreased to 53.2 MME, daily exposure to 8 mg lorazepam, and daily exposure to 130 mcg dexmedetomidine and 200 mcg clonidine at baseline with no additional requirements for cares, dressing changes nor wound vacuum changes. This case study, while not directly causative, shows the correlative improvements in administering neurodevelopmentally appropriate cares can have on exposure to sedation medications.
Conclusions: Nursing education on cue-based and four-handed cares rooted in theories from both the Neonatal Integrative Care Model (IDC) and the Individualized Family-Centered Developmental Care Model (IFDC) is an effective way to increase nursing understanding and comfort. While further research is warranted, it can also potentially contribute to correlative decrease in the required amount of sedation medications utilized for pediatric patients with congenital heart disease.
