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Hospitals across the world are experiencing a growing epidemic of aggressive, escalating, and violent patients and visitors. Despite the significant burden on health care organizations, there is a lack of evidence supporting effective management strategies. This article describes one hospital unit’s journey to implement behavioral standards and create a de-escalation algorithm that improved staff perceptions of safety by 25% and reduced events of escalation by 75%. Health care facilities can effectively improve safety through staff engagement in intervention design, development of an interprofessional response to escalation, and effective staff education for management of events of aggression/escalation.

Background Escalating and aggressive visitor behaviors have become increasingly common in healthcare settings nationally, negatively impacting staff and patients alike. Most healthcare providers do not innately possess the specific skills to manage such behaviors. Management of escalating and aggressive behaviors presents a particularly bedeviling challenge when staff safety must be balanced with the needs of parent-neonate bonding. Purpose In the Intensive Care Nursery (ICN), the frequency of aggressive and hostile incidents from visitors increased such that the staff felt frustrated by and uneasy about their work environment. Methods The ICN convened an interprofessional team to strategize interventions aimed at consistently managing aggressive behavior and supporting the staff after aggressive and/or hostile visitor encounters. Findings Following staff education and training, the unit launched a de-escalation management algorithm in July 2018 that assisted in identifying high-risk families at admission and drove consistent action and management of all visitor behaviors. In the 12 months following the intervention, the frequency of behavioral escalation decreased by 75% and staff perception of safety increased by 25%. Implications for practice Collaborating with staff to design consistent strategies to manage aggressive and escalating visitor behavior can improve safety and improve employee satisfaction in the ICN. Implications for research Additional research on the effectiveness of the algorithm in other ICNs and alternative areas of practice is needed. Furthermore, validation of a staff perception survey measuring the impact of escalating visitor behaviors on employees would be an important next step in this research.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=43.

Supplemental oxygen plays a critical role in the care of infants born at the lower limits of viability, but not without the risk of morbidity resulting from high levels or prolonged exposure.The purpose of this quality improvement project was to reduce exposure to hyperoxia as evidenced by SpO2 values within the established target range (88%-92%) among very preterm infants (VPIs) in a level 3 neonatal intensive care unit (NICU). Reducing exposure to hyperoxia in this population of exquisitely vulnerable infants has been associated with reduced morbidity, including retinopathy of prematurity, chronic lung disease, and brain injury.Two populations of interest were identified: VPIs receiving supplemental oxygen and NICU clinicians.Interventions were employed to (1) improve knowledge regarding hyperoxia and associated outcome sequelae in an interdisciplinary sample of clinicians (pretest posttest design) and (2) reinforce content of the educational intervention by triggering caregiver behaviors to reduce time the VPIs is above target SpO2 range while receiving supplemental oxygen (cohort design).: Retrospective chart review, baseline clinician knowledge assessment, education, posteducation assessment, collaborative rounds with regular feedback citing time VPIs spent above target oxygen saturation levels (SpO2), and evaluation of impact on time infants spent above target SpO2 range aligned with the project purpose.Pre- and postintervention dependent variables included clinician knowledge of hyperoxia and related evidence as measured by a 24-item multiple-choice Knowledge Assessment Tool before and after attending an educational presentation. Time VPIs were exposed to hyperoxia was evaluated using SpO2 readings and calculating the percentage of time readings were above target range before and after the introduction of educational and behavioral interventions.Outcome 1 was to increase knowledge about hyperoxia among clinician caregivers. Paired-samples t test showed a significant difference between preintervention and postintervention Knowledge Assessment Tool scores (P = .000). Outcome 2 measured reduction in time spent with SpO2 readings above target range. An independent-samples t test was used to compare outcomes in preintervention and postintervention VPI cohorts. Mean time spent with SpO2 greater than target range increased in the postintervention cohort, reaching statistical significance with P = .047.Knowledge acquisition on the subject of hyperoxia in VPIs was achieved. Decreasing the percent time VPIs were exposed to hyperoxia was not attained. The postintervention VPI cohort spent more time above the target saturation range despite greater knowledge among clinicians.

Glucose is the primary substrate for cerebral metabolism and function. When there is a recurrent and prolonged imbalance in glucose homeostasis, the result is cerebral energy failure, which can lead to neurologic injury in the neonate. However, for neonates with transient hypoglycemia, the relationship between low plasma concentrations, cerebral injury, and neurodevelopmental outcomes remains uncertain. This article reviews glucose metabolism in the fetus and neonate, the neuroprotective responses to hypoglycemia, and the continued diagnostic and therapeutic dilemmas that clinicians face in the management of neonatal hypoglycemia.

In the United States, approximately 100,000 infants are born to diabetic mothers each year. If diabetes in pregnancy is uncontrolled, the diversity of resulting health problems can have a profound effect on the embryo, the fetus, and the neonate. These infants are at risk for a multitude of physiologic, metabolic, and congenital complications such as macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, cardiomegaly, and central nervous system disruption. Preconception control of glucose metabolism throughout the trajectory of a woman's pregnancy is a significant factor in decreasing the adverse impact of diabetes on the fetus and newborn. Meticulous attention to neonatal glucose levels, thorough physical examination, and precise diagnosis are prerequisites to appropriate care for the neonate.

Patient safety is one of the greatest imperatives in healthcare today, yet there are many obstacles that must be overcome to make healthcare delivery truly safe. Critically ill newborns are among the most medically fragile patients in hospitals today. Given their size and gestational age, the tolerance for error within this population is extremely small. Medical errors that may be less consequential in adults can be disastrous for infants. Developing a culture of safety demands a mind-set that continuously seeks out vulnerabilities and prospectively addresses them through systems-based rather than individual-based solutions. The complexities of clinical care and intricacies of human behavior may prevent total elimination of risk, but caregivers are in a position to develop a culture of safety that can minimize risks for adverse events in the neonatal intensive care unit. Specific strategies used to successfully implement a staff-focused patient safety program are described in this article. These strategies include the development of systemwide and unit-based interdisciplinary safety teams to proactively identify and address safety concerns, development of specific tools and techniques used for analysis and prioritization of risk, resources that teams used to support an environment of safety; and implementation of staff-driven solutions to address safety concerns.

Objective To propose and implement a family‐centered systems approach to manage newborn jaundice for safer outcomes. Design Observational study for known adverse outcomes. Setting Semiprivate urban birthing hospital. Patients/Participants 31,059 well babies discharged as healthy from a cohort of 41,961 live births (1990‐2000). Interventions Incremental implementation of a systems approach that incorporated a hospital policy to (a) authorize nurses to obtain a bilirubin (total serum/transcutaneous) measurement for clinical jaundice, (b) universal predischarge total serum bilirubin (at routine metabolic screening), and (c) targeted follow‐up, using the bilirubin nomogram (hour‐specific, percentile‐based total serum bilirubin/transcutaneous bilirubin). Main Outcome Measures Known adverse outcomes assessed for early‐ and late‐onset severe hyperbilirubinemia before, during, and after systems approach implementation. Results Adverse outcomes decreased for well babies: exchange transfusion, intensive phototherapy, and readmission. During the study period, there were no "never events" (total serum bilirubin greater than or equal to 30 mg/dl), while "close calls" (total serum bilirubin greater than or equal to 25 mg/dl) were 1 in 15,000 as compared to a reported incidence of 1 in 625. Conclusions Reduced adverse events, significant reduction in close calls, and no never events met family expectations for safer experiences with this approach.

Kernicterus is a tragic and unacceptable outcome for jaundice in an otherwise healthy newborn. But as health care practices and attitudes have changed over the years, reemergence of kernicterus has been evident in the medical literature and in the community. Current practice management for jaundice is prone to misunderstanding and oversights. Not all health care providers are involved in the process and there was a loss of concern about potential bilirubin toxicity. To ensure patient safety, address the root causes of kernicterus, and enhance the human factor performance, a system-based approach to hyperbilirubinemia to prevent kernicterus is described.

In the upheavals of its long history, India's traditions and mores have been continuously evolving. India has absorbed, adopted, and adapted outside cultures and influences, which have merged into Indian society. This article describes the traditional practices of childbearing and neonatal care in India today. The impact of 850 million people on the health care system along with the educational process for the Indian nurse is discussed. The author reports on her neonatal care experiences over the past 9 years in India.

Because of trends in the health care environment, hospitals are searching for ways to continuously improve the quality of care and to decrease the costs of care. One approach that is gaining widespread recognition throughout the United States is the use of case management and practice guidelines such as critical paths, CareMaps, and in the neonatal field, NeoMaps. The NeoMap is a clinical tool which delineates practice guidelines for each discipline that provide care to a specific infant population. It reduces variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines are linked to both health and economic outcomes, they have significant impact on health care costs. In this paper, case management and the development of the NeoMap will be described in relation to the Intensive Care Nursery (ICN) at Pennsylvania Hospital.

Hyperbilirubinemia continues to be a common problem of the term and near-term neonate. Each year more than 60% of infants born in the United States develop jaundice, making it difficult at times to differentiate jaundice due to pathologic reasons from jaundice due to physiologic ones. Now, the knowledge that bilirubin may even have a beneficial role as an antioxidant has caused a great deal of renewed interest in the management of jaundice. The American Academy of Pediatrics has published revised guidelines for management of neonatal jaundice that have resulted in much discussion. The article reviews current theories of bilirubin production and clearance, noninvasive and nonintrusive techniques to assess and care for jaundice, and newer concepts of preventive and treatment modalities from a nursing perspective.

Aspiration pneumonia is associated with significantly high morbidity and mortality rates, accompanied by high health care costs. As a result, aspiration pneumonia preventive efforts are a national priority. The development of an intervention model for the prevention of aspiration pneumonia in high-risk medical-surgical inpatients at an urban teaching hospital is described. The intervention model consists of the implementation and evaluation of a risk assessment tool and development of an aspiration pneumonia prevention protocol.

Health care reform, managed care, and the current outcomes movement have generated a rapid acceleration toward the development and implementation of clinical pathways in the field of neonatology. This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for a neonatal intensive care nursery. This neonatal clinical pathway is a clinical tool that delineates practice guidelines for each discipline that provides care to a specific infant population. It has reduced variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines and documentation are linked to health and economic outcomes, they begin to significantly impact health care costs.

Evaluation of the Neonatal Resuscitation Program (AAP and AHA) as an Educational Tool for Healthcare Providers of Syrian Arab Republic

Computer-Integrated Respiratory Mannequin Model to Simulate Pseudo-Adaptive Control of PaCO 2 and Neonatal Ventilation † 1912