Any invasive procedure in neonatal intensive care units puts tiny patients at risk of harm.
A Utah-based hospital has dramatically reduced the number of invasive procedures endured by patients in the facility's neonatal intensive care unit.
Procedures such as blood draws, central line insertions, and radiological exams can cause a range of harm to fragile neonates, including deadly bloodstream infections such as sepsis.
In 2008, Dixie Regional Medical Center in St. George, Utah, launched an initiative to reduce infections and other harms linked to invasive procedures in the Intermountain Healthcare facility's NICU. The program—preventing pain and organisms from skin and catheter entry or POKE—has achieved impressive results:
- More than 11,000 "pokes" have been avoided
- Operational costs have been reduced 28%
- Length of stay has decreased 21%
"In the beginning, we were trying to reduce infection in the neonates. We knew that every time we punctured their heels over a 24-hour period there was an increased chance of sepsis. We knew that if we kept lines in for longer than seven days, there was an increased chance of central line-associated bloodstream infections. We have only had one CLABSI in more than 10 years," says Jeannette Cutner, BSN, RN, a nurse manager at Dixie Regional.
POKE has been adopted at other Intermountain hospitals as well as several other health systems such as Loma Linda University Health, University of Alabama at Birmingham, and Florida Hospital.
Providing value-added care
The POKE program is based on core principles, says R. Erick Ridout, MD, a neonatologist at Dixie Regional. "The most important first step was aligning the team under the idea of all care needing to be value-added, and care that was not value-added represented harm."
Care team culture is critically important, he says.
"The most important thing is recognizing that just culture is the foundation for everything—that means folks are accountable for the care they provide, and they will support things we can improve. That builds a virtuous cycle that drives toward safety and zero instances of harm."
There are several elements to drawing the line between invasive procedures that add value in the NICU and those that do not add value, Ridout says.
"At first, the only way we could identify care that was value-added was looking at the literature, but that was woefully lacking. So, we had to rely on a highly engaged team. And the only way to have a highly engaged team is to have everyone feel valued, which requires leadership managing the team from a position of humility, deep respect, and deference for those at the frontline."
Observation of the patient is crucial in the POKE program, he says. "You fall back on the reams of data the baby already provides."
"If we look at a pre-term baby who is thriving, gaining appropriate weight every day, with normal temperature—checking all the boxes—conducting labs on that baby to make sure it is normal does not help. It hurts the baby. That's a very common practice—babies are routinely put through pokes, and labs are run every Monday, Wednesday, and Friday to demonstrate babies are normal when they are telling you they are normal already," Ridout says.
The first step to implement the POKE program was gathering data, he says. "We first started out rudimentarily on paper, then we programmed a database to record every single decision we made and what it meant on behalf of the patient."
Data is a powerful staff motivator when launching the POKE program at a health system or hospital, Cutner says.
"If you give 50 or 60 RNs something that is measurable every day—which is something we talk about daily with our parents and grand rounds in the morning—everyone is aware of the interventions that were done to the baby the day before. It used to be in the 40 to 70 range, and now it's down to near zero. We build a case for every poke every day," she says.
Cultural change requires significant effort, Cutner says.
"It takes leadership and building up all of the charge nurses who work inside the unit to where they all want to be at 100% when they come to work and do what's best for the baby. You need lines of communication between each other and between the disciplines, so no one is afraid to speak up."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Neonates receiving NICU care can be exposed to deadly hospital-acquired infections such as sepsis.
A harm-aversion program adopted at Intermountain Healthcare is based mainly on the principle that only value-added care should be provided to patients.
To implement the NICU program, changing care team culture is a significant challenge.