Leadership and Professional Image

Leadership and Professional Image (C 493)

Task 1

Western Governors University

The proposal that I have suggested for the Labor & Delivery Unit that I work on, is expanding our current Baby-Friendly Practice to include parental involvement and initiating Skin-to-Skin contact in the operating room setting. In 2015, Medstar Franklin Square Medical Center became the first hospital in the state of Maryland to receive Baby-Friendly designation. Briefly, Baby-Friendly designation is achieved by adhering to the “Ten Steps to Successful Breastfeeding”, which are steps that consist of evidence-based practices that have been shown to increase breastfeeding initiation and duration (Baby-Friendly USA, 2019). One of the crucial steps to breastfeeding success is to initiate breastfeeding in the first hour of life. Several studies indicate that immediate (within five minutes) skin-to-skin contact between newborn and mother is shown to increase successful breastfeeding. Despite the increasing evidence of the benefits of skin-to-skin at birth, we have not incorporated this simple, yet extremely beneficial intervention. This issue is current and relevant because research data shows that when skin to skin is initiated at birth, exclusive breastfeeding rates at 6 weeks are increased when compared to no skin-to-skin contact. According to a randomized controlled study published in African Health Sciences, 72% of infants in the skin-to-skin contact group were exclusively breastfed at 6 weeks vs. 57.6% of the infants that were in the control group (Sharma, 2016). The purpose of this proposal is not to prove the benefits of exclusive breastfeeding. The purpose is to challenge ourselves to provide the same evidence-based care to our c-section patients, that we currently provide to our mothers and newborns during vaginal deliveries. We are the second highest delivering hospital in the region with approximately 220-250 deliveries a month. Approximately one-third of those

deliveries are performed by cesarean section. I propose that the newborns born to mothers undergoing a c-section, do not miss out on the many benefits of early skin-to-skin contact.

In order to address a practice change, I had to first evaluate our current practice. C-section teams at the facility that I work at consist of many team members that include: an OB/GYN, a CNM or a second surgeon to assist, a Surgical Tech or Scrub RN, a circulating RN, a baby RN, a Neonatologist or CRNP, a NICU RN, and an Anesthesiologist or CRNA. The current practice in my institution during c-section deliveries includes having a sterile drape over the mother that mounts to IV poles. The drape which is meant to provide a sterile environment, impedes the parents view of their baby being born. The OB delivers the newborn and resuscitation begins while waiting one minute for delayed cord clamping. After the cord is clamped and cut, the newborn is handed off to a baby RN who then places the newborn on a radiant warmer to be assessed by the NICU team. If after initial assessment and interventions, the newborn is stable, the NICU team leaves and the baby RN assumes care of the newborn. The baby RN then begins to complete a long list of assessments and tasks for the newborn. There is little parental involvement during this time. The newborn and father of the baby (or other support person) are then taken to the recovery room while the mother remains in the operating room to complete surgery. When the mother arrives to the PACU/recovery room, the mother is stabilized and assessed by the circulating RN and Anesthesiologist. If the mother is stable, attempts at initiating skin-to-skin are taken. At this point, the nurse encourages and assists the patient with breastfeeding. The nurse encourages the mother to continue skin-to-skin for at least an hour and as often as she desires.

My proposal includes a multi-disciplinary collaboration to facilitate parental involvement and early skin-to-skin contact in the Operating Room as opposed to waiting until the mother is in the PACU. After evaluating our current practice, I identified the barriers that may interfere with successfully initiating a process/practice change. Barriers include the sub-optimal OR layout, lack of appropriate equipment and supplies, inadequate staffing, and lack of education and training. While discussing the idea of skin-to-skin in the OR with my RN peers, valid concerns were voiced. Some thought that safety would be an issue. How do we safely take care of a newborn who is laying on the chest of a mother during major surgery? Who is monitoring the newborn? How do we ensure that the newborn will not slip off of the mother? Staff were resistant to yet “another change.” Staffing concerns were expressed by the Charge RN’s. Often, we are working short staffed and efficiency sometimes takes precedent over patient-centered care. Delaying the required assessments and tasks would slow down the usual workflow. The OB providers were concerned that the process would interfere with surgery because the mother’s arms and the baby could encroach upon the operating space. Concerns from the Anesthesia department included safety and monitoring of their patient (who is the mother) and the limited physical space at the head of the OR table. Equipment issues include very narrow OR tables. One of our Surgical Techs expressed concerns that lowering the anesthesia drape for the parents to view the baby being delivered, could compromise the sterile field. Concerns from the NICU included inability to fully assess the newborn at birth. Despite all of the concerns, everyone agreed that early skin-to-skin is beneficial to both mother and baby.

The resources necessary for this practice improvement include the key stakeholders, new supplies, current supplies, policy development, education and training. My plan would involve working with key stakeholders to develop guidelines outlining what criteria must be met in order to initiate a skin-to-skin c-section. The current OR layout must be assessed for possible changes that could optimize space to allow for more space at the head of the OR table. Improving the layout of the OR would improve workflow and should not have a great financial impact. This can be achieved by working with the members of the multidisciplinary team (Nursing, Surgical techs, Anesthesia, OB providers, and NICU team) to evaluate the current layout and possible improvements. I would also like to introduce a new dual-layered anesthesia drape. The solid part of the drape can be lowered and raised as needed, allowing the parents to view the birth of their child through the clear drape while maintaining a sterile field. After choosing a new drape, we would have to work with suppliers to include the new drape in our c-section bundles. The cost may be slightly increased, but the benefit for our patients would be worth the price. Finally, if the newborn and mother are stable, the newborn may be placed skin to skin on the mother’s chest and covered with warm baby blankets. A baby nurse would be designated to stay with the mother and baby throughout the duration of skin-to-skin contact in the OR and transfer to PACU. We currently have a designated baby nurse for every c-section, therefore there should not be an increase in cost for staff during skin-to-skin. However, the routine and responsibilities of the baby nurse will change.

The key stakeholders for my proposed practice improvement are the OB providers, Nursing Staff, Surgical team staff, NICU team (Neonatologist/CRNP, RN, RT), Anesthesia

department and most importantly our patients. It is imperative to have the OB providers on-board in order to successfully implement skin-to-skin c-sections. This change would alter their current practice. However, with effective team collaboration, the impact of the change can be minimized, and the benefits maximized. The Surgical Technicians will be involved in the OR redesign and becoming familiar with the new supplies and processes. The NICU team, in collaboration with the OB providers, Anesthesia Department and Nursing, will be responsible for determining what patients and situations are appropriate for a skin-to-skin c-sections. Examples include: only patients with spinal/epidural anesthesia, uncomplicated pregnancies, gestational age range 39-41 weeks, APGAR score >8 at 1 minute and etc. The NICU team would be responsible for determining if the newborn is stable to do skin-to-skin. Nursing will be key to adjusting workflow and routine to successfully implement skin-to-skin in the OR. It is vital that the Anesthesia department is involved in the planning and implementation of the proposed change. Nursing and Anesthesia must collaborate to successfully and safely monitor the mother and the newborn. Changes would include changing cardiac lead positioning, minimizing nausea and vomiting with the use of antiemetics and sharing a “workspace” at the head of the OR table. Finally, the patient must want to have a skin-to-skin c-section. If the situation is appropriate, a skin-to-skin c-section should be offered. The RN, OB and Anesthetist will all be involved in educating and preparing the patient for a skin-to-skin c-section. All team members (including the patient) should have the authority to discontinue skin-to-skin for safety and medical reasons.

Upon discussion of this topic with the NICU team, they were strong proponents of skin-to-skin contact within 5 minutes of birth. They have been instrumental in implementing and

encouraging skin-to-skin after vaginal deliveries and in the NICU. Most were intrigued with the idea of implementing that practice in the OR. As I stated previously, a concern was evaluation of the newborn. A suggestion was made that the newborn should be brought over to the warmer for a quick assessment. The goal would to be to return the newborn to the mother within 1-5 minutes. As long as the 1-minute APGAR is >8 and newborn appears to be doing well, baby will be placed skin-to-skin on the mother’s chest.

The OB providers have been very supportive thus far during our baby friendly journey. One of the OB providers was very receptive; however, she was concerned that skin-to-skin may interfere with surgery especially if complications arise. After further discussion, it was suggested that any team member has the authority to immediately discontinue skin-to-skin for medical or safety reasons.

As I also discussed previously, I had many conversations with my RN peers. While most of the RN’s agreed with the “idea” of skin-to-skin in the operating room, there were reservations about actually implementing the change. Once we began talking more about it, we realized that we already have most of the resources that we need to make skin-to-skin c-sections a reality. It will be very important to our success to have adequate staffing to allow for the baby RN to remain with the couplet throughout surgery and recovery. The baby RN will provide a safe environment for the newborn and mother. The newborns vital signs will be assessed while on the mother’s chest; however, the usual tasks and assessments will be delayed in order to allow for bonding and breastfeeding. We also discovered there were some intriguing devices that would help the mother hold her baby during her surgery. An example was the Joey Band Sleepbelt. At this time, I did not fully research the availability, cost and research on such devices.

Understandably, the biggest challenge was the Anesthesia Department. They are responsible for ensuring that the mother remains stable, safe and comfortable throughout the procedure. We discussed the issue of the OR space and ability to monitor the mother throughout the surgery. Most agreed that some changes in the OR layout would improve the possibility that we can share the head space. It was also discussed about re-arranging the cardiac leads to allow newborn access to the mother’s bare chest. Anesthesia concerns also included that they could not be responsible for monitoring the baby, because the mother was their patient. After informing them that a nurse will be at the mother’s side throughout skin-to-skin contact, they were more agreeable.

One of our Surgical Technicians expressed concerns about compromising the sterile field by lowering the drape when the newborn was delivering. We discussed possible solutions. We did some internet searches and found that there were alternative drapes that would provide a clear window for the parents to view the birth of the baby without contaminating the sterile field.

One of the key elements of this proposal is to begin with education of the Labor and Delivery staff, the NICU staff, the Obstetric providers (MD, DO and CNM) and Anesthesia staff. There are several studies regarding the benefit of skin-to-skin contact after delivery. We have already incorporated skin-to-skin into our practice, so realistically, it is not such a far stretch to expand this practice to the operating room.

I would start with educating and sharing the research with staff in order to roll out this practice change. My goal would be to have the key stakeholders “buy in” to my proposal. I would share several articles citing examples of how other institutions have successfully implemented skin-to-skin c-sections. I would present my data of how my proposed practice change will increase patient satisfaction and improve patient outcomes. I would also bring this data to the multidisciplinary meetings as well as meetings with OB operations to ensure that all ends of the Labor and Delivery care continuum were aware of the current research and improved outcomes. I estimate that this would take approximately one-two months, as I would want to attend the NICU team huddles and staff meetings, the Labor and Delivery team huddles and staff meetings and the Anesthesia department meetings, as well as the OB Operations which happen monthly. I would also make articles available for the journal clubs held by the NICU and Labor and Delivery.

Next, I would propose the way that we could hardwire and standardize the process of parental involvement and skin-to-skin initiation in the OR. I would suggest involving all stakeholders to initially develop guidelines including what criteria must be met prior to offering a patient a skin-to-skin c-section. Of course, these can be revised or amended as we move further along in this process change. I propose that we start trialing the process with only scheduled c-sections of uncomplicated pregnancies. On admission, we currently educate our patients on our “Infant Feeding and Care Practices”. Our practice includes skin-to-skin immediately at delivery for vaginal deliveries. We inform our patients that after their c-section, we will initiate skin-to-skin as soon as possible in the recovery room. I would propose that we educate and offer our patients (that meet the criteria I mentioned) a skin-to-skin c-section. If the patient desires a

skin-to-skin c-section, the admitting RN would notify the OB provider and Anesthesiologist. The RN would also notify the Surgical Technician to ensure that the correct drape is available and utilized for the c-section. The RN would also notify the charge nurse to ensure that staffing of the baby RN is available. Initially a checklist could be used to ensure that all appropriate parties are notified and prepared. We would then proceed as usual for the c-section. During the initial “time out” upon admission to the OR, the circulating RN will verify that everyone is aware of the plan for a skin-to-skin c-section. The patient will be draped with the new clear window drape. When the NICU team arrives for the delivery, they will be notified of the intent for skin-to-skin. The parents will be able to view their baby being born. We will continue to do delay cord clamping by one minute. After one minute, the umbilical cord will be clamped and cut. The newborn will be handed off to the baby RN who will take the newborn to the warmer for drying and quick evaluation by the NICU team. If the newborn is stable and the initial APGAR is >8, the newborn may be taken over to the mother to initiate skin-to-skin. Warm baby blankets will be provided. The baby RN will stay at the mother’s side to ensure safety and decrease the risk of infant falls. We could possibly use a Joey Band to assist with skin-to-skin. The baby RN will assess vital signs every 15 minutes while on the mother’s chest in OR. Our current practice is to obtain vital signs every 30 minutes; However, I would propose closer monitoring while in the OR due to cooler temperatures in the OR. The mother and newborn would remain together throughout the surgery and transfer to the recovery room. After the mother and newborn have had at least one hour of skin-to-skin contact and have had an opportunity to initiate breastfeeding, the baby RN can proceed with footprints, physical

assessment, and scheduled medications. We already document skin-to-skin initiation and discontinuation in the newborn EMR, therefore that process will not change. We will be required to document why skin-to-skin was delayed or terminated early. The EMR can be used to perform audits and to evaluate consistency.

Once the process has been decided upon, my next steps would include saturating the affected areas with the plan. As previously mentioned, I would utilize staff meetings, team huddles, rounds, email and journal clubs. This saturation would include a “go live” date which will be carefully planned to allow for dissemination of the information to the majority of staff and providers. However, it must be timely enough so that the campaign does not lose momentum. At this stage I would focus specifically on the staff working the week of the “go live” and recruit them to be “champions” of the campaign. Doing so will ensure that staff will have a resource and liaison to bring feedback if improvements or tweaks are needed. Surveys may be utilized to evaluate the process and elicit improvement tactics if necessary. Feedback from patients will also be crucial. A questionnaire will be developed focusing on patient satisfaction, and exclusive breastfeeding.

I would expect that three months would be needed to educate, hardwire a process and roll it out the staff. Adjustments may be made along the way based upon feedback from the participants. At the five-month point, I would perform chart audits to evaluate our compliance with the new process. At this point, I would also evaluate feedback from the patients and exclusive breastfeeding rates at discharge and the six-week mark. I would share the data with staff and set a goal that 100% of patients (who meet criteria and desire a skin-to-skin c-section) are given the opportunity to have skin-to-skin at delivery. Upon chart review and feedback from

patients and staff, we can further explore what barriers remain. As the process becomes hardwired, I would re-evaluate at the six-month and one-year mark. If compliance declines or is less than ideal, I would explore the groups to determine if there are issues with compliance of the process, documentation of the process or both.

Firstly, I was an RN working as a detective, searching for ways to improve a process that will increase patient satisfaction and exclusive breastfeeding, all while being fiscally responsible. I did my “detective” work by talking with my peers at Journal Club meetings/Staff meetings, and my Nurse Manager and Educator for ideas to increase exclusive breastfeeding. Being a member of AWHONN (Association for Women’s Health, Obstetric and Neonatal Nurses) has enabled me to investigate ways that the latest literature is proving to be best for patient outcomes among our patient population.

After considering some possible options, I was an RN working as a scientist by evaluating the current literature for validity. After reviewing several research articles that were qualitative and quantitative in nature, I searched for consistency in their results. There was an abundance of evidence-based research that supported immediate skin-to-skin contact at delivery. Would it be so far-fetched to expand that practice to the operating room? A Randomized Controlled Study issued in the British Journal of Midwifery, showed an increasing trend in exclusive breastfeeding rates at 6 weeks when early skin-to-skin contact was initiated (Gregson, 2016). From there I came across articles that demonstrated how some hospitals were initiating the practice of skin-to-skin contact in the delivery room. Looking at the overall picture, I

concluded that with some minor changes to our practice, we could increase patient satisfaction and maternal/newborn outcomes by initiating skin-to-skin contact in the OR.

As a manager of the healing environment, I (as a bedside nurse) can utilize my resources to change practice and improve patient outcomes on a larger scale. When a nurse sees evidence-based research that displays better outcomes for patients, the nurse can work with their unit leadership, seek additional financial resources and identify key stakeholders to advocate for changes at the bedside. In this case, due to fact that we have already made huge strides to become a Baby Friendly Hospital, and the financial impact would be minimal, the proposed changes were fairly easy to get organizational support.

REFERENCES

Baby-Friendly USA ~ 10 Steps & International Code. (n.d.). Retrieved January 17, 2019, from

https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/

Gregson, S., Meadows, J., Teakle, P., & Blacker, J. (2016). Skin-to-skin contact after elective

caesarean section: Investigating the effect on breastfeeding rates. British Journal Of Midwifery, 24(1), 18. doi:10.12968/bjom.2016.24.1.18

Sharma, A. (2016). Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding

in term neonates: a randomized controlled trial. African Health Sciences, 16(3), 790. doi:10.4314/ahs.v16i3.20

Place an Order

Plagiarism Free!

Scroll to Top