A Care Model Change Promoting Bonding, Infant Thermoregulation, and Breastfeeding Evidence Based Practice Betsy McCune, MSN, RNC-OB; Sarah Spear, BSN, RNC-MNN; Shannon Mooney, RN; Michele, Johnston, RN, CLC

One Question Among Others: Is bathing the newborn soon after birth the best practice?

OBJECTIVES Explain the connection between Baby Friendly designation, research/recommendations, and care model change. Describe outcomes resulting from implementation of a care model change.

Background Sept, 2012-received grant for Baby Friendly journey (Welborn Foundation) to address: Obesity rate: US: 13%; IN youth (2 to 17 yrs): 14.3% (2011 data) Infant mortality rate/100,000: US: 6.1%; IN: 7.6%; Vanderburgh County 8.1% (2010 data) Breastfeeding initiation rate: IN: 72.1% Vanderburgh County: 65.5% (2010 data) Perinatal Core Measures breastfeeding initiation and breastfeeding exclusivity rate reports (January, 2015) St. Mary’s: Designated as Baby Friendly Hospital 11/26/2014

Background Keeping healthy moms and babies together 23 out of 24 hours St Mary’s model of care and location of nursery made this difficult to achieve.

Ten Steps for Successful Breastfeeding Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implementing this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within a half-hour of birth. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. Give newborn infants no food or drink other than breast milk, unless medically indicated. Practice rooming-in (allow mothers and infants to remain together) 24 hours a day. Encourage breastfeeding on demand. Give no artificial nipples or pacifiers to breastfeeding infants. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Search parameters: 2003 through present; OVID database Literature Review Search parameters: 2003 through present; OVID database (Total of 3 different research articles; all observational cohort studies) Search Terms Results Research Breastfeeding exclusivity + newborn bath delay 45 1 Newborn care practices + breastfeeding promotion 6 2 Breastfeeding exclusivity 165 Newborn bath delay Organizational recommendations , standards, practice guidelines (based on research ?) 4

Research Lipka, D.V., & Schultz, M.K. (2012). Wait for Eight: Improvement of newborn outcomes by the implementation of newborn bath delay. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 41, Issue sl. S46-S47. DOI/10.1111/jogn.2012.41.issue-sl/issuetoc. (no “N” given in report). The incidence of newborns experiencing hypothermia . . . during the transition period was reduced by delaying unnecessary interventions. Preer, G., Pisegna, J.M., Cook, J.T., Henri, A.M. & Philipp, B.L. (2013). Breastfeeding Medicine, 6, 485-490. DOI: 10.1089/btm.2012.0158 Delaying the newborn bath increased exclusive breastfeeding in the hospital from 32.7% to 40.2% (p < .05). “The odds of breastfeeding initiation with delayed bathing were 166% greater and for exclusive breastfeeding 59% greater” (p. 485). (702 newborns; 2.4 hrs first bath versus 13.5 hrs first bath) Sobel, H.L, Silvestre, M.A. A., Mantaring, J.B.V., Oliveros, Y.E., & Nyunt, S. (2011). Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatrica, 100, 1127-1133. Performance and timing of immediate newborn care interventions were below WHO standards and deprived newborns of basic protections against infection and death. (90% of 481 newborns got an early bath).

Recommendations 1.American College of Nurse Midwives (2004): Delay admission bath for 24 hours. 2.Save the Children/BASICS II/Mother Care (2003) : Delay bathing for at least 6 hours. Keep the baby with mother to promote breastfeeding and warmth. 3.United States Agency for International Development (2004): Delay bathing for 24 hours. 4.World Health Organization (2013; reaffirmed from 2003): Delay bathing for 24 hours; if not possible for cultural reasons, wait at least 6 hours. The mother and baby should not be separated and should stay in the same room 24 hrs/day.

Clinical Question Does a care model revision increase breastfeeding initiation/ exclusivity rates, reduce maternal/newborn separation time, and improve newborn thermoregulation?

Evidence Based Practice Goal Promote breastfeeding, bonding, and thermoregulation for newborns by transitioning to couplet care, including delaying baby’s first bath for 8 or more hours after birth, and adding “Lullaby Time” in the afternoon.

The Process: Team Formation Team members include: Post Partum staff nurses Pediatricians Obstetricians Led by: Ashly Fisher, BSN, RN; Lacy Hanmore, BSN, RN; Lorna Bullock, BSN, RN; Melanie Jones, RN; Sarah Spear, BSN, RNC; Shannon Mooney, RN; Michele Johnston, RN, CLC; Allissa Wheatley, RN, IBCLC; Nicole Brungs, BSN, IBCLC; Betsy McCune, MSN, RNC

Process: Previous Model Newborns remained with their parents in Labor and Delivery for one to two hours Newborns were then transported to the newborn nursery for immediate assessment, bath, and other care. Two separate nurses cared for the mother baby dyad. (One nurse for mom and one for the baby in separate locations.)

Previous Model Concerns The previous process, which separated mothers/families from their babies: decreased baby’s own ability for thermoregulation without external warming measures. decreased opportunities for mother’s success at exclusive breastfeeding. interrupted the flow of newborn care and education.

Revised Model Transfer moms and babies to the mother-baby unit together, and perform and complete both mother and newborn admission care in the same room. To promote thermoregulation, breastfeeding, and bonding, wait until the baby is 8 or more hours old to complete the first bath. Have pediatricians assess the newborn in the mother’s room, thereby providing improved educational opportunities. Promote “Lullaby Time” in the afternoon.

Outcomes Measured Breastfeeding initiation rates Breastfeeding exclusivity rates Percentage of newborns receiving external warming measures after transfer to postpartum (use of warmers, warm blankets) Separation time between mother/family and infants

Implementation Plan Staff and physician communication, along with education, played a key role in the implementation of Couplet Care. (Cross training staff) Labor and Delivery staff educated parents/family on new process; skin to skin initiated at birth (90%+ initiation rate) “Newborn Nursery” renamed to Newborn Continuing Care Observation babies: Transfer to Neonatal Intensive Care under care of neonatologist Newborn care supplies re-located One 3SW RN designated as Continuing Care RN each shift Room enhancements made for pediatricians to perform newborn assessments in mother’s room

Implementation Change implemented with births on July 7, 2014 forward Couplet Care nursing (1 nurse for both mom and baby) Babies kept with moms in L&D/ transferred with mom to postpartum Observation babies sent to NICU for stabilization. Assessments and all newborn care occurred at mom’s bedside. First bath delayed until baby 8 or more hours old based on newborn’s stability and temperature Newborn care education/bath demonstration and participation provided at bedside with parents Breastfeeding and skin to skin contact promoted Patients/families encouraged to limit visitors between 2 and 4 in the afternoon.

Outcomes: Evaluation Pre versus post practice model change Average time moms/infants separated with transfer from L&D to postpartum Pre-2.5 hrs. versus post – 0 hrs. Newborns with external warming measures prior to first bath Pre-100% versus post-20%

GOAL: 74% through June 2014; up to 76% in July, 2014 PDCA: CHECK Breastfeeding initiation rate: 1 RN for mom/1 for baby GOAL: 74% through June 2014; up to 76% in July, 2014

GOAL: 74% through June 2014; up to 76% in July, 2014 PDCA: CHECK Breastfeeding Initiation: Couplet Care Change Change GOAL: 74% through June 2014; up to 76% in July, 2014

PDCA: CHECK Breastfeeding exclusivity rate: 1 RN for mom/1 for baby GOAL: 53%

PDCA: CHECK Breastfeeding exclusivity: Couplet Care GOAL: 53%

Lessons Learned Planning and staff involvement are vital. You can anticipate about 90 % of the roadblocks. Keep physicians informed about how changes will impact them. Get their suggestions. Naysayers can be transformed and become cheerleaders. Show them the evidence and get them involved from the beginning. Just do it!

Questions?