Happy New Year! I hope that you had a wonderful Holiday Season. Please enjoy this newsletter and know that our next one will be posted electronically on our new website! The BCH Outreach Team, specifically Cynthia Jensen, has been working hard to get this up and running. The goals for this website are for it to be easy and useful for you and your teams. We will be looking to you for feedback and ways to expand this resource. I want to thank the BCH Outreach Team for all their hard work this year. They are a great team! I look forward to 2016. JANUARY 2016 VOLUME 7, ISSUE 1 Outreach Program Winter Newsletter Greengs!! 1-2 Welcome Tanya 3 Preemie Project 3 Levels of Maternity Care 4 Periviability Counsleing 5-6 AIM Conference 40th Anniversary 6 Maternal Early Obstetric Warning Signs (MEOWS) 7 An Outreach Story 8 Magnesium for Neuroprotecon 9 UCSF Safe Sleep Program 10 NRP 2017 Updates 10 -11 Outreach Website Registraon 12 Access/Contact Info 12 Greengs from the Outreach Program! Cynthia Jensen RN, MS, CCNS Happy New Year! I cannot believe that I have been in the role as Outreach Program Manager for 6 months now, time is flying. Thank you for your patience and support as I try to fill the big shoes that Jill Thornton left behind when she retired last June. February 1 st will be the anniversary of our move to Mission Bay. This has been a blessing and a huge learn- ing experience for everyone here. Hoping to see more of you come by for a tour and visit if you haven’t already. We have great meeting facilities and will be hosting more conferences here on campus in addition to those we provide in the community. Change is in the air... An astute professor once told me that the only person who likes change is a baby with a dirty diaper and I have to agree! Although difficult, we all know that change can be good, and helps us continually improve ourselves and our services. Outlined below are some upcoming changes to the Outreach Program. I sincerely hope that these changes will help us to better serve you. Meet the newest member of the Outreach team: our new website! Starting with phase one this month, we will be improving your access by launching the new Outreach website at: bchsfoutreach.ucsf.edu. This phase will allow you to learn about the program, see a calendar of upcoming clas- ses, and access UCSF policies, procedures and resources. The policies and procedures will be in a password protected area of the site so users will have to set up an account. Once we verify that the applicants are outreach affiliates, we will send a link with a log on and password. We want all of your staff to have access, any time of the day or night so please encourage them to create accounts! The plan for the second phase is in pro- cess. We are hoping to build in a system for online payment for classes, stay tuned for details. Continued on page 2 Welcome from Diane VonBehren RNC-OB, MS Perinatal Services Director
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Transcript
Happy New Year! I hope that you had a wonderful Holiday Season. Please enjoy this newsletter and know that our next one will be posted electronically on our new website! The BCH Outreach Team, specifically Cynthia Jensen, has been working hard to get this up and running. The goals for this website are for it to be easy and useful for you and your teams. We will be looking to you for feedback and ways to expand this resource. I want to thank the BCH Outreach Team for all their hard work this year. They are a great team! I look forward to 2016.
JANUARY 2016 VOLUME 7, ISSUE 1
Outreach Program Winter Newsletter
Inside this Issue
Greetings!! 1-2
Welcome Tanya 3
Preemie Project 3
Levels of Maternity
Care
4
Periviability
Counsleing
5-6
AIM Conference 40th Anniversary
6
Maternal Early
Obstetric Warning
Signs (MEOWS)
7
An Outreach Story 8
Magnesium for
Neuroprotection
9
UCSF Safe Sleep
Program
10
NRP 2017 Updates 10 -11
Outreach Website Registration
12
Access/Contact Info 12
Greetings from the Outreach Program! Cynthia Jensen RN, MS, CCNS
Happy New Year!
I cannot believe that I have been in the role as Outreach Program Manager for 6
months now, time is flying. Thank you for your patience and support as I try to fill the
big shoes that Jill Thornton left behind when she retired last June. February 1st will be
the anniversary of our move to Mission Bay. This has been a blessing and a huge learn-
ing experience for everyone here. Hoping to see more of you come by for a tour and
visit if you haven’t already. We have great meeting facilities and will be hosting more
conferences here on campus in addition to those we provide in the community.
Change is in the air...
An astute professor once told me that the only person who likes change is a baby with
a dirty diaper and I have to agree! Although difficult, we all know that change can be
good, and helps us continually improve ourselves and our services. Outlined below are
some upcoming changes to the Outreach Program. I sincerely hope that these changes
will help us to better serve you.
Meet the newest member of the Outreach team: our new website!
Starting with phase one this month, we will be improving your access by launching the
new Outreach website at: bchsfoutreach.ucsf.edu.
This phase will allow you to learn about the program, see a calendar of upcoming clas-
ses, and access UCSF policies, procedures and resources. The policies and procedures
will be in a password protected area of the site so users will have to set up an account.
Once we verify that the applicants are outreach affiliates, we will send a link with a log
on and password. We want all of your staff to have access, any time of the day or night
so please encourage them to create accounts! The plan for the second phase is in pro-
cess. We are hoping to build in a system for online payment for classes, stay tuned for
details. Continued on page 2
Welcome from Diane VonBehren RNC-OB, MS Perinatal Services Director
PAGE 2 VOLUME 7, ISSUE 1
It’s not easy going green
Outreach is committed to environmental responsibility and one of the ways we hope to decrease waste and use of natural
resources (in our case trees) will be to have more web based materials for our classes. We get several complaints each
year about the size of the slides on our class handouts being too small. We already use a tremendous amount of paper
and if we were to increase size of the slides we would need a lot more of it. Our solution will be to email handouts a few
days before the class in pdf format so the attendees can view them in larger size, and keep a copy on their computer. You
will notice that nearly all of the larger conferences you attend use this system with the same goal in mind. While we will
miss the hard copy handouts, going green is the right thing to do.
In the near future, registration, evaluations and CEUs will all become electronically based. We will also be moving to
more electronic submissions for case conferences instead of faxing or mailing. The benefit of this is to decrease the risk
of losing protected health information, as well as reduce the large amounts of paper used for printing charts that may be
hundreds of pages long. We will work with your hospital information systems to transition this new process over time.
We love feedback!
We are always looking for ways to improve our services and would love to hear from you. We now have a dedicated email address for Outreach which is: [email protected] or call us at (415) 353-1574. Wising you and yours an amazing 2016,
Tanya Kamka Joins UCSF BCH Perinatal Outreach Team
Preemie Project at UCSF Medical Center by Tanya Kamka, RNC-NIC, MSN
Delivering care to Extremely Low Birth Weight (ELBW) Infants (<28 weeks gestation or <1000 gram birth weight) presents many complex and unique medical, social and ethical issues. The UCSF Benioff Children’s ICN is dedicated to providing this population with not only the best chance of survival, but survival without morbidities. The Preemie Project is a collaborative effort across multiple disciplines that will provide a best practice guideline for the less than 28 week infant. These guidelines are a compilation of sound evidence, and practices that have been successful in other centers. These will be implemented in March 2016, and will be followed up with a quality improvement bundle for IVH reduction. This has been such a comprehensive effort critically focused on standardizing care for our ELBW infants. We look forward to keeping you abreast of our challenges and successes implementing the Preemie Project!
Tanya has been in the UCSF Benioff Children’s Intensive Care Nursery just over a year and has recently
joined our Outreach team as the Neonatal Outreach Educator. Prior to joining UCSF Tanya worked at a lev-
el IV NICU in Southern California for seven years where she gained extensive experience in caring for cardi-
ac, surgical, and extremely low birth weight (ELBW) infants. Tanya was a core nurse in the development of
the Small Baby Unit, dedicated to optimizing outcomes for ELBWs. After caring for multiple patients with a
rare skin disorder Epidermolysis Bullosa, and developing a care guideline for all patients with fragile skin,
Tanya obtained her Master’s degree in nursing education in 2013 from Walden University. She is thrilled to
join our team and looks forward to working with each of you in supporting your units!
Please join us in welcoming Tanya to our BCH Family!
As this year comes to an end, now is the time to review your department readiness regarding maternal safety.
Preeclampsia is often associated with severe maternal morbidity and mortality for pregnant mothers, every peri-
natal unit should have established standards of maternal early warning signs. The following warning signs have
been set forth by the National Partnership for Maternal Safety and have been endorsed by the following profes-
sional organizations: ACOG, AWHONN, ACNM, and SMFA. Chances are if you were asked on a multiple
choice test which of the following below criteria are abnormal: you would answer “all of the above”. Yet, every
day these warning signs go unrecognized and contribute to serious maternal morbidity and death.
Maternal Early Obstetric Warning Signs (MEOWS) by Valerie Huwe, RNC-OB, MS, CNS
The Maternal Early Warning Criteria
Measure Value
Systolic Blood Pressure (mm Hg) <90 OR > 160
Diastolic Blood Pressure (mm Hg) >100
Heart rate (beats per minute) <50 OR >120
Respiratory Rate (breaths per minute) <10 OR > 30
Oxygen Saturation on room air at sea level <95
Oliguria, mL/hr for = 2 hrs < 35
Maternal agitation, confusion or unresponsiveness
Woman with preeclampsia reporting a non-remitting headache or shortness of breath
If a patient in your department has any one of these validated criteria, then a prompt bedside evaluation by a
physician or other clinician who can initiate emergency diagnostic and therapeutic interventions should
occur. All too often there is a tendency to disregard these warning signs or “normalize” an abnormal clinical
presentation. Close nursing surveillance, followed by a well-chosen, well-executed team response to these
criteria can prevent serious morbidity and maternal death. As 2015 comes to an end, take time to review your
perinatal guidelines and treatment of maternal warning signs in your department. Consider establishing goals
for 2016 that promote maternal safety and optimize health outcomes for pregnant women and infants. If
UCSF Maternal Fetal Medicine consultative services are needed; don’t hesitate to call our Access Center 1
(877) 822-4453 and speak directly with one of our specialists.
PAGE 8 VOLUME 7, ISSUE 1
It was a dark and stormy night… I traveled
to Eureka to teach a S.T.A.B.L.E. course last Febru-
ary. Before teaching a Monday morning class I turned
in early after a long rainy drive and dinner. My phone
started to vibrate at midnight with texts from a St Jo-
seph’s Eureka nurse, who is also a friend. The text
said something to the effect of “We are going to have
a 24 weeker, do you want to come in?” A few minutes
later I was getting dressed and heading out the door.
I knew the weather was bad and worried that we
wouldn’t be able to fly a transport team up. As luck
would have it there was already a UCSF pediatric
transport team who arrived to take a sick child back
to SF. They had all of the equipment needed…for a
child. Because they have the skills to take care of any
pediatric patient they were asked to be present at the
delivery to assess if the baby was viable and to assist
with the resuscitation. When I arrived, UCSF Flight
Nurse Charlie Hood and Transport nurse Catherine
Brown were already back in the NICU with a feisty
little 700 gram baby and were helping to manage her
respiratory needs. Also present were 2 St Joe’s
RNs, an RT and pediatrician. It always amazes me
how a 700 gram baby can take on a room full of
providers and make them run non-stop! It was a
group effort to get the tiny girl intubated, “surfed”
and settled.
Charlie and Catherine had to race off to the other
child so I stayed behind watching and assisting the
providers at St Joe’s to help this little person and pre-
pare for transport. The weather was iffy and the travel
window was only open for a short time to send anoth-
er neonatal team from UCSF but this lucky little lady
had the odds in her favor again and the team was giv-
en the green light. I felt good leaving her in St Joe’s
capable hands before the neonatal transport team ar-
rived. She had an airway, had been given surfactant,
had IV access, stable glucoses and was normothermic,
you really can’t ask for more than that.
Baby Codie spent a total of 132 days in the NICU and
was discharged home on nasal cannula. Codie’s mom
Corrie is a police officer who had hundreds of vaca-
tion hours donated by her coworkers at Eureka PD so
that she could stay with Codie for the duration of her
hospitalization in our newly opened single-patient
room ICN. Corrie and her family’s dedication and
constant presence no doubt contributed to Codie’s
ability to thrive, grow and overcome significant medi-
cal challenges. It took a village of professionals, col-
laboration, communication, feistiness, luck and a fam-
ily’s love to get Codie to be the sassy, thriving girl she
is today!!
I wanted to share a story with you that highlights what outreach is all about celebrating the relationships we have
to provide better outcomes for women, infants and children. By Cynthia Jensen, Outreach Program Manager
Codie , 4 days old Feb 2015
Charlie Hood RN, CFRN, CCRN, CEN , transport nurse is
reunited with Baby Codie and her mom Corrie during a
follow up visit
Codie Dec. 2015
PAGE 9 VOLUME 7, ISSUE 1
Magnesium Sulfate Update: In Utero Neuroprotection for Early Preterm Infants
Valerie Huwe RNC-OB, MS, CNS
Brain injury associated with prematurity can lead to lifelong motor and sensory disabilities. Doyle and col-
leagues concluded that the number of pregnant women needed to be treated with magnesium sulfate in or-
der to prevent one pediatric case of Cerebral Palsy was 63.
The exact mechanism of fetal neuroprotection is not fully understood however several theories exist regard-
ing the role of magnesium sulfate. Most theoretical models suggest that magnesium sulfate may minimize
the inflammatory pathways of injured neurons and can induce healing substances that promote repair of in-
jured neuronal tissue.
Recent concern for fetal and neonatal bone demineralization and fractures associated with long-term in
utero exposure to magnesium sulfate have led to an FDA drug reclassification of Magnesium Sulfate from
Category A to Category D and advise continued use not exceed seven days. Accordingly, ACOG continues
to support the use of magnesium sulfate for fetal neuroprotection before anticipated early preterm delivery
when the gestational age is <32 weeks.
In a recent publication by Molly Killion MS, RN, CNS she highlights magnesium sulfate as a worthwhile
strategy to prevent cerebral palsy for preterm and low birth weight infants with relatively low risk to the
mother. She also points out; the optimal treatment regimen has not yet been established. Dosing considera-
tions include: provider comfort, institutional familiarity, and safe medication administration practices. More
research is needed to determine the least amount of magnesium sulfate required for pregnant women to pre-
vent cerebral palsy in preterm (<32wk) infants.
Physicians electing to use magnesium
sulfate for fetal neuroprotection
should use specific guidelines such as
the UCSF protocol. The UCSF pro-
tocol defines: the inclusion criteria,
treatment regimens, concurrent tocol-
ysis recommendations, monitoring
parameters, and is available to our
contract hospitals on our website.
References:
American College of Obstetricians and Gynecologists. (2012). Patient safety checklist No. 7: Magnesium sulfate before anticipated preterm birth for neuroprotection. Obstetrics and Gynecology, 120(2 Pt 1), 432-433. doi:10.1097/AOG.0b013e318268054c American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine. (2010). Committee Opinion No. 455: Magnesium sulfate before anticipated preterm birth for neuroprotection. Obstetrics and Gynecology, 115(3), 669- 671. doi:10.1097/AOG.0b013e3181d4ffa5 Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D: Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev. 2009:CD004661 Killion MM. (2015). Magnesium Sulfate for Neuroprotection. MCN. 40(6):394. doi: 10.1097/NMC.0000000000000187. Salmeen, K. E., Jelin, A. C., & Thiet, M. P. (2014). Perinatal neuroprotection. F1000 Prime Reports, 6, 6. doi:10.12703/P6-6.
PAGE 10 VOLUME 7, ISSUE 1
This past summer, UCSF Benioff Children’s Hospital San Francisco adopted the American Academy of Pediat-
rics recommendations related to infant safe sleep practices to reduce the risk of Sudden Infant Death Syndrome
(SIDS) and sleep-related suffocation, asphyxia and entrapment among infants. Unless there is a medical reason,
infants less than 1 year are placed on their back to sleep and children under 35 inches or less than 2 years of age
will sleep in a crib. No toys, stuffed animals, pillows, crib bumpers or extra bedding will be in the crib. For the
baby’s safety, bed sharing or co-sleeping is not allowed. Parent and family education is provided to reinforce
safe sleep practices. For a copy of our Safe Sleep policy, please contact the UCSF BCH Outreach office.
UCSF BCH Implements Safe Sleep Policy by June Shu-Ling Chan, RN MSN MSA
I said this newsletter was about change and there are some major changes coming to a delivery room near you.!!
The NRP is updated every 5 years guided by the rigorous work of the International Liaison Committee on Re-
suscitation (ILCOR). Working together, the American Academy of Pediatrics, NRP Steering Committee and
the American Heart Association come to a consensus on the new guidelines and update the program accord-
ingly. The program updates were announced on October 15th 2015. Materials will be available in Spring 2016
and implementation will be required by January 1st 2017.
Continued on page 11
A Summary of the 2017 NRP Guidelines by Cynthia Jensen
PAGE 11 VOLUME 7, ISSUE 1
Summary table of SOME of the Changes to NRP 2017 Topic 2017 Guidelines
Thermoregula-tion
Keep temp between 36.5 and 37.5 C (97.7 to 99.5 F) throughout resuscitation and stabilization for non-asphyxiated babies
Note: if a baby is a candidate for cooling therapy remember to acquire vascular access before the baby is cooled and avoid hyperthermia at all times
Suctioning for Meconium
Non-vigorous babies no longer need to be intubated for endotracheal suctioning of meconium however the presence of a team member with full resuscitation skills is required as meconium is a risk factor for perinatal depression
As of January 1st 2016 we are no longer intubating non vigorous babies for meconium at UCSF
Delayed Cord Clamping (DCC)
Current evidence shows that DCC for 30-60 seconds is beneficial for vigorous preterm and full term newborns
DCC not indicated if placental circulation is not intact (abruption, previa etc)
It is the practice at UCSF to perform 30 seconds of DCC for all babies <34 weeks to decrease the incidence of intraventricular hemorrhage, anemia and need for transfusions.
Assessment for Heart Rate
Use a stethoscope to assess heart rate
Cord palpation is less accurate
Consider placement of ECG leads and use of cardiorespiratory monitor (CR Monitor) and pulse oximeters when PPV is required
Use CR Monitor during chest compressions
Oxygen Begin PPV with 21% oxygen for babies ≥35 weeks
Begin PPV with 21-30% oxygen for babies < 35 weeks
Begin free flow oxygen (blow by) at 30% and adjust as needed
If baby has labored breathing or saturations do not increase with free flow oxygen, consider use of CPAP at 5cm H20
Positive Pressure Ventilation (PPV)
If a preemie needs PPV use a device that can give CPAP (flow inflating bag or T-piece resuscita-tor)
Assistant auscultates for increasing HR during first 15 seconds of PPV
If HR rises continue PPV for 15 more seconds and reassess
If HR <60 reassess ventilation, perform corrective steps as necessary and intubate or insert LMA.
If airway in place, chest moving and no ↑ in HR begin chest compressions in 100%
Chest compressions
Use 2 thumb technique
Once airway in place and secured, compressor moves to head of bed
Continue chest compressions for 60 seconds before assessing HR
Medications Use normal saline or O-negative blood for volume replacement
Consider I/O if no other access as all meds can be infused there
The preterm baby < 32 weeks
Keep delivery room 23-25 C (74-77 F)
Use polyethylene wrap, hat and chemical mattress
Monitor vital signs with leads and CR Monitor and pulse oximeter
Trial CPAP as alternative to intubation and surfactant administration
For a complete list of changes please see: Summary guideline: http://www2.aap.org/nrp/docs/15535_NRP%20Guidelines%20Flyer_English_FINAL.pdf For changes to training of providers and instructors see: http://www2.aap.org/nrp/docs/Busy%20People%20Summary%20Final%2010-2015.pdf
For the complete summary of changes please review: https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-13-neonatal-resuscitation/