Management of Neonatal Abstinence Syndrome with the Eat ...

o Decreasing the use of pharmacotherapyminimizes the risk of medication errors.

o Nonpharmacological methods are regarded assafe and effective ways to promote infant andcaregiver bonding.

o Implementing nonpharmacological methodsrequires constant care team presence,communication, and collaboration.

o The Clinical Nurse Leader can utilize their skillsin communication, collaboration, and patientadvocacy to educate all members of the careteam and coordinate a schedule for supervisionand care to ensure someone is always availableto feed, console, and monitor the infant.

o The results of the six QI projects included in thisreview indicated that the ESC methodsignificantly reduced the average length ofhospital stay compared to the FNASS.

o The results must be viewed with caution due tothe low quality of this body of evidence.

o Limitations to all studies include the QI designs,small sample sizes, potential for researcherbias, and the invalidation of the ESC method.

o Further research is needed to validate the ESCmethod and to discover long-term infantoutcomes associated with the ESC method.

o If the results of future higher quality studies areconsistent with those in this body of evidence,the ESC method should be considered as apractice recommendation for management ofNAS.

I would like to express my gratitude to TaylorJones-Swing, DNP, CRNP-PC, who served as myreader for this project.

Neonatal abstinence syndrome (NAS) describesinfants experiencing withdrawal symptoms due toprenatal exposure to opioid medications. In 2016,NAS occurred in seven out of every 1,000newborns born in the United States. Hospital costand length of stay are at least 6-times greater ininfants with NAS than in healthy infants.

The most widely used method for NASmanagement is the Finnegan Neonatal AbstinenceScoring System (FNASS). The clinician assessesfor withdrawal symptoms and scores the infantaccordingly. With FNASS, first-line treatment of aninfant experiencing withdrawal is scheduledadministration of opioid medications. Concernswith FNASS include the variability of clinicianassessments, the startling of the infant with parts ofthe assessment, and the association of opioidadministration with increased hospital cost andlength of hospital stay.

The Eat, Sleep, Console (ESC) method is analternative to FNASS. With ESC, the infant isassessed on their ability to eat appropriately, sleepfor at least 1 hour undisturbed, and be consoledwithin 10 minutes. If the infant does not meet thesecriteria, they are managed first withnonpharmacological methods, such as swaddling,rocking, and reducing environmental stimuli, beforethe infant’s care team considers as neededadministration of opioid medications.

The purpose of this review was to investigate thefollowing question: Among infants with NASadmitted in the hospital, does the ESC methodcompared to the FNASS affect average length ofhospital stay as evidenced by the number of daysin the hospital?

The databases PubMed, Embase, and Science Direct weresearched with the following keywords: neonatal abstinencesyndrome, neonatal opioid withdrawal syndrome, eat, sleep,console, and ESC method. A total of six articles were chosenfor this evidence review. All included articles were qualityimprovement (QI) projects that evaluated the average length ofstay with the ESC method compared to the FNASS. Chosenarticles were published in the years 2016 through 2021.Articles excluded were unrelated to the topic, published before2016, not available in English, or of qualitative, integrative, ordescriptive study designs.

o All six QI projects discovered a significant decrease in theaverage length of hospital stay with the ESC methodcompared to the FNASS.

o On average, the length of stay was approximately 7 dayswith the ESC method, while the length of stay was roughly14 days with the FNASS.

o The use of pharmacotherapy for treatment of infants withNAS significantly decreased with the ESC methodcompared to the FNASS in all six projects.

o One project reported a decrease in hospital cost by 40%with the ESC method compared to the FNASS.

Management of Neonatal Abstinence Syndrome with the Eat, Sleep, Console Method

ReferencesBlount, T., Painter, A., Freeman, E., Grossman, M., & Sutton, A. G. (2019). Reduction in length of stay and morphine use for NAS with the “Eat, Sleep, Console” method. Hospital Pediatrics, 9(8), 615-623. https://doi.org/10.1542/hpeds.2018-0238Dodds, D., Koch, K., Buitrago-Mogollon, T., & Horstmann, S. (2019). Successful implementation of the Eat Sleep Console model of care for infants with NAS in a community hospital. Hospital Pediatrics, 9(8), 632-638. https://doi.org/10.1542/hpeds.2019-0086Grossman, M. R., Lipshaw, M. J., Osborn, R. R., & Berkwitt, A. K. (2018). A novel approach to assessing infants with neonatal abstinence syndrome. Hospital Pediatrics, 8(1), 1-6. https://doi.org./10.1542/hpeds.2017-0128

Miller, P. A., & Willier, T. (2021). Baby STRENGTH: Eat, Sleep, Console for infants with neonatal abstinence syndrome. Advances in Neonatal Care, 00(0), 1-8. https://doi.org/10.1097/ANC.0000000000000840

Parlaman, J., Deodhar, P., Sanders, V., Jerome, J., & McDaniel, C. (2019). Improving care for infants with neonatal abstinence syndrome: A multicenter, community hospital-based study. Hospital Pediatrics, 9(8), 608-614. https://doi.org/10.1542/hpeds.2019-0083

Wachman, E. M., Houghton, M., Melvin, P., Isley, B. C., Murzycki, J., Singh, R., Minear, S., MacMillan, K. D. L., Banville, D., Walker, A., Mitchell, T., Galimi-Hayes, R., Jorgensen, S., Gomes, D. R., Hodgins, F., Whalen, B. L., Diop, H., & Gupta, M. (2020). A quality improvement initiative to implement the Eat, Sleep, Console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative. Journal of Perinatology, 40, 1560-1569. https://doi.org/10.1038/s41372-020-0733-y

Alison Pritchard, MSN & CNL Student

Background & Significance

Methods & Literature Profile

Evidence Summary

Nursing Implications

Conclusions

Acknowledgements

Perinatal Quality Collaborative. (n.d.). [Eat, sleep, console logo]. https://www.pqcnc.org/node/14046

Blum, K. (2020). [Infant holding adult’s finger] [Photograph]. Pain Medicine News. https://www.painmedicinenews.com/Article/PrintArticle?articleID=57083

Comparing Skin-to-Skin Care to Oral Sucrose for Pain Management in Preterm NeonatesCatherine Shank, BS, MSN Student

University of Maryland Baltimore, School of Nursing

REFERENCES:Campbell-Yeo, M., Johnston, C. C., Benoit, B., Disher, T., Caddell, K., Vincer, M., Walker, C., Latimer, M., Streiner, D. L., & Inglis, D. (2019). Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive

care unit hospitalization: a single-blind randomized controlled trial. Pain, 160 (11), 2580-2588. https://doi.org/10.1097/j.pain.0000000000001646Centers for Disease Control and Prevention. (2020, October 30). Preterm birth. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htmCommittee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. (2016). Prevention and management of procedural pain in the neonate: An update. Pediatrics, 137(2). DOI: https://doi.org/10.1542/peds.2015-4271Ghoneim, A. A. (2016). Effects of sucrose and kangaroo care on pain alleviation among preterm neonates undergoing invasive procedures. American Journal of Nursing Science, 5(4), 146-151. doi: 10.11648/j.ajns.20160504.14Nimbalkar, S., Shukla, V. V., Chauhan, V., Phatak, A., Patel, D., Chapla, A., & Nimbalkar, A. (2020). Blinded randomized crossover trial: Skin-to-skin care vs. sucrose for preterm neonatal pain. Journal of Perinatology, 40, 896-901.

https://doi.org/10.1038/s41372-020-0638-9Sen, E. & Manav, G. (2020). Effect of kangaroo care and oral sucrose on pain in premature infants: A randomized controlled trial. Pain Management Nursing, 21(6), 556-564. https://doi.org/10.1016/j.pmn.2020.05.003Shukla, V., Chapla, A., Uperiya, J., Nimbalkar, A., Phatak, A., & Nimbalkar, S. (2018). Sucrose vs. skin to skin care for preterm neonatal pain control – a randomized control trial. Journal of Perinatology, 38, 1365-1369.

https://doi.org/10.1038/s41372-018-0193-9

BACKGROUND

• 1 in 10 babies born preterm in the United States• Painful procedures common in this population;

leads to stress, abnormal neurodevelopment, and abnormal long-term pain perception

• Some nonpharmacological neonatal pain management techniques include:• Sucrose: common, but ineffective and can

lead to adverse events• Skin-to-skin care (SSC): alternative

approach, also helps stabilize vital signs, aids in maternal satisfaction/bonding, and decreases morbidity/mortality rates

METHODS

PICO(T): Among preterm neonates (<37 weeks gestation), does SSC, compared to oral sucrose, affect neonatal pain as evidenced by premature infant pain profile (PIPP) score?

Literature search:• Databases: PubMed and Scopus• Keywords: sucrose, skin-to-skin, kangaroo care,

preterm, premature, neonatal intensive care unit, pain*, premature infant pain profile

• A gray literature search was also performed• Limits: Past 10 years, English• After analysis of titles, abstracts, and full

articles, five articles were included in the review.

IMPLICATIONS / CNL ROLE

• Moderate certainty of net benefit for both interventions

• SSC should be incorporated into practice as an alternative approach

• When selecting a technique, unique factors should be considered, such as:• Stability of neonate and safety of each

intervention• Availability of caregiver for SSC• Caregiver preference

• Clinical Nurse Leader role includes:• Advocacy/risk anticipation by recognizing

need for pain management• Evidence-based practices incorporated into

guidelines to support clinical judgement• Communication to provide education and

guidance to ensure continuity of care

CONCLUSIONS

• Evidence on if SSC or sucrose is more effective is inconsistent, but not clinically significant

• Future high-quality research should focus on:• Long-term impact of SSC and sucrose• Sustained efficacy of SSC and sucrose• Effectiveness of each intervention on

different procedures• Different pain assessment tools to better

understand impact on pain response• Optimal dose of sucrose and time of SSC

EVIDENCE SUMMARY

Design

• Parallel (n=4), crossover (n=1)• Randomized controlled trials (n=4),

quasi-experimental (n=1)• Blinded (n=3)

Sample

• Minimal gestational age varied (28-32 weeks)

• Sample size varied (60-242)

Intervention• Sucrose dose, time of SSC, and

timing of PIPP score varied

Outcomes

• Good quality evidence that SSC and sucrose had similar effectiveness (n=2)

• Good and low quality evidence that sucrose is more effective than SSC (n=2)

• Good quality evidence that SSC is more effective than sucrose (n=1)

Miracle Babies. (n.d.). [Skin-to-Skin (Kangaroo) Care for Preterm and Ill Infants in the Neonatal Intensive Care Unit (NICU)] [Photograph] https://www.miraclebabies.org/skin-to-skin-kangaroo-

care-for-preterm-and-ill-infants-in-the-neonatal-intensive-care-unit-nicu/

ACKNOWLEDGEMENTS:

Special thanks to Dr. Katie McElroy for assistance on this project.

A Comparison of Swaddle Bathing and Conventional Bathing on Neonates’ Thermoregulation in the NICU

Caroline E. YeakleUniversity of Maryland, Baltimore

School of Nursing

Background & Significance

Neonatal Intensive Care Units (NICUs) provide highly specialized care to preterm and critically ill neonates. Annually, neonatal intensive care is estimated to cost 26.2 billion USD (Cheah, 2019). Neonates admitted to the NICU are prone to physiological instability, especially heat loss. Stable thermoregulation of the neonate is incredibly important, as temperature instability can lead to health complications including “hypoglycemia, apnea, hypoxia, impaired neurological status, acidosis, pulmonary insufficiency and hemorrhage” (Fernández & Antolín-Rodríguez, 2018). Because of this, care-giving practices by the nurse must be performed in ways that reduce the stress level of the neonate and prevent heat loss.Bathing, a common practice performed by nurses in the NICU, can be a highly stressful event for a neonate, especially if they are preterm. Traditionally, the most common methods of bathing neonates in the NICU are a conventional tub bath or a sponge bath. However, these bathing methods have been shown to cause increased stress and disruptive thermoregulatory responses of the neonates during and after the bath. A third bathing method, known as a swaddle bath, has been proven to cause less temperature instability in both preterm and full-term neonates in the NICU. A swaddle bath is performed by swaddling the neonate, immersing the neonate into the tub water, and un-swaddling and re-swaddling the neonate as each extremity is gently washed. A benefit of the swaddle bath is that the neonate remains in a flexed position throughout the bath, which is thought to cause less distress and improve thermoregulation.

In this literature review, the following clinical question was explored: In neonates

admitted to the Neonatal Intensive Care Unit (NICU), is a swaddle bath compared to a

sponge bath or a conventional tub bath more effective in reducing temperature

instability in these neonates post-bathing?

Five studies were included in the review. CINAHL and PubMed were used. Keywords included swaddle, bath, and bathing. CINAHL yielded 10 results and PubMed yielded 12 results. The results were scanned for peer-reviewed clinical trials or systematic reviews of clinical trials that focused on neonates in the Neonatal Intensive Care Unit (NICU), swaddle bathing, and temperature control. Studies performed over ten years ago were excluded. Eight abstracts were screened and five studies that fit the topic were selected for literature review.

All five studies explored the effect of swaddle bathing versus traditional bathing (tub bath or sponge bath) on the thermoregulation of neonates in the NICU. All were rated an evidence Level II and good quality.

The gathered data from the literature review suggests that swaddle bathing is the safest bathing method to be performed on neonates in the NICU because it leads to fewer disruptions in thermoregulation and causes the least amount of stress to the neonate.As a NICU nurse and a Clinical Nurse Leader (CNL), one must use the competencies of risk

anticipation and reduction as well as interprofessional communication and collaboration to work with other team members to plan when to perform the swaddle bath. It is best to perform the bath in a stimulus-free environment when the neonate is calm and stable. The nurse should also work together with the parents or caregivers to schedule the baths around feeding and bonding time, that way all the needs of the neonate are being appropriately met.Additionally, the CNL can serve as an educator and instruct the family members on how to perform the swaddle bath themselves and explain the benefits of this bathing technique for their child. Involving the parents in the bathing process with the neonate will also promote bonding. Post-bath is an optimal time for the parents to perform skin-to-skin bonding, breastfeeding, or bottle feeding (Denton & Bowles, 201). By including the parents and caregivers in this practice, the CNL is caring for the family unit and promoting both the physiological health and behavioral health of the neonate.

➢ For neonates in the NICU, the swaddle bathing method causes less disruption in thermoregulation compared to conventional bathing methods (sponge or tub bath).

➢ The mean body temperature loss was significantly lower for neonates who received a swaddle bath compared to a traditional tub bath or sponge bath.

➢ Swaddle bathing is a safe and effective practice that reduces heat loss and temperature instability in neonates.

➢ The literature review supports the practice change of conventional bathing methods to swaddle bathing in the NICU.

➢ Future studies should further examine the benefits of this bathing method on the family unit, such as reductions in parental stress and increased confidence in caring for their neonate after discharge from the NICU.

Bathing neonates is a routine practice performed by nurses in the hospital. Neonates admitted to the Neonatal Intensive Care Unit (NICU) are a particularly vulnerable population, and simple caregiving practices, such as a bath, can lead to undue stress and instability in these preterm and critically ill neonates. Neonates’ thermoregulation, in particular, becomesunstable during a bath, leading to heat loss and stress. A bathing technique known as a swaddle bath has been shown to reduce temperature instability in neonates compared to traditional bathing methods, such as a sponge bath or conventional tub bath. A literature review was performed to compare the effects of swaddle bathing and traditional bathing on the thermoregulation of neonates in the NICU. One systematic review and four randomized controlled trials were selected. Results concluded that the swaddle bath is the safest bathing method to avoid temperature instability in neonates admitted to the NICU. Four out of the five studies showed that conventional bathing methods (either a sponge bath or tub bath) led to significantly lower body temperatures in neonates post-bath. The collection of evidence is sufficient to alter practice. Because neonates admitted to the NICU are such a vulnerable population, nurses should implement the swaddle bathing practice to reduce stress and prevent temperature instability in neonates.

AuthorsLevel of Evidence (Melnyk and Fineout-

Overholt, 2019)

Type of StudySample

SizeMethods Results

Edraki et al., 2014 II Single-blind randomized

clinical trial (RCT) 50➢ Axillary body temperature was measured 10 minutes

before and 10 minutes after the bath for each group (conventional bathing and swaddle bathing).

The mean body temperature 10 minutes after the bath was significantly lower in the control group than in the experimental group (P< 0.001)

Ceylan et al., 2018 II

Clinical trial with a randomized crossover

design35

➢ Neonates had each bath (sponge bath and swaddle bath) 3 days apart

➢ Axillary body temperature was measured pre-bath and at minutes 1, 5, 15, and 30 post-bath

Body temperatures after the swaddle bath were significantly higher than after the sponge bath (P= 0.00)

Caka et al., 2018 II RCT 80

➢ Neonate’s body temperature was measured immediate post-bath and again at 10 minutes post-bath for each group (traditional tub bath and swaddle bath)

Post-bath body temperatures were significantly higher in the experimental (swaddle) group compared to the control (traditional tub bath) group (P= 0.001 and 0.028)

de Freitas et al., 2018

II Randomized crossover trial, double-blinded 43

➢ Axillary body temperatures were measured 10 minutes before the bath (baseline), 10 minutes post-bath, and 20 minutes post-bath for each group (conventional bath and swaddle bath)

Mean temperature changes did not differ significantly between the 2 bath types (P= 0.88)

Fernández et al., 2018

II Systematic review 9 studies➢ Researchers selected articles with a primary outcome

of reduced neonatal stress and temperature instability Results show that the Swaddle bath was less related to temperature changes and stress levels

Methods

Results

Summary & Conclusions

Implications for Practice & the Role of the Clinical Nurse Leader

Çaka, S. Y., & Gözen, D. (2018). Effects of swaddled and traditional tub bathing methods on crying and physiological responses of newborns. Journal for Specialists in Pediatric Nursing, 23(1), n/a-1. https://doi.org/10.1111/jspn.1220Ceylan, S. S., & Bolւşւk, B. (2018). Effects of swaddled and sponge bathing methods on signs of stress and pain in premature newborns: Implications for evidence-based practice. Worldviews on Evidence-Based Nursing, 15(4), 296–303. https://doi-org.proxy-hs.researchport. umd.edu/10.1111/wvn.12299Cheah, I. (2019). Economic assessment of neonatal intensive care. Translational pediatrics, 8(3), 246–256. https://doi.org/10.21037/tp.2019.07.03De Freitas, P., Bueno, M., Holditch-Davis, D., Pires Santos Jr., H., & Fumiko Kimura, A. (2018). Biobehavioral responses of preterm infants to conventional and swaddled tub baths: A randomized crossover trial. Journal of Perinatal & Neonatal Nursing, 32(4), 358–365. https://doi-org.proxy-hs.researchport.umd.edu/10.1097/ JPN.0000000000000336Denton, D., & Bowles, S. (2018). Implementing researched-based best bathing practice in the NICU and well-baby nursery: swaddle bathing. Neonatal Intensive Care, 31(1), 41–44. http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct= true&db=rzh&AN=128168558&site=eds-live.Edraki, M., Paran, M., Montaseri, S., Nejad, M. R., & Montaseri, Z. (2014). Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants: A randomized clinical trial. Journal of Caring Sciences, 3(2), 83–91. https://doi.org/10.5681/jcs.2014.009Fernández, D., & Antolín-Rodríguez, R. (2018). Bathing a premature infant in the intensive care unit: A systematic review. Journal of Pediatric Nursing, 42, e52–e57. https://doi-org.proxy-hs.researchport.umd.edu/ 10.1016/j.pedn.2018.05.002

References

Abstract

• Currently, rates of NAS 6.7 per 1000 in-hospital births

• Total hospital costs for NAS births increased from $65.4 million in 2004 to $462 million in 2014.

• The standard of care of NAS is administration of a narcotic or central nervous system depressant and admission to the NICU.

• Average length of stay in NICU is 23 days• Average length of pharmacotherapy is 17 days.• Mean hospital costs for newborns requiring

pharmacologic treatment is $19 737

Methods

Evidence Summary

Implication For Nursing Practice

Role Of the CNL

• Educate families about the benefits rooming-in may have for both infant and mother

• Advocate for their patients to improve outcomes for infants with NAS

• Implement best practices based on evidence, interprofessional communication, and leadership.

• Bring awareness of current research on alternative treatments for NAS by implementing them in the clinical setting.

Conclusion

Abrahams, R. R., MacKay-Dunn, M. H., Nevmerjitskaia, V., MacRae, G. S., Payne, S. P., & Hodgson, Z. G. (2012). An evaluation of rooming-in among substance-exposed newborns in British Columbia. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 32(9), 866–871. https://doi.org/10.1016/S1701-2163(16)34659-X

Atkins, N.A., Durrance, C.P., (2021) COVID-19 Converges With The Opioid Epidemic: Challenges For Pregnant And Postpartum Women With Opioid Use Disorder, " Health Affairs .DOI: 10.1377/hblog20210218.887791

Holmes, A. V., Atwood, E. C., Whalen, B., Beliveau, J., Jarvis, J. D., Matulis, J. C., & Ralston, S. L. (2016). Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics, 137(6), e20152929.

https://doi.org/10.1542/peds.2015-2929Howard, M. B., Schiff, D. M., Penwill, N., Si, W., Rai, A., Wolfgang, T., Moses, J. M., & Wachman, E. M. (2017). Impact of Parental

Presence at Infants' Bedside on Neonatal Abstinence Syndrome. Hospital pediatrics, 7(2), 63–69. https://doi-org.proxy-hs.researchport.umd.edu/10.1542/hpeds.2016-0147

Newman, A., Davies, G. A., Dow, K., Holmes, B., Macdonald, J., McKnight, S., & Newton, L. (2015). Rooming-in care for infants of opioid-dependent mothers: Implementation and evaluation at a tertiary care hospital. Canadian family physician Medecin de famille canadien, 61(12), e555–e561

Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. (2015). 2015;35(8):667]. J Perinatol. 2015;35(8):650–655

Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. (2012) JAMA.;307(18):1934–1940pmid:22546608

Singh, R., Rothstein, R., Ricci, K. et al. Partnering with parents to improve outcomes for substance exposed newborns—a pilot program. J Perinatol 40, 1041–1049 (2020). https://doi-org.proxy-hs.researchport.umd.edu/10.1038/s41372-020-0662-9

References

• The original Finnegan scale was used to determine the severity of withdrawal symptoms and the need of pharmacologic intervention.

• Parental presence was associated with a decrease in NAS scores, and decrease in length of stay. The infants that roomed-in had significantly shorter lengths of stay when compared to infants admitted to the NICU.

• Average hospital costs decreased by nearly 50% and average length of pharmacotherapy decreased from 17 days to 8 days after implementing a rooming-in system.

• All five of the studies successfully addressed the PICOT question and revealed a decrease in opioid therapy, hospital LOS, and cost for infants with NAS and their families.

Figure 1: Correlation of parental presence and NAS outcomes.

The Impact of Rooming-in on Infants with Neonatal Abstinence SyndromeShani Barkhordarzadeh, Nursing StudentMalissa da Graca, MS, CRNP, RNC-OB

University of Maryland School of Nursing

Background

• Database: CINAHL• Search criteria: “non-pharmacologic

treatment” “rooming-in”, and “neonatal abstinence syndrome”.

• Peer-reviewed research articles, published in the past ten years were included

• 5 studies were used for evidence review

• Rooming-in promotes the use of a multidisciplinary team model.

• Support and education are readily available in order for the family to properly care for their newborn and create a healthy bond.

• rooming-in reinforces the parent’s faith in their own parental abilities while allowing for ongoing education by staff.

• The rooming-in model was associated with a reduction of opioid pharmacotherapy, length of stay, and hospital cost.

• In conclusion, implementing rooming-in resulted in decreased length of stay, hospital costs, and length of pharmacologic treatment.

• Rooming-in can reduce NICU bed use and hospital resources, as well as safely alleviate some negative psychosocial stressors which new mothers may struggle with.

• Rooming-in promotes non-pharmacologic care including breastfeeding and skin-to-skin time, which encourages the parent–infant bonding and attachment.

Virtual Reality Simulation to Reduce Pediatric MRI Anxiety Erin Parkinson

Faculty: Dr. Luana Colloca, MD, PhD, MSUniversity of Maryland Baltimore, School of Nursing

BackgroundIt was found that up to 30% of children undergoing MRIexaminations reported feelings of anxiety and which canmake it difficult to lay still during the examination, thusprolonging the process as well as their anxiety. Currentpractice is to provide children with sedation and anesthesia toreduce anxiety symptoms and quicken the process. It isestimated that about 25% of pediatric patients receiveanesthesia priori to MRI examination. While this is effective inreducing symptoms, there are risks of adverse events whichrequire extra monitoring of the patient. Because of theserisks, non-pharmacologic interventions, such as virtual reality(VR), to reduce anxiety levels should be explored. A searchfor relevant literature was conducted to locate evidence of VRsimulations being an effective tool to reduce anxiety inchildren undergoing medical procedures.

Conclusions • MRI procedures can evoke anxiety symptoms in children

requiring the risky use of anesthesia to complete the process

• Virtual reality offers a non-pharmacologic way to prepare children for the procedure by offering a life-like and interactive simulation of the experience

• Studies have shown the VR education prior to examination significantly reduces anxiety levels in children and children find the education enjoyable

• Current literature does not provide sufficient evidence for a change in practice, but does serve as a base for future research

Implications for Nursing PracticeThere has been a recent push for providing more holisticcare prioritizing the use of non-pharmacologic treatmentsand therapies. Because of the risks associated withanesthesia use in children, the exploration of VRsimulations prior to MRI should be considered. VRtechnology poses little to no risk to patients whencompared to anesthesia, thus increasing patient safety. It’suse also prevents additional monitoring, thus preservinghealthcare resources and staff.

METHODSThe search for relevant literature began using the databases PubMed, Google Scholar, and CINAHL Plus. The keywords “virtual reality”, “children/pediatrics”, “anxiety”, “anesthesia”, and “MRI” were used to find research articles. Additional inclusion criteria were they had to be peer reviewed, primary research, full text was available, and published between 2016 and 2021. Studies were excluded if they used virtual reality as a distraction technique during procedures. The PubMed database initially generated 147 articles, Google Scholar produced 17,600, and CINAHL Plus produced 13 for a total of 17, 760. After screening titles and abstracts for inclusion criteria, this number was reduced to 227. The full articles were then analyzed, and 6 studies were selected for review.

Evidence Summary• Rothman et al. compared full instruction including VR

simulation to partial instruction of just a booklet and found that the full instruction reduced anxiety levels and anesthesia use in children undergoing MRI

• Marquess et al. found a significant decrease in anxiety levels in adult males undergoing radiation therapy when VR education was used

• Liszio et al designed a VR app for children undergoing MRI and found that it significantly reduced anxiety levels and children found it enjoyable to use

• Ashmore et al. also designed a VR app for children undergoing MRI and found that it increased understanding of the procedure and significantly decreased anxiety levels

• Ryu et al conducted two studies where children undergoing surgery requiring anesthesia were randomized into traditional instruction and VR simulation groups for education

• Ryu et al. found that in both studies, children in the VR group had significantly lower anxiety levels and higher compliance rates

PICOT QuestionDoes virtual reality simulation as an education tool,significantly reduce anxiety symptoms in pediatric patientsundergoing MRI procedures when compared to sedation andanesthesia?

REFERENCESAshmore, J., Pietro, J. D., Williams, K., Stokes, E., Symons, A., Smith, M., Clegg, L., & McGrath, C. (2019). A Free Virtual Reality Experience to Prepare Pediatric Patients for Magnetic Resonance Imaging: Cross-Sectional Questionnaire Study. JMIR Pediatrics and Parenting, 2(1), e11684. https://doi.org/10.2196/11684

Liszio, S., Graf, L., Basu, O., & Masuch, M. (2020). Pengunaut trainer. a playful VR app to prepare children for MRI examinations: in-depth game design analysis Proceedings of the Interaction Design and Children Conference. https://doi.org/10.1145/3392063.3394432

Marquess, M., Johnston, S. P., Williams, N. L., Giordano, C., Leiby, B. E., Hurwitz, M. D., Dicker, A. P., & Den, R. B. (2017). A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy. Journal of Radiation Oncology, 6(3), 317–322. https://doi.org/10.1007/s13566-017-0298-3

Rothman, S., Gonen, A., Vodonos, A., Novack, V., & Shelef, I. (2016). Does preparation of children before MRI reduce the need for anesthesia? Prospective randomized control trial. Pediatric Radiology, 46(11), 1599–1605. https://doi.org/10.1007/s00247-016-3651-6

Ryu, J.-H. ., Park, S.-J. ., Park, J.-W. ., Kim, J.-W. ., Yoo, H.-J. ., Kim, T.-W. ., Hong, J. S., & Han, S.-H. . (2017). Randomized clinical trial of immersive virtual reality tour of the operating theatre in children before anaesthesia. British Journal of Surgery, 104(12), 1628–1633. https://doi.org/10.1002/bjs.10684

Ryu, J.-H., Park, J.-W., Nahm, F. S., Jeon, Y.-T., Oh, A.-Y., Lee, H. J., Kim, J.-H., & Han, S.-H. (2018). The Effect of Gamification through a Virtual Reality on Preoperative Anxiety in Pediatric Patients Undergoing General Anesthesia: A Prospective, Randomized, and Controlled Trial. Journal of Clinical Medicine, 7(9). https://doi.org/10.3390/jcm7090284

Role of the CNL• Review present data on anesthesia use and related

adverse events in children undergoing MRI examination• Collaborate with relevant staff to gain different

perspectives on the problem and discuss potential solutions.

• Drive further research based on current evidence• Promote patient safety by offering other non-

pharmacologic methods to reduce anxiety in addition to VR education

Comparing the Effectiveness of Virtual Reality and Biobehavioral Non-Pharmacologic

Interventions on Venipuncture Induced Pain Among Children Ryan Ho, MSN Student

Faculty: Professor Elizabeth Johnson, MSN, CPNP-PCUniversity of Maryland Baltimore, School of Nursing

BACKGROUND AND SIGNIFICANCE

-Venipuncture is a common procedure that children and adolescents experience during healthcare visits. Unfortunately, venipuncture is commonly associated with pain due its nature.• According to one study, 51% of children aged 7–12 years and

28% of adolescents (> 12 years of age) who underwent venipuncture reported high levels of distress (Wong et al., 2019).

• Another survey amongst 283 children who underwent vaccinations at a public clinic found 52% of participants appeared distressed before, during, and after the procedure (Ouach et al., 2018).

-Increased pain levels are associated with a variety of negative outcomes, including the development of needle apprehension, which can last into adulthood and lead to long-term health consequences (Ialongo & Bernardini, 2016). These consequences stem from noncompliance with preventative healthcare measures associated with needlestick requirements (McMurtry, 2015). In addition, poor health stemming from noncompliance is associated with decreased quality of life as well as expensive costs (Galea & Maani, 2020).-Current interventions geared towards pain reduction are multimodal in their approach and not based off any unanimous recommendation. They include biobehavioral nonpharmacological approaches, such as the provision of distraction measures or repositioning a client with the help of a parent. Despite these strategies, high levels of distress persist, as indicated by the previously noted statistics. -An alternate, less commonly utilized pain reducing intervention, is explored with the following PICOT question: Amongst pediatric clients 6-18 years of age undergoing venipuncture procedures in healthcare settings, are virtual reality (VR) based interventions more effective than other biobehavioral, non-pharmacological interventions at reducing pain scores experienced during the procedure?

METHODS AND LITERATURE PROFILEIn order to find relevant research articles for this

assignment, the search engine ‘PubMed’ was utilized. In order to find a general list of potential articles, the keywords "virtual reality" and "venipuncture" were typed into the search bar. This search yielded 25 results. Several different exclusion criteria were then applied to narrow down the results to more relevant articles. These criteria included full-text and publication date within 5 years. After application of the exclusion criteria, 1 title was omitted because it was a study protocol, not an actual completed study. At this point in the search, 14 articles were retained for further screening. Upon title screenings, another 2 articles were rejected because they were not randomized controlled trials. 12 articles then remained, and an abstract screen excluded another article due to poor study design (inappropriate age group). Of the remaining 11 articles, the best 6 were selected for PICOT review. See Appendix A for the methodology used to conduct the evidence search.

EVIDENCE SUMMARY

-Six randomized controlled trials (RCTs) were included in this evidence review: Caruso et al., (2019), Gerçeker et al., (2018), Aydin et al., (2019), Erdogen et al., (2021), İnangil et al., (2020), and Koç Özkan & Polat (2020). Their primary objectives were to examine the effectiveness of VR at reducing pain in pediatric clients within the 6-18 year age group. • In two of the studies, conducted by Caruso et al. (2019) and

Gerçeker et al. (2018), VR was not found to be more effective than the nonpharmacological pain interventions utilized, which varied from nonprocedural conversation to the application of cold and vibration.

• Another study by Erdogan et al. (2021) also compared VR with cold vibration in pain reduction and found the latter to be more effective.

• The last three studies, conducted by İnangil et al. (2020), Aydin et al. (2019), and Koç Özkan & Polat (2020), found VR to be more effective than nonpharmacological biobehavioral interventions.

-Each study presented with various strengths and weaknesses. Caruso et al. (2019), Erdogan et al. (2021), and Koç Özkan & Polat (2020) received Cs because they failed to achieve power. Gerçeker et al. (2018), İnangil et al. (2020), and Aydin et al. (2019) received Bs. All achieved power and had overlapping strengths such as minimization of confounding variable and accurate randomization. Regardless of the quality ratings each study received, all studies involved relatively small sample sizes, except for Caruso et al. (2019). This, in combination with some of the stringent inclusion and exclusion criteria, reduces generalizability of results. -Findings of İnangil et al. (2020), Aydin et al. (2019), and KoçÖzkan & Polat (2020) appear to be consistent with conclusions from existing literature - that VR is more effective at pain reduction than biobehavioral nonpharmacological pain interventions. Additional studies should be conducted before final recommendations are made. Additional studies should also address weaknesses of existing literature.

SUMMARY AND CONCLUSION

-Gerçeker et al. (2018), Caruso et al. (2019), Aydin et al. (2019), Erdogen et al. (2021), İnangil et al. (2020), and KoçÖzkan & Polat (2020) all showed virtual reality to be an effective tool at pain reduction. -Three studies did not find VR to be the most effective pain reducing intervention available. These included Erdogan et al. (2021) (VR was found to be less effective than Buzzy at pain reduction), Gerçeker et al. (2018) (no difference between VR and Buzzy at pain reduction), and Aydin et al. (2019) (found VR to be no more effective than multiple different biobehavioral nonpharmacological interventions at reducing pain).-Caution must be taken when considering the recommendations of each individual study, given the variance of weaknesses and associated quality ratings. Given that none of the studies found virtual reality to be an ineffective nor dangerous intervention, its implementation can still be performed based on a moderate to low strength recommendation.

REFERENCESAydın, A. İ., & Özyazıcıoğlu, N. (2019). Using a Virtual Reality Headset to Decrease Pain Felt During a Venipuncture Procedure in Children. Journal of PeriAnesthesia Nursing, 34(6), 1215–1221. https://doi.org/10.1016/j.jopan.2019.05.134 Caruso, T. J., George, A., Menendez, M., De Souza, E., Khoury, M., Kist, M. N., & Rodriguez, S. T. (2019). Virtual reality during pediatric vascular access: A pragmatic, prospective randomized, controlled trial. Pediatric Anesthesia, 30(2), 116–123. https://doi.org/10.1111/pan.13778 Erdogan, B., & Aytekin Ozdemir, A. (2021). The effect of three different methods on venipuncture pain and anxiety in children: Distraction cards, virtual reality, and buzzy® (randomized controlled trial). Journal of Pediatric Nursing. 10.1016/j.pedn.2021.01.001Galea, S., & Maani, N. (2020). The cost of preventable disease in the USA. The Lancet Public Health, 5(10), 513–514. https://doi.org/10.1016/s2468-2667(20)30204-8 Gerçeker, G. Ö., Binay, Ş., Bilsin, E., Kahraman, A., & Yılmaz, H. B. (2018). Effects of virtual reality and external cold and vibration on pain in 7- to 12-year-old children during phlebotomy: A randomized controlled trial. Journal of PeriAnesthesia Nursing, 33(6), 981–989. https://doi.org/10.1016/j.jopan.2017.12.010 Ialongo, C., & Bernardini, S. (2016). Phlebotomy, a bridge between laboratory and patient. Biochemia Medica, 26(1), 17–33. https://doi.org/10.11613/bm.2016.002 İnangil, D., Şendir, M., & Büyükyılmaz, F. (2020). Efficacy of cartoon viewing devices during phlebotomy in children: A randomized controlled trial. Journal of PeriAnesthesia Nursing, 35(4), 407–412. https://doi.org/10.1016/j.jopan.2020.01.008 Koç Özkan, T., & Polat, F. (2020). The effect of virtual reality and kaleidoscope on pain and anxiety levels during venipuncture in children. Journal of PeriAnesthesia Nursing, 35(2), 206-211. doi:10.1016/j.jopan.2019.08.010McMurtry, C. M., Pillai Riddell, R., Taddio, A., Racine, N., Asmundson, G. J., Noel, M., … Shah, V. (2015). Far from “just a poke.” The Clinical Journal of Pain, 31. https://doi.org/10.1097/ajp.0000000000000272Ouach, I., Reszel, J., Patel, Y., Tibbles, J. A., Ullyot, N., Wilding, J., & Harrison, D. (2018). Children’s Pain and Distress at a Public Influenza Vaccination Clinic: A parent survey and public observation study. Journal of Community Health, 44(2), 322–331. https://doi.org/10.1007/s10900-018-0590-1 Wong, C. L., Lui, M. M., & Choi, K. C. (2019). Effects of immersive virtual reality intervention on pain and anxiety among pediatric patients undergoing venipuncture: A study protocol for a randomized controlled trial. Trials, 20(369). https://doi.org/10.1186/s13063-019-3443-z

IMPLICATIONS FOR NURSING PRACTICE

AND CNL ROLE-The CNL can champion the adoption of VR interventions in hospital units that do no already utilize them. -The CNL can laterally integrate the shared use of a VR intervention between a unit's nursing staff and hospital-wide phlebotomy team.-The CNL will facilitate communication between the nurses, phlebotomy team, and parents to promote the most effective utilization of VR. For example, the CNL may request that nurses administer parent surveys to identify patients at highest risk for a negative phlebotomy experience based on past experiences. After these patients have been identified as priorities for virtual reality use, the nurse will relay this information to the phlebotomy team who will come to perform the intervention. -To evaluate the effectiveness of the chosen VR intervention at pain reduction, the CNL may also record data on the microsystem level. Combining this information with data of the costs associated with virtual reality implementation, the CNL can make additional conclusions about the economic viability of this tool. This can be the basis for further studies.

Implementation of a Therapeutic Exercise Program for Children Post Cancer TreatmentNicole Clemente

Dr. Michele Michael, PhD, PNP, CNEUniversity of Maryland Baltimore, School of Nursing

BACKGROUND & SIGNIFICANCE• Pediatric cancers and the symptoms experienced following various treatment protocols often leads to disinterest in engaging in physical activity (PA) and subsequent functional morbidities post-discharge (Li et al., 2018). • A lack of PA impacts their overall physiological and psychosocial wellness as evidenced by obesity, CV disease, osteoporosis and mental health problems (Beulertz et al., 2016; Braam et al., 2016). • Evidence demonstrates that programs combining psychosocial and physical wellness can positively improve overall quality of life for the child. • Physical fitness programs include weekly aerobic as well as weight-bearing exercises performed in a circuit training-setting. • Making therapeutic exercise programs engaging may promote a desire or motivation for children to adapt physical activity into their lifestyle (Howell et al., 2018).

PURPOSE• The purpose of this project was to evaluate the feasibility

of implementing a physical activity (PA) program in children post cancer treatment and determine if the interventions increased PA levels and quality of life scores.

ROLE OF CNL• Evaluate Evidence-based practices for further evaluation and implementation

of PA programs (O’Grady & Van Graafeiland, 2012).• Coordinate care with communication with other disciplines including a

physical therapist, child life specialist, and other members. A goal is to facilitate teamwork and collaboration (O’Grady & Van Graafeiland, 2012).

• Serve as a clinician to promote psychosocial wellness and facilitate this aspect of care (O’Grady & Van Graafeiland, 2012).

• Since there is limited research on this topic the CNL will have to analyze how treatment in order to strive for a higher level of quality care.

EVIDENCE SYNTHESIS

SEARCH METHODS• Databases: Pubmed and CINAHL• Keywords: pediatric, cancer, and physical activity• Limitations: Dated between 2016 to 2021, English, Clinical trials or

research articles• Original yield was a total of 124 articles• Exclusion criteria: restricted access to the full article, undesired outcome,

insufficient sample size, lack of PA in implementation, or sample wasundergoing active treatment.

• Results: 5 articles were selected, including 3 RCTs and 2 Quasi-experimental studies. These articles met the characteristics for the desiredsample and implemented PA programs with results for further analysis.

IMPLICATIONS FOR NURSING• Encouraging providers to continue exercise programs once the child is discharged and involving the care of other disciplines. •Coordinating care by providing family centered care, education and discharge planning to prepare the family and child. • Managing multiple roles for both in-patient and out-patient care including assessing effectiveness of exercise program in the home• Communicating with multidisciplinary team.•Creative measures when implementing programs and promoting engagement.

PICOP: Pediatric patients who have completed acutecancer treatmentI: Therapeutic exercise programC: routine PA unit protocolsO: improved levels of PA and quality of life

SUMMARY & CONCLUSIONS• Evidence suggests that implementation of therapeutic exercise programs promote physical and psychosocial wellness in this unique cohort. • The type of program interventions reviewed varied with different methods of measurement and evaluation. Further research is required on a larger scale to identify the strategies that produce significant results. • Nurses act as the providers to ensure that therapeutic exercise programs are incorporated into the patient’s plan of care.• A CNL can coordinate care so that the program continues for the child and family after the patient is discharged.

Author Type of Study Sample Size

(n)

Results Level of

Evidence

(l/G)

Beulertz, et

al.. (2016)

Explorative, prospective study

Control: n=13Intervention: n=20

-Intervention group reached the motor performance level comparable to the healthy children.-Intervention group had a significant increase in the level of activity.-Intervention group showed an increase in their emotional well-being.

III/B

Braam. Et

al., (2018)

Randomized Controlled Trial

Control: n=38Intervention: n=30

-At 4 months there was no significant differences between either group for physical and psychosocial functioning.-Both groups showed an increase in quality of life.

I/A

Howell, et

al., (2018)

Randomized Controlled Trial

Control: n=25 Intervention: n=53

-The intervention group showed a significant increase in their levels of moderate to vigorous activity (MVPA). -Significant improvements in the mean change for fitness, neurocognition, and health-related quality of life in the intervention group.

I/B

Li, et al.,

(2018)

Prospective Randomized Controlled Trial.

Control: n=105Intervention: n=117

-Significant increase in PA levels at 6 and 12 months in the intervention group. -The intervention group had significantly decreased levels of cancer-related fatigue and increased quality of life scores at 12 months.

I/A

Muller, et

al., (2016)

Prospective, uncontrolled, single-center study

n=150All participants received the intervention

-The sample had significant increases in in gait cycles/day and gait cycles/hr at 12 months. -Health related quality of life: Global score increased at the completion of rehab, at 6 months and at 12 months. Increase in physical well-being score at the completion of rehab and at 6 months.

III/B REFERENCESBeulertz Beulertz, J., Prokop, A., Rustler, V., Bloch, W., Felsch Dipl-Stat, M., & Baumaan, F.T. (2016) Effects of a 6-month, group-based, therapeutic exercise program for childhood cancer outpatients on motor performance, level of activity, and quality of life. Pediatric blood and cancer, (63)1, 127-132.https://doi.org.proxyhs.researchport.umd.edu/10.1002/pbc.25640

Braam, K.I., Van Dijk-Lokkart, E., Kaspers, G.J.L., Takken, T., Huisman, J., Buffart, L.M., Bierings, M.B., Merks, J.H.M., Van den Heuvel-Eibrink, M.M., Veening, M.A., & Van Dulmen-den Broeder. (2018). Effects of a combined physical and psychosocial training for children with cancer: a randomized controlled trial. BMC Cancer, 18, 1289. https://doi.org/10.1186/s12885-018-5181-0

Howell. C.R., Krull, K.R., Partin, R.E., Kadan-Lottick, N.S., Robison, L.L., Hudson, M.M., & Ness, K.K. (2018). Randomized web-based physical activity intervention in adolescent survivors of childhood cancer. Pediatric Blood and Cancer, (65)8, e27216. https://doi-org.proxyhs.researchport.umd.edu/10.1002/pbc.27216

Li, W.H.C., Ho., K.Y., Lam, K.K.W., Chui, S.Y., Chan, G.C.F., Cheung, A.T., Ho, L.L.K., Chung, O.K. (2018). Adventure based training to promote physical activity and reduce fatigue among childhood cancer survivors: a randomized controlled trial. International Journal of Nursing Studies, (83), 65-74. https://doi.org/10.1016/j.ijnurstu.2018.04.007

Muller, C., Krauth, K.A., Gerb, J., & Rosenbaum, D. (2016). Physical activity and health-related quality of life in pediatric cancer patients following a 4-week inpatient rehabilitation program. Supportive Care in Cancer, 24, 3793-3802. https://doi-org.proxy-hs.researchport.umd.edu/10.1007/s00520-016-3198-y

O’Grady, E.L., & VanGraafeiland, B. (2012). Bridging the gap in care for children through the clinical nurse leader. Pediatric Nursing, 38(3), 155-167.

https://www.worldcoo.com/blog/en/sports-grants-for-children-with-cancer/