After several PDSA's and administrative approval and vetting, the UNC team utilized the PQCNC tracking tool resource to achieve success with implementing the North Carolina statewide hypoglycemia algorithm including the use of glucose gel. The tool serves several purposes from educating and empowering patients to partner in care, to providing a clear timeline of interventions and treatments. The tool tracks elements of care such as glucose levels, gel administration, and frequency of feedings as well as informs the parent why their newborn is at risk and being monitored. With careful planning, implementing, and adapting (including translating into Spanish), UNC has achieved great strides in ensuring staff compliance with the statewide hypoglycemia protocol as well as improving continuity of care between newborn nursery and NICU.
In October, teams discussed the challenges and successes of implementing glucose gel in the management of hypoglycemic newborns. Some of the challenges staff shared related to appropriate administration of glucose gel as there are several steps to take, including transfer of the gel from an adult size tube to a small syringe to ensure accurate dosing. With staff education results in hand and using the PQCNC video resource on proper preparation and administration, the team at WakeMed Raleigh took it a step further and created an initial competency sheet to validate skill. Outlining each step in the process from clarifying the physician order to drying the buccal cavity, the quick competency requires all staff to be observed completing the necessary steps accurately. Furthermore, it sets a standard of care that will lead to sustainability of the task for future new hires and new employees.
Teams from across North Carolina convened in Raleigh on October 14th to hear presentations ranging from education plans for implementation of the PQCNC statewide hypoglycemia algorithm to various methods of EMR integration to achieve sustainability. Discussion topics included the use of donor breastmilk as supplementation in the at-risk for hypoglycemia term newborn, adopting glucose gel as a treatment, and the increase in the standardization and use of an IV weaning protocol for newborns who did require an escalation of care resulting in continuous IV infusion.
At the initiative kickoff meeting in January 2019, teams were introduced to an algorithm to manage hypoglycemia. If an algorithm was already in use at a facility, teams were encouraged to examine their current practice and to consider incorporating the use of glucose gel. The Atrium facilities embraced this idea and began meeting to discuss their current algorithm. Multiple system wide calls were held to obtain feedback from as many providers as possible. The algorithm was expanded and administration of glucose gel was included. After several PDSA cycles of small changes, a system wide algorithm was produced. The algorithm has been rolled out to all Atrium facilities to begin staff education on the changes thus standardizing the management of neonatal hypoglycemia across their healthcare system.
PQCNC created a state-wide algorithm to kickoff the Newborn Hypoglycemia Prevention and Care initiative to assist teams with a strong resource as they began standardizing the care and management of newborns at-risk for hypoglycemia. However, one team took it a step further. Understanding there were many scenarios and steps their staff would have to interpret when they rolled out the PQCNC algorithm, Vidant Medical Center saw an opportunity to ease implementation for their staff. They added line items on the algorithm for staff to document blood glucose results, as well as time of testing and treatment if carried out. The document is not only a guide for standardization it is now a working algorithm to ensure the protocol produces an accurate clinical pathway every time. The team also plans to collect these tools to track compliance and identify opportunities for further implementation support if necessary.
Donor breast milk has long been a staple of Neonatal Intensive Care Units to provide premature infants with the “next best thing” to mother’s milk. For many of the reasons donor breast milk is beneficial to premature infants, it is also beneficial to term infants. There are several challenges to utilizing donor breast milk in the Newborn Nursery population but Duke Regional Hospital has managed to successfully overcome them. Laura Zamora, an RN in Duke’s Lactation Services outlines the workflow surrounding management of donor breast milk and how it is utilized to supplement hypoglycemic infants in the Newborn Nursery at Duke Regional in a recorded presentation that you can find here. They have fully embraced that “breast is best” and provided donor breast milk as an option for all of their infants who need it.
Diagnosis of gestational diabetes (GDM), large for gestational age, small for gestational age and maternal use of beta-blockers, represent the most common risk factors threatening a newborn with hypoglycemia at birth. These maternal indications can largely be determined prior to delivery and therefore, beginning to partner with parents before birth is an optimal time to educate.
WakeMed Health and Hospitals, in Raleigh, decided to do just that. Working closely with their public relations department to convert the PQCNC parent education form to include their hospital logo, the team successfully produced two documents, one in English and one in Spanish. The nurse leaders on the postpartum floor then reached out to the leaders of the high-risk obstetric clinic and health department to educate them on the PQCNC project and goal they were trying to achieve. Aiming the education at mothers 26 weeks and greater, the clinic and health department have added the hypoglycemia documents to their current information packet. Once they deliver, the same education is presented again in the inpatient setting as well. Mothers with the above risk factors can now be aware of what to expect both before delivery and after.
We commend the WakeMed team for thinking outside the inpatient setting and beginning to partner with patients before birth to optimize the care provided to their newborns!
Treating and managing asymptomatic at-risk newborns for hypoglycemia relies on sticking to the basics - reinforcing the clinical skills of obtaining a heel-stick blood sample is one intervention some teams have deemed a priority. Utilizing the PQCNC video titled, “Proper Heel-stick Demonstration” and the PQCNC illustration outlining proper puncture site, teams are requiring their staff to view these resources prior to performing return demonstrations of the skill. Some teams have even added these informative tools to their annual education blitzes and new hire orientations to ensure continued competency with the skill. Though obtaining a heel-stick blood sample is a high-frequency clinical task performed daily, teams have recognized incorrect habits have formed over time potentially leading to inaccurate results. Going back to the basics and reviewing this critical task is helping to ensure the most accurate blood glucose sample is obtained, resulting in optimal management of the newborn at-risk.
With much evidence pointing to the benefits of glucose gel as a viable, effective, and inexpensive treatment option, teams across the state are giving it a go. Utilizing the PQCNC webinar resources available to them is proving useful - teams are sharing the videos on proper glucose gel administration with all staff to educate them on proper technique to achieve optimal glucose absorption. With baseline data showing over 60% of teams not using gel as a treatment option, the potential to improve care provided to newborns, keep moms and babies together, and promote breastfeeding efforts by our highly engaged teams is tremendous. The video is available on the NHPC webinar page to view at any time to support implementation efforts.
After months of review and numerous discussions, considering all current North Carolina algorithms and evidenced-based recommendations, the Newborn Hypoglycemia Prevention and Care collaborative achieved one of the primary goals teams desired: a statewide protocol for Management of At-Risk Newborns for Hypoglycemia.
Over 250 attendees at the initiative kickoff last week solidified these efforts and approved the document after careful review and expert engagement. Mirrored after the 2011 American Academy of Pediatric (AAP) version, the North Carolina statewide algorithm takes it a step further and includes the use of glucose gel as an intervention.
Blessed by Dr. David Adamkin himself, the author on the statement on Neonatal Hypoglycemia for the AAP, the resource is meant to provide teams with a standardized protocol right out of the gates, as we begin our work to improve care for the hypoglycemic newborn and those as risk.
Find it in Initiative Charter/Work Plans/Action Plans here