In To Err is Human, the Institute of Medicine (IOM) estimated that approximately 98,000 Americans die each year because of medical errors (IOM, 1999). These alarming statistics changed the landscape for those working in the healthcare field and initiated a discussion on the need for improved patient safety. The IOM's follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century, was equally significant (IOM, 2001). This report was a call to action to make the health care system safer, effective, patient centered, timely, efficient, and equitable for all Americans. As a result, thousands of continuous quality improvement projects have been initiated in hospitals across the United States in an effort to improve patient safety and quality of care. For those working with neonates, these efforts begin with the very first breath. This In Focus Series includes four articles that address neonatal safety and quality of care from birth to admission to the neonatal intensive care unit (NICU).
In the first article, Harach disseminates updated recommendations from the Neonatal Resuscitation Program (NRP) regarding room air resuscitation in the delivery room. She notes that oxygen is one of the most commonly used drugs in the NICU. However, recent research has shown deleterious effects on the neonate after even brief exposure to 100% oxygen. The use of 100% oxygen even briefly has delayed the onset of the first cry and established respiratory effort; brief exposures to high concentrations of oxygen have also been implicated in long-term neurological deficits and childhood cancers (Vento, Escobar, Cernada, Escrig, & Aguar, 2012). The updated recommendations of the NRP call for initial room air resuscitation with oxygen administration with guidance of pulse oximetry to provide a safe transition to extrauterine life.
In the second article, Barber addresses the maintenance of airway safety for infants requiring endotracheal tube intubation and assisted ventilation. Unplanned extubations (UEs) threaten the lives of critically ill infants who require mechanical ventilation. Barber reviews the limited neonatal literature on UEs and identifies commonalities that may be seen with UEs in the NICU. She describes a continuous quality improvement project aimed at the reduction of UEs in the NICU. With detailed attention to identifying at risk infants, standardization of procedures, including endotracheal tube attachment, and careful documentation, including a proposed data collection tool, UEs may be significantly reduced in the NICU (Chiang, Lee, Lee, & Wei, 1996).
Daily patient rounding was introduced in the adult intensive care unit in 2006 (Meade, Bursell, & Ketelsen, 2006). In the third article in this series, Graci outlines a unique quality improvement project completed in a large Level III urban NICU in which hourly assessment was provided for infants and their families. The project addressed the three Ps: parent, position, and physical inspection. The outcome of the project was improved nursing and parental satisfaction with the care provided to infants. Graci discusses the extensive planning, education, and implementation involved in this quality and safety improvement project.
Finally, though NRP ensures safety for all neonates in the delivery room in the United States, the same is not true elsewhere. In fact, the statistics are staggering: three million infants are considered stillborn at birth worldwide, while another three million infants die during the first 28 days of life (Carlo et al., 2010). Helping Babies Breathe (HBB) is a comprehensive educational training program that equips birth attendants for neonatal resuscitation in resource-limited areas. Initiated by the American Academy of Pediatrics (AAP) and many collaborative partners including the World Health Organization, the purpose of HBB is to improve the neonate's first minute of life by providing training and lifesaving equipment for traditional birth attendants (TBAs). In the last article, I discuss the problems leading to neonatal death globally, review HBB, and describe the training session for one group of TBAs and American nurse practitioner educators in Haiti.
The importance of safety and improved quality of care for infants in the delivery room and throughout the NICU stay must be the highest priority of the health care professionals working with them. This includes ensuring that the first breath is safe, the airway is protected and secure, and the 3Ps are hourly assessed. Bedside and advanced practice nurses, physicians, and their assistants must advocate for the highest quality of care and safety for the infants in our care and for those around the world who so desperately need our attention. We must ensure that every infant is provided safe entry into the world.