Title: IHS Electronic Health Record EHR
1The International Council of Nursing Conference
Yokohama ------ Japan
28 May 1 June 2007
2(Subject)
Department of Obstetric Gynaecology Tuen Mun
Hospital New Territories West Cluster Hospital
Authority Hong Kong Special Administrative
Region China
3(Subject)
Presenters Ms. Esther Siu (Nurse Specialist) Ms.
Lo Tsui Lam (Registered Nurse Midwife) Ms. Rose
Chan (Nursing Officer)
NTWC, TMH
Date 1st June 2007
4Prevention of Neonatal Hypothermia in Delivery
Suite
5Introduction
- All gestational age newborns at risk of losing
heat soon after birth
6Introduction
- Neonatal hypothermia induced cold stress and
result in - Metabolic rate, leading to O2 consumption
- Caloric consumption and glycogen stores
- Development of acidosis due to pulmonary
vasoconstriction - Thermal shock and DIC (in the more serious
cases), progressing to death
7WHO
Definition of hypothermia (C)
36.4c ? 36c Mild hypothermia
35.9c ? 32c Moderate hypothermia
Below 32c Severe hypothermia
WHO, 1997
8Definition of hypothermia in neonates
- Axilla temperature
- is the current mode
- for monitoring babies body temp
9Operative Definition of Hypothermia in Delivery
Suite
Hypothermia Temp below 36ºC
Moderate hypothermia Temp at 35-35.9ºC
Profound hypothermia Temp less than 35ºC
Optimal temp. range36.837.2 C
10Background
- Study results (May July 2001) from
Paediatricians - (TMH) illustrated the prevalence of neonatal
hypothermia on admission to NNU from Delivery
Suite - 22 moderate hypothermia
- 1.5 profound hypothermia
11An alarming data
from 1st May to 5th July 2004
Profound hypothermia
Moderate hypothermia
2004 May - July
2001 May - July
12What happened between 2001 to 2004?
Fridge
13Actually in2002 2003 Delivery Suite were
endeavored to manage neonatal thermal regulation
14- Tackle the problem of suboptimal
- ambient temperature in
- Delivery Suite
- Standardized and reinforced
- the practice
15- Standard guidelines and protocol on Neonatal
Thermal Regulation - was developed and endorsed by the Consultants of
the two departments. - Periodical audit was conducted to ensure all
staff to adhere the standard practice protocol.
16Why still cold ?
Why??
Why????
Why ???
17Joint Meeting(OG Paed. AM) in July 2004
- Discussed the Root Causes
18Root causes
- Adequate ambient temperature for the births
- Compliance with the protocol guidelines on
neonatal thermoregulation
- Space of improvement on practice
- Discrepancy on procedure of temperature taking
- Problem on neonatal transportation
19CQI Program
Objective
- Reduce the incidence and monitor the prevalence
of neonatal hypothermia in Delivery Suite
20Prevent Neonatal Hypothermia
21Environment
- Room Temp
- Incubator Temp
- Resuscitaire Temp
- Heater
22Procedure
- Reinforce current guideline
- Change practice in receiving baby inside the
operating theater - Apply evidence based practice
- Polyethylene occlusive skin wrapping
- Standardized measurement tool
23Procedure
- Reinforced current practice to prevent heat loss
- Hypothermia should be avoided
- Placing the infant under a radiant warmer
- Rapidly drying the skin
- Removing wet linen immediately
- Wrapping the infant in pre-warmed blankets
The International
Guidelines for Neonatal Resuscitation, 2000
24Apply Polyethylene Occlusive Skin
Wrapping in Preterm Infants
- Use of occlusive polyethylene wrap improved
admission temperatures for infants - Bredemeyer, S., et. al , 2005
- Admission temp significantly ? during
resuscitation by occlusive wrapping after birth. - Vohra, et. al , 1999
- Bjorklund Hellstrom-Westas, 2000
- Lyon Stenson 2004
25Procedure
- Change practice (mainly in OT)
- Warm towel / blanket, shawl
- Receiving baby directly from surgeon
26Baby wrapped with
Polyethylene sheet in Delivery Suite
- Criteria
- 1. lt 36 weeks
- 2. BW lt 2.5 kg
- 3. 1st Body Temperature lt 36º c
27Procedure
- Standardized measurement tool and procedure with
neonatal unit on temperature taking
28Transport
- Incubator Temp
- Maintain 37- 37.5c
- During transferred to Neonatal unit
- Use of a polyethylene plastic sheet wrapping the
infant - Kattwinkel et al, 1999
- Vohra et al, 1999
- Bjorklund and Hellstrom-Westas, 2000
- Lenclen et al, 2002
- McCall, et al, 2005
29Re-establish protocol
- Baby lt 37 wks
- Baby templt 36.8c
- B.W. lt 2.5kg
30Evaluation
31Data analysis
- Overall prevalence of neonatal hypothermia in
D.S. - Overall prevalence of hypothermia amongst
neonatal admission - Compliance rate for application of polyethylene
occlusive skin wrapping to prevent neonatal
hypothermia
32Compare the overall prevalence of neonatal
hypothermia rate in D.S. in the year of 2004
2005
Overall prevalence of hypothermia rate
Year
33Results
- No neonatal hypothermia
- was reported on arrival of postnatal wards during
the data collection period in - 2004 2005
34Results (Hypothermia rate on NNU admission)
35Mode of delivery for babies with hypothermia on
NN admission
36Audit on practice of Polyethylene Occlusive skin
wrapping for newborn in 2005
37Improvement
- Overall prevalence of neonatal hypothermia at one
hour after birth in DS
0.5
0.23
38Improvement
- Incidence of hypothermia on Neonatal Admission
18.7
12.8
39Findings
- Hypothermia significantly occurred in the
vulnerable group of newborns on neonatal
admission. - The vulnerable group of sick babies included
premature (38), LBW (65), suffering
hypoglycaemia since birth or birth asphyxia. - The vulnerable group of babies with C/S birth in
OT were more easily prone to hypothermia.
40Other Findings
- Among the group of hypothermia babies on
admission to NNU - Babies
- without polyethylene sheet wrapping
- not compliance with the practice guideline
- Body temp dropped 1 to 1.5 ºc
- Babies were transported by an incubator
- with insufficient temperature (33.5 35.8 ºc)
- Body temp. dropped 0.3 0.7 ºc
-
41Recommendation
Issues to help decreasing the incidence of
hypothermia rate on NN admission included
- Maintenance of an optimal ambient temperature for
birthing (delivery room operating
room) by regular checking and auditing - Strictly compliance with the practice protocol
(both medical and nursing staff)
42Recommendation
- Application of evidence based practice
- (polyethylene occlusive skin wrapping) especially
for the extreme premature or low birth baby - Ensure adequate temperature of pre-warmed
incubator (at least 37.5 ºc or above) for
neonatal transport.
433rd Phase
- Collect clinical data for evaluation in 2006
-
- Audit on the compliance with protocol
44Results (Hypothermia rate on NNU admission)
45Mode of delivery for babies with hypothermia on
NN admission
C/S Caesarean Section, V/D Vaginal Delivery,
BBA Born Before Arrival
46Audit on practice of Polyethylene occlusive
skin wrapping for newborn in 2005 2006
of compliance rate
47Conclusion
- An optimal ambient temperature for delivery
- An adequate temperature of incubator for
transportation - The application of polyethylene occlusive skin
wrapping - All help the vulnerable small clients
- to prevent heat loss.
48Conclusion
- Continue quality improvement required
multi-discipline approach. - Collaboration among paediatricians,
obstetricians, nurse midwives with advices from
anaesthetist, OT NS, ICN and helpfulness from EM
dept. would help our small vulnerable clients in
less risk of hypothermia.
49Whats going on???
- Keep Continuous improvement!!
- Our team is endeavored to manage
- neonatal thermal regulation
50Acknowledgement
Managerial support
Professional advice
Dr. K.B. Cheung (COS OG) Dr. S.F. Wong
(Consultant OG) Ms. Joan Ip (DOM OG) Dr.
K.T. So (COS PAM) Dr. N.S. Kwong
(Consultant PAM) Ms. Winnie Lee (DOM PAM)
- Dr. K.K. Lam (COS Anae
ICU) - Infection Control Nurses
- Ms. Isabel Lee (OT NS)
- Clinical data collection in NNU
- Ms. Helen Ng (WM D7)
- Ms. K M Choi (WM D6)
- Technical support
- Dept. of EM TMH
All Midwives in D.S.
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