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Caring for hearts and minds: a quality improvement approach to individualized developmental care in the cardiac
Samantha C Butler1,2, Valerie Rofeberg3, Melissa Smith-Parrish4
1Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States.
Insights
Individualized developmental care (IDC) improved for infants in the cardiac intensive care unit (CICU) using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Quality improvement efforts enhanced lighting, sound, bedding, and positioning, but family participation remained challenging.
Area of Science:
- Neonatal care
- Developmental pediatrics
- Quality improvement science
Background:
- Infants with congenital heart disease (CHD) face significant developmental risks due to medical complications and intensive care unit (ICU) stressors.
- Individualized developmental care (IDC) aims to mitigate these risks by aligning the infant's environment with their developmental needs, reducing stress and pain.
- The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) provides a framework for implementing IDC.
Purpose of the Study:
- To implement and evaluate a quality improvement (QI) initiative to increase the provision of IDC using the NIDCAP model in a cardiac ICU.
- To assess the impact of QI interventions on the delivery of specific IDC components.
Main Methods:
- A multidisciplinary team utilized a Key Driver Diagram and Plan-Do-Study-Act (PDSA) cycles for QI.
- Bedside audits of NIDCAP-based IDC were conducted to collect baseline and ongoing data.
- Interventions focused on improving lighting, sound, bedding, positioning, self-regulation, and caregiving facilitation.
Main Results:
- Over 357 NIDCAP audits, improvements were observed in lighting, sound management, bedding, clothing, self-regulation, positioning, and caregiving facilitation.
- Family participation and infant holding in the cardiac ICU were areas that proved difficult to improve.
- Infants with higher medical complexity were less likely to receive IDC.
Conclusions:
- A multidisciplinary, evidence-based QI intervention effectively improved the implementation of IDC within the NIDCAP model over time.
- Bedside auditing was a valuable tool for monitoring and driving improvements in IDC delivery.
- Further efforts are needed to address barriers to family participation and ensure equitable IDC for medically complex infants.
Introduction:
Infants with congenital heart disease (CHD) are at high risk for developmental differences which can be explained by the cumulative effect of medical complications along with sequelae related to the hospital and environmental challenges. The intervention of individualized developmental care (IDC) minimizes the mismatch between the fragile newborn brain's expectations and the experiences of stress and pain inherent in the intensive care unit (ICU) environment.
Methods:
A multidisciplinary group of experts was assembled to implement quality improvement (QI) to increase the amount of IDC provided, using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), to newborn infants in the cardiac ICU. A Key Driver Diagram was created, PDSA cycles were implemented, baseline and ongoing measurements of IDC were collected, and interventions were provided.
Results:
We collected 357 NIDCAP audits of bedside IDC. Improvement over time was noted in the amount of IDC including use of appropriate lighting, sound management, and developmentally supportive infant bedding and clothing, as well as in promoting self-regulation, therapeutic positioning, and caregiving facilitation. The area of family participation and holding of infants in the CICU was the hardest to support change over time, especially with the most ill infants. Infants with increased medical complexity were less likely to receive IDC.
Discussion:
This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of IDC in the NIDCAP model improved over time using bedside auditing of IDC.
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