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Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement
Dana B McCarty1, Erika Clary-Williams2, Kristen D LeBLond3
1Division of Physical Therapy, Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Insights
A new Collaborative Eye Exam Model (CEEM) in the Neonatal Intensive Care Unit (NICU) reduced desaturation events and improved heart rate recovery in preterm infants undergoing eye exams for Retinopathy of Prematurity (ROP). Staff found the CEEM improved the exam experience.
Area of Science:
- Neonatal care
- Ophthalmology
- Pediatric critical care
Background:
- Infants born prematurely require routine eye exams for Retinopathy of Prematurity (ROP) screening in the Neonatal Intensive Care Unit (NICU).
- Preterm infants have underdeveloped sensory systems, and painful stimuli during exams can negatively impact developmental outcomes.
- Current eye exam protocols may cause distress and physiological instability in vulnerable infants.
Purpose of the Study:
- To evaluate the effectiveness of a novel Collaborative Eye Exam Model (CEEM) designed to minimize pain and improve physiological stability during ROP screening in preterm infants.
- To compare pain scores and vital sign changes between the CEEM and standard of care (SC) eye exams.
- To gather stakeholder feedback on the CEEM's impact on infant and staff experience.
Main Methods:
- An interdisciplinary NICU team developed the CEEM, incorporating pain management best practices.
- Pain scores and vital signs (heart rate, oxygen saturation) were systematically recorded before, during, and after eye exams.
- Mixed-effects regression models analyzed the relationship between the CEEM, birth gestational age (BGA), postmenstrual age (PMA), and physiological outcomes.
- Survey feedback was collected from NICU staff regarding their experience with the CEEM.
Main Results:
- The CEEM significantly reduced desaturation events (p=0.003) and improved heart rate recovery (p=0.04) compared to SC, particularly in infants with earlier BGA.
- While no differences in pain scores were observed, the CEEM showed a trend towards reduced bradycardia and tachycardia in some analyses.
- Stakeholders reported a significant improvement in both infant and staff experience with the CEEM.
Conclusions:
- The CEEM is a promising intervention for improving physiological stability and the overall experience during ROP screening eye exams in preterm infants.
- Infants may experience differential benefits from the CEEM based on their specific birth gestational age and postmenstrual age.
- The CEEM demonstrates the value of interdisciplinary collaboration in optimizing care for high-risk neonates.
Introduction:
Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes.
Methods:
An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM.
Results:
Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM.
Discussion:
Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.
