Dianne L. Smith, RN, CPN Patricia Cordner, RN, CLC Fletcher Allen Health Care, NICU

1. NIC/Q Quality Improvement Project: Oral Care Protocol for Intubated Infants in the Neonatal Intensive Care Unit (NICU) Dianne L. Smith, RN, CPN Patricia Cordner, RN, CLC Fletcher Allen Health Care, NICU

2. Purpose • VAP rates in the NICU reached a significant high of 5 cases in Quarter 3 of 2010 based on STATIT data. • The NIC/Q Committee determined that preventive measures were needed to decrease the NICU’s rate of VAP.

3. What is NIC/Q? • NIC/Q: The multidisciplinary QI committee in the NICU at FAHC. Meets weekly. Biannual national meetings through Vermont Oxford Network (VON).

4. What is VAP? • VAP: Infant intubated & ventilated (trach or ETT) at time of or within 48 hrs before onset of the pneumonia & has S/S of worsening gas exchange & at least three of the following 1. Temp instability with no other recognized cause 2. Leukopenia or leukocytosis 3. Change in sputum or increasing resp. secretions or increasing suctioning requirements 4. Apnea, increased RR, flaring with retractions or grunting 5. Wheezing, rales, or rhonchi 6. Bradycardia or tachycardia & CXR findings for at least one of the following: a. New infiltrate b. Consolidation c. Cavitation d. Pneumatoceles OR two or more serial CXRs with progressive or persistent infiltrate. And is receiving treatment for > three days.

5. Literature Findings • Fresh breast milk given via the oropharyngeal route can protect against neonatal infections, as VAP • How so? • Colostrum, early breast milk, especially, is highly concentrated with immune factors which offer barrier protection and promote bacterial cell wall lysis, anti-inflammation, and immunomodulation. Further research has shown that these immune agents can interact directly with oral mucous membranes and be absorbed. • Breast-fed infants have benefited by this traditionally, but not those infants unable to feed, notably those who are intubated, typically ELBW infants (extremely low birth weight, < 1000 gm).

7. Methods • The NIC/Q committee therefore worked to create infection prevention measures. Nursing members of the committee focused on developing a protocol incorporating the use of breast milk as an oral “cleansing” agent, swabbed in the mouths of intubated infants. • The protocol was completed and rolled out in June, 2011.

8. Oral Care Protocol for Intubated Infants in the NICU • Dip a new swab into colostrum or mature milk (fresh, not previously frozen) • Ensure the swab absorbs all drops of colostrum or is saturated when there is ample supply • Coat the entire buccal mucosa • Perform every 3 hours prior to a scheduled gavage feeding; OR if the infant is NPO, at least once daily for the duration of intubation • Document care in PRISM in NICU Combined Flow Sheet, “Newborn Hygiene” row • Oral swabs are located in Cabinet 10, drawer # 5 on the back wall of the NICU, near oral syringes. There are 2 sizes: petite 6mm and petite 8mm. • Important Notes: • Use only fresh colostrum or breast milk, not previously frozen • (immune-protective properties are altered when milk is frozen) • Separate a small aliquot (3-5 ml) of fresh colostrum or mature milk into a separate breast milk container to use for oral care within 48 hours of pumping and label as such • Fresh colostrum or mature milk may be frozen within 48 hours and used later for feeding, once enteral feeds are established • Infants on enteral feedings receive mouth care q. 3 hr. before gavage feedings • NPO infants receive mouth care at least once daily • If no fresh breast milk or colostrum, perform routine oral care with sterile water (there is no harm in using thawed, previously frozen breast milk for oral care; however you do not want to deplete stores of milk that may be needed for feeds in the future) • Keep oral mucosa clean, moist and intact; keep lips clean, soft and intact by providing routine oral care • * This oral care protocol was developed by the NIC/Q Committee for the prevention of VAP. This care may benefit any infant in the NICU, especially those who are NPO, who have a Replogle, and who receive primarily gavage feeds.

9. Findings • Exceptionally positive reception from nursing staff. 25% of the ~ 80 NICU nurses, all shifts, have been randomly interviewed by the NICU Nurse Educator after roll-out of the oral care protocol. No negative feedback. • The EHR’s of two ELBW intubated infants were audited for documentation of oral care for the extent of their time intubated, spanning 4 weeks collectively: oral care was documented ~ 75% of the time as per the protocol, essentially equal on each baby, demonstrating good compliance for a new protocol.

10. PRISM Documentation

11. Baby’s Firsts Card • “Firsts” for my family to remember! • First held (date): By Whom: • First temp done by family (date): By Whom: • First Oral Care done by family (date): By Whom: • First diaper change by family (date): By Whom: • Other important firsts:

12. FAHC VAP Rates * Oral Care Protocol started June, 2011

13. VAP Rates from 90 US Hospitals (2009): Pooled means by birth weight category • Benchmarking data from NHSN (National Healthcare Safety • Network, a CDC data base)

14. Conclusions • Oropharyngeal administration of mother’s milk is well-tolerated by NICU infants, even those who are the most critically ill. • The oral care protocol encourages family-centered care by providing a way for mothers to be involved with their infant, despite being unable to feed (i.e. by providing the milk and/or by assisting with the care.) • This is a simple and inexpensive method of oral care, which will potentially promote decreased VAP rates in the NICU. • Further assessment of VAP rates will be followed quarterly.

16. References • American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005; 115,496-506. • Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding andMaternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153, AHRQ Publication No. 07-E007, Rockville, Md: Agency for Healthcare Research and Quality. Retrieved September 4, 2009 from www.ahrq.gov/downloads/pub/pdf/brfout/brfout.pdf • Marchbank T, Weaver G, Nilsen-Hamilton M, Playford RJ. Pancreatic secretory trypsin inhibitor is a major motogenic and protective factor in human breastmilk. American Journal ofPhysiology—Gastrointestinal and Liver Physiology. 2009; 296, G697-703. • Rodriguez N.A., Meier P.P., Groer MW, Zeller JM. Oropharyngeal administration of colostrum to extremely low birth weight infants: Theoretical Perspectives, Journal of Perinatology, Jan, 2009,29, 1-7. • Rodriguez, N.A., Meier, P.P., et al. A pilot study to determine the safety and feasibility of oropharyngeal administration of own mother’s colostrum to extremely low-birth-weight infants. Advances in Neonatal Care. 2010, 10 (4), 206–212. • Spatz DL. Ten steps for protecting and promoting the use of human milk and breastfeeding in vulnerable infants. Journal of Perinatal and Neonatal Nursing. 2004; 18,385-396.