1. EPIQ Newsletter February 2016
EPIQ
Evidence Based Practices for Improving Quality
“What’s with all the abdominal girths”
Page 5
Inside this issue
Page 1 Our Babies
Page 2 Brought to You by
EPIQ
Page 4 Handling Audits
Page 6 EPIQ Conference
Drive to Zero…
Since the implementation of the new UVC/UAC insertion practice
guidelines, there have been ZERO incidences of skin breakdown on
the abdomen of infants born at less than 29 weeks gestation.
Our Babies…
The EPIQ steering committee is committed to focusing on the
outcomes of infants born at less than 29 weeks gestation.
Between January and December 2015 there have been 29 infants
born at less than 29 weeks gestation. The following table illustrates
a breakdown of their gestational ages.
Gestational Age Number of Infants Born
23+0-6 Weeks 1
24+0-6 Weeks 4
25+0-6 Weeks 2
26+0-6 Weeks 5
27+0-6 Weeks 7
28+0-6 Weeks 10
Total 29
Exclusions:
Case Room deaths/Palliative Care
Transfers from St. Boniface General Hospital (4)
Out-born infants who died
There were no NICU deaths in this group between January and
September 2015!

2. 2
EPIQ Newsletter February 2016
Brought to You By EPIQ
1
Indomethacin Prophylaxis
Patent ductus arteriosus is a very significant risk
factor for intraventricular hemorrhage and
severe intraventricular hemorrhage. The use of
prophylactic indomethacin decreases the
hemodynamic instability of the infant, thereby
decreasing IVH incidence and severity. The new
HSC guideline for administering prophylactic
indomethacin is as follows:
• For infants less than 27 weeks, administer
indomethacin within 12 hours of life
• For infants between 27+0 and 27+6 weeks
consider indomethacin on an individual
basis. For example: infants who did not
receive antenatal steroids are at a higher
risk of developing IVH, and thus may
benefit from receiving indomethacin
prophylaxis
• 28 weeks – generally not recommended
Platelet counts and electrolytes need to be
monitored, as well as fluid balance. If a cardiac
anomaly is suspected, an echocardiogram must
be performed prior to indomethacin usage.
Indomethacin Prophylaxis &
PDA Rates
2
Outcomes
The graphs below show that with the use of
indomethacin in our patients fewer babies have
PDAs; therefore, fewer ligations are required.
The second graph depicts how infants receiving
indomethacin prophylaxis are not necessarily
less likely to develop IVH, but the severity of the
hemorrhage is less, reducing their risk for
negative long-term developmental outcomes.
0
5
10
15
20
25
30
35
40
45
IVH
Severe
IVH
Percent
Prophylaxis
No Prophylaxis
Indomethacin Prophylaxis
& IVH Rates
0
10
20
30
40
50
60
PDA
PDA
Liga3on
Percent
Prophylaxis
No Prophylaxis

3. 3
EPIQ Newsletter February 2016
1
Antenatal Steroids
Over the last year neonatology has been
working closely with obstetrics, emphasizing the
benefits of ANS, particularly receipt of a
complete course. As a team, neonatology and
obstetrics are recommending administration of
ANS to mothers at < 24 weeks gestation when
there is a risk of imminent delivery and active
care for the neonate is planned. In addition, a
second course of ANS is recommended to
mothers at <34 weeks gestation if delivery
imminent and two or more weeks has elapsed
since the first course. The graph below shows
changes in ANS receipt since 2014.
Antenatal Steroid Receipt
2
The graph shows how immediately after the
practice change was implemented, the number
of patients who did not receive ANS when they
met eligibility criteria was lower compared to
before the practice change was implemented.
As expected, the number of eligible patients
who received complete courses of ANS was
increased. This positive change is to be expected
immediately following any practice change roll-
out. Great job! The next six months following the
practice change, the number of patients
0
10
20
30
40
50
60
July-­‐Dec
2014
Jan-­‐
June
2015
July-­‐Dec
2015
Percent
Complete Partial None
3
receiving ANS continued to increase, albeit
with somewhat decreased acceleration. The
number of patients who did not receive ANS
when they were otherwise eligible, seems to be
on the rise. What is yet to be determined are
the reasons for this change. There may be
clinician, patient, and system factors all
contributing to this trend. Or perhaps the trend
can be attributed to natural fluctuations in
statistics.
The next table shows the effect administration
of ANS has had on our infants born at <29
weeks.
Composite Outcome is defined as death or any
of BPD, NEC, severe IVH or ROP needing
treatment
The graph illustrates how almost 90% of infants
whose mothers were eligible to receive ANS
were subjected to a composite outcome. In
contrast only 50% – 55% of infants whose
mothers actually receive a partial or complete
course of ANS suffered from composite
outcomes.
0
10
20
30
40
50
60
70
80
90
Percent
Complete Partial None
Composite Outcomes vs. Antenatal Steroid Receipt

4. 4
EPIQ Newsletter February 2016
1
Nine of 14 consecutive infants less than 29
weeks born between March 30th, 2015 and
July 11th, 2015 were audited. The average
gestational age was 25.3 weeks (±1.5 weeks).
The average birth weight was 798 grams
(±239 grams). These 9 infants had 2641
“discrete interventions” during the first 7 days
of life. This resulted in an average of 293 (±43)
interventions per child (the median was 298).
Implications
“Minimal handling and gentle care” is part of
the EPIQ Intraventricular Hemorrhage
Intervention Bundle; with emphasis being
placed on the first few days of life where the
risk of IVH is highest and the events causing
PVL occurs. The evidence grade applied to
this intervention is “1C” indicating that the
benefits appear to outweigh the risks and
burdens of the implementing the intervention,
despite the supporting evidence being of low
quality.
NEC Assessment
Abdominal girths - once per shift is sufficient. The inter-rater reliability
of girth measurement is poor. The character of the abdomen (i.e.:
soft, distended, taut, loopy, or discolored) is more important than the
measurement from shift to shift.
Aspirates - a large volume of the gastric aspirate 2-3 hours post feed in the absence
of other clinical signs of gastrointestinal pathology is not as clinically significant as
the presence of blood or bile in the aspirate.
The most clinically significant indicator of suspect NEC is an increase in frequency
and severity of apnea & bradycardia of prematurity.
2
Discrete Interventions:
Medical staff, nurses, respiratory therapists,
and family caregivers performed the
bedside interventions. The bedside nurse
was responsible for recording whenever
the patient was subjected to a form of
handling. The handling events that were
monitored were as follows:
• Vital signs
• Diaper changes
• Position changes
• Repositioning of electrode leads
• Abdominal girth measurement
• nCPAP adjustments
• Oral or nasal suctioning
• ETT suctioning
• Skin care
• Heel pokes
• Weighing attempts
• X-rays or ultrasounds
• IV attempts and venipuncture
• Kangaroo care
• Bed linen changes
• Line insertion or repositioning
• NG tube insertion
• ETT re-taping/repositioning
• Extubation or surfactant
• Dressing changes
• Wound care
Handling Audit

5. 5
EPIQ Newsletter February 2016
1
Results
What we did well
Painful procedures such as IV/heel pokes,
NG tube insertions, and ETT manipulations
were well minimized.
Areas of Improvement
Abdominal Girths. “What’s with all the
abdominal girths!?” was a comment made
during the review of the audit results.
Abdominal girth measurement accounted
for 9.4% of the handling these infants
received in the first 7 days of life. Between
days 2 and 7, each infant was subjected to
4-5 girth measurements each day.
Abdominal girth measurement as an
assessment for necrotizing enterocolitis is not
an evidence-based practice. Placing the
measuring tape underneath the patient by
lifting their legs increases intracranial pressure
and thus increases the risk of IVH. Also, the
measuring tape itself poses a paper-cut risk
to the infant, increasing the risk of infection.
As a result of this audit, it was proposed at
the Fall Education Days to only measure
abdominal girths once per shift or if there is a
perceived problem.
Kangaroo Care. The handling audit revealed
an average of less than 1 kangaroo care
event performed per baby per day in the first
7 days of life. The benefits of kangaroo care
have been well documented. Kangaroo
care promotes milk production in the
mother. Human milk (especially mother’s
own milk) reduces the risks of necrotizing
enterocolitis, protects against nosocomial
2
infection and late-onset sepsis through
passive immunity, and promotes brain
development in the premature infant.
While minimal handling is important,
kangaroo care is an extremely
therapeutic intervention and should be
promoted and encouraged daily.
Position changes and diaper changes: The
handling audit revealed that our patients
undergo an average of 5 to 6 position
changes and up to 7 diaper changes per
day. The “micro-preemie” diapers used at
HSC’s NICU are specially designed for
infants with immature skin. Because of this,
routine position changes and diaper
changes only need to be done every six
hours, rather than every three. While
bedside nurses currently do well “blocking
care”, a developmentally appropriate
patient-driven rather than nurse-driven
approach can be used. For example, if
the patient is awake outside of their
“scheduled touch-time”, the nurse can
use the patient’s awake-time to perform
assessments, diaper changes, and position
changes, rather than adhering to strict
nurse-driven touch-times.

6. ↓ EPIQ Newsletter February 2016
EPIQ Conference
Each year, MiCare funds two delegates
from each EPIQ site to attend the
conference. This year’s delegates from HSC
are Catherine Lesawich RN NNP and
Kathryn Walker.
At the conference, each NICU will present
a summary of their last year’s changes and
outcomes. There will also be presentations
titled “Breast Milk & Stem Cells; Fresh Milk”,
“Demystifying Eating on CPAP”, and
“Photoprotection of TPN”.
Doris Sawatzky-Dickson & Renee Freisen
have been chosen as delegates to attend
the FiCare Workshop where they will learn
about Family Integrated Care in the NICU.
The Banff Centre, Banff, AB
FiCare Workshop
February 5th – 7th 2016
EPIQ Conference
February 7th – 9th 2016
EPIQ Training Workshop & CNN Annual Meeting
February 9th & 10th 2016
EPIQ Steering Committee Members
Dr. Molly Seshia MD (Chair)
Dr. John Baier MD
Nicole Sneath RN NNP
Deb MacDonald CRN
Barb Swaine CRN
Karen Bodnaryk RN
Tanya Tichon RN
Sue Roberts RN
Jennifer McCoy RN BN
Sharla Fast RD
Jeremy Amman RD
Kelli Greeley
John Minski RRT