NRS-490: Neonatal Respiratory Disease Change Project Report

This report presents a change project proposal aimed at reducing the incidence of neonatal respiratory disease (NRD) and readmission rates in the Neonatal Intensive Care Unit (NICU). The project investigates the combined impact of medication, education, and enhanced infection control measures. T...Read More

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Background:
Neonatal respiratory disease (NRD) is a syndrome that affects about 10% of new born
infants. Some examples of neonatal respiratory disease in infant include respiratory distress
syndrome (RDS) and pneumonia. This disease is an important cause of mortality and morbidity
in infants. It is the leading cause of death particularly in premature babies. In US, about 10% of
babies are born premature. In neonatal intensive care units (NICU), 15% of term infants and 29%
late preterm infants admitted to the NICU develop adverse respiratory morbidity. These
conditions occur because of delayed adaptation to the extra-uterine life and increased rate of
caesarean section delivery. New born infants are vulnerable to respiratory disease as their fluid
filled foetal lungs adapt to the extra-uterine environment (Gallacher, Hart & Kotecha, 2016). As
it is a major cause of death, considering ways to reduce occurrence of NRD is critical to reduce
death rates.
Problem statement:
The main problem that increased the need for developing a change project was the high
burden of infant mortality rate and hospital readmission due to NRD in the NICU. Mourani et al.
(2014) report about the issue of intensive care readmissions after preterm births of infants with
respiratory failure. The study revealed that 50% of the readmission occurs in preterm infants in
the first or second year of life. Rehospitalization is a negative outcome as it not influence
physical health outcome of infants but also contributes to large financial burden and stress for
families. Hence, this research proposal aims to find out if medication, education and symptom
control could improve symptoms and reduce occurrence of NRD in the NICU. This has been
planned as recent research by Var et al. (2015) showed the scope of newborn infection control in
acceleration reduction of newborn mortality rate. The change project is likely to give valid

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information on how combined intervention of education, infection control and medications
together can prevent NRD in NICU.
Purpose of the change proposal: The main purpose of the change proposal is to assess whether
use of medication, education and increase in infection control reduce the risk of neonatal
respiratory disease in children in ICU and lead to better outcome and prevention of readmission
in the future or not.
PICOT:
The PICOT question for the change project is as follows:
For infant admitted to the NICU (P), does use of medication, education and increase in
infection control (I) compared to standard treatment (C) prevent neonatal respiratory diseases in
children and reduce readmission rates (O) over a period of six months (T)?
The PICO elements in the question are as follows:
Population (P): Neonates
Intervention (I): use of medication, education and increase in infection control
Comparator (C): Standard treatment
Outcome (O): prevent neonatal respiratory diseases and readmission rates
Literature search strategy employed:
To find articles that helped to give answer to the research question, the search for
literature was done in CINAHL and PubMed. The key terms used for the search process were

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‘pneumonia’, ‘neonatal respiratory disease’, ‘preterm babies’, ‘newborn infants’, ‘intensive care
unit’, ‘medicine’, ‘education’ ‘infection control’ and ‘readmission’. Other search terms were
developed by using synonyms in place of the above keywords. To ensure getting the most
accurate papers, the search terms were combined with the Boolean operator ‘AND’. The
significance of including ‘AND’ is that it can narrow down the search process and help in
retrieving only those papers which had the key terms. Only articles published between 2010 to
2020 was included in the literature review. Other inclusion criteria were that studies must be
published in English language, they must report about any NRD and they must have
interventions like medicine, infection control and education. The final selection of the articles
was done based on the inclusion criteria.
Evaluation of the literature:
Total four articles were found to give answer to the PICOT question. The cohort study by
Azab et al. (2015) revealed the clinical effectiveness of a VAP prevention bundle in reducing
ventilator associated pneumonia in neonates. The VAP prevention bundle had several
components such as head of bed elevation, hand hygiene practices, handling of respiratory
equipment, nasal continuous airway pressure and re-intubation. The significance of the study is
that it revealed that infection prevention bundles like the above can reduce length of stay and
VAP in neonates. However, it does not give any idea about the effect of education and
medicines on rate of NRD. This study also had a low sample size. In contrast, Che et al. (2016)
revealed the efficacy of fluconazole for prophylaxis in preterm infants. By conducting five
independent RCTs, the study was successful in preventing invasive fungal infections. The
limitation in the study was that it did not considered education and infection control measures.

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Another study by Li et al. (2017) evaluated the effectiveness of budesonide nebulisation
on the treatment of VAP of newborns. The analysis of the therapeutic effect in neonates revealed
that budesonide nebulisation decreased mechanical ventilation time and reduced the death rate.
However, the study did not consider additional infection control measures. Small sample size
was also a limitation of the study which suggested need for multi-centre RCT in the future. The
significance of the study by Zhou et al. (2013) was that it explored about the efficacy of an
infection control program in reducing VAP in Chinese NICU. The study was done with all
neonates who received mechanical ventilation within 48 hours and bundle of preventive
measures were implemented. The significance of this study was that this multi-component
infection control measure resulted in decrease in VAP and long term benefits were found too.
However, lack of combination of drug and infection control is a gap that needs to be considered
in future research.
Applicable nursing theory utilized:
The nursing theory that will be utilized in the change process includes the theory of
planned behaviour. This theory has been chosen it explains and predicts various social
behaviours. Hence, by giving training to staffs regarding incorporating education and infection
control measures while administering medications to neonate, the relation between attitudes and
and outcome could be explored. As the incidence of NRDs was rising, lack of implementation of
evidenced based practice in medication prescribing was a major practice gap. Using the above
theory as a conceptual framework can help to evaluate the effect of the change project on health
professional’s competence in reducing rate of NRDs (Moon & Jang, 2018).
Proposed implementation plan:

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Based on the review of literature, it was found that no single paper together explored the
effect of medicine, education and infection control on reducing NRDs in NICU. Although one
study used VAP bundle, but it did not included the above desired interventions. Hence, the
change projects proposed to conduct a randomized controlled trial (RCT) that will have two
groups. The first group will have neonates in the NICU who will be given prophylaxis or
medications, education and infection control and the second group will be the controlled group
who will be given only infection control. The study will be done in two paediatric hospitals and
the infants will be randomly assigned to the intervention and the control group. The key outcome
measures will be decrease in hospital rate, rate of reduction in any of the NRDs and reduction in
overall health care costs. The significance of using RCT method is that it is the most effective
method to explore the impact of a desired intervention on disease outcomes. The blinding and
randomization process is likely to give valid results (Probst et al., 2016).
Identification of potential barriers:
As the change projects will be an experimental project, taking informed consent from
parents of young neonates can be a challenge during the process. They may not accept to take
part in such studies. Another barrier is that exploration of three types of intervention will require
lot of resource, staff preparation and training. Getting the cooperation of hospitals and all the
multi-professional teams in experimental trial might be difficult. It may require lot of time and
effort too.

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References:
Azab, S. F., Sherbiny, H. S., Saleh, S. H., Elsaeed, W. F., Elshafiey, M. M., Siam, A. G., ... & Ismail, S.
M. (2015). Reducing ventilator-associated pneumonia in neonatal intensive care unit using “VAP
prevention Bundle”: a cohort study. BMC infectious diseases, 15(1), 314.
Che, D., Zhou, H., Li, T., & Wu, B. (2016). Duration and intensity of fluconazole for prophylaxis in
preterm neonates: a meta-analysis of randomized controlled trials. BMC infectious diseases, 16,
312. https://doi.org/10.1186/s12879-016-1645-5
Gallacher, D. J., Hart, K., & Kotecha, S. (2016). Common respiratory conditions of the
newborn. Breathe (Sheffield, England), 12(1), 30–42. https://doi.org/10.1183/20734735.000716
Li, B., Han, S., Liu, F., Kang, L., & Xv, C. (2017). Budesonide Nebulization in the Treatment of
Neonatal Ventilator Associated Pneumonia. Pakistan journal of medical sciences, 33(4), 997–
1001. https://doi.org/10.12669/pjms.334.12907
Moon, J. E., & Jang, K. S. (2018). The Performance of Healthcare-associated Infection Control
Guideline among Hospital Nurses: A Structural Equation Model. Iranian journal of public
health, 47(5), 648–657.
Mourani, P. M., Kinsella, J. P., Clermont, G., Kong, L., Perkins, A. M., Weissfeld, L., Cutter, G., Linde-
Zwirble, W. T., Abman, S. H., Angus, D. C., Watson, R. S., & Prolonged Outcomes after Nitric
Oxide (PrONOx) Investigators (2014). Intensive care unit readmission during childhood after
preterm birth with respiratory failure. The Journal of pediatrics, 164(4), 749–755.e3.
https://doi.org/10.1016/j.jpeds.2013.11.062

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Probst, P., Grummich, K., Heger, P., Zaschke, S., Knebel, P., Ulrich, A., Büchler, M. W., & Diener, M.
K. (2016). Blinding in randomized controlled trials in general and abdominal surgery: protocol
for a systematic review and empirical study. Systematic reviews, 5, 48.
https://doi.org/10.1186/s13643-016-0226-4
Var, C., Bazzano, A. N., Srivastav, S. K., Welty, J. C., Ek, N. I., & Oberhelman, R. A. (2015). Newborn
Infection Control and Care Initiative for health facilities to accelerate reduction of newborn
mortality (NICCI): study protocol for a randomized controlled trial. Trials, 16, 257.
https://doi.org/10.1186/s13063-015-0771-5
Zhou, Q., Lee, S. K., Jiang, S. Y., Chen, C., Kamaluddeen, M., Hu, X. J., ... & Cao, Y. (2013). Efficacy
of an infection control program in reducing ventilator-associated pneumonia in a Chinese
neonatal intensive care unit. American journal of infection control, 41(11), 1059-1064.