The delayed bathing implementation project should be easily sustainable going forward. It reinforces the need for all disciplines to collaborate in the delivery of evidence-based care. Newborn baths are necessary to prevent the spread of communicable disease through blood and body fluid, but they can promote family-centered care concepts. The resources required for the sustainability of this project have already been put into practice at the facility. The educational content has been created and is readily available to any team member. The project plan can be reproduced at other institutions providing Maternal-Child services.
During the project implementation, staff were encouraged to provide ongoing feedback and identify best practices that could continually improve the project. To that end, several key projects are currently being worked on: the ongoing revision of the electronic medical record (EMR) and the development of a competency checklist for newly hired staff. The EMR has limitations to capture adequate documentation and nursing staff identified several components they would like to see captured in the documentation. Currently, revisions to the EMR are being developed and will be built and trialed. Additionally, a competency checklist regarding the clinical concepts and skills necessary to participate in the delayed bathing initiative is being developed and will be added to the orientation packet for all new staff in the Maternal-Child Health units. This is similar to any other competency or evidence-based initiative that has been implemented.
Further next steps include exploring the concept of delayed immersion bathing vs. delayed sponge baths and implementing “swaddle” bathing in the Neonatal Intensive Care Unit, which allows preterm and high-risk infants to remain in a calm, midline, flexed position during bath time, reducing stress and caloric consumption (Finn, Meyer, Kiersten, & Wright, 2017). Another next step is to expand the data collection to include the at-risk population of infants born to diabetic mothers and infants below the 10th % or above the 90th percentile at birth.
To ensure that this initiative persists, nursing leadership continues with leader rounding, soliciting feedback, suggestions, and identifying barriers. At a minimum, an annual evaluation of patient and staff education materials will be reviewed and modified. Parent education material for placement on the Get-Well Network, an interactive patient engagement solution, is currently in development as well. Ongoing outcome performance will continually be shared with nursing and physician staff. Nursing leadership attends the OB and Pediatric Physician Business
Meetings on a monthly basis and will continue to do so to elicit any physician or patient feedback that has been communicated to them regarding the program.
Conclusion
The implementation of the delayed infant bathing program in our community hospital was received favorably by all team members, including parents and families. As an evidence- based practice initiative, delayed bathing of newborns demonstrated improved clinical outcomes, increased provider knowledge, and enhanced parent involvement in the care of their newborn.
It is aligned with our organizational strategic plan to improve overall quality and safety within the organization. Additionally, the project promoted teamwork and collaboration among team members and disciplines. It was extremely rewarding to see the project from concept to implementation. An additional goal is that it motivates health care professionals within the Maternal-Child Health service line to question the care we deliver and explore continuous best practices in the care of mothers and newborns.
References
American Academy of Pediatrics. (n.d.). Benefits of breastfeeding. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx
American Academy of Pediatrics. (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3). Retrieved from
http://pediatrics.aappublications.org/content/pediatrics/129/3/e827.full.pdf
American Nurses Credentialing Center. (n.d.). ANCC Magnet Recognition Program ®. Retrieved from https://www.nursingworld.org/organizational-programs/magnet/ Babendure, J. B., Reifsnider, E., Mendias, E., Moramarco, M. W., & Davila, Y. R. (2015).
Reduced breastfeeding rates among obese mothers: A review of contributing factors, clinical considerations and future directions. International breastfeeding journal, 10(21),
https://doi.org/10.1186/s13006-015-0046-5
Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics, 125(5), e1048-e1056.
doi:10.1542/peds.2009-1616
Baby Friendly USA. (2012). Baby Friendly USA: The gold standard of care. Retrieved from
https://www.babyfriendlyusa.org/
Brogan, J., & Rapkin, G. (2017). Implementing evidence-based neonatal skin care with parent- performed, delayed immersion baths. Nursing for Women’s Health, 21(6), 442-450. doi: 10.1016/j.nwh.2017.10.009.
Centers for Disease Control and Prevention. (2014). National Center for Health Statistics:
Trends in out-of-hospital births in the United States, 1990-2012. Retrieved from
https://www.cdc.gov/nchs/products/databriefs/db144.htm
Centers for Disease Control and Prevention. (2017, December 11). Breastfeeding: Data &
statistics. Retrieved from https://www.cdc.gov/breastfeeding/data/index.htm
Centers for Disease Control and Prevention. (2018, March 21). Breastfeeding: Guidelines &
Recommendations. Retrieved from
https://www.cdc.gov/breastfeeding/recommendations/index.htm
Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, E. A., & Nommsen-Rivers, L. A. (2014). In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. The Journal of Pediatrics, 164(6), 1339-1345. doi: 10.1016/j.jpeds.2013.12.035
De, A. K., Biswas, R., Samanta, M., & Kundu, C. K. (2011). Study of blood glucose level in normal and low birth weight newborns and impact of early breastfeeding in a tertiary care center. Annals of Nigerian Medicine, 5(2), 53-58. doi: 10.4103/0331-3131.92951 Dias, E., & Gada, S. (2014). Glucose levels in newborns with special reference to hypoglycemia:
A study from rural India. Journal of Clinical Neonatology, 3(1), 35-38. doi:10.4103/2249-4847.128729
Finn, M., Meyer, A., Kiersten, D., Wright, K. (2017). Swaddled bathing in the Neonatal Intensive Care Unit. NeoReviews, 18(8), e504-e506. doi:10.1542/neo.18-8-e504 Gross, E. (2017). Parent letter. Unpublished manuscript.
Harder, T., Bergmann, R., Kallischnigg, G., Plagemann A. (2005). Duration of breastfeeding and risk of overweight: A meta-analysis. American Journal of Epidemiology, 162(5), 397- 403. https://doi.org/10.1093/aje/kwi222
Harvey, I., & O'Brien, M. (2011). Addressing health disparities through patient education: The development of culturally-tailored health education materials at Puentes de
Salud. Journal of Community Health Nursing, 28(4), 181-189. doi: 10.1080/07370016. 2011.614827
Haydu, S., & Gamba, R.. (2016). California infant feeding guide. Retrieved from
https://www.cdph.ca.gov/Programs/CFH/DMCAH/CDPH%20Document%20Library/N
UPA/California-Infant-Feeding-Guide-2016.pdf
Horta, B., Loret de Mola, C., Victora, C. (2015). Long term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and meta-analysis. Acta Paediatrica, 104(467), 30-37. doi: 10.1111/apa.13133 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st
century. Washington, DC: National Academies Press.
Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
Institute of Medicine. (2008). Retooling for an aging America. Building the health care
workforce. Washington, DC: National Academies Press.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Kellams, A. L., Gurka, K. K., Hornsby, P. P., Drake, E., Riffon, M., Gellerson, D., ... &
Coleman, V. (2016). The impact of a prenatal education video on rates of breastfeeding initiation and exclusivity during the newborn hospital stay in a low-income population.
Lipka, D. V., & Schulz, M. K. (2012). 'Wait for eight': Improvement of newborn outcomes by the implementation of newborn bath delay. Journal of Obstetric, Gynecologic &
Neonatal Nursing, 41,S46-7. doi:10.1111/j.1552-6909.2012.01360_27.x
LiVolsi, K. (2017). Delayed bathing--knowledge pre-assessment. Unpublished manuscript. LiVolsi, K. (2017). Delayed bathing: An evidence-based initiative aimed at improving
neonatal outcomes. Unpublished manuscript.
Melnyk, B. M., Fineout-Overholt, E., Gallagher, L., & Kaplan, L. (2012). The state of evidence- based practice in US nurses. Journal of Nursing Administration, 42(9), 410-417.
doi: 10.1097/NNA.0b013e3182664e0a
Merten S., Dratva, J., Ackermann-Liebrich U. (2005). Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics, Nov; 116(5); e702-8. doi:10.1542/peds.2005-0537
Modrek, S., Basu, S., Harding, M., White, J. S., Bartick, M. C., Rodriguez, E., & Rosenberg, K. D. (2017). Does breastfeeding duration decrease child obesity? An instrumental
variables analysis. Pediatric obesity, 12(4), 304-311. doi: 10.1111/ijpo.12143 Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study.
Putnam Publishing Group.
Planetree. (2018). Patient-centered care designation. Retrieved from
https://planetree.org/designation-2/
Preer, G., Pisegna, J. M., Cook, J. T., Henri, A. M., & Philipp, B. L. (2013). Delaying the bath and in-hospital breastfeeding rates. Breastfeeding Medicine, 8(6), 485-490.
doi: 10.1089/bfm.2012.0158
Rayfield, S., Oakley, L., & Quigley, M. A. (2015). Association between breastfeeding support and breastfeeding rates in the UK: A comparison of late preterm and term infants. BMJ
Samayam, P., Ranganathan, P. K., Kotari, U. D., & Balasundaram, R. (2015). Study of
asymptomatic hypoglycemia in full-term exclusively breastfed neonates in first 48 hours of life. Journal of Clinical and Diagnostic Research, 9(9), SC07-SC10.
doi:10.7860/JCDR/2015/14971.6610
Sasidharan, C. K., Gokul, E., & Sabitha, S. (2004). Incidence and risk factors for neonatal hypoglycemia in Kerala, India. Ceylon Medical Journal. 49(4): 110-113.
Straussman, S., & Levitsky, L. L. (2010). Neonatal hypoglycemia. Current Opinion in
Endocrinology, Diabetes, and Obesity, 17(1), 20-24.
doi:10.1097/MED.0b013e328334f061
Su, J., & Wang, L. (2012). Research advances in neonatal hypoglycemic brain injury.
Translational Pediatrics, 1(2), 108-115. doi:10.3978/j.issn.2224-4336.2012.04.06
The Leapfrog Group. (n.d.). The Leapfrog Group. Retrieved from http://www.leapfroggroup.org/ The Joint Commission. (2018). About our standards. Retrieved from
https://www.jointcommission.org/standards_information/standards.aspx
U.S. Department of Health and Human Services, Office of the Surgeon General. (2011). The
Surgeon General’s call to action to support breastfeeding executive summary. Retrieved
from https://www.surgeongeneral.gov/library/calls/breastfeeding/index
Victora, C., Bahl, R., Barros, A., Franca, G., Horton, S., Krasevec, J., Murch, S., Sankar, J., Walker, N., and Rollins, N. (2016). Breastfeeding in the 21st century: Epidemiology, mechanisms and lifelong effect. Lancet, 387(10017), 475-490.
https://doi.org/10.1016/S0140-6736(15)01024-7
World Health Organization. (n.d.). Breastfeeding. Retrieved from
Appendix A
SURVEY MONKEY
Delayed Bathing—Knowledge Pre-Assessment
1. The current CMS benchmark for exclusive breastfeeding during the inpatient post-partum period is: A. 30 %
B. 40% C. 50% D. 60%
2. SH’s exclusive breastfeeding rate for 2016 was: A. 27%
B. 37% C. 47% D. 57%
3. Currently, the practice at SH is to administer the infant’s first bath at hours of life: A. Within the first hour of birth
B. 2-4 hours C. 8 hours D. 24 hours
Appendix A (continued)
4. Breastfeeding has been associated with the following health benefits: A. Reduction in otitis media
B. Reduction in respiratory illnesses for babies and children C. Reduction in hospitalization from any cause
D. All of the above
5. Effects on newborns from cold stress include which of the following: A. Decreased surfactant efficiency
B. Post-natal weight loss
C. Increased oxygen consumption leading to respiratory distress D. All of the above
6. During the discharge process from the Mother-Baby Unit, the RN is performing discharge teaching to a mother whose newborn infant is being exclusively breastfed. The most appropriate instructions for the mother to receive are:
A. Discontinue breastfeeding and offer formula feedings only going forward B. Feed the infant less frequently
C. Temporarily discontinue breast feeding and formula feed for a 2 week period D. Continue to breast feed every 2-4 hours
Appendix A (continued)
7. The most common metabolic problem in the newborn period is: A. Hypothyroidism
B. Galactosemia C. Hypoglycemia
D. PKU (Phenylketonuria)
8. List 2 evidence-based benefits of vernix: A.
B.
9. List 3 evidence-based benefits of delayed bathing: A.
B. C.
10. The World Health Organization (WHO) recommends administering the first newborn bath: A. Within the first hour after birth
B. At 2-4 hours of life C. At 8 hours of life D. At 24 hours of life
Appendix C
Parent Letter
Dear Parents,
We encourage providing your baby’s first bath at approximately 24 hours of life. There are many benefits to delaying the initial newborn bath including:
Allowing for increased bonding time with your baby Allowing for parents to be involved in your baby’s first bath Reducing the risk of infant hypoglycemia (low blood sugar) Reducing the risk that your baby will become cold
Increasing the ability for your baby to breastfeed Improving the hydration of your baby’s skin
Your baby’s nurse will talk to you about your newborn’s first bath and
invite you to participate!
We ask all visitors and anyone handling your baby to practice good
handwashing before and after their first bath!
Appendix D
DELAYED BATHING BUDGET PROPOSAL
Delayed Bathing Component Costs Associated
Salary / Benefits / Non-Productive Time of staff required to perform tasks
$0—incorporated into daily responsibilities of nursing care
Capital expenditure for initial purchase of necessary equipment to transform care at the
bedside
Neonatal / Infant Scales
Radiant Portable Heating Lights 4 @ $1200 = $4800.00 6 @ $1000 = $6000.00
Hands-on classroom education for all staff 170 staff members x $40 (average salary) x 2
hours = $13,600. This is training / non-productive time build in to the annual operational budget Marketing costs for parent education material to
be given out at MD offices prenatally and during hospital prenatal classes.
Initial template of Education Material = $495.00 Annual supply for distribution = $0 (To be printed internally after creation of
template) Cost of EMR revision to capture necessary
components of delayed bathing implementation and run quality report
$0—to be handled by internal nursing IT team
Cost of physician education during Grand Rounds Lecture Series for OB, Peds and Family Medicine
$0—education to be done by internal expert nursing staff
Necessary space modifications for project $0