Development of an Alarm Algorithm, With Nanotechnology Multimodal Sensor, to Predict Impending Infusion Failure and Improve Safety of Peripheral Intravenous Catheters in Neonates Background: Peripheral intravenous catheters connected to an infusion pump are necessary for the delivery of fluids, nutrition, and medications to hospitalized neonates but are not without complications. These adverse events contribute to hospital-acquired patient harm. An artificial intelligence theory called fuzzy logic may allow the use of appropriate variables to predict infusion failure. Purpose: This innovative study aimed to develop an intravenous infusion nanotechnology monitoring system that would alert the nurse to impending peripheral intravenous infusion failure. Methods: An intravenous infusion nanotechnology monitoring system, using predictor variables of pressure, pH, and oxygen saturation used in a fuzzy logic alarm algorithm was developed to alert the nurse to impending peripheral intravenous infusion failure. Findings: The developed intravenous infusion nanotechnology monitoring system is composed of a peripheral intravenous catheter with nanotechnology multimodal sensor, an intravenous pump, a fuzzy logic algorithm, and alarm. For example, using this system, an elevated in-line pressure, a low pH, and a low venous oxygen level would generate an alarm for possible impending infusion failure. Implications for Practice: With further development, this technology may help nurses predict and prevent adverse outcomes from intravenous infusions. This work shows how nurses can be content experts and innovators of technology that they use to make clinical decisions. Implications for Research: After regulatory approval, a randomized controlled trial may be performed to investigate whether interventions at the time of an alarm would result in fewer adverse outcomes and improve safety. Correspondence: Elena M. Bosque, PhD, ARNP, NNP-BC, Department of Neonatology, Seattle Children's Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105 (elena.bosque@seattlechildrens.org). The author thanks Owen Gatenby for his assistance with the technical drawings and preliminary 3-dimensional model design of the catheter with multimodal sensor. The author acknowledges all exceptional NICU nurses who have supported the preliminary studies to support this area of work. This work is owned by the inventor and the University of Washington CoMotion Innovation Department Hub. The author received partial funding for some of the preliminary work from (1) American Heart Association California Affiliate Pre-Doctoral Fellow grant from 1992 to 1993 for the study of fuzzy logic oxygen saturation prototype alarm system, and (2) Masimo Corp Sponsored study grant from 2015 to 2016 for the study of neonatal in-line pressure. The author has a patent for related work and patents, in process, for the invention described in this article. Bosque EM, Siler W, Goldman SL, inventors; Fuzzy Logic Alarm System for Pulse Oximeters. US patent 5,830,135. November 3, 1998; Bosque E, inventor. Prototype Alarm System for Intravenous Pump or Catheter Based Upon Fuzzy Logic. US patent application No. 16/609152 62/491,865. October 28, 2019; Bosque E, inventor. Alarm System for Intravenous Pump or Catheter Based Upon Fuzzy Logic. International Patent Application under Patent Cooperative Treaty (PCT) PCT/US2018/029901. April 27, 2018. The author declares no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

A Quality Improvement Project to Improve the Use of Mother's Own Milk (MOM) With Precision Oropharyngeal Therapy Background: Bioprotective properties of mother's own milk (MOM) support the use of targeted MOM administration methods, including oropharyngeal therapy (OPT) with MOM, which may mimic the protective effects of swallowed amniotic fluid, thereby improving infant health outcomes. Purpose: To increase the use of MOM-OPT in premature infants in the first week of life. Methods: Quality improvement methods were used to implement precision dosing of OPT. Results: After changing processes and replacing the colostrum immune therapy practice with longer-term precision OPT, the percentage of ordered doses administered to infants in the first week of life increased from 24% to 64%. There was also a 15% increase in very low birth-weight infants who received MOM (from 50% to 65%) at discharge. There were no reported adverse events related to OPT administration. Implications for Practice: Replacing the unit's short-term colostrum immune therapy protocol with the longer-term precision OPT increased the number of doses given in the first week of life and increased the number of very low birth-weight infants discharged receiving MOM. Implications for Research: Researchers should consider studying the reported positive effects of OPT related to infant response (positive oral stimulation, reduction in oral aversion, and improved oral feeding skills), parent participation in care, and maternal milk expression behaviors (longer milk expression duration). Correspondence: Christine M. Wetzel, DNP, RNC-NIC, IBCLC, Carle Hospital, 611 West Park, Urbana, IL 61821 (chris.wetzel@carle.com). The Carle Hospital supported this quality project. The Carle Women's Legacy Circle provided a grant to purchase 10 hospital-grade breast pumps to utilize for bedside milk expression. The team acknowledges support and encouragement from Lori Fossier, RN, William Stratton, MD, Chris Dippel, RN, Hannah Simpson, RN, Jessica Halpin, RN, the NICU leadership and VON team, the entire NICU staff, and the Vermont Oxford Network Micro-Premature Infant 2 Homeroom faculty. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Weight-Based Estimation of Insertion Length of the Nasogastric Tube in Extremely Low Birth-Weight Infants Background: Nasogastric (NG) tubes are used in the neonatal intensive care unit (NICU) for various indications. However, evidence of the best practice for estimating the NG tube insertion length in extremely low birth-weight (ELBW) infants is limited. Purpose: To determine a weight-based estimation formula of NG tube length in ELBW infants. Methods: This prospective study was performed at a single-center level III neonatal intensive care unit. Low birth-weight infants admitted between May 2009 and May 2010 who required radiography for clinical reasons were included. Radiographs of participants whose current body weights (BWs) were less than 2500 g were reviewed, and the appropriate ideal insertion length of the NG tube adjusted based on radiographs and the infant's current BW was assessed. A regression model was used to determine the ideal insertion length of the NG tube with respect to the current BW. Results: Overall, 533 radiographs (152 patients weighing 422-2486 g) were analyzed. Among the patients, 246 had BWs less than 1000 g and 287 had BWs more than 1000 g. Formulas that predicted NG tube length (centimeters) were derived as follows: (5 × weight [kg] + 10 [BW < 1.0 kg]) or (3 × weight [kg] + 12.5 [1.0 < BW <2.5 kg]). Implications for Practice: The application of the weight-based formula for estimating the NG tube length derived from the present study together with commonly used morphological methods may improve the accuracy of the NG tube insertion procedure in ELBW infants. Implications for Research: Further studies in other cohorts are needed. Correspondence: Katsuya Hirata, MD, Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan (khirata0513@gmail.com). The authors thank Nami Kakuno, Machiko Yoshida, Hisae Taniguchi, Junko Nishino, Hiroko Moriyama, Yuko Ozoe, and the medical staff of the NICU at OWCH for their support during this study. Y.K. conceptualized and designed the study. K.H. contributed to the data analysis and drafted the manuscript. Y.O. and K.W. reviewed the results and provided conceptual suggestions. All the authors reviewed the draft manuscript and approved the final manuscript. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother–Infant Interaction Background: Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers. Purpose: The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose–response effect between time in SSC and quality of interaction. Methods: Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose–response correlations were calculated between mean time spent in SSC and each of the interaction scales. Results: There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction. Implications for Practice: Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother–infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group. Implications for Research: Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC. Correspondence: Charlotte Sahlén Helmer, RN, Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, 601 74 Norrköping, Sweden (charlotte.sahlen.helmer@liu.se). This work was supported by the County Council of Östergötland (LiO-12134, LiO-17711, LiO-278801), South Sweden Nursing Society (SSSH-2008), Hälsofonden (LiU 2009), and Linköping University. The authors gratefully acknowledge participating families, Lisbet de Jounge, Birgitta Lundin, and staff members at the neonatal intensive care units at Linköping University Hospital and at Sachs' Children's Hospital in Stockholm. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

A Kangaroo Care Pathway for NICU Staff and Families: The Proof Is in the Pouch Background: Kangaroo care (KC) improves bonding and neonatal health outcomes worldwide. However, concerns for patient safety, interrupted workflow, and parent readiness continued to impede KC in a level IV neonatal intensive care unit (NICU). Its current policy did not recommend using more than 1 staff member during patient transfer. In addition, NICU staff and parents lacked skills training and education regarding the feasibility of routine KC. Purpose: A KC pathway was developed and integrated within a multifaceted, champion-based, simulated educational training program for NICU staff and families to promote earlier and more frequent KC by increasing their knowledge and comfort with this practice. Methods: Patient data collected before and after the study determined the frequency, timing, and mode of respiratory support during KC. Pre- and posttest surveys evaluated nurses' knowledge and comfort level with KC. Results: The frequency of KC occurred 2.4 times more after the intervention. The percentage of KC episodes for intubated patients nearly doubled. The posttest survey scores for nursing knowledge and comfort level also markedly improved. Implications for Practice: The KC pathway ameliorated feelings of discomfort by depicting criteria and instructions for safe practice. Multidisciplinary champions were invaluable in assisting the nursing staff with patient transfer during KC. Implications for Research: More dose–response studies are needed to maximize the clinical benefits of KC in developed countries. Correspondence: Karen Stadd, DNP, CRNP-BC, MSN, Johns Hopkins Hospital, 4404 Prancing Deer Dr, Ellicott City, MD 21043 (kstadd@yahoo.com). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi Background: Mother–infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother–infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother–infant relationship in Malawi are limited and studies that observed mother–infant interactions could not be located. Purpose: This study explored mother–infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants. Methods: This observational study explored maternal and infant interactive behaviors. We recruited 83 mother–infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads). Findings: Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births. Implications for Practice: Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants. Implications for Research: Future studies of factors that contribute to positive interactions in Malawi are needed. Correspondence: Kaboni Whitney Gondwe, PhD, GH, UCM, RN, MRM, College of Nursing, University of Wisconsin-Milwaukee, 1921 E Hartford Ave, Milwaukee, WI 53211 (kabonigondwe@gmail.com; gondwe@uwm.edu). Research funded by Duke University Graduate School, Duke Global Health Institute, and Duke University School of Nursing PhD Fellowship for the first author. The authors acknowledge out study participants; Professor Ellen Chirwa, PhD, RN, MRM; Matron Phoebe Jamieson, BSN, RN, RM; and nurses, nurse in-charge, other matrons, and doctors at Queen Elizabeth Central Hospital. Dr Brandon, who is a Co-Editor for Advances in Neonatal Care and the coauthor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. The other authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Development of an Innovative Nonanimal Training Model for Infant Pleural Effusion Drainage via Pigtail Catheter Placement Background: Chest tube placement is an important skill for providers and bedside nurses caring for critically ill infants, allowing for the evacuation of pleural fluid and pneumothoraces. No realistic simulation models are commercially available for trainees to practice and learn this skill on infants. Purpose: Our objective was to develop an inexpensive and reproducible model for percutaneous pleural pigtail placement for pleural fluid removal via the Seldinger technique. Methods: The model was developed using hardware material and a discarded infant resuscitation manikin. The rib cage was constructed using electrical cable wires. Discarded and expired 250-mL bags of intravenous fluids were placed inside the chest cavity to simulate pleural fluid. Shelf liner was wrapped around the chest and abdomen of the infant model to simulate the skin layer. Pediatric critical care faculty performed the procedure on the final model and scored it for realism and utility for teaching. Without including the discarded manikin and fluid bags, the cost of the materials for the model was less than $20. Results: Eight pediatric critical care faculty tested the pleural pigtail placement model. All faculty agreed the model provides a realistic simulated reproduction of placing a pleural pigtail, felt the model was simple to use, and indicated they would use it as a teaching tool in the future. Implications for Practice: An effective model for pleural pigtail placement can be inexpensively constructed using discarded bags of intravenous fluid and easy-to-find hardware materials. Implications for Research: Future studies are needed to assess whether this model helps providers and nurses develop and maintain the clinical skills for successful percutaneous pleural pigtail catheter placement. Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=35&autoPlay=true Correspondence: Adrian D. Zurca, MD, Penn State Hershey Children's Hospital, 500 University Dr, Mail Code H085, PO Box 850, Hershey, PA 17033 (azurca@pennstatehealth.psu.edu). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Healthcare Satisfaction and Unmet Needs Among Bereaved Parents in the NICU Background: Learning directly from bereaved parents about their experiences in the neonatal intensive care unit (NICU) can improve services at end-of-life (EOL) care. Parents who perceive that their infant suffered may report less satisfaction with care and may be at greater risk for distress after the death. Despite calls to improve EOL care for children, limited research has examined the EOL experiences of families in the NICU. Purpose: We examined parent perceptions of their infant's EOL experience (eg, symptom burden and suffering) and satisfaction with care in the NICU. Methods/Search Strategy: Forty-two mothers and 27 fathers (representing 42 infants) participated in a mixed-methods study between 3 months and 5 years after their infant's death (mean = 39.45 months, SD = 17.19). Parents reported on healthcare satisfaction, unmet needs, and infant symptoms and suffering in the final week of life. Findings/Results: Parents reported high levels of healthcare satisfaction, with relative strengths in providers' technical skills and inclusion of the family. Greater perceived infant suffering was associated with lower healthcare satisfaction and fewer well-met needs at EOL. Parents' understanding of their infant's condition, emotional support, communication, symptom management, and bereavement care were identified as areas for improvement. Implications for Practice: Parents value comprehensive, family-centered care in the NICU. Additionally, monitoring and alleviating infant symptoms contribute to greater parental satisfaction with care. Improving staff knowledge about EOL care and developing structured bereavement follow-up programs may enhance healthcare satisfaction and family outcomes. Implications for Research: Prospective studies are needed to better understand parental perceptions of EOL care and the influence on later parental adjustment. Correspondence: Amy E. Baughcum, PhD, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (Amy.Baughcum@nationwidechildrens.org). This research was supported by a grant from the Research Institute at Nationwide Children's Hospital (grant number 20051014). The study was conducted through Nationwide Children's Hospital in Columbus, Ohio. A portion of this work was presented at the Society of Pediatric Psychology Annual Meeting, Portland, Oregon, March 2017. The authors would like to thank the families who generously participated in this work. Dr. Fortney, who is a Guest Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Implementation of the Neonatal Sepsis Calculator in Early-Onset Sepsis and Maternal Chorioamnionitis Background: Utilization of the neonatal sepsis calculator published by Kaiser Permanente is rapidly increasing. This freely available online tool can be used in assessment of early-onset sepsis (EOS) in newborns 34 weeks' gestation or more based on maternal risk factors and neonatal examination. However, many hospitals lack standard guidelines for its use, leading to provider discomfort with practice change. Purpose: The goal of this project was to study the antibiotic use rate for EOS at a level III neonatal intensive care unit and create standardized guidelines and staff education for using the sepsis calculator. Our ultimate goal was to decrease antibiotic use for EOS in newborns 34 weeks' gestation or more. Methods: A standard quality improvement Plan-Do-Study-Act (PDSA) model was utilized with a plan to study the problem, implement the intervention, and test again for improvement. The primary outcome of interest was a decrease in the use of antibiotics for EOS in neonates 34 weeks' gestation or more. Results: Over a 4-month period, prior to sepsis calculator implementation, antibiotic use for suspected EOS was 11% and blood culture was done on 14.8% of live births. After implementation of the sepsis calculator and completion of the PDSA cycle, sepsis calculator use was greater than 95%, antibiotic use dropped significantly to 5% (P = .00069), and blood culture use dropped to 7.6% (P = .00046). Implications for Practice: Staff education and systematic intervention using a PDSA model can significantly impact patient care, decreasing the administration of antibiotics to infants at risk for sepsis. Implications for Research: Future research is needed to decrease antibiotic use in premature infants less than 34 weeks' gestation with similar risk factors and clinical features. Video Abstract available athttps://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=34&autoPlay=true Correspondence: Gangaram Akangire, MD, MS, FAAP, Section of Neonatology, Children's Mercy Kansas City, University of Missouri–Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 (gakangire@cmh.edu). The authors thank pediatric nurse practitioners Kristie Hobbs, APRN, and Heather Williams, APRN, and neonatal nurse practitioners Jean Bohning, APRN, and Pamala Moor, APRN, for their help with data abstraction. The authors also thank Medical Writing Center at Children's Mercy for their help in editing and proof reading the manuscript. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care Background: Family-centered care (FCC) in neonatal intensive care units (NICUs) was initiated in 1992 to promote a respectful response to individual family needs and support parental participation in care and decision-making for their infants. Although benefits of FCC have been reported, changes in the maternal experience in the NICU are unknown. Purpose: The purpose of this study was to compare mothers' experiences in NICUs where FCC is the standard of care and to compare these with the experiences of mothers 2 decades ago. Methods: In this qualitative descriptive design, mothers of infants born under 32 weeks postconceptional age were asked to describe their experiences with their infant's birth and hospitalization. Open-ended probing questions clarified maternal responses. Saturation was reached after 14 interviews. Iterative coding and thematic grouping was used for analysis. Results: Common themes that emerged were: (1) visiting; (2) general caregiving; (3) holding; (4) feeding; and (5) maternal ideas for improvement. Findings indicated important improvements in privacy, mother–nurse relationship, ease of visiting, and maternal knowledge and participation in infant caregiving. Implications for Practice: Mothers suggested improvements such as additional comforts in private rooms, areas in the NICU where they can meet other mothers, and early information on back-transport. Better recognition and response for mothers without adequate social support would provide much needed emotional assistance. Implications for Research: Future research addressing benefits of webcams, wireless monitors, back-transport, maternity leave, and accommodations for extended visiting for siblings would address other needs mentioned by mothers. Correspondence: Madalynn Neu, PhD, RN, FAAN, College of Nursing, University of Colorado, 13120 E. 19th Ave, Aurora, CO 80045 (madalynn.neu@ucdenver.edu). This work was supported in part by grants from the University of Denver Center for Community Engagement to Advance Scholarship and Learning, the PROF Fund at the University of Denver, and Sigma Theta Tau, Alpha Kappa Chapter-at-Large. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses