Prioritizing Family-Centered Care in a Level IV NICU:Development and Implementation of a Skin to Skin Care Bundle

Background: Skin to skin care (SSC), also known as kangaroo care, is the practice of placing a mostly undressed infant onto the bare chest of a parent, where they can be held for an extended period. Evidence shows that SSC provides many benefits to infants and their parents, particularly for the high-risk population of premature or acutely ill infants. Despite the known benefits, SSC is underutilized in the neonatal intensive care unit (NICU); national surveys find that SSC is only routinely used in the NICU 8% of the time. Detailed policy regarding SSC practice and extensive education for NICU staff and parents have proven effective at increasing the incidence of SSC in the NICU. Methods: A quality improvement project was conducted in an urban Level IV NICU with the goal of improving the time to first SSC interaction following admission and following surgical procedures. Pre- intervention surveys were distributed to staff to identify attitudes and perceived barriers towards the practice of SSC in this NICU. From current evidence-based recommendations and staff feedback from the surveys, a skin to skin intervention bundle was developed and implemented. Retrospective chart reviews were conducted for 3 months pre-intervention and 6 weeks post-intervention to determine the time to first SSC interaction following admission and following surgical procedures. This data was analyzed to assess the impact of implementation of the SSC bundle. Results: Eighty-eight NICU staff members completed the pre-intervention survey. Most caregivers' responses indicated that they recognize the benefits of SSC, with the most identified barrier to offering SSC being concern for adverse events. The percentage of patients that received SSC during hospitalization, and the percentage of patients that received SSC post-operatively did not significantly change from pre-to post-intervention (p=0.22, p=0.054). Of the admitted patients who received SSC during hospitalization, the median time to first SSC interaction decreased from 9 days to 6 days. This did not indicate significant change following intervention (p=0.09). Of the surgical patients who received post-operative SSC, the median time to first SSC interaction decreased from 10 days to 3 days. This did show a significant decrease following intervention (p=0.025). Conclusions: The benefits of SSC are well-studied, but further emphasis on its importance is needed to induce culture change and encourage SSC to become standard of practice on this unit. While most outcome measures were not statistically significant, the decreased median times to first SSC interaction following admission and surgical procedures posed clinical significance. More follow-up time is needed to assess the overall impact of this practice change. As the SSC bundle is now established, continuation of the practice change should be easily feasible. A multidisciplinary group of champions would be beneficial to continue to promote the continued use of SSC on this unit.