Memorandum
TO:
Dennis Phillpott, Neonatal Nurse Manager
FROM:
Tracy James RNC
DATE:
October 28, 2010
RE:
Proposal for new non-sedated MR scans policy
It is the desire of the physicians to begin routinely ordering MR scan prior to discharge on many
of our infants(SP). For the safety of our infants we hope to complete the MR scans without the
use of sedation, and the staff will (would)need to be educated on how to package and transport
infants to radiology(CI) Please find the attached proposal on how to educate the staff for the
proposed non-sedated MR scan policy. Please contact me if you have any questions at 616-8680772 or jamest2@ferris.edu.
New Non-Sedated MRI Scan Policy Proposal
For
Dennis Phillpott Neonatal Manager
At
DeVos Children's Hospital
October 28, 2010
Tracy James RNC
Abstract
This report regarding implementation of non-sedated MR scans at DeVos Children's Hospital is a
proposal on how to obtain MR scans for the neonatal population without the use of sedation
medications. The proposal is a review for management and contains suggestions on how to
implement the new policy. This information is from a wide literary search as well as interviews
of neonatal staff members. The results show that there is not enough information known about
sedation medications and what effects these medications might have on infants' developing
brains. The results also indicate that it is reasonable to expect an infant to have a successful scan
without the use of sedation medications. The recommendation is that the NICU staff be educated
on how to prepare infants properly to insure a high number of successful MR scans without the
use of sedation. Thorough abstract.
Overview
The last 30 years has seen many advances in neonatal medicine. Many of those advances
have increased the survivability of very low birth weight and premature infants. Even though the
survival rate has increased, the number affected by cerebral palsy and other neurological
disorders has remained constant over the last 10 years. Improved imaging studies are helping
professionals understand and diagnose neurological problems associated with infants born with a
low birth weight and premature. MR scans have become a very useful and integral part of early
diagnosis and intervention in the neonatal population. The following proposal is a plan for
DeVos Children's Hospital Neonatal Unit to better serve our population by having routine MR
scans prior to discharge for our infants born weighing less than 1250 grams and/or less than 32
weeks gestation.
Problem
NOTE -- The information in this section is taken from the informational report Implementing
Non-Sedated MRI policy and procedure submitted to Dennis Phillpott on October 12, 2010.
The World Health Organization states that 9.6% of births worldwide in 2005 were
preterm and as many as 5-15% of preterm infants born will have motor impairments. In addition,
30-50% will have some type of behavior or academic impairments. In 2002, the Quality Standard
Subcommittee of the American Academy of Neurology and the Practice Committee of the Child
Neurology Society began to look at goals and parameters for when physicians should obtain
imaging studies on newborns (Ment, Bada, Barnes, Grant, Hirtz, Papile, Pinto-Martin, Rivkin,
and Slovis, 2010). According to Ment et al, "VLBW (very low birth weight) infants (BW < 1,500
grams) now represent 1.45% of all live births in the United States" ( 2010). The use of MR
imaging has enable the medical staff to better understand the preterm brain; and how the lesions
and infarcts seen on the scans can translate to possible handicaps in the future(SC). This
understanding will lead the health care team to appropriate interventions for the infant.
Many facilities use sedation during MR scans, which requires added staff, advanced
education, more training and adds numerous risks to the infant. It is the desire of the
Neonatologists and the rest of the staff to obtain MR scans without the use of sedation. In the
article "Prolonged Recovery and Delayed Side Effects of Sedation for Diagnostic Imaging
Studies in Children", it states, "Our data demonstrates that children may experience prolonged
recovery as well as significant incidence of delayed side effects after sedation for a diagnostic
procedure" ( Malviy, Voepel-Lewis, Prochaska, and Tait, 2000). "Safety for the patient is the
biggest motivation for moving to a non-sedated MRI," said Pam Jackson Neonatal Nurse
Practitioner(CNP). She also states that, "It is recommended by the Physicians and Nurse
Practitioners at DeVos Children's Hospital that infants born at less than 1250 grams or prior to
32 weeks gestation have a MR scan just prior to discharge". The Nurse Practitioners and
Physicians work together to decide who and when an infant needs to have an imaging scan
completed. Mrs. Jackson says, "Procedural sedation with the use of sedatives and narcotics can
have unintended consequences". Research shows that, "Little is known about the clinical
effectiveness, immediate toxicity, effects on special patient populations, or long-term effects
after neonatal exposure to analgesics or sedatives" (Anand, Hall, 2006). The results from these
scans will allow for a more individualized plan of care for the infants even after discharge from
the neonatal unit.
Plan
The first part of the proposal, is to create a more open communication relationship with
the Radiology Department(UC). We must work with them to organize a time when the scan is to
be scheduled. According to the University of Washington, "It is important to allow preparation
time in the intensive care unit before taking the infant to the scan. Infants should be fed 30-45
minutes before the scan" (Mathur, p. g. 58, 2010). Once the MR scan is ordered, the bedside
nurse will call Radiology and inform them of the infants feeding times(NPD). Radiology can
then try find a time in their schedule that can correlate to the infants feeding schedule(NPD,A).
Once a time is agreed upon, and the infant is fed, we are then able to start packaging the infant.
Packaging the infant properly is important for how well the infant will stay still and calm
throughout the procedure. In the NICU, packaging should include swaddling the infant in 1-2
blankets, placing ear muffs on to reduce the noise level, placing MR compatible pulse-ox on
their toe for heart rate and oxygenation monitoring, and then finally placing them into a vacfixed device(NPD,NPD).
Resources
The neonatal unit is well staffed with trained professionals. With in-house training
lessons on packaging and equipment, the bedside nurses will be proficient in packaging the
infants within 3 months of starting the initiative. The Neonatal Unit at DeVos Children's Hospital
purchased a vac-fixed device nearly 3 years ago and many of the staff is already familiar with
how to use it(CC,SVD). The only piece of equipment we need to purchase is the MR compatible
pulse ox device which costs $6000 and in/(OF) which we would need two on hand(CNP,UE:in
which/of which). Upon discussions with the Nurse Practitioners and charge nurses it is agreed
that the transport team, delivery room team and the charge nurses will be trained as superusers(CI). There are 56 nurses involved in these groups, which is about ¼ of our staff. Superuser are known to the general staff as the people to go to when they need assistance. A new MRI
checklist will be created; and it will prompt the bedside nurse to use the super-user to help them
package the infant(CC). To keep cost at a minimum, members of the transport team Tracy
James, Chad Sikora and Emily Geerlings, have agreed to educate the other staff members who
will become super-users in small group impromptu in-services or on a one to one basis. This will
allow us to educate staff during their normal schedules without paying for extra meeting costs.
This should take 1 month to complete. When we train a smaller section of the nursing staff, it
enables us to have them become more proficient in packaging and helps to create a more unified
technique. Good adds here –makes what’s needed clearer.
Conclusion
In the past, institutions have used sedation to ensure a quality scan. However, with all the
advances in medicine and knowledge, there is still little known about the long-term effects of
these medications on the developing brain and nervous system(CI). It is clear that routine MR
scans are vital tools in the diagnoses and treatment of the premature population. With the right
training, education and equipment, the Neonatal staff will be able to obtain good quality MR
imaging scans without the use of sedation(CI). The safety of the infants will be the main factor
when obtaining and completing these diagnostic tests. With time and training of the staff, it is
our goal to see a near 100% success rate for our non-sedated MR scans.
References
Agryropoulou, M. I. (2010). Brian lesions in preterm infants: initial diagnosis and follow-up.
Retrieved from Ferris State University Library website:
http://0-galenetgroup.com.libcat.ferris.edu/servlet/HWRC/hits?docNum=A225251826
Anand, K. J. S., Hall, R.W. (2006). Pharmacological therapy for analgesia and sedation in the
Newborn. Archives of disease in childhood, Fetal and neonatal edition 91(6), 448-453.
Doi: 10.1136/adc.2005.082263
Cooley, B. D., Hogan, M. J. (2006). Image-guided interventions in neonates. European Journal
of Radiology 60 (1), 208-227.
Malviya, S., Voepel-Lewis, T., Prochaska, G., & Tait, A. R., (2000). Prolonged recovery and
Delayed side effects of sedation for diagnostic imaging studies in children. Official
Journal of the American Academy of Pediatrics, 105(3). Doi:10.1542/peds.105.3e42
Mather, A., Neil, J., & Inder, T. (2010). Understanding brain injury and neurodevelopmental
disabilities in the preterm infant: The evolving role of advanced magnetic resonance
imaging. Seminars in Perinatology, 34 (1), 57-64.
Mathur, A. M., Neil, J., McKinstry, R. C., Inder, T. E. (2007). Transport, monitoring, and
Successful brain MR imaging in unsedated neonates. Pediatric Radiology, 260-266.
Doi:10.1007/s00247-007-0705-9
Ment, L. R., Bada, H.S., Branes. P., Grant, P.E., Hirtz, D., Papile, L.A., (2002). Practice
Parameter: Neuroimaging of the neonate. American Academy of Neurology 58, 17261740.
Walden, M., Turnage Carrier, C. (2002). Sleeping beauties: The impact of sedation on neonatal
Development. Journal of Gynecological and Neonatal Nursing, 32(3), 393-401.
Doi: 10.1177/0884217503253454
English 321
Ruzicka
Assignment Evaluation – proposal
Front matter:
__X__Effective use of transmittal memo, title page and abstract
_____Adequate use of transmittal memo, title page, and abstract
_____ Inadequate use of or missing transmittal memo, title page, and abstract
Content:
__X__ Thorough, effective explanation of the problem
_____ Inconsistent explanation
_____Inadequate explanation
__X__ Thorough, effective explanation of the plan
_____ Inconsistent explanation
_____Inadequate explanation
__X__ Thorough, effective explanation of the resources
_____ Inconsistent explanation
_____Inadequate explanation
Introduction/conclusion:
__X__ Effective overview introducing the problem
_____ Adequate overview
_____ Weak overview
__X__ Effective conclusion summarizing main points of problem and solution
_____ Adequate conclusion
_____ Weak conclusion
Organization:
__X__ Information presented in logical order with effective use of transitions
_____ Generally logical organization, some information and ideas out of place
_____ Poorly organized and difficult to follow
Format:
__X__ Correct, consistent use of appropriate format
_____ Inconsistent use of appropriate format
_____ Incorrect use of appropriate format
Documentation:
__X__ Consistent, correct use of in-text citations and references page
_____ Inconsistent or incorrect use of in-text citations and reference page
_48__content score
Grammar (-1 pt), punctuation (-1/2 pt), and spelling (-1/2, 1, or 1 1/2 pts)
_____ Sentence Fragments
_____Comma Splices
__X__Subject-verb disagreement
_____Run-ons (fused)
__X__Noun-pronoun disagree
__X__ Unneeded Comma
_____ Dangling/misplaced modifiers
__X__ Comma/conjunction
_____ Mixed constructions
__X__ Comma/introductory
__1__Usage errors
__X__Comma/nonrestrictive
__X__ Colon/semi-colon
_____ Quotations
__X__ Apostrophes
__X__ 1-3 spelling errors
_____ 4-6 spelling errors
_____ >6 spelling errors
__6__ Points lost for grammar, punctuation, and spelling errors
_____ Late or incomplete rough draft
_____Late final draft
_42__ Final score
Tracy,
You’ve got a clearly-explained proposal here. Should be well-received by the administrator. P
& G more of a problem on this assignment for some reason.
DR