Running head: CCHD IN THE NICU 1

Screening for Critical Congenital Heart Defects in the Neonatal Intensive Care Unit

Laura G. Stewart

Old Dominion University

CCHD IN THE NICU 2

Screening for Critical Congenital Heart Defects in the Neonatal Intensive Care Unit

Children’s Hospital of the Kings Daughters (CHKD) is a private, not-for-profit, acute

care facility which maintains operations through efforts of fundraising and health foundations.

The Neonatal Intensive Care Unit (NICU) at CHKD is a 64-bed unit with a staff of 190, 130 of

which are registered nurses. On a given shift, there can be up to 31 nurses, depending on census

and acuity. Staffing ratio’s range from 1:1 to 4:1 based on acuity.

In the NICU at CHKD, patient care is managed by a Neonatology group and all other

specialties are involved by consult. Consulting physicians leave recommendations, but the

ultimate decisions are made by the NICU medical team. Many patients with known congenital

heart defects (CHD) are stabilized in the NICU, then transferred to the Pediatric Intensive Care

Unit (PICU) if surgical intervention will be required within the first two weeks of life. In all

other instances of CHD that will not require surgical intervention in the first few weeks, the

NICU maintains care with on-going Cardiology consult. Nursing staff and unit educators

identified a deficit in consistent nursing interventions in the care of these populations. These

deficits may prevent timely intervention to an infant with known or unknown CHD or other

cardiac-affected conditions. A work-group of targeted NICU nurses was assembled to identify

areas for improvement, brainstorm, formulate a protocol for nursing interventions, and

collaborate with the Cardiology team to improve care to these patients (see Appendix).

Clinical Problem

Congenital heart disease and prematurity are the two leading causes of infant mortality,

with a CHD prevalence of 0.8% and a critical CHD (CCHD) prevalence of 0.17% (Steurer et al.,

2017). Six to ten percent of infant deaths can be attributed to CHD, with 30-50% of these deaths

the result of a congenital malformation (Kumar, 2016). Prenatal detection only occurs in 25-
CCHD IN THE NICU 3

30% of cases, and up to 20% of cases of CHD are diagnosed after discharge (Eckersley, Sadler,

Parry, Finucane, & Gentles, 2016). These undiagnosed or late-diagnosed conditions can lead to a

29% mortality rate as compared to 12% mortality when early detection is accomplished.

Nursing interventions aimed at the identification of CHD are crucial to lowering

mortality rates and maintaining patient safety in the NICU. Nurses are in a unique position to

correlate assessment findings with interventions to affect care decisions. Upon brainstorming as

a group, a team of targeted nurses formulated a list of nursing interventions for the cardiac-

affected population in the NICU. These interventions were discussed with the Cardiology team

and recommendations were given. Numerous areas of improvement were identified, with a key

area of deficit which affected our process for CCHD screening. While several specific areas for

improvement in our cardiac-affected patient population were targeted, the clinical problem that

exists with our CCHD screening process is global to our entire NICU patient population.

Critical Congenital Heart Defect Screening

In 2011, the United States Secretary of Health recommended the addition of pulse

oximetry for CCHD screening to the newborn screening procedure (Manja, Mathew, Carrion, &

Lakshminrusimha, 2015). These guidelines, though, are for term or near-term infants, to be

performed after 24 hours of life or just before discharge. The NICU cares for a patient

population of premature infants that can have a 2 to 3-fold higher incidence of CHD in infants

less than 37 weeks. There is little evidence to be found regarding how CCHD screening should

be handled in the NICU population. For NICU patients (which are not always premature),

screening “before discharge” can result in the late detection of asymptomatic CHD in the

absence of echocardiogram. Recently, our NICU took a transfer of a term baby that was 1 week

old, admitted with feeding difficulties. This baby was inpatient for approximately a week and a
CCHD IN THE NICU 4

half before feedings improved to a level appropriate for discharge. The “before discharge”

CCHD screening was performed about an hour before anticipated discharge with a failing result.

Discharge was delayed and further testing was performed to reveal an undiagnosed coarctation.

Had the CCHD screening been performed sooner, intervention could have been initiated early.

Guidelines for CCHD screening could be adjusted to the NICU population, utilizing the existing

recommendations for term or near-term infants.

Pulse oximetry for CCHD screening carries a low false positive result at 0.035% (Kumar,

2016). False-positive results can be easily repeated as is recommended, resulting in an

insignificant economic impact. With evidence showing that 50-70% of unknown CHD can be

diagnosed with pulse oximetry, the benefit to this intervention far outweighs the minimal

financial burden produced.

Formal mechanisms. There is a NICU specific policy (CHKD, 2017) regarding

screening for CCHD. These guidelines state that screening by pulse oximetry will be performed

on any patients that did not receive an echocardiogram during their admission. A probe is to be

placed on the infant’s right hand for 3-5 minutes as a pre-ductal reading. Then the pulse

oximeter probe is to be placed on the infants left foot for 3-5 minutes as a post-ductal reading. A

greater than 4% discrepancy between the two readings should be reported to the medical team.

The policy states that screening will be performed prior to discharge. This process is generally

supported by literature (Kemper & Hudak, 2018), but with some missing elements to be

discussed later.

Informal mechanisms. Existing practice for screening is such that there is a standing

order on admission for all infants in the NICU to have screening before discharge. Realistically,

this takes place whether the infant has received an echocardiogram or not and is usually
CCHD IN THE NICU 5

performed just hours before discharge. Generally, the task is performed in a one-after-the-other

manner, rather than simultaneously.

Discrepancies in formal and informal practice. When considering the process for

screening, there are no directions to repeat a failed screen. Evidence-based research suggests

that a discrepancy of greater than 3% (not greater than 4%) should be repeated two times, and

any saturation less than 90% should be considered a failed result (Kemper & Hudak, 2018).

Recommendations of research are such that screening is not necessary when an echocardiogram

has been performed. Neither formal mechanisms nor informal practice reflect this. No method

of monitoring exists regarding holding screening when an echocardiogram has been performed at

some point during the admission. Many infants, especially premature babies, get an

echocardiogram, yet the order for screening before discharge remains until the task is completed.

This order is generated during a NICU admission order set. Also, guidelines offer that either

simultaneous or one-after-the-other screening is acceptable (Kumar, 2016), which the

organizational policy does not reflect.

Nursing Interventions

After analysis of formal and informal mechanisms and the resulting discrepancies, it is

concluded that the process for CCHD should be updated based on research. Recommendations

for screening can be adapted to the neonatal population by adjusting current screening guidelines

that apply to term newborns. Three key changes should be made for how nursing administers

this intervention. First, based on the available research (Manja et al., 2015), screening in the

NICU should occur once a patient has reached 35 weeks’ gestation (corrected) and has been off

supplemental oxygen for 24 hours. Any infant entering the NICU at 35 weeks’ gestation or older

can follow the current recommended guidelines for screening to occur after 24 hours of life (and
CCHD IN THE NICU 6

once off supplemental oxygen). Second, policy should be changed to reflect a threshold of 3%

difference in pre and post-ductal saturations, and any saturation less than 90% (Kemper &

Hudak, 2018) as failing, and updated to include either simultaneous or one-after-the-other

monitoring. Failed screens should be repeated at least once, or twice as this research suggests.

Finally, practice should be updated so that infants who have received an echocardiogram during

their admission will have their CCHD screening order removed (Manja et al., 2015)

Conclusion

Concern for consistent and effective care of CHD infants in the NICU led to the

formation of a focused work-group to collaborate with Cardiology to improve care. These

discussions led to a compilation of several nursing-driven interventions that could improve care.

These interventions, specifically related to CCHD screening, will serve to eliminate the deficits

in consistent nursing care and promote timely intervention to infants with known or unknown

CHD. With specific consideration for our current process of CCHD screening, it is hypothesized

that following the updated guidelines outlined here will result in a decrease in late diagnosis of

CHD in the NICU at CHKD. With mortality rates falling from 29% for late diagnosis of CHD to

12% when diagnosed early (Eckersley et al., 2016), improving care through collaboration and

research-based practice for nursing intervention will prove crucial to maintaining patient safety

in the NICU.
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Appendix

OLD DOMINION UNIVERSITY SCHOOL OF NURSING

NURS 403 Clinical Implementation Project

Organization Mentor Identification Form

Student Name: Laura G. Stewart

Course Number: NURS 403

Semester and Year: Summer 2019

Experience Site:

Children’s Hospital of the Kings Daughters (CHKD), Neonatal Intensive Care Unit (NICU)

Experience Mentors:

Jan Thape, MSN, RNC-NIC, NICU

Tammy Dichiara, PA for Pediatric Cardiology at CHKD

Brief description of experience:

A need was identified that the development of guidelines for the care of cardiac-affected

infants was necessary, which included certain activities that should be performed on ALL

patients (cardiac-related or not) that would help our medical team collaborate more effectively

with the CHKD Cardiology department. A small workgroup was formed, and several meetings

were held to help develop some guidelines for staff. I had the opportunity to be a facilitator of

these meetings, and for disseminating information to the Educators and the workgroup.

Objectives for experience:

CCHD IN THE NICU 8

1. To collaborate with NICU Educators to identify a core team of nurses that display

adequate experience and desire to advocate for and improve the care delivered to the

cardiac-affected patient population in the NICU.

2. To identify patient populations that may require specialized nursing interventions on

admission to the NICU.

3. To brainstorm with the identified core nurse workgroup to develop interventions that

should be included in guidelines for nursing assessment and intervention for patients in

the NICU.

4. To discuss with a liaison from the CHKD Cardiology department the interventions they

feel are important for nursing to perform on known and unknown cardiac-affected

infants.

5. To disseminate the information gleaned from meetings with Cardiology to the workgroup

to formulate guidelines for nursing interventions based on identified areas of

improvement.
CCHD IN THE NICU 9

References

Children’s Hospital of the Kings Daughters (CHKD) NICU Department Manual. (2017).

Screening for critical congenital heart disease in the NICU, (Policy No. 1125-P-AS-

04).

Eckersley, L., Sadler, L., Parry, E., Finucane, K., & Gentles, T.L. (2016). Timing of diagnosis

affects mortality in critical congenital hearth disease. Archives of Disease in Childhood,

101(6), 516. DOI: 10.1136/archdischild-2014-307691

Kemper, A., & Hudak, M. (2018). Revisiting the approach to newborn screening for critical

congenital heart disease. Pediatrics, 141(5), e20180576. DOI: 10.1542/peds.2018-0576

Kumar, P. (2016). Universal pulse oximetry screening for early detection of critical congenital

heart disease. Clinical Medicine Insights, Pediatrics, 10, 35-41.

DOI: 10.4137/CMPed.S33086.

Manja, V., Mathew, B., Carrion, V., & Lakshminrusimha, S. (2015). Critical congenital heart

disease screening by pulse oximetry in a neonatal intensive care unit. Journal of

Perinatology, 35(1), 67-71. DOI: 10.1038/jp.2014.135

Steurer, M.A., Baer, R.J., Keller, R.L., Oltoman, S., Chambers, C.D., Norton, M.E.,…Jelliffe-

Pawlowski, L.L. (2017). Gestational age and outcomes in critical congenital heart disease.

Pediatrics, 140(4), 1-11. DOI: 10.1542/peds.2017-0999