NICU Assessment Survey 04 - Engage Grow Thrive

NICU Assessment Survey

This questionnaire, along with our onsite assessment, will assist us in understanding the culture of care in the NICU and develop recommendations to support you in achieving your goals. Please give detailed responses when possible.

Name:

Role:

Email:

Telephone #:

# NICU Beds:

# of Nursing Staff:

# Neonatologists:

# Residents / # NNPs / # PAs

LEADERSHIP

Who are/will be the members of the Small Baby Care Steering Committee. (include member’s roles, responsibilities, etc.) involved in your small baby program?

Describe your NICU nursing leadership structure (including all role titles and responsibilities).

Identify your medical model of care. (Attending, Fellows, Residents, NNP, PA)

Describe process for reinforcement/accountability for clinical practice goals/standards.

Describe daily rounds. Include all the roles present and their contribution.

QUALITY IMPROVEMENT

Describe your NICU QI Team?

How do you decide QI projects and what are they at the current time?

Are there any specific tools or methods utilized to standardize practice? (PDSA, LEAN)

How is data shared with the multidisciplinary NICU Team?

Are parents involved in QI work, if yes describe role(s)?

ENVIRONMENT

Describe the physical environment for ELBW/VLBW care. (Single room, multiple beds [POD/Bay])

Describe bedside patient and family supportive equipment.

Do you anticipate need for product or environmental changes? If yes, please describe.

DELIVERY ROOM/TRANSPORT MANAGEMENT

Describe your partnership and collaboration with OB, L & D, and/or MFM services.

Describe your “Golden Hour” practice?

Describe the physical location/relationship between the delivery room and the NICU?

Describe the transport process from the delivery room to the NICU.

Describe the transport process from referring hospitals to your NICU.

RESPIRATORY

Describe initial delivery room respiratory stabilization practice.

Describe your standard respiratory practices (for example, first intention jet ventilation for small babies, CPAP until X weeks CGA, etc).

Describe the extubation process.

CARDIAC

What are your routines for obtaining an echocardiogram?

Describe approach to PDA management. (i.e. Medical, Surgical Management)

NEURO

Describe your neuro-protection practices.

FEN

Describe your general practice for line insertion and removal (UAC/UVC/PICCs/PIVs). Are there routines for certain gestations.

When is enteral nutrition initiated via feeding guidelines?

HEM/LABS

Describe your process for lab draws and routine for lab tests (Are there “routine” labs? Who draws labs? Etc.).

Describe your transfusion practice?

ROUNTINE CARE/VITAL SIGNS

What is your standard frequency for VS?

Is any care of the ELBW done in tandem with a 2nd care provider? Who is commonly providing the second set of hands?

Describe how care is modified according to infant cues.

DISCHARGE

Describe coordination of discharge management between families and the clinical team (discharge coordinator/navigator?)

PARENT PARTNERSHIP

Please describe how parents are involved in daily care.

What are the resources available for parents to learn about and understand the care of their small baby?

Describe your family advisory group.

DOCUMENTS TO PROVIDE

• Please provide all tools utilized in your NICU (for example golden hour checklist, IVH prevention bundle, feeding guideline, etc.)
• Standard of Care
• QI Tools, checklists, guidelines, algorithms and order sets
• Policies/procedures for small baby care
• Documents to support above responses
• Please email documents to: [email protected]