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Authors

De Luca D, Tissiéres P, Helder O, Thiele, N, Perapoch J

© Christian Klant Photography

User group

Healthcare professionals, neonatal units, hospitals, health services, and technical staff

Statement of standard

Physiological monitoring is provided to any infant admitted to a NICU, which is tailored to the individual clinical situation.

Rationale

Neonatal intensive care allows the monitoring of several physiological parameters, with a range of technologies available. New techniques will expand the number of physiological parameters measurable in NICUs and will provide monitoring previously available for older patients. (1)

The increased range of monitoring parameters available produces challenges in their measurement and interpretation, due to the novelty and complexity of the monitoring technology, to a lack of understanding of some relatively new monitoring parameters or to technical errors in the monitoring itself or human error. (2,3) Neonatal quality-assurance procedures and protocols should be directed to the improving the accuracy and quality of monitoring. (4) Although monitoring errors are generally less frequent and severe than drug administration errors (2), improved evaluation of monitoring results will allow better clinical decisions.

Standard monitoring technologies are used in NICUs (ECG, saturation, plethysmography), but advanced monitoring may be necessary and include double saturation and perfusion index, (5) near-infrared spectroscopy (NIRS) (6,7),electrical cardiometry (8,9), amplitude-integrated-EEG (10,11), heart rate variability (12), complex respiratory function monitoring (including electrical impedance tomography, respiratory inductance plethysmography and semi-quantitative lung ultrasound) (13–15), and metabolic monitoring. (16,17) All these technologies provide potential benefits for neonatal care and individual use is recommended only after healthcare professionals’ education and training (see TEG Education & Training).

Benefits

Short-term benefits

  • Improved understanding of the disease process (18)
  • Targeted clinical decisions to the individual condition (18)

Long-term benefits

  • Reduced mortality (19)
  • Reduced risk of major morbidities (19)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about different monitoring technologies used and commit to help reduce monitoring errors in the unit. B (High quality) Patient information sheet
       
For healthcare professionals    
2. A unit guideline on the use of monitoring equipment, application and interpretation as well as management of monitoring errors is adhered to by all healthcare professionals. B (High quality) Guideline
       
3. Training on the use of monitoring equipment, application and interpretation as well as different monitoring technologies is attended by all responsible healthcare professionals, targeted for each professional group. B (High quality) Training documentation
       
For neonatal unit    
4. A unit guideline on the use of monitoring equipment, application and interpretation as well as management of monitoring errors is available and regularly updated. B (High quality) Guideline
       
5. Regular, timely maintenance and calibration of available devices is conducted by appropriately trained technical staff. B (High quality) Guideline
       
For hospital    
6. Training on the use of monitoring equipment, application and interpretation as well as different monitoring technologies is ensured. B (High quality) Training documentation
       
7. Monitoring errors are evaluated and actions taken. (20) B (Moderate quality) Audit report
       
For health service    
8. Monitoring errors are evaluated and actions taken. (20) A (Very low quality)
B (Moderate quality)
Audit report
       

Where to go

Further development Grading of evidence
For parents and family  
N/A  
For healthcare professionals  
N/A  
For neonatal unit  
N/A  
For hospital  
N/A  
For health service  
  • Develop new monitoring systems as appropriate.
B (High quality)
   

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about monitoring technologies used.
For healthcare professionals
  • Attend training on the use of monitoring equipment, application and interpretation as well as different monitoring technologies and their physiological/clinical value.
  • Attend training on technical details about the way to start monitoring, positioning electrodes, and calibration.
For neonatal unit
  • Develop and implement a unit guideline on the use of monitoring equipment, application and interpretation as well as management of monitoring errors.
  • Develop information material on monitoring for parents.
  • Develop a protocol and flow chart for serial calibration and maintenance of monitoring devices.
  • Develop an internal monitoring protocol, including reference values for evaluation and technical details for each device.
For hospital
  • Support healthcare professionals to participate in training on the use of monitoring equipment, application and interpretation as well as different monitoring technologies and their physiological/clinical value.
  • Support healthcare professionals to participate in training on technical details about the way to start monitoring, positioning electrodes, and calibration.
For health service
N/A
 

Sources

  1. De Luca D, Romain O. Biomonitoring in neonatal critical. J Ped Pueric. 2015;28:276–300.
  2. De Franco S, Rizzollo S, Angellotti P, Guala A, Stival G, Ferrero F. The error in neonatal intensive care: a multicenter prospective study. Minerva Pediatr. 2014 Feb;66(1):1–6.
  3. Snijders C, van der Schaaf TW, Klip H, van Lingen RA, Fetter WPF, van Lingen W P F Fetter RA, et al. Feasibility and reliability of PRISMA-medical for specialty-based incident analysis. Qual Saf Health Care. 2009 Dec;18(6):486–91.
  4. Ursprung R, Gray J. Random safety auditing, root cause analysis, failure mode and effects analysis. Clin Perinatol. 2010 Mar;37(1):141–65.
  5. Van Laere D, O’Toole JM, Voeten M, McKiernan J, Boylan GB, Dempsey E. Decreased Variability and Low Values of Perfusion Index on Day One Are Associated with Adverse Outcome in Extremely Preterm Infants. J Pediatr. 2016 Nov;178:119–124.e1.
  6. Höller N, Urlesberger B, Mileder L, Baik N, Schwaberger B, Pichler G. Peripheral Muscle Near-Infrared Spectroscopy in Neonates: Ready for Clinical Use? A Systematic Qualitative Review of the Literature. Neonatology. 2015;108(4):233–45.
  7. Plomgaard AM, van Oeveren W, Petersen TH, Alderliesten T, Austin T, van Bel F, et al. The SafeBoosC II randomized trial: treatment guided by near-infrared spectroscopy reduces cerebral hypoxia without changing early biomarkers of brain injury. Pediatr Res. 2016 Apr;79(4):528–35.
  8. Boet A, Jourdain G, Demontoux S, De Luca D. Stroke volume and cardiac output evaluation by electrical cardiometry: accuracy and reference nomograms in hemodynamically stable preterm neonates. J Perinatol Off J Calif Perinat Assoc. 2016 Sep;36(9):748–52.
  9. Boet A, Jourdain G, Demontoux S, Hascoet S, Tissieres P, Rucker-Martin C, et al. Basic Hemodynamic Monitoring Using Ultrasound or Electrical Cardiometry During Transportation of Neonates and Infants. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2017 Nov;18(11):e488–93.
  10. Goeral K, Urlesberger B, Giordano V, Kasprian G, Wagner M, Schmidt L, et al. Prediction of Outcome in Neonates with Hypoxic-Ischemic Encephalopathy II: Role of Amplitude-Integrated Electroencephalography and Cerebral Oxygen Saturation Measured by Near-Infrared Spectroscopy. Neonatology. 2017;112(3):193–202.
  11. Del Río R, Ochoa C, Alarcon A, Arnáez J, Blanco D, García-Alix A. Amplitude Integrated Electroencephalogram as a Prognostic Tool in Neonates with Hypoxic-Ischemic Encephalopathy: A Systematic Review. PloS One. 2016;11(11):e0165744.
  12. Sullivan BA, Fairchild KD. Predictive monitoring for sepsis and necrotizing enterocolitis to prevent shock. Semin Fetal Neonatal Med. 2015 Aug;20(4):255–61.
  13. Frerichs I, Amato MBP, van Kaam AH, Tingay DG, Zhao Z, Grychtol B, et al. Chest electrical impedance tomography examination, data analysis, terminology, clinical use and recommendations: consensus statement of the TRanslational EIT developmeNt stuDy group. Thorax. 2017;72(1):83–93.
  14. Reiterer F, Sivieri E, Abbasi S. Evaluation of bedside pulmonary function in the neonate: From the past to the future. Pediatr Pulmonol. 2015 Oct;50(10):1039–50.
  15. Brat R, Yousef N, Klifa R, Reynaud S, Shankar Aguilera S, De Luca D. Lung Ultrasonography Score to Evaluate Oxygenation and Surfactant Need in Neonates Treated With Continuous Positive Airway Pressure. JAMA Pediatr. 2015 Aug;169(8):e151797.
  16. Black C, Grocott MPW, Singer M. Metabolic monitoring in the intensive care unit: a comparison of the Medgraphics Ultima, Deltatrac II, and Douglas bag collection methods. Br J Anaesth. 2015 Feb;114(2):261–8.
  17. Finnbogadóttir SK, Glintborg D, Jensen TK, Kyhl HB, Nohr EA, Andersen M. Insulin resistance in pregnant women with and without polycystic ovary syndrome, and measures of body composition in offspring at birth and three years of age. Acta Obstet Gynecol Scand. 2017 Nov;96(11):1307–14.
  18. Elliott M, Coventry A. Critical care: the eight vital signs of patient monitoring. Br J Nurs Mark Allen Publ. 2012 Jun 24;21(10):621–5.
  19. Paliwoda M, New K, Bogossian F. Neonatal Early Warning Tools for recognising and responding to clinical deterioration in neonates cared for in the maternity setting: A retrospective case-control study. Int J Nurs Stud. 2016 Sep;61:125–35.
  20. Nasrabadi AN, Peyrovi H, Valiee S. Nurses’ Error Management in Critical Care Units: A Qualitative Study. Crit Care Nurs Q. 2017 Jun;40(2):89–98.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, De Luca D, Tissiéres P al., European Standards of Care for Newborn Health: Monitoring errors. 2018.

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