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Creating a NeuroNICU:

People, Practices, Possibilities

Kathi Salley-Randall, RN, MSN, CNS, NNP-BCNeuroNICU Program Consultant

kathi@synapsecare.com

• What is a NeuroNICU

• Why the NeuroNICU Trend

• How we created a NeuroNICU

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Outline

Assessm

ent

Monitoring

Protection

Developm

ent

4 Pillars of Neuro-NICU Care

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How do we assess the brain?Pillar #1: Neuro-AssessmentTraining included detailed neonatal neuro exam, Sarnat, and Neonatal Pain, agitation, 

and sedation Scale (N‐PASS)

Specialized ImagingMRI/MRS, Ultrasound, CT (for emergencies/trauma), F‐MRI, PETs

Pillar #2: Bedside neuromonitoring devices

Continuous videoEEG (cEEG)

Amplitude integratedEEG (aEEG)

Near infraredSpectroscopy (NIRS)

BRAIN FUNCTION BRAIN PERFUSION

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Pillar #3: Neuro-Protection• Initially the term (NP) applied to treatments and cares to prevent injury and cell death

• IVH Prevention• Therapeutic Hypothermia• Cocktails on Ice

Pillar #4 - Neuro-development

The 4 Pillars of Neuro-Conscious NICU

• Neuro-Assessment– Clinical /pain

assessment– Metabolic– MRI/MRS– Ultrasound– Follow up care

• Neuro-Monitoring– EEG– aEEG– NIRS– Hearing Screen– N-Trainer

• Neuro-Development– Environment – Sleep– Stress/Separation– Positioning– Support during

procedures

• Neuro-Protection– Cooling– Medications– Nutrition– IVH Bundles (Head

position, etc..)

POSSIBILITIES FOR ALL

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Where are you now?Where are you going?

• Neuro-NICU’s can be a:• QI project• Expanded Program• New unit design/environment• Change in culture

Why is there a NeuroNICU Trend?

• Recognition of improved survival with increased morbidities

• Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high‐risk infant follow‐up to focus on brain care

• Bringing new care practices and research findings to the bedside

• To improve the short and long term outcomes for infants and their families. 

Neonatal Brain Injury• There are a number of causes and

diagnoses

• Outcomes depend on location, timing, extent of injury, interventions

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Perinatal-Neonatal Brain Injury

• The incidence of neurological

disabilities related to perinatal brain

injury has not decreased in decades• CP, Cognitive impairment, Epilepsy• Term and preterm infants are affected

Degos V et al. Anesth Analg2008;106:1670-1680

What we still don’t know• On the basis of our follow-up data we feel that the

size of the hemorrhage on ultrasound is by no

means the only guideline to outcome.

• There may well be other factors influencing the

result which we cannot yet diagnose by

ultrasound.

• M. I. Levene - Letter to the Editor, Lancet, 1981

Graphic Credit: Dr. Dieter Wolke, UK

IQ scores at 26 years (n=359)

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Graphic Credit: Dr. Dieter Wolke, UK

What we still don’t knowNeither structural brain alterations nor the

medical complications common in the NICU

population fully explain the variation in

long-term neurobehavioral development

Milgrom, 2010

Why is there a NeuroNICU Trend?• Recognition of improved survival with increased morbidities

• Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high‐risk infant follow‐up to focus on brain care

• Bringing new care practices and research findings to the bedside

• To improve the short and long term outcomes for infants and their families. 

Neuro-NICU’s:Getting above the clavicles

• UCSF NeuroIntensive Care Nursery –2007• Phoenix Children’s NeuroNICU – 2009• Johns Hopkins• St. Louis Children’s• Vanderbilt Medical Center• Children’s National Medical Center,

Washington D.C.• Boston Children’s - Peds Neuro ICU

Glass, Bonifacio, Peloquin, Shimotake, et al. Neurocritical Care for Neonates. Neurocrit Care. 2010 June ; 12(3): 421–429. doi:10.1007/s12028-009-9324-7.

Photo credit – www.ucsf.edu

• Lucile Packard Children’s at Stanford• Loma Linda University Children’s

Hospital• Sharp Mary Birch & Rady’s

Children’s – San Diego• Riley Children’s – Indiana• CHOC – Orange, CA• And More…

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The Neuro-Conscious NICU Team

• Nursing• Identification of Risk• Triage patient,

staffing, equipment• Clinical Assessment• Apply equipment

• Neurology• Mechanism of injury• Coordinate application

and interpretation of EEG/aEEG

• Manage seizure

• Neonatology• Stabilize infant• Attention to

physiology and diagnosis

• Advanced Life Support

• Family & Follow Up• Prognosis• Long-term continuity• Support

The Neuro NICU is multi-disciplinary

Child Neurology

Developmental Behavioral Pediatrics/High Risk Infant follow‐up Clinic

DevelopmentalTeam

Pediatric Neurosurgery

Child Psychiatry

Neonatology

Neuroradiology

Why is there a NeuroNICU Trend?• Recognition of improved survival with increased morbidities

• Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high‐risk infant follow‐up to focus on brain care

• Bringing new care practices and research findings to the bedside

• To improve the short and long term outcomes for infants and their families. 

HOW TO CREATE A NEURO-NICU?

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Photo credit: @kyletdaddio - Twitter

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ONE UNIT’S JOURNEY

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The LPCH Journey• 2012:

• Written proposal and budget submitted,

• Funding approved for equipment, training, and support staff

• Decision to make “virtual” unit within the unit

• Meetings with related departments to share vision

• Develop and trend “top 10” list

Who could BE Served

• Term Infants• HIE• Induced

Hypothermia• Seizures• Meningitis• Stroke• Cerebral Vascular

Malformations• ECMO• Metabolic Disease

• Preterm infants• Developmental

Care• Neuro-Protective

Interventions• Seizures• IVH, PVL

Who will BE served at LPCHTHE TOP 10 LISTS FOR LPCH

HIE/CoolingSeizures

ECMO/pre‐ECMOSevere 3‐4 IVH/hydrocephalus

Critical/unstablePremie ≤ 28 weeksCNS anomaliesMetabolic

Cyanotic CHDCNS infection

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CRITERIA 1/14 1/24 1/28 2/5 2/12

HIE/Cooling 1 2 1 0 0SZS 2 1 1 0 1

ECMO/pre‐ECMO 2 1 0 0 1Severe 3‐4 

IVH/hydrocephalus 0 0 0 0 0Critical/unstable 4 2 2 2 2Premie ≤ 28 weeks 1 1 2 0 2CNS anomalies 1 0 0 0 0

Metabolic 0 1 1 0 0Cyanotic CHD 1 2 1 3 1

CNS inf 0 0 0 0 0

_______ _______ _______ _______ _______Total NNICU 12 10 8 5 7

Total, Criteria 1‐5 9 6 4 2 4Total NICU census 34 37 31 23 26

NNICU/NICU 35.3% 27.0% 25.8% 21.7% 26.9% 34

Top 12 priority diagnoses for Neuro NICU

Priority Diagnosis Priority Diagnosis

1 HIE/cooling 7 Metabolic disease

2 Seizures 8CNS anomalies or Primary neurologic disorders

3 ECMO/pre‐ECMO 9 Cyanotic CHD4 Critical/unstable 10 CNS infection5 Preemie <29 weeks  11 Symptomatic PDA

6Grade III/IV or hydrocephalus

12 ALTE

The LPCH Journey• 2013:

• aEEG Nurse Training – application• aEEG MD Training – interpretation

• 3-Day NeuroNICU Training Courses, including hypothermia, NIRS and aEEG;

• Nurse Staffing Organized

• April - Opening of the NeuroNICU

• Start NeuroNICU Database

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The LPCH Journey• 2014

• Annual course continues

• Annual “skills” day for aEEG, NIRS, Cooling, Developmental Care

• Add additional NNP hours for bedside coverage

• Research:• CA Transport Cooling Trial – Servo vs Passive Cooling• Electrode Impedance QI project• Completed Optimized Cooling Trial• Late Hypothermia Enrollment

The LPCH Journey• 2015

• Annual course + skills day continue

• Add additional NNP hours for bedside coverage

• Add aEEG documentation to nurse charting

• aEEG Quiz for MD’s

• Summer Case Study Series (bedside)

The LPCH Journey• 2016

• Annual course + skills day continue

• Hire part-time NeuroNICU Nurse Educator

• Annual aEEG + NIRS Quiz for MD’s

• Research• HEAL (High-Dose Epo Trial)• Premature Infant Cooling Trial• Transfusion of Prematurity + NIRS

The LPCH Journey• 2017

• Annual course + skills day continue

• Annual aEEG + NIRS Quiz for MD’s

• Clinical Improvement Project = Seizures• Treatment Algorithm• Bedside Review of aEEG/Communication Audit

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The LPCH JourneyProgram Stats:• 1 year anniversary – 226 patients

• 2 year anniversary – 260 patients

• 3 year anniversary – 370 patients

• 4 year anniversary – 494 patients

• Total 1,350 infants

Clinical service• Specialized care by Neuro NICU trained RN team (n=90)

• Daily joint rounds with Neurology service

• On-site NNP or educator 5 days a week

• EPIC enhancements: Neuro NICU tab, dot phrases for neuro exam and aEEGinterpretation, order sets for hypothermia and seizures

• Neuro NICU database in REDCap for research, QA/QI, and program planning

Education• Annual didactic training (2-Day Course) –Open to the public – Next Sept 26-27, 2018

• Annual “skills day” for NeuroNICU nurses on aEEG, NIRS, cooling an developmental care

• Annual online review quiz for Medical Providers on aEEG, NIRS

• Weekly “5 Minute Friday Lectures”

Where are you now?Where are you going?

• Neuro-NICU’s can be a:• QI project• Expanded Program• New unit design/environment• Change in culture

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Neuro-NICU Pillars

• Neuro-Assessment– Clinical /pain

assessment– Metabolic– MRI/MRS– Ultrasound– Follow up care

• Neuro-Monitoring– EEG– aEEG– NIRS– Hearing Screen– N-Trainer

• Neuro-Development– Environment – Sleep– Stress/Separation– Positioning– Support during

procedures

• Neuro-Protection– Cooling– Medications– Nutrition– IVH Bundles (Head

position, etc..)

Framework of NICU Care

Practice Personnel

Research/QI Equipment

Final Thoughts• Brain injury is a reality of many infants in the NICU.

• The brain is the organ that has the greatest impact on long term quality of life and function.

• We have the opportunity to improve the quality of life of high-risk infants, and the quality of care provided through the expansion of new technologies, therapies, and practices.

• www.synapsecare.com• Free webinars on various NeuroNICU topics• Upcoming hypothermia training course• Monthly developmental care book club• Monthly aEEG Q&A call – review cases + hot

topics

• Annual NeuroNICU Nurse Training Course – Feb 2019 in San Diego, CA

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Resources

THE CONFERENCE

February 3-5, 2019Neuro NICU Nurse Training

San Diego, CA

www.synapsecare.com#onenurse

register now at: www.synapsecare.com

Some featured topics:• Advanced NeuroExam

• HIE updates

• Trauma Informed Care

• Pain in the Brain

• Using aEEG

• Touch & Massage

• Caregiver Fatigue

• Music Therapy

The ONE Conference will focus on the four pillars of Neuro NICU nursing care:

Neuro-assessment, Neuro-monitoring, Neuro-development, and Neuro-protection

Download our FREE NeuroNICU Program & Practice QuickStartwww.quickstart.synapse.com

San Diego, CAKona Kai Resort & Spa

SPEAKERS INCLUDE:

Marsha Campbell-Yeo

Mary Coughlin

Lauren Heimall

Kathi Randall

Rachelle Sey

Jayne Solomon

Shannon Tinkler

Michelle Waddell

Kara Ann Waitzman

and more!

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• Innovative Care of the Newborn Brain

• Stanford University• 2 day Course• September 26-27, 2018• ONLINE REGISTRATION:

• tinyurl.com/neuronicu-sept

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Resources

Innovative Care of the Newborn Brain

Our Invited Guest Faculty

September 26-27, 2018 Join us for a 2-day Neuro-NICU training course. In addition to our local experts in neonatology, neurology, developmental pediatrics and high-risk infant follow up care, we have several inter-national experts joining us to provide a range of break-out sessions for beginners and advanced users of therapeutic hypothermia, aEEG and NIRS. This is a conference not to be missed!

Lina Chalak MD, MS Epi Associate Professor in Pediatrics & Attending Neonatologist UT Southwestern Medical Center Dallas, TX - USA

Dr Lina Chalak’s clinical and translational research expertise is related to neonatal brain injury, HIE identification and therapies, as well as the use of NIRS to evaluate neurovascular unit and cerebral auto-regulation.

Lena Hellström-Westas MD, PhD Professor of Perinatal Medicine Senior Consulting Neonatologist Uppsala University Hospital Uppsala, Sweden

Dr. Lena Hellström-Westas is one of the pioneering clinical researchers on amplitude-integrated EEG monitoring with a focus on early prediction of outcome in asphyxiated infants and preterm infants, seizure detection, sleep and pain assessments.

Marianne Thoresen MD, PhD Professor of Neonatal Neuroscience, University of Bristol, UK & Professor of Physiology, University of Oslo, Norway

Dr. Marianne Thoresen is considered one of the world’s leading experts on both the basic science and clinical use of neonatal hypothermia and other neuroprotective strategies. She has been cooling neonates since 1998 and played an important role in implementing hypothermia throughout the UK.

Course Description This course has been designed to bring you an intense focus on one organ system, the neonatal brain and nervous system; the organ system that is ultimately responsible for our quality of life. We will take you on a journey from fetal life, through specialized care in the NICU, and finally beyond the doors of the NICU, to the infant’s real home.

Date & Time

September 26 & 27, 2018 0800 to 1700

Location Frances C. Arrillaga Alumni Center 326 Galvez Street—Stanford University Registration $400 until June 1st, 2018 $450 after June1st; $500 at the door Registration Fee Includes: Printed Sylla-

bus, Parking, Lunch and Light Snacks

Refund Policy 50% refunds will be given for cancellations re-

ceived in writing by August 30th, 2018 Agenda + Registration https://tinyurl.com/neuronicu-sept

Course Objectives 1. Identify risk factors, incidence and common

causes; describe the pathophysiology, di-agnostic work-up, two potential medical treatments, procedures, referrals; and list two nursing interventions or care considera-tions, for infants with the following condi-tions: • Hypoxic Ischemic Encephalopathy • CNS Malformations • Seizures • ELBW Infants

Full list of objectives and course schedule can be found online at: https://tinyurl.com/neuronicu-sept

Contact Information: Shannon Tinkler—NeuroNICU Educator Email: STinkler@stanfordchildrens.org Krisa Van Meurs—NeuroNICU Medical Director Email: vanmeurs@stanford.edu

0810: Why a NeuroNICU? - The LPCH story up until now— Kathi Salley Randall

0830: Fetal and neonatal brain development: Timing, significance, and out-comes—Courtney Wusthoff, MD, MS Epi

0915: Neurological Examination of the Newborn - Courtney Wusthoff, MD, MS Epi

1030: IVH and white matter injuries: Under-standing the pathophysiology, and risks for the small and big baby -Valerie Chock, MD, MS Epi

1115: HIE – Insult, impact, & interventions Krisa Van Meurs, MD

1145: Systemic Implications of Hypothermia Bedside Management Pearls Sonia L. Bonifacio, MD

1300: Mild HIE: Should we cool? Lina Chalak, MD, MS Epi

1330: The past and future of neonatal neuroprotection—Marianne Thoresen, MD, PhD

1430: Short-Term and Early Neurodevelopmen-tal Outcomes of Extremely Preterm Infants—Susan R. Hintz, MD MS Epi

1530: 5 Ways to Offer Neuro-Protective Care in the NICU—Kathi Salley Randall

1600: Psychological Support in the NICU to ef-fect short and long-term neonatal outcomes—Dr. Richard Shaw

0815: aEEG in Every Day Practice Lena Hellström-Westas , MD, PhD

0900: NIRS in the NICU—Now and the Future Directions—Lina Chalak, MD, MS Epi

0945: Diagnosis and management of neonatal seizures Courtney Wusthoff, MD, MS Epi

1130: Comfort Care vs Critical Care Diana Kobayashi, NNP

1300: BREAK-OUT SESSIONS— Beginner & Advanced aEEG/NIRS/Cooling Cases

1500: Looking back to look forward: The parent’s perspective of life in the NICU and beyond LPCH Family-Centered Care Department

1045: Pain and the preterm brain— Lena Hellström-Westas , MD, PhD

Wed, September 26 Thurs, September 27

Nursing CE Credits This course is pending approval for Nursing Continuing Edu-cation by California Board of Registered Nursing Provider Number CEP 15417 for 14 contact hours. No CME credits