Critically Low Temperatures At Birth: Small Tests Of Change Solve a Big Problem

Purpose for the program: To investigate the etiology of low newborn (NB) temperatures at birth. A critical aspect of newborn care is thermoregulation of the newborn environment to ensure safety and facilitate growth and optimal outcomes.[1]

Proposed change: In 2012, a clinical nurse specialist (CNS) and maternity center manager (CM) engaged nurses in a test-of-change approach to improve NB thermoregulation based on observed low birth temperatures (LT). Organizational nursing professional practice model (PPM) provided structures and processes within the work environment to enable and assure excellence in care delivery. Within the PPM, unit-based, nurse-led and nurse-driven professional practice councils (PPC) seek care delivery innovations in a rapidly changing environment.[2] An iterative approach of small tests of change was systematically used to evaluate outcomes and gain salience among nurses.[3]

Implementation, outcomes and evaluation: Baseline data for temperatures at birth, defined as within 30 minutes of delivery, was collected for all cesarean section deliveries (CS) during a two-week period in 2012. Newborns had LT (≤36.1C) at birth in 15 percent of cases. The first test-of-change was to standardize OR temperature monitoring during every CS to ensure OR temperatures of 71-73 F.[4] After three months of monitored compliance, NB temperatures were re-audited.  Low temperature at birth for CS rose to 22 percent. Concurrently temperatures in newborns delivered vaginally (VD) were collected to clarify whether the OR temperature was the problem.  LT for VD was 6.2 percent at birth. 

Discussion with colleagues and internal/external consultants led the team to question whether disposable thermometers used with NBs might produce false low temperatures. A nurse measured newborn temperatures with both disposable and non-disposable (calibrated by clinical engineering) thermometers over a two-week period. There were numerous incidences of lower temperature readings using disposable thermometers.  PPC members reviewed the thermometer discrepancies and subsequently eliminated all disposable thermometers. Four months later, data collected revealed zero LT at birth for NB experiencing VD or CS.

Implications for nursing practice:  Direct care nurses were engaged in the audit and feedback process and in discovery of each small test of change; this created a culture of inquiry and performance improvement. Removal of disposable thermometers from the units saved $1,500 annually, allowing the unit to purchase the calibrated thermometers for all patient rooms. There also is the potential for prevention of NICU admissions for unstable temperatures, keeping NB and mother together. Next steps:  reinforcing standards for temperature frequency to regulate NB temperatures during transition.

Keywords: practice improvement, newborn, test-of-change