The Infant Position Assessment Tool and a Unit Protocol to Improve Interdisciplinary Developmental Positioning

PURPOSE: Developmental care positively affects neurodevelopmental outcomes in infants, with supportive positioning known to be particularly beneficial (Coughlin et al., 2010). There is a gap between evidence and practice because positioning is not standardized in most neonatal intensive care units (NICUs) despite findings of positive neurodevelopmental and musculoskeletal outcomes (Spilker et al., 2016). The National Association of Neonatal Nurses (NANN) has emphasized that without consistent positioning, abnormal body alignment transpires, resulting in positional deformities and atypical movement. NANN set guidelines including “womb-like boundaries to improve neurobehavioral organization such as gentle flexion and midline orientation to promote positive growth of neuromotor and muscular systems” (Hunter, 2010).

Occupational therapy practitioners provide interventions including education and recommendations to promote optimal developmental care (Nightlinger, 2011). Research indicates use of a standardized tool coupled with education to improve positioning proficiency of NICU interdisciplinary teams (Coughlin et al., 2010; Spilker et al., 2016). The purpose of this study was to describe the implementation of a developmental positioning protocol in a NICU and report outcomes using the Infant Position Assessment Tool (IPAT).

METHOD: This quality improvement project was initiated by an occupational therapist, nurse practitioner, and clinical nurse specialist to create a protocol to improve interdisciplinary positioning. An occupational therapy in-service highlighted evidence supporting developmental positioning, introduced the IPAT and a standardized positioning bundle, and allowed nursing demonstration of positioning techniques. NANN’s recommendations and product guidelines were the basis for the bundle, which included equipment for infants with gestational age (GA) <30 wk (Tortoise, a fluidized full-body positioner) and GA 30–32 wk (small Snuggle Up, a soft boundary for infants <1,300 g, or medium Snuggle Up for infants >1,300 g, as well as Frederick Frog, a bean bag to provide additional containment for more active infants). Team members assisted with promotion of the bundle as a new standard of practice and with adequate stocking of equipment.

To assess the impact of the bundle and occupational therapy education, the IPAT, a six-item tool with cumulative scores ranging from 0 to 12, was used as an outcome measure. This tool was chosen because there are few outcome measures identified as valid and reliable in terms of infant positioning. A sample of convenience was used over a 2-wk period. Inclusion criteria were GA <32 wk, infant unswaddled in an incubator, and no tests at time of scoring.

RESULTS: One hundred three preintervention scores were collected, with a mean score of 7.5 ± 2.2. A score of 10–12 is ideal (allowing for circumstances that impede positioning, including drains and surgical sites), and a score of <8 indicates that an infant requires significant repositioning. Posteducation IPAT audits of 104 infants 6 mo after rollout revealed significantly improved scores, from 7.5 ± 2.2 to 9.0 ± 2.2 (p < .001), that further improved to 10.5 ± 1.4 at the 12-mo audit (p < .001). An occupational therapist–led mandatory nursing education refresher and skill check are now completed yearly for continued competence.

CONCLUSION: Developmentally supportive positioning is inconsistently performed in many NICUs. This study found that the implementation of an interdisciplinary positioning protocol led by occupational therapists can improve positioning outcomes on the IPAT in infants <32 wk GA. The results support the use of a positioning protocol to significantly affect neurodevelopmental and musculoskeletal outcomes in the NICU setting.

References

Coughlin, M., Gibbins, S., & Lohman, M. B. (2010). Reliability and effectiveness of an infant positioning tool to standardize developmentally supportive positioning practices in the neonatal intensive care unit. Newborn and Infant Nursing Reviews, 10, 104–106. https://doi.org/10.1053/j.nainr.2010.03.003

Hunter, J. (2010). Therapeutic positioning: Neuromotor, physiologic, and sleep implications. In C. Kenner & J. M. McGrath (Eds.), Developmental care of newborns and infants: A guide for health professionals (2nd ed., pp. 285–312). Chicago: National Association of Neonatal Nurses.

Nightlinger, K. (2011). Developmentally supportive care in the neonatal intensive care unit: An occupational therapist’s role. Neonatal Network, 30, 243–248. https://doi.org/10.1891/0730-0832.30.4.243

Spilker, C., Hill, C., & Rosenblum, R. (2016). The effectiveness of a standardized positioning tool and bedside education on the developmental positioning proficiency of NICU nurses. Intensive and Critical Care Nursing, 35, 10–15. https://doi.org/10.1016/j.iccn.2016.01.004