Monitoring Premature Infants in Car Seats: Implementing the American Academy of Pediatrics Policy in a Community Hospital Joel L.

Bass, Kishor A. Mehta and Jeanne Camara Pediatrics 1993;91;1137

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Monitoring

Premature Academy
Joel L. Bass,

Infants Pediatrics
MD; Kishor

in

Car

Seats: in

Implementing

the Hospital
RN, MSJD

American

of

Policy
A. Mehta, MD;

a Community
Jeanne Camara,

and

ABSTRACT. Objectives. In 1990, the American Acadpublished its first policy recommending universal emy of Pediatrics (AAP) Committeee on Injury and Poi- use of car seats for infants. In 1980, the First Ride son Prevention issued a policy statement which recom- program was created with the aim to encourage unimended that all infants born at less than 37 weeks versal use of infant car seats among babies disgestational age be monitored in their seat before car discharged from the hospital. In 1990 this concept was charge to identify infants at risk for apnea associated established formally as Academy policy.2 These AAP with car seat use. The objective of this report is to sumcontributed to an increased use of infant marize the experience of a community hospital in imple- initiatives car seats nationally. menting this recommendation, including: education of However, as with many endeavors, large-scale imhealth professionals about the problem and its management, development of an effective hospital policy andplementation sometimes reveals problems that were procedure for testing at-risk infants, overcoming logisti- not anticipated initially. In 1985, Bull was the first to cal difficulties for nursing staff who implement the pol- describe the positional problems of premature inicy, overcoming liability concerns, and summarizing the fants in car seats, suggesting that some car seats declinical results which we observed during a 15-month signed for full-term infants might not be completely period. appropriate for these small infants.3 Crash testing of Methods. MetroWest Medical Center, Framingham selected automotive restraints for premature infants Union Campus is a community hospital with a Level II that some systems could provide effecNeonatal Unit with approximately 2200 deliveries annu- documented tive restraint.4 However, a 1986 report by Wilett ally. Hospital procedures and policies were developed to implement the AAP policy for safe transportation of pre- demonstrated that premature infants are often submature infants. Consequently, infants less than 37 weeks ject to episodes of desaturation, sometimes associgestation at birth were monitored for a 90-minute obser- ated with bradycardia, while in car seats.5 Ofpre-20 vation period for oxygen saturation, apnea, or bradycar- mature infants, 60% had episodes of desaturation dia in the car seat that they would be going home in from <80% and 25% had bradycardia <80 beats/mm. the nursery. None of the 10 full-term neonates studied had any Results. Policies and procedures for car seat monitordetected during the study. These data ing were instituted successfully during 15-month period. abnormalities confirmed in a subsequent study in 1989 with a Sixteen of 87 (18.4%) monitored infants 26 to 36 weeks were larger sample of patients6 in which 30% of 53 premagestation had abnormal results. In addition, one 37-week ture infants had some abnormality including bradygestational newborn who was monitored because of duskiness during feeds also became apneic and bradycardia <80 beats/mAn, apnea, or desaturation <85% cardic in the car seat. during the car seat tests. None of the 9 full-term Conclusions. A car seat monitoring program can be neonates observed demonstrated abnormalities. incorporated effectively into a Level community II hosBased largely on these studies, the AAP Committee pital nursery discharge plan provided that appropriate on Injury and Poison Prevention issued a policy medical staff policies, nursing procedures, and adminisstatement on the safe transport of premature infants trative support to deal with the logistics of the program is policy statement provides information established. Our monitoring results are consistent with in 199O. This on proper dimensions of car seats premature for inprevious reports that premature infants are at risk of desaturation in car seat. a In addition, we have demonfants, proper positioning of infants in the car seat, strated that a full-term neonate may also be at risk recommends if monitoring of infants born at less than other evidence of desaturation (eg, duskiness during 37 weeks gestational age in the car seat before disfeedings) is observed. Pediatrics 1993;91:1137-1141; car charge and recommends alternative restraints for seats, child restraint devices, prematurity, apnea. those infants who experience desaturation or bradyIn
(AAP)

1974 the Committee

the MA;

American

Academy

of

Pediatrics

cardia. MetroWest
Campus, is

Medical
a community

Center, per
about

Frammngham
hospital with

Union
approxi-

on

Injury

and

Poison

Prevention

mately
From ham,
Nursing

2200
Nursery

deliveries
with

year
450

and

a Level

II Special
annually.

Department of Pediatrics, MetroWest Medical Center, FramingBoston University School of Medicine, Boston, MA; and Perinatal
Services, MetroWest Medical Center, Framingham, MA.

Care

admissions

There

Received

for publication Jul 22, 1992; accepted Reprint requests to (J.L.B.) Dept of Pediatrics, 115 Lincoln St. Framirtgham, MA 01701.

Dec

30, 1992. MetroWest by the

Medical American

Center, Acad-

are 45 pediatricians on staff ery. Since November 1990, we have plement the AAP recommendations
of with the present this process report and

who use the nursattempted to imin our nursery.

is to describe to summarize our our

PEDIATRICS
emy

(ISSN

0031

4005).

Copyright

1993

of Pediatrics.

The purpose experience own findings

concerning

the

frequency

of

car

seat-

PEDIATRICS Vol. 91 2012 Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 6,No. 6 June

1993

1137

associated desaturation Level II Nursery.

or

apnea

encountered

in was a

planning

to use
Two other 36 weeks, felt it was

the

Cosco

Dream

Ride

for

transages the both

METHODS
All infants determined by dates and/or than 37 weeks gestation at birth were staff and scheduled to be monitored 24 the car seat that they would be going The nurses informed the parents of the
in the car seat as babies well as born potential at more benefits

portation. of 35 and physician

newborns, with gestational were not tested because not necessary. These were

examination to be lessthe patients of the same pediatrician, a new member identified by the nursing of the staff. Overall, 16 of the 87 (18.4%) infants had hours before discharge in study results (Table). This included 7 of 33 home in from the nursery. abnormal neonates of 36 weeks gestation and 9 of 54 risks to premature infants (21.2%)
of the monitoring trial, (16.7%)

infants recorded

of

35 the

weeks 36-week

or

less neonates

gestation

with

as
ped

part

of the

nursing

discharge

process.
than 37

At

the

discretion
were also

of the abnormalities
moni-

detected.
for

Desaturations

as low
and

as 66%
as low

iatrician,

weeks

tored. 70% for the infants that had 35 weeks or less Patients were positioned in the car seat as according to the AAP as Five of these 16 infants received a pneupolicy for 90 minutes, using blanket rolls when necessary; and gestation. pulse, respiration, and oxygen saturation were monitored with mogram, and two had abnormalities detected and nursery equipment, including System VI Infant Monitor (Air were discharged on theophylline. One infant was Shields Vickers, Hatboro, PA), Nonin Model 8800 Cardiorespiraalso sent home on a home monitor. tory Oximeter (Nonin Medical, Plymouth, MI), Neotrak 515A NeoNine neonates of 37 to 38 weeks gestation also natal Monitor (Corometrics Medical System, Wallingford, CT), or Nellcor N-200 (Nellcor, Inc., Hayward, CA). were tested. The physician request for the study in The infants were placed in the car seat in a crib in the nursery, these newborns was based on low birth weight with harness strap fastened and retainer clip positioned on the (n = 4), cyanotic or dusky spells (n = 3), irregular chest in a reclining position appropriate for infant transport and heart rate (n = 1), and unknown (n = 1). One of these were monitored for 90 minutes. Desaturations <90%, apnea 20

were

had an abnormal result. This was a 6 pound seconds, or bradycardia 80 beats/mm were noted as well as any infants repositioning or stimulation needed during that time. If symptoms 10 ounce baby who was in the regular nursery. The persisted the test was terminated. The nurse recorded all data and nurses had noted some duskiness during feeding informed the primary care pediatrician of the results. The pediafor this reason the pediatrician ordered the car trician then determined the discharge plan. For infants who hadand seat test. The baby was noted to desaturate (80%) and significant desaturation, apnea, or bradycardia, transport in an alternative restraint that can be reclined used and as a car bed become apneic and bradycardic in the car seat. The (Cosco Dream Ride) was recommended. In addition, at the discre- results of a repeat car seat test in a Cosco Dream Ride tion of the pediatrician, further evaluations including pneumowere normal. A pneumogram performed before gram were conducted on selected infants. discharge showed significant episodes of central apRESULTS From November 1992 a total of 87 25, infants 1990 through were monitored February with

nea and beats/mm), 29,

phylline. ges-

frequent and

episodes the patient

of bradycardia was placed

on

(50 oral

to 70 theo-

tational ages at birth ranging from 26 through 36 weeks (Fig 1). Only one parent, a mother of twins, During refused the test, because she did not want to delay discharge. She did, however, decide to transport herscribed baby in a Cosco Dream Ride and allowed her other countered.
baby, baby who (32 was weeks) discharged was not later, tested to be tested. Another lenge. because the mother developing

DISCUSSION

the time numerous Physician

Use of

period of implementation education

the AAP policy

the

observations issues were was the first

was critical

deenchalto

physician

support

because

it

provided

Premature
MetroWest

Car

Seat

Test

Medical Center

Fig 1. Eighty-seven infants monitored .0 U, with gestational ages at birth ranging m from 26 through 36 weeks. Study pe0 riod extended from November 25,1990 through February 29,1992.
.

U, G)

E z

34 Gestational Age

35

36

1138

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TABLE.
Weeks Oi
=

Results
87)*

of

Car

Seat

Tests:

Gestational

Ages

26

to

Abnormality 02 saturation 85-89%

80-84% 70-79%

5 5 4 80 s
abnormal result 6

5.7 5.7 4.6 1.1 2.3 2.3

18.4

36 of 90 minutes to account times that infants might served that five infants uration after 30 minutes, utes to first desaturation.

for longer possible travel actually experience. We obhad a first episode of desatranging from 35 to 75 mmGiven these results, we feel of the car seat test is an

that

the

appropriate

duration

area

which

requires

further

investigation
strict that

on

a larger

<70% Bradycardia, Apnea, 20

Any
*

beats/mm

1 2 2 Medical February Center, 29, 1992.

single

sample of patients. It also was necessary tion guidelines for

to provide physicians so

interpretathey would

Study

performed November 25,

at 1990

MetroWest through

Framingham,

have

criteria

for

action

in the

event

of abnormal

test

results as well as concrete management guidelines for infants at risk. TheAAP policy suggests that the Swinger Car Bed is a possible choice for transport of infants who fail the test. This was not feasible convincing documentation that monitoring in the car those because the Swinger Car Bed was not available loseat was an accepted professional standard of care. In and was quite costly. The Cosco Dream Ride addition, it was necessary to develop a medical staffcally can be reclined and used as a car bed was the policy which linked the AAP policy to hospital policy which only crash-tested alternative available and therefore and delineated the respective roles of nurses and recommended when an alternative restraint was physicians (Fig 2). The AAP policy statement does was required. not specify the time for observation in the car seat. In to physician support, nursing cooperWilletts report5 infants were monitored for 90 mm- In addition is essential to successful implementation of a utes including 30 minutes before, during and after ation seat monitoring program. The Nursing Service the car seat test. We chose a total monitoring period car
MA,

METROWEST
FRAMINGHAM PERINATAL AND

MEDICAL
UNION PEDIATRIC

CENTER
CAMPUS NURSING SERVICE

NEWBORN DISCHARGE OF PREMATURE

NURSERY INFANTS IN CAR SEATS

I.

As per the recent less than 37 weeks

American

Academy have

of

Pediatrics of

policy observation

(see

attached) infants all

born to

at

gestation will for possible

a period

the car in

seat

prior

discharge,

to monitor

apnea,

bradycardia

or oxygen

desaturation.

II.

General the most

policies recent

regarding American

the

safe

transportation of Pediatrics

of premature policy (see

infants attached).

will

reflect

those

of

Academy

Fig
charge

2.

Medical
of premature

staff

policy
infants in

for
car

disseats. Ill. Nursing will staff will perform the period physician. of observation as per established procedure and results

be reviewed

by the

childs

IV.

After seat

review the child

of the will

results

of monitoring

the

pediatrician

will

determine

in which

infant

car

be discharged.

V.

Ifabnormal. such

parents

are to be further seats, etc.for #{149}

cautioned a period

about

placing three

infant months.

in any

upright

device

as swings,

feeding

of at least

VI.

As even parents caution

a normal will

monitoring that

period

cannot

guarantee baby should baby

a safe

result alone

in all circumstances in a car in a car. seat and that

be informed be taken

no premature

be left

should

whenever

a premature

is transported

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1139

was reluctant to implement the policy benally, we had planned to use continuous printouts cause it represented a major change in their routine for each test, but because of mechanical failures with requiring allocation of additional personnel andthe equipment as well as problems regarding the raised issues concerning nursing liability. Nurses storage and interpretation of extensive printouts on were educated about the test by discussions which each newborn, a data collection summary sheet was took place at regularly scheduled staff meetings and, developed (available upon request). as with the physicians, the AP A policy was ultiIdentification of neonates of less than 37 weeks mately effective in convincing nurses of the useful- gestation in the regular nursery was an additional ness of the test. nursing challenge. This activity was quite significant A detailed nursing procedure to specify the details because in our experience 38% of the premature inof implementation (Fig 3) was developed to facilitate fants tested were 36 weeks gestation and therefore nursing compliance with the policy. A means of doc-fulfilled the criteria for testing. There was also a need umenting the procedure was also required. Origi- to coordinate the nursing discharge plans with Visinitially

MetroWest

Medical

Center

(Framingtiam

Union

Campus)

NURSERY PROCEDURE: Nursing born care of all infants than 37 weeks being discharged age. from the wellborn and special care nurseries who were

at less

gestational

NURSING
1
.

ACTION: bring they

the

RATIONALE: to nursery the to use for

Have

family/caretakers car seat

assembled the babys

are planning day before

the

discharge discharge. should

planned
2.

The for

infant 90

be placed in the car undisturbed.

seat

2.

The

time

for

the

observation

minutes

period feedings

should and

be between be done tIre at least planned

24 hours

before

Fig 3. Nursing

procedure for monitoring premature infants in car seats prior to hospital discharge.

discharge.
3.

Place

lead

on baby and

to monitor

pulse.

respiration 4. Place

oxygen seat

desaturation. in riding position

infant In car

in a crib in nursery. 5.
Leave Note apnea infant any undisturbed for of less than or less 20 than 90 minutes. 90%.

5.

Document
seat flow test sheet

car seat test car on

flow will sheet. become This part of

desaturation or greater equal any

than

equal

seconds 80. Document Check event. from car that

or bradycardia episode monitor 6. At end seat.

7
.

permanent

record.

and

stimulation recording remove care.

needed. same

is on and of 90 Resume

minutes routine

infant

Post who

observations will make discharge

for review recommendations planning

by physicians for discharge. witit family or

8.

Discuss caretakers

of the infant.

1140

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iting them risk

Nurses who visit that, in the event not only in the

premature of a test car seat

infants failure, the but when

to educate infant is placed

similar

position

in

other

equipment

(eg,

atic episodes of desaturation however, use a 90-minute at car seat, in contrast to the in infant Willett.

in our

patients.8

We used

did, by

observation
30-minute

period
period

in the

In addition, in Willetts studies no full-term infant feeder). had difficulty with the test. We did identify signifiAnother significant implementation issue was the abnormal examination results in a 37-week problem of parental compliance. Many parents cantly Our sample of neonates >36 weeks was, brought the car seat in late or unassembled and were neonate. a selected one in which the physicians often impatient to be discharged. However, withhowever, chose neonates for testing whom they thought might proper support from physicians these difficulties be whereas Willetts sample was selected ranwere minimized. It was felt that incorporating a de- at risk, Because the 37-week neonate who failed our scription of the program into the childbirth educa- domly. test had a highly abnormal pneumogram, we feel tion program would help to prepare parents for this strongly that physician or nurse suspicion of a probpossibility. In general, parents were able to return or lem (eg, duskiness during feeds) should lead to seexchange newly purchased car seats after discharge rious consideration of performance of a car seat test if required. However, because some parents did not these newborns may be at risk when posihave the time or resources to buy a new seat on short because upright in a restraint device. notice, it was also necessary for the hospital car seattioned a car seat monitoring program can rental program to include the Cosco Dream Ride. In conclusion, effectively into a community hospiThis facilitated the discharge process for parents andbe incorporated II discharge plan, provided that appropriate was essential to ensure compliance with the recom- tal Level medical staff policies, nursing procedures, and admended transport. support to deal with the logistics of the Administrative misgivings about staff liability also ministrative program are established. Despite a number of initial were encountered. This was exemplified first by difficulties, this program is now a well accepted part nursing concerns that they would be responsible for improper assembly of the seat. This was alleviated by our of nursery routine. asking the parents to assemble the car seat themACKNOWLEDGMENTS selves using the manufacturers written instructions.
We would like to acknowledge the support of Debbie Durgin, The issue of liability for false negatives on tested RNC, BS, Assistant Nurse Manager, Perinatal Services and Ann babies also was raised but was substantially outCollari, RN, BS, Clinical Preceptor Level II Nursery, MetroWest weighed by the concern about liability of not testing Medical Center, who helped considerably in collecting our data the baby. This was particularly cogent in our own and in suggesting improvements to our procedure. We also apthe efforts of all the staff nurses in the Special Care Nursinstitution where several years before the develop- preciate ery, whose dedication and support this program could not ment of the AAP policy we had experienced the without succeed. We also would like to acknowledge Tma-Marie Clark for death of a premature infant in a car seat on the trip her help in our database management. home from the nursery on the day of discharge. Overall, our data are consistent with the observaREFERENCES tions of Willett et al56 that premature infants are at 1 . American Academy of Pediatrics, Committee on Injury and Poison risk for desaturation in the car seat. Our failure rate Prevention. Auto Safety for the infant and young child.American Acad(18.4%), however, was substantially lower than their emy of Pediatrics News and Comment. Elk Grove Village, IL; American

reported desaturation
This may

results cutoff
have

(Table was

1) despite 90% and

from the

the fact that our Willetts was 85%. 2.

fact that our case
3.

Academy
American

of Pediatrics;
Academy of

1974;10:11
Pediatrics, Committee on Accident and Poison

resulted

Prevention. Safe transportation pital. Pediatrics. 1990;86:486-487

Bull MJ, Stroup KB. Premature

of newborns
infants

discharges
in seats. car

from
Pediatrics.

the

hos-

mix

and

method

of observation

were

not

identical.

1985;75:336-339 Willetts study took place in a tertiary care center KB. Automotive restraint systems for premawhere at least 40% of their patients were <32 weeks 4. Bull MJ, Weber K, Stroup ture infants. J Pediatr. 1988;112:385-388 gestation6 and all were from the neonatal intensive 5. Willett LD, Leuschen MP, Nelson LS, Nelson RN. Risk of hypoventilacare unit (Level III) in contrast to our sample where tion in premature infants in car seats. Pediatr. I 1986;109:245-248 14.9% were <32 weeks, and asymptomatic 36-week 6. Willett LD, Leuschen Ml, Nelson LS, Nelson RN. Ventilatory changes in infants positioned in car seats.Pediatr. I 1989;15:451-455 infants from the regular nursery were included in convalescent Academy of ediatrics, P Committee on Injury and Poison addition to premature infants from the special care 7. American Prevention and Committee on Fetus and Newborn. Safe transportation nursery (Level II). Willett also used recorded data for of premature infants. Pediatrics. 1991;87:120-122 analysis, which we, for the most part, did not. This 8. Graff M, Soriano C, Rovell K, Hiatt IM, Hegyi T. Undetected apnea and bradycardia in infants. Pediatr Pulmonol. 1991;11:195-197 may have resulted in underreporting of asymptom-

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1141

Monitoring Premature Infants in Car Seats: Implementing the American Academy of Pediatrics Policy in a Community Hospital Joel L. Bass, Kishor A. Mehta and Jeanne Camara Pediatrics 1993;91;1137
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 6, 2012