110 - Increasing rates of family caregiver holding of infants in a surgical NICU: a quality improvement initiative

Publication Number: 4108.110

Clare Howard, Boston Children's Hospital, Boston, MA, United States; Emily Serino, Boston Children's Hospital, Boxford, MA, United States; Avery Forget, Boston Children's Hospital, Medford, MA, United States; Jenna Kelley, Boston Children's Hospital, East Boston, MA, United States; Denise Casey, Boston Childrens Hospital, Foxborough, MA, United States; Kristen T. Leeman, Boston Children's Hospital, Winchester, MA, United States

Background: Infant holding is associated with improved neurodevelopmental outcomes in preterm infants and improved family caregiver bonding. Level III/IV NICUs care for a large population of surgical infants with unique barriers to holding including medical complexity, recent procedures, and support devices including lines and tubes. However, given that positive tactile experiences have been shown in a variety of contexts to improve pain perception and stabilize infant vitals, these infants are likely to have important benefits from early and frequent family caregiver holding.

Objective: Our study aims to increase rates of family caregiver holding for surgical infants in the Boston Children’s Hospital NICU from a baseline rate of 72% to greater than 80%.

Design/Methods: Our multidisciplinary team conducted baseline surveys of staff to identify barriers to parent caregiver holding and develop a key driver diagram to identify drivers and change concepts. Outcomes measures included the rate of eligible surgical team infants that are held by family caregivers. Process measures included the rate of reported “unknown holding eligibility.” Balancing measures included rates of unplanned extubations and dislodgements of tubes and lines. PDSA cycle interventions included identification of multidisciplinary holding champions, addition of holding eligibility to daily rounds discussions, and revision of the unit holding guideline to clearly define eligibility.

Results: Baseline survey data identified the following barriers to holding: family caregiver presence and hesitancy to hold, line and tube safety, lack of communication of holding plan among multidisciplinary team. Audit data was collected from July 2024 to Oct 2025. Our process measure, average rate of “unknown holding eligibility,” decreased significantly from 9.1% to 1% after our first intervention with special cause variation on p chart analysis (Fig 1). The outcome measure of the rate of family caregiver holding in eligible infants has remained 72% with an initial trend up after project start, but no significant change over the study period. The highest identified barrier to holding was family caregiver presence at the bedside and when subset data was limited to only babies where family caregivers were present on the unit, overall study period rates were higher with rates of 86%. No difference in the balancing metrics of unplanned extubations or dislodged tubes was found.

Conclusion(s): Opportunities exist to improve the frequency and timeliness of family caregiver holding in level IV NICUs. Next steps include additional PDSA cycles focused on ongoing barriers to holding.

Rate of Unknown Holding Eligibility July 2024 - October 2025
Figure_1.pdfControl chart showing the percentage of babies with unknown nursing eligibility over the study period. PDSA cycles are labeled. UCL = upper control limit, LCL = lower control limit, CL = center line.