Thermoregulation of the neonate with Dr. Jessica Jones

Ben Courchia, MD:  Hello everybody, welcome back to the incubator podcast. We are back with a new episode of our special series on thermal regulation. And today we are joined by none other than Dr. Jessica Jones. Jessica, how are you this morning?

Dr. Jessica Jones:  I'm good. Thank you so much for having me.

Ben Courchia, MD:  No, it's a pleasure to have you on. I'm just gonna go through your bio quickly for people who are not familiar with your work. You are a nurse practitioner with 21 years of neonatal nursing experience. You've practiced as an NNP for the last 16 years, and you're currently the coordinator of advanced practice providers with Pediatrics Medical Group in Tampa, Florida. Shout out to our home state. She's, you're also the, you're also a clinical assistant professor at Baylor University's Louise Harrington School of Nursing, and you completed your Doctor of Nursing Practice degree at the University of Florida in 2023. Your areas of interest include management of ELBW infants, thermal regulation, obviously, as this is the topic of this episode, fluid and electrolyte management, as well as improving communication between nurses and physician through education. Jessica, thank you so much for making the time to be with us today.

Dr. Jessica Jones:  Thank you so much. I'm really excited to be here.

Ben Courchia, MD:  My first question has nothing to do with hormone regulation, but I am looking, I was looking at your bio, I was doing research for this podcast and it seems like you have had a career where you've always looked for that step to continue getting both personally and professionally better on your own, but also providing a tremendous added value to your team. I'm wondering where does that, for many of us, we're always looking for, one day I'll arrive at this stage.

Dr. Jessica Jones:  All right.

Ben Courchia, MD:  And I'm done, you know, like it's the student syndrome, you know, you're, you're in nursing school, a medical school, and you say, one day I'll be a doctor. And that's it. And I'm done. But I see someone like you and it looks like you're never done and you're always reaching. And I think that's kind of fun and that's kind of cool. Where does that passion come from?

Dr. Jessica Jones:  Yes, yes. Yes.

Dr. Jessica Jones:  Um, I honestly have to kind of attribute that to my parents. A lot of it was how I was raised, just kind of always striving for excellence. And my, you know, my dad, that voice in my head, um, you know, never do things halfway. And so that's kind of been my, my life's work is to, to be like that and also to impart that into my children. And so, um, to be honest with you, when I graduated from nursing school, many moons ago, I never considered becoming a nurse practitioner, but my mom harassed me to the point where I was like, fine, I'll do it, you know, and now I couldn't be more grateful, um, that she really kind of.

Ben Courchia, MD: Mm-hmm. Right.

Dr. Jessica Jones:  have got me to that position. And I was fostered in a NICU that had such a growth mindset. And I really, I've worked with some amazing neonatologists as a nurse and they are now my colleagues. I work side by side with them. And so I think really having an environment that was healthy and fostered growth and learning and piqued that interest really is what did it for me.

Ben Courchia, MD:  I love that answer. And I think the growth mindset that you're mentioning is sometimes something that could be very scary for institutions because it involves maybe a leap of faith on the part of, of the team. And I'm wondering for you, what did that growth mindset look like, um, with the team that you were working with?

Dr. Jessica Jones:  So I think definitely in the beginning, it was interesting because when I was training as a nurse practitioner, as a student, it was kind of still where NNPs were a new concept. So there were no nurse practitioners in our unit. The neonatologist who did my clinical training while I was in school kind of didn't know what to do with me. So they essentially trained me like a fellow. One of the neos, which is at the end, middle of the 24 hour, 30 hour shift would say, just don't call me unless somebody needs ECMO, you know, pretty much that kind of mindset. So it was a lot of it, you know, throwing you into the deep end,

Ben Courchia, MD:  Mm. Uh-huh.

Dr. Jessica Jones:  But it was just never being afraid to ask that question and always the whys, the whys, the whys, going back to the whys and that's my mentality now and in talking to nurses and teaching the future generation of nurse practitioners just remember why are we doing what we're doing.

Ben Courchia, MD:  That's great. Yeah, I think that's such an important point. As a nurse practitioner, I feel like it's sometimes can feel like a huge upgrade on the amount of responsibilities that you carry going from nursing to being a nurse practitioner. And yet for you, you continue to look for opportunities to participate in quality improvement initiative, research activities. I feel like when I was a fellow, and I started these things, you feel a very big sense of imposters and it's like, I don't know, I don't know how to do that stuff. Like, what do you mean? Like, I'm gonna take on this clinical question. And I think this is something that we all go through in the first things that we tackle. Was that something that you, not struggled, but something that challenged you and how did you overcome this particular aspect of growing into this new role when it came to quality improvement research and other activities?

Dr. Jessica Jones:  I mean, it's definitely something you hear about, right? That imposter syndrome. And thankfully, I mean, I've been a nurse practitioner for so long, I feel like that's kind of, that door has closed as far as feeling like, oh, what am I doing? But definitely my role is as a new faculty and as kind of trying to launch quality improvement initiatives and having these discussions, you start to kind of question, like, am I really equipped to do this? And I think, again, having a strong team surrounding you saying, hey, we can do this, let's do it together. What are those questions that you have kind of enforcing yourself into the uncomfortable area, right? If I don't, I don't know a lot about this. We tend, our nature is just to stay away from it, right? Well, I'm just not even gonna, you know, but no, just...

Ben Courchia, MD:  Yeah, we don't want to seek discomfort.

Dr. Jessica Jones:  Yes, yes, and kind of forcing us ourselves into that discomfort zone and saying, okay, I don't know a lot about thermoregulation, but let me just start reading. Let me just start looking into it. Let me just start putting myself into those positions where I'm going to have to know more, which is a hard thing to do. But that's kind of what I've had to do with myself as I kind of go to that next chapter. Okay, let me just look more into this. Let me start reading more about quality improvement and evidence-based practice and not just, you know, okay, I see this research study idea, but really how did that even come about? How did they develop that clinical question and how did they get the nurses on board and how did they get the neo team on board and bridge that gap between everybody? So definitely kind of forcing yourselves into that uncomfortable zone has been what I've had to do to get to that point.

Ben Courchia, MD:  Mm-hmm.

Ben Courchia, MD:  Yeah, for me, that was when I started drafting my first protocols. I'd like the question I was familiar. I was like, okay, I can draft a question. I had the literature review pretty well. I had it down. Like I had read the papers, but then you're like the stats and it's like, Hmm, don't know how to do that. Uh, and where do we go from here? And like you said, I think it's about learning. I think to me, what you're describing is learning the skill to be able to roadmap your way to success because you're not like, you're not, it's not the matrix, you're not going to press a button and all this stuff is going to be downloaded into your brain.

Dr. Jessica Jones:  Yes.

Ben Courchia, MD:  but being able to say, all right, I'm gonna leverage this resource, that resource, and slowly make progress, I think, is something that we don't recognize as much. So our topic of the day is thermal regulation, and I wanted to ask you, of all the aspects, I mean, everything in neonatology is up for question, up for debate, up for reassessment, but what drove you to thermal regulation specifically? Does it have to do with your background or is this something that happened one day in the unit? Where did that come from?

Dr. Jessica Jones:  Thanks for watching! I think yes to all of that. I think one of the things that I love about thermoregulation is first and foremost, I'm a nurse. I'm a nurse at heart. That's where I started off is at the bedside. Thermoregulation is a clinical practice that really is fully nurse-owned. They're completely autonomous in that area with ventilatory support and RDS and you're looking at sepsis or cardiovascular issues within the baby. It's definitely a team effort obviously and you need RT's help and physician help and input and all of those things, but thermoregulation, like that's, that's fully on the nurse. And in a world where sometimes nurses, I feel like, don't feel like they get the respect or they don't really have a voice. This is where you have a voice. And not only do you have a voice, you have the opportunity to make a huge impact on the outcomes of your patient. And when you look at those statistics, you know, that, that 28% increase in mortality with one degree Celsius below, you know, a normal admission temperature on those elbow babies, that's a huge impact that you have right off the bat.

That's what kind of drove me as a nurse, being able to look at my fellow nurses and say, hey, you have the opportunity to really make a huge impact on the outcome of your baby. And let's start with just that basic vital sign, right? Thermoregulation. You have control over that. You have full autonomy over that. And so let's run with it. And then just looking at our statistics and some of the issues where we were struggling within our own unit and saying, okay, we identify a problem of admission temperatures being an hour, you know, our admission temperatures are great, but at one hour of life, all of a sudden, now we've overheated the baby or now we're, you know, we've done too many procedures and left that baby exposed to the elements for too long and now their temperature is low. And so just kind of, again, something that's a, you know, should be an easy fix. And looking at that, we always talk about like that low hanging fruit, right? Let's give them a win. Let's do something that we can give them full autonomy over and set them up for success because that's what you build on, right? 

Hey, look, this quality improvement , we went from 25% abnormal or hypothermia hyperthermia on admission to now we're 98%. Great job. And let's build on that. Now let's look at what our temperatures look like in the first six hours of life. And the nurses are encouraged because they've seen the success. They've seen that they've had a say in this. They've been able to contribute to that team and to the outcome. And so just kind of starting with that low hanging fruit and then building with that.

Ben Courchia, MD:  Yeah. So many things to unpack there because I think thermal regulation, I don't know if you agree, is kind of the perfect example of how perfection can be the enemy of good enough, where we try to do so many things during golden hour. Try to do so many things in a certain way that sometimes thermal regulation gets forgotten and then you realize that you're finicking with maybe, I don't know, with a line, with something and then you've forget that there's an aspect of the care that has dramatic impact on morbidity, mortality as well. And so I think it's interesting that you mentioned that how as institutions sometimes try to improve on A, B, C and D, and then finally realize, shoot, we now have made, we've regressed on the, in the process of thermoregulation. How do you guys navigate that to, because the same way that we have bundles that we put in place to minimize certain outcomes. I feel like thermal regulation is part of a bundle where we try to think of all sorts of interventions that we would like to accomplish all the while in a timely manner and do it in such a way that the baby's temperature is maintained. How did you guys tackle that practically speaking?

Dr. Jessica Jones:  So really giving the nurses a voice, to be honest with you, because again, you're looking at group dynamics and you're looking at, okay, well, we've got these neonatologists or NMPs who are putting in lines and that's their area of expertise. And they obviously, baby needs IV access and all of those things. Well, the nurses kind of sometimes end up feeling like they're taking a backseat and when do I speak up? That's a huge issue of the climate and the type of environment that you're working in. And so really, again, empowering these nurses with the education. I can talk about that in a little bit, but to give them a voice where we say like, Hey, thermoregulation is important. And now at 15 minutes, every 15 minutes during that golden hour, we do a temperature check. It doesn't matter what you're doing, who's putting in lines, who's giving servanta, you know, what they're doing, but we stop and we get a temp check and we document to make sure we're still in a good position with that baby so that an hour into it, you know, we don't all of a sudden take a temperature and we're two degrees below our target. And so again, really focusing on communication and empowering nurses to feel like they have a voice. And thankfully we work in a really healthy environment. I can't speak enough about our practice where the nurses do feel like, hey, I'm heard. And the neonatologists and the advanced practice providers respect them enough to stop and listen. And I think really fostering that type of environment is crucial.

Ben Courchia, MD:  Yeah, it's interesting that you mentioned that because obviously this series on thermoregulation has, we have a five part series involving doctors and nurses, but what's interesting is that this message has been echoing throughout the series where doctors have been saying also the same thing, where they said we've sort of grown into this new reality where thermoregulation has always

quote left to the nurses and we completely ignored it. And now there's this realization that yes, the nurses are in the driving seat, but we have to be this co-pilot that helps them achieve this outcome. And how do we do our things to allow them to be successful at achieving thermal regulation and then become active members of this initiative? And I think this is a huge shift, um, in our way of practicing. And, and I think that's, that's probably going to be one of the big takeaways of this series. Did you encounter any resistance from this new dynamic? I know you've been praising the team, so I'm assuming you're going to say no, but I think change is always difficult, especially in the ICU because it's such a high intensity environment.

Dr. Jessica Jones:  Yes.

Dr. Jessica Jones:  Yes, yes. And I think, honestly, I can't say we received a lot of pushback or challenges. I think the biggest thing is learning that it's okay to speak up. And in fact, we had a bedside lap done a couple of weeks ago and, you know, surgeons can be scary, you know, even 21 years into this, pediatric surgeons sometimes can be a little intimidating. And we, you know, as a tiny baby who needed a, you know, a drain put in and, you know, they're cleaning the site of course, voided all over the bed. And I said, like, you know what, let's just stop. And I asked the surgeon, can we just take a minute? We'll get a warming mattress to put underneath the baby. We'll get some hats, all of those things. I said, I know that's not a huge, you know, important thing to you, but for us that thermoregulation. And she actually stopped. She said, you know what, I appreciate that because we're now seeing the outcomes of temperature regulation and thermoregulation on babies from surgical outcome standpoint. And so absolutely that's one of their initiatives. So I would not have known that if I not, you know, had not kind of stopped and spoken up, which again, even 21 years into this can be a little bit intimidating, but that's where I think again being able to arm these nurses with the knowledge and the statistics to say like, Hey, this does make a difference. And I know that it does. And here's why. And so I think that has been one of the biggest takeaways for me is always, you know, being ready to have that, that answer of like, okay, well, here's why we're doing what we're doing and making sure that nurses feel comfortable and educated enough to be able to speak up. But thankfully, no, there wasn't too much pushback because everybody wants to know about those outcomes. When you start talking about thermoregulation and obviously mortality and outcomes, but even the way that affects fluid and electrolyte balance, right? Your use of humidity. And you look at, okay, well, you've got excessive, you know, water losses and that leads to increased risk of PDA and IVH and BPD because all of the ways that we manage that. And so it does spiral out. And so again, it kind of looks like, well, we're just talking about a temperature. But when you look at those key outcomes that we're looking at from a Vermont Oxford Network standpoint, you know, those are all key drivers, right? IVH, BPD, huge benchmarks that we look at. And it all, in my head, kind of starts with regulation, thermoregulation.

Ben Courchia, MD:  Right. What does that education, I guess we can call it this way, of the team and the staff about outcomes look like? Because it's one of these things about thermal regulation where the data is very impressive. And I think if you were practicing in an isolated part of the world with no support whatsoever, you might see a very dramatic difference. But when you're talking about the United States, which is a developed country and with all these resources, sometimes it can be difficult to see the change and to grasp the effect of what we're doing on our population because thankfully our outcomes are good and we have good survival. So how do you provide that education to the team and how do you go beyond the one slide with the number on it to try to get people to grasp the magnitude of what these little changes can have on the baby and your population?

Dr. Jessica Jones:  Yeah, that's a great question. And it's something I'm actually really excited about. One of the things that we came up with, some of it stemmed from my doctoral project that I was working on, looking at thermoregulation and the use of humidity in this patient population. But one of the things that kind of stemmed from that was a class that we started developing myself and Jane Solomon, who is a dear colleague, brilliant woman. She's in charge of all of our quality improvement outcomes. But we titled it Care and Calculations. And it was a kind of free class that we set up. I come up with my first one was on fluid and electrolyte balance and fluid management in this patient population developed my PowerPoint presentation and we offered it at two times during the month of I think we started in February and we had the support of our hospital management so they actually paid the nurses to join online via Teams from home. 

Ben Courchia, MD:  That's an unlikely occurrence to happen, by the way.

Dr. Jessica Jones:  That was 100%, because it is hard to say, hey, on your day off, nurse who is already tired and overworked and probably working overtime because of staffing issues, will you just, you know, yes.

Ben Courchia, MD:  Let me stop you right there. The business world, it is very well accepted that if you are attending some form of training for your job, you are paid for the time you spend training. And when I spoke to my friends who are working in whatever accounting and all these things, and you tell them, yeah, my day off and they're like, you get paid for this, I'm like, no, I'm just do this for. And they're like.

Dr. Jessica Jones:  100%. No, it's just expectation, professional expectation, right?

Ben Courchia, MD:  It's nuts.

Dr. Jessica Jones:  Yes, 100%. And then you think about, well, why are nurses getting burnt out? Because we're asking so much of them, right? And so that was a huge win. And again, I speak to the culture in our unit. But having that support from the administration to say, hey, we'll pay you for that hour that you're logging in from home. We try to do one in the morning, one in the afternoon to capture both night shift and day shift nurses. We don't want night shift nurses to feel left out. And so we sat there. I did the lecture on teams. We had a couple of practice questions,

Ben Courchia, MD:  Shoot.

Dr. Jessica Jones:  Here's again why we're doing what we're doing when you're looking at protocol or when we look at why we're concerned about the effect of humidity and insensible water losses on the outcomes of this baby. Here's why. And we really kind of just went back to basics and gave them that knowledge. And we've done that pretty much every month. We've had a topic, hey, what are you guys worried about? What's going on in our unit? Are we having some issues with light onset sepsis? Okay, well, let's look at that and let's look at what contributes to that. Let's look at how the physician's management of it impacts your role as a nurse. And so that's one of the things that we did.

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  something that I'm super proud of. I love, I wouldn't have been able to do it without the, you know, again, the support of the team and the administration, but we've had those classes and the nurses have, I mean, showed up in droves. I'm really proud of them for really taking ownership of it and saying, okay, this is something that we wanna do. And it's empowered, it's, I think, led to better communication during multidisciplinary rounds. It's led to them feeling more empowered to go up to the physician and say, hey, I see this, you know, your sodium looks like this and I'm worried about this having, you know, just empowering them to have those discussions, I think, has been a huge, huge factor in it.

Ben Courchia, MD:  Absolutely. Yeah. I mean, it's such an important point as well, just because of the fact that there's not a big investment on the part of the community at large when it comes to education of healthcare professionals. Even, I think I can speak on behalf of nurses and doctors and everybody else. There's not a great way to keep up. It's really the burden is on the individual. And for a lot of us, there's other forces and it's difficult to find the time. So I think this is huge and the fact that the hospital is supporting this in a meaningful manner, not just saying, hey, go tap on the shoulder, great job. I think that's huge. That is huge. Yeah, exactly.

Dr. Jessica Jones:  Here's your pizza, right? That's your free pizza for lunch. So no, I do, because especially when you look at the demographics of most nurses, you know, like they're moms, right? Like it's a great career. I've got four children of my own. And so asking them to do even more on their time off, it's a lot. It's a big ask. And I think that's when you, as physician provider groups, also have to kind of look and say, how do I invest in these nurses, right? How do I foster an environment that makes it healthy and safe for them to ask those questions because guess what? You're being held accountable for those outcomes of IVH and BPD and PDA, right? It's all of that is tied together. Well, guess where it starts? It starts at the bedside, truly. And so if those nurses aren't your best friends and they don't feel comfortable coming to talk to you, there's going to be some trouble. And I think really going back, like you said, you're talking about like physicians that really kind of never paid attention to thermoregulation, you know, to a certain extent. I don't know that many of them know how to work those incubators and, and do all of that.

Ben Courchia, MD:  Right. Yeah, that's right.

Dr. Jessica Jones:  And so making sure that we foster a healthy environment is crucial.

Ben Courchia, MD:  Yeah. And so going back to that aspect, obviously, of trying to improve thermal regulation, we were talking earlier about sometimes the tasks we take on and how difficult they can be. I mean, thermal regulation, I think, is particularly a difficult one, because when you're looking at trying to improve this particular outcome, so many factors are involved. Every aspect of what we do, if we are, and I think this applies both for just right after birth.

And when we were talking like this about surgical babies who are being operated on, I think you're looking at it and everything we do affects the more regulations. So how did you guys approach this in a systematic manner so that you could not get overwhelmed by the task and actually make a dent on a progressive basis?

Dr. Jessica Jones:  Well, I think some of it was just going back to basics, right? I think once we kind of get comfortable, we start cutting corners sometimes. We start not necessarily doing things the right way. Um, and nobody wants to be that person that's like, Hey, we're not supposed to do this, but I think them knowing that this was kind of a focus of mine, especially through my doctoral project, I started going, you know, when I was going to some of the elbow deliveries, I noticed the nurses were cutting open, um, that, that polyethylene bag, right? They were just kind of laying the baby on it and just kind of cutting it open. Cause of course you need to access to the baby and all things but also completely, you know takes away the purpose of that bag, which is to maintain those, you know, the thermoregulation and minimize this insensible water losses. So even going back like, Hey guys, we're not supposed to be cutting the bag open. The baby's not just laying on a plastic bag and it's soaking wet. So let's make sure that we're doing things the right way. Which again, nobody wants to kind of be that, you know, the police officer, but looking at chart audits and again, kind of reminding like, well, here's why we're doing what we're doing. And although it can and the breath sounds and things like that, there's a purpose to it. And so just starting back with looking at what are we doing right now and are we doing it effectively in the way that it's meant to be done? And that in of itself can take some time. And I think that's what's hard to grasp. I think sometimes as healthcare providers, we want those immediate results. We wanna give that medication and see the result right away. And so knowing that those PDSA titles can take some time to kind of go through and pinpoint, okay, what exactly is the problem? Or you go through one cycle

except one problem, but that's opened up the door to a whole other problem, right? It's never ending. And so I think that's some of the challenge of it for sure. Yes, 100%, yes.

Ben Courchia, MD:  I've been there. Yeah. I think I know the answer to this question, but I'm gonna ask it anyway. How do you make sure that, like you said, you don't wanna be the police and policing people around, but how do you walk that fine line in order to get things to improve without hurting your stock within your team that people then just see you and they're like, ugh, here she comes.

Dr. Jessica Jones:  Yes.

Dr. Jessica Jones: Yeah, 100%. I think a lot of it, I think a lot of it comes down to relationship, truthfully. I take a lot of...

Ben Courchia, MD:  I know the answer you're going to give, but I feel like people need to hear it.

Dr. Jessica Jones:  you know, a relationship with everybody, and then also a sense of humility and recognizing like, hey, I'm struggling with this too, or this is an area where as advanced practice providers we're not really doing great, or as physicians where we need help with that. And so really approaching it from a position of humility, but then also you have to have a relationship there in any type of scenario. And that doesn't just go down to medicine and nursing, but you know, in any area where you have to bring correction, to come from a place of, you know, of respect and relationship. You know, I can correct my kids or, you know, or correct a friend, not even correct, but just say like, hey, maybe we need to work on this or do this a little bit better when there's an established respect and relationship there. And I think that is where we get into the weeds a lot as advanced practice providers and as physicians and as nurses, there has to be a mutual respect and relationship in order to kind of have those hard discussions.

Ben Courchia, MD:  Yeah. And I think also the fact that you've involved them in the process, uh, makes it a fair endeavor and not just like, Hey, you have no voice in this. I tell you how you do it and you just do it. And yeah, I think that's a, yeah.

Dr. Jessica Jones:  Right, here's what you do. 100%. Yeah. And I just, and I do think, you know, I realized we were kind of having some, some challenges at our level two hospital a while ago, you know, and I'm like, why aren't they following the protocol? There's a protocol written for this. Like it's an easy, you know, like, why are you calling me at three in the morning? And I realized because the nurses didn't understand why they were doing what the protocol told them to do. Right. And it doesn't matter as nurses, you know, you're, you know, your license is on the line and they're going to call you if they're uncomfortable. And so kind of again, went back to like, let me explain to you why we're doing this and educating them and that helped tremendously where it wasn't just this authoritarian, you're going to do this and we're not asking your input. And so that has been a huge part of it is bringing the nurses into those conversations about writing protocols, writing guidelines for sure.

Ben Courchia, MD:  What has, you've mentioned the relationship between nursing and physicians, and you were talking about how you guys really honed in on communication. Can you tell us a little bit about what that looks like and how granular you guys took this on?

Dr. Jessica Jones:  Um, well, one of them was, you know, we don't, we're not a traditional teaching facility, so we don't have fellows. We don't have a lot of that environment where you've got three hour teaching rounds going on and things like that. And so one of the biggest things that we were trying to transition to was nursing led multidisciplinary rounds. We had always had it where the physicians kind of presented the patients and the nurses would maybe chime in if they felt comfortable enough to speak up about the patient or what the plan was. And so we really wanted to kind of reverse that and make the nurses.

Ben Courchia, MD: Mm-hmm.

Dr. Jessica Jones:  Feel more involved and invested in their patient care and again that kind of went back to okay Well, why don't they want to present to these physicians? Well, they were nervous about it, right? Nobody wants to look stupid. Nobody wants to feel like you know, their voice doesn't count So we had to go way back to you know, okay, let's start with the education. Here's a script. Here's why we're doing it Here's how you calculate fluids. Here's you know, how you interpret your CBC. Here's what we're looking for And so it definitely takes a lot of work and investment in time and resources to kind of go back to that, and making sure that the nurse is new. Like, hey, you should feel respected, you should feel heard. Now, granted, that doesn't mean that we're gonna do everything that you want us to do, right? There's a balance that has to be had there. And I don't know that we have it perfectly, but we definitely have a lot of dialogues back and forth about, okay, well, and I think that's, again, one of the things that I love especially about my role is I feel like I do speak both languages. I can go to the nurses and say, well, like, no, here's what they meant, where we're doing it. But then also go to the physicians and say, well, like, well, here's what the nurses are concerned about, right? They're the ones at the bedside for 12 hours doing what we're asking them to do. And so trying to translate between both roles, for sure.

Ben Courchia, MD:  And I think that makes a case for the value that people like you nurse practitioners with that dual background bring to the team in order to cement a good relationship between the nursing body and the physician body. I think that's again another great example of that. I wanted to ask you a little bit about taking on thermal regulation as a project. I often say on the podcast that there are some very, quote, sexy projects to take on where it's like, hey, if I take on plant extubation or if I take ventilator days, it's amazing. You then, less ventilators at the bedside, you look like a rock star and it's like, oh, look at that. We have much less BPD, this and that. Exactly. And there's some projects that are what I call the building of the highways, right? It's like, you build the highways, it's slow, it's long, it's not pretty, but then you think like, how would we do it without, how would we do without the highway?

Dr. Jessica Jones: Yeah. Yes, yes. Saving money, yeah.

Ben Courchia, MD:  And I feel like thermal regulation is one of these projects where it's not really tangible. Like there's not like one less machine at the bedside. There's not like one less device, but yet we know from the evidence that it, that it is a critical aspect of care. Um, what, what has been the, you've, you've been working on this for some time. It's not something that you've taken on and dropped within a few months. So what keeps you from returning to the, to the aspect of, of achieving, um, good temperature in your patients, and what is the feedback that you're getting from the staff, from the patients themselves, from the data that really reinforces this cycle of, we can always get better at this.

Dr. Jessica Jones:  Well, I think one of the hard, you're absolutely right. One of the hard things about thermoregulation is you can't always see the impact that it's making, right? You don't count that baby that didn't get the IVH or that baby that did not have that poor outcome, right? And so in some ways it's kind of intangible. You don't see that immediate result. And so it's hard because nurses want to see, hey, like, you know, we're doing, you know, X, Y, and Z, or, you know, we're doing surfactant or CuroSurf or whatever it is, and now we're down to 21%.

Ben Courchia, MD:  Yeah. Something we did exactly. Yeah. Tangible. Yeah.

Dr. Jessica Jones:  Weaning off the ventilator, like something that you can see, yeah, something that's super, you know, I can hold this in my hand and take, yeah, take pride in that. So it's definitely, you're definitely playing the long game. And that is the hardest thing is to keep the nurses and all of the, you know, everybody involved in the project and at the goal in hand because you're definitely playing the long game. And so, you know, one year, two years later, being able to look at, okay, well, our BPD rates are this and our mortality rate is now this.

That is what is hard. I think our physicians, we do have meetings every year. We call it the state of the unit. Not my title, I wish I would have come up with that. But our neo group does present our outcomes. Like here's where we are with IVH, here's where we are with BPD. So it is something where the nurses can see and help it to be tangible. But I think just keeping in mind, like you said, is that you never really have arrived. And I know that we do focus on that 28% statistic right but there's also a 2021 study that showed that the mortality rate for newborns in general who become hypothermic is five-fold higher when they become hypothermic within the first five days of life right so you have to take those tiny baby steps okay we're looking at the golden hour now we're looking at the first six hours but also reminding the nurses like it doesn't just stop at that after that first 72 hours these especially those elbow

Dr. Jessica Jones:  And even again, when you're talking about, we don't think sometimes about using humidity to help maintain thermoregulation, right? Like we kind of sometimes compartmentalize where there's humidity and then there's temperature, but making them understand how it all kind of works together and how that humidity is tied to insensible water losses and those insensible water losses can affect how we manage the baby. And then that affects BPD rates and PDA rates. And that sometimes you don't see until four weeks out, you know? And so I think just having those constant conversations, which again, I think is can be exhausting and tedious, but putting your mind to it and saying, no, we're going to force the issue. I don't know, people may cringe when they see me coming through the unit and asking those questions about temperature. But I think also when it becomes part of the culture and it's something that they get used to, like, all right, we're going to be asking what the temperature is. And it is hard, especially in the delivery room, right? We're worried about the airway. We're worried about securing an ET tube and all those things. And so I'm always the one that says, hey, let's put that servo probe on now. Let's not wait till we get upstairs, get the temperature. And so it is one more step. And I think a lot of it is putting it and that's sometimes on the providers like, Hey, let me not forget this last part. And like, let's motivate the nurses to do this and really work side by side with them.

Ben Courchia, MD:  So as we're getting close to the end of this conversation, I have two more questions. I guess my first question, and I'll end with the other one after that, but you're talking about temperature probe, you're talking about equipment. How important is it for the entirety of the staff to be familiar with the equipment that they have in order to achieve the goals that they set for themselves? Because that is something that to me sparked this whole mini series where I accidentally set.

Dr. Jessica Jones:  Mm-hmm. Okay.

Ben Courchia, MD:  I say accidentally because I had not intended to be there, but I had sat in on an in-service for our incubators. And I was like, I didn't know all these features were there. And then I realized that I'm working with a wooden stick here, and there's all these things that I could be using. So how did you guys leverage this to actually get the providers to be familiar with the technology they have available to achieve your target goals for thermal regulation?

Dr. Jessica Jones:  Mm-hmm. 100%.

Dr. Jessica Jones:  That's a great question. Well, one of the things that stands out to me is an experience that I had as a relatively new nurse practitioner. And I was working with a colleague and the baby came, or sorry, the baby didn't. The nurse came to us and said, hey, baby's temperature's all over the place, unstable. And where do you go? Like next, it's to a septic workup, right? And so I kind of stopped and said, well, wait, what is your temperature inside the incubator reading? They're like, what? And so go to the bedside and go start troubleshooting, correctly, it wasn't reading correctly, it was causing the baby to have some temperature instability, right? But the provider who's working with me did not necessarily know how that incubator worked. And so we were literally headed down this huge road of septic workup, you know, IV pokes, LPs, antibiotics, for just a knowledge gap that was there and that has just continued 17, 16 years later to stand out in my mind. And so I'm a big advocate of knowing how to use your equipment. When we have our nurse interns coming through the unit, I don't just give them the talk on the thermoregulation. I tell them, hey, go find an empty incubator, turn it on, see how it works. Because we don't use it to its fullest capabilities a lot of the time. We don't look at the trends and how it monitors trends, right? And sometimes you don't necessarily

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  won't see the baby's temperature drop low or go up high because the bed is doing the work for them, right? And so really understanding how the bed works is key, I think, to being able to maintain a thermonutral environment and making sure that the baby's temperature stays stable. We found out we were using the wrong temperature probes. We, somewhere along the line, you know, somebody found some that were cheaper and who doesn't want a cheaper, you know, set of temperature probes and so that's what they started ordering. We'll come to find out they were not the correct probes for what we needed.

Ben Courchia, MD:  Right.

Dr. Jessica Jones:  And so just little things like that, again, which sometimes I don't think we always look at, but they make a huge impact. As soon as we started changing out and used the proper probes, all of a sudden, we had a lot better success with our thermoregulation initiatives.

Ben Courchia, MD:  Do you think it is important for physicians as well to be familiar with that? Because I think that, as you said in the beginning, we tend to think that the nurses are in the driver's seat of this endeavor, but we also don't understand all the complexities that could be involved in the tech and the baby and all that stuff that can sometimes say, oh yeah, just put a blanket on it and it'll keep stay warm.

Dr. Jessica Jones:  100%. And I do think, I mean, when you consider how much people are investing in the equipment, truthfully, to not use it to its fullest capability really is a shame. And so I think it's absolutely important for the physicians and the advanced practice providers to understand how it works so that you can know what questions to ask. So when a nurse comes up to you and says, hey, the baby's temperature is now reading 35 degrees Celsius, and you want to start, well, let me give you the answer on how to fix it. OK.

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  what the actual problem is, there's an issue there, right? So being able to even understand which questions to ask is key and the only way to know that is to understand how the equipment works.

Ben Courchia, MD:  Mm-hmm. Yeah. Yeah. My last question for you today, Jessica, is you've demonstrated your degree of meticulousness and how you have an ability, I think through proper communication to really set the expectation for your team and show them that not only the expectation is at a certain place, but that they have the ability to reach that expectation. I think that's something that came quite transparently to us through this conversation. Can you tell us a little bit about the ripple effect of this, when you're talking about thermal regulation on how the team in your institution looks at achieving excellence in other areas, not just thermal regulation. Is that something you guys observe where the standard is raised across the board, even though you're not really sometimes picking on other aspects of care?

Dr. Jessica Jones:  Oh, 100%. I think because I do firmly, I'm obviously I'm biased, I'm a nurse, but I think it all starts at the bedside. And I think when you empower nurses and that you educate them and you really give them the ability to feel like they have a say, it, there is a hundred percent of ripple effect. And when you feel like, Hey, I can go to you with a problem now because there's a mutual respect there. Um, and I'm confident that I'm not going to get yelled at or belittled or any of those types of things. I think now more and more we see, you know, we're talking about, you know, having a psychological, you know, safety in the unit and feeling comfortable and how it so much does impact your overall outcomes. And I think that when you expect excellence out of everybody with the, but you approach it from a, from a place of humility and respect and relationship, I think it can't help but in effect all the other aspects of your team and the way that you work together.

Ben Courchia, MD:  I love it. It's sort of what we say at the incubator that we always say we have ambitious goal but in a humble approach. I think it is a good recipe. I love that, Jessica, thank you so much for making the time to be with us today. It was a great conversation. I think we learned a lot about how to approach aspects of quality initiative and I think you've gotten me at least excited about thermal regulation. So thank you for that and thank you for all the work that you do.

Dr. Jessica Jones:  Thank you so much for having me.

Ben Courchia, MD:  Thanks.