History-making birth of octuplets brings best out in neonatal nurses

Memorable event confirms nurses’ belief in their training, professionalism

Imagine losing control of the normal routine in your intensive care unit, while hordes of reporters, photographers, and curiosity seekers invade your floor trying to get a glimpse of not one but eight of your critically ill patients.

The world may have celebrated the Dec. 20 arrival of the Chukwu octuplets — but for the hard-working neonatal nurses at Texas Children’s Hospital in Houston, coming to work each day under the glare of public scrutiny was anything but festive.

Adequate staffing, equipment needs, security, and patient confidentiality were paramount issues on the minds of nurse managers and staff at the facility’s neonatal unit.

More than two months after the infants’ arrival, those nurses are now beginning to look back on the historic event. Despite the pressure of hosting what initially were the world’s only surviving octuplets, the business of patient-care in the 48-bed neonatal ICU went surprisingly well, the nurses recall. Looking back, they credit the benefit of solid nurse training and professionalism for the outcome.

But make no mistake, the buzz surrounding the births was intense. From the earliest, nurses tried to make certain that once the critically ill preemies were placed in their hands, life in the nursery would be normal. At moments, however, conditions seemed doubtful.

Working in any ICU is stressful. Suddenly for some, it got tougher. Everyone learned to adapt as the days wore on, according to one nurse. "It’s been interesting," says 25-year veteran Pamela L. Marrs, RN, with a trace of irony. The remark leaves one wondering what she really meant.

Expectations were suddenly exceeded

Until a week before Christmas, a Sunday, when the infants arrived, multiple "prematures" at Texas Children’s weren’t considered unusual. Several triplets, quadruplets, and at least one set of quintuplets have been patients of the NICU in past years, but those events were nothing compared to octuplets, according to Marrs.

Nkem Chukwu, the octuplets’ 27-year-old mother, delivered at St. Luke’s Episcopal Hospital. Texas Children’s and St. Luke’s share the same labor and delivery and neonatal ICU. Otherwise, they’re unrelated facilities.

From the outset, the babies were frail and given at best only an 85% chance of survival. Fear of infection ran high. The smallest baby, Chijindu Chidera, who weighed less than 11 ounces, died within six days. By mid-January, the remaining septuplets were still listed as critical.

For the arrival, nurses were well-prepared. Most had attended numerous orientations and planning conferences held by administration. Everyone anticipated the crush of news media and public scrutiny. Intradepartmental coordination was viewed as essential to keep Texas Children’s and the unit running smoothly.

What ultimately occurred, according to some, exceeded expectations. Nurses ended up pulling long shifts, nerves became frayed, and people got testy. Managers ran to attend impromptu meetings at all hours. They had to brief security officers, mollify concerned families of other patients, and repeatedly block dozens of unscheduled, uninvited guests, including photographers, from entering the nursery.

On a typical day, unit secretaries answered more than 40 phone calls and hundreds of inquiries from strangers and well-wishers. Excluded from the total were the usual calls from physicians, relatives, and friends of other patients. Nurses answered the phones when secretaries were unavailable.

People visiting the hospital on other business would wander up to the floor and ask for a glimpse of the preemies. Press conferences and meetings interrupted the normal flow of events. At the end of their shifts, tired nurses who stayed largely out of the spotlight during the media blitz, were often stopped in the halls by uniformed guards and asked for identification.

Despite all of that, "things went well. Medically, the patients’ management was considered standard for our unit," says Cynthia G. Sanders, RN, MS, assistant director of nursing, referring to those first memorable weeks. The credit goes to advanced planning and teamwork from everyone, including nurses and other hospital departments, which were extremely supportive of the ICU.

Staff coverage became a big concern

In retrospect, Sanders says, the biggest challenges and concerns they faced could be summarized in the following categories:

Staffing and coverage.

Of paramount importance was ensuring proper staff coverage, Sanders says. With an average daily census running at about 40, the unit’s demands on adequate coverage were high. With the octuplets, the census remained at 50 and above for several days. Even during normal conditions, the hospital relies heavily on agency and registry staff to cover open positions, Sanders adds. In most cases, ratios range around one nurse for every two preemies, but one-on-one coverage is considered common.

Alerted well in advance of the possibility of premature octuplets, the critical care unit went into action, Marrs recalls. When "Mom" was in week 23, the department set up a call schedule and planned to increase nurse coverage for the unit as a whole beyond the usual complement. All nurses who were normally scheduled off or listed on-call were notified.

The actual number varied by shifts and daily workload, but staffing just for the Chukwu babies ranged between 12 to 14 extra clinicians. Not all were nurses. Each team consisted of a physician, respiratory therapist, registered nurse, and nurse practitioner.

Equipment and supplies.

Equipping the unit for the mass arrivals also took planning. In descriptions similar to mounting a military campaign, the unit needed eight times of what would be normal for one infant. That meant one infant warmer, one heart monitor, three IV pumps, and a ventilator multiplied by eight, Sanders observes.

Managers scoured the hospital asking other departments for contributions, and the equipment materialized. Weeks ahead, central supply also set up carts labeled "octuplets" with the supplies. The carts were quickly called into action.

Planning also included notifying and coordinating with labs, the pharmacy, radiology, security, and patient relations. "Labs and X-ray were told to expect a sudden large volumes of work," Sanders says. Furthermore, each administrative department was kept informed regarding changes in the babies’ conditions and related important events.

Security and confidentiality.

The most urgent concern involved maintaining security, Sanders recalls. At stake was preserving patient confidentiality not only for the Chukwu babies, but for the 40-odd other preemies in the unit.

The other parents understood the situation, but they were no less concerned than the Chukwus about their own infants’ privacy rights, recalls Marrs.

Sanders worked closely with the parents, says Marrs, explaining events and keeping them informed. According to Sanders, the other parents were really good about cooperating. "No one expressed any resentment or thought their babies were getting second-rate care," Sanders says.

Overall, security was tight. Uniformed guards manned entrances and screened visitors. Nurses, according to Marrs, received training in discreetly confronting people. But keeping security tight required constant management of the players, Sanders acknowledges.

For managers, what counted most was to minimize distractions and enable nurses to discharge their responsibilities. "As managers, our job was to allow that to happen," says Sanders. Her best advice in these difficult moments: Plan ahead. Keep your nurses fully informed at all times, and involve them in every stage of planning.