Focus on Pediatrics-Overcoming an adverse teaching environment

Apnea management skills blocked by many barriers

Each year, about 400 infants are discharged from Phoenix Children's Hospital on an apnea monitor. To ensure the safety of the baby who has this life-threatening condition, parents are required to attend two classes to learn how to respond to the alarm.

The timing of events is not always conducive to teaching, says Jane Diaz, RN, MSN, manager of the Apnea Management Program at the children's hospital. Parents are often exhausted, having spent many hours at the hospital with their baby. Others have a lot of anxiety caused by the baby's diagnosis. "If we feel there is a high level of anxiety, we will teach the family in private. Otherwise, we teach in a group," she says. Classes are held Monday through Friday at 1 p.m. and 3 p.m.

The first class session provides instruction on how to respond to the apnea monitor alarm, and the second class teaches parents how to perform infant CPR. The emphasis in the alarm response class is on learning to follow a step-by-step process that keeps the parent calm. "Every time the monitor alarms, we don't want families to dive into the room waking up the baby, putting them on the floor, and beginning CPR. About 99% of the time, all babies need is a touch and they are absolutely fine," explains Diaz.

Parents are taught to walk to the baby's room when the alarm goes off, counting the beeps from the alarm. The alarm indicates that the baby has stopped breathing or has had a drop in heart rate. Each beep is one second, and by counting, they can determine how long the episode is lasting.

In the child's room, they check the baby's color to determine if CPR is needed immediately. If the color is normal, they check to see if the baby is breathing. This can be done by looking for movement in the baby's chest or licking their fingers and putting them in front of the baby's nose and mouth to feel air. The next step is to gently stimulate the baby. If there is no response, they pick the baby up, place him or her on their shoulder, pat the baby's back firmly, flick the fingers, flick the toes, and slap the bottom of the baby's feet. If there is still no response, they begin CPR.

It's important that parents do not rush into the room and immediately perform CPR or turn off the alarm, says Diaz. The monitor is computerized and helps the management team track the severity of each episode to determine how the baby is progressing.

Educational reinforcements

A member of the apnea management team calls parents within one week following discharge. During the phone call, the team member assesses parents' knowledge of the information taught in the classes. "If we recognize that they retained very little, we review in depth what we taught. Sometimes we encourage them to come back and take the class again," says Diaz.

There are many reasons why parents might not remember all they were taught. Anxiety and exhaustion play a factor. Also, parents might have been given the diagnosis before being asked to attend the class and could be in a state of denial.

To help reinforce the teaching, parents are given a packet of detailed information. They receive a poster that covers the steps for infant CPR that they can hang in the baby's room. They also receive a flowchart that covers the steps for responding to the alarm on the apnea monitor.

A list of indicators, such as an increased number of alarms or a color change in the baby, accompanied by the name and phone number of a contact person, helps parents respond appropriately to problems. For example, one set of indicators would trigger a call to the apnea management program; another group would initiate a call to the baby's physician; and another set would generate a call to paramedics.

Parents are told to call the apnea management program any time, day or night. However, follow-up calls by the apnea management team are made on a case-by-case basis as long as the baby is on a monitor.

For information on teaching parents apnea management, contact:

Jane Diaz, RN, MSN, Manager, Apnea Management Program, Phoenix Children's Hospital, Ancillary One, 1111 East McDowell Road, Phoenix, AZ 85006. Telephone: (602) 239-4740. Fax: (602) 239-3556. E-mail: