The Implementation of PEARS Training: Supporting Nurses in Non-Critical Care Settings to Improve Patient Outcomes

Journal of Pediatric Nursing (2013) 28, 267–274

The Implementation of PEARS Training: Supporting Nurses in Non-Critical Care Settings to Improve Patient Outcomes Nancy Famolare BSN, RN a,⁎, Jane C. Romano MS, RN b a

Life Support Program, Children's Hospital Boston, Boston, MA, USA Resuscitation Quality Program, Children's Hospital Boston, Boston, MA, USA

b

Key words: Pediatric; Cardiopulmonary arrest; PEARS

Children's Hospital Boston's Life Support Program began offering the newly developed American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) course for nurses working in non-critical care settings in December of 2007. The goal was to provide an appropriate alternative to pediatric advanced life support (PALS) training for clinical staff caring for the general pediatric population. To date, more than 900 nurses have completed the course with feedback from the participants being extremely positive. Even more impressive is a more appropriate use of the hospital's emergency medical response system promoting early intervention and the significant reduction in cardiac arrests on inpatient units. During a 12-month period, nurses involved in activations of the response system were asked to rate their ability to assess, categorize, decide and act after each event. The overwhelming majority agreed they were able to apply the PEARS systematic approach of assessment and early intervention to the situation. This article describes the planning and implementation of PEARS training for non-critical care nursing staff and provides data that demonstrates improved patient outcomes. Supporting activities and strategies promoting early recognition and interventions contributing to the successful reduction of cardiac arrests on inpatient units are also discussed. © 2013 Elsevier Inc. All rights reserved.

Background THE AMERICAN HEART Association (AHA) launched the Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) course in December 2007. The PEARS Provider Course was designed to enhance the healthcare provider's ability to recognize deteriorating patients in order to prevent cardiac arrest. The training strengthens basic pediatric life support knowledge and skills preparing participants to initiate and manage the first few minutes of a pediatric arrest event. The goal of this new course was to offer an appropriate alternative to pediatric advanced life support (PALS) training for clinical staff caring for the general pediatric population. ⁎ Corresponding author: Nancy Famolare, BSN, RN. E-mail address: [email protected] (N. Famolare). 0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2012.05.005

Prior to the development and implementation of this level of training, the Life Support Program staff at Children's Hospital Boston (CHB) recognized that the training offered, either basic life support (BLS) and/or pediatric advanced life support (PALS), was not adequately meeting the needs of nurses practicing in non-critical care settings. Feedback from staff indicated BLS; which is the foundation for all advanced care, was not enough, and PALS, was often perceived as too in depth. The newly developed PEARS course served to bridge the gap between the two courses. In 2006, CHB began participation in the Children's Health Corporation of America (CHCA) collaborative project: Eliminating Codes and Associated Mortality on Inpatient Units. Physician and nursing representatives identified various strategies to establish reliable systems to prevent detect and correct patient deterioration resulting in the development of a multifaceted plan. One component of the plan was the implementation of the AHA PEARS course as primary training

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collaborative. Other methods supporting early recognition and action that complemented the training are described later in this article. Overall, the positive impact and outcomes of the CHCA collaborative in the surgical programs were evident and precipitated the expansion of the project strategies.

for nurses in non-critical care practice settings. In collaboration with nurse educators and leadership, the CHB Life Support Program incorporated the newly created intermediate level course into the schedule of course offerings. Beginning in December 2007 and for the next several months, PEARS courses were conducted weekly and required for all staff nurses (n = 200) in surgical programs which includes orthopedics, transplant, trauma and general surgery inpatient units. Over the next 7 months, these four practice areas documented 202 sequential days without a respiratory or cardiac arrest event (Figure 1). To be clear, respiratory and cardiac arrest events were determined based on the following Get With the Guidelines—Resuscitation (http://qi.outcome.com) (Outcome Science, Inc., 2009) definitions:

Review of the Literature The evidence of early recognition and prevention leading to better outcomes for patients spans many years in the literature. In 1990, Schein, Hazday, Pena, Ruben and Sprung stated that the emphasis needs to be on events preceding the arrest and the problem is not the absence of pertinent information but rather the response to this information (Schein, Hazday, Pena, Ruben, & Sprung, 1990). The physiological signs leading to cardiopulmonary arrest are often correctable with greater efficacy when treatment was initiated earlier (DeVita, Braithwaite, Mahidhara, Stuart, & Simmons, 2004) and that up to 70% of these events were preventable (Buist et al., 2002). As early as 1987, Arno Zaritsky, MD, chairperson of the AHA subcommittee on pediatric resuscitation when the PEARS course was developed wrote, “Attention must be directed toward early evaluation and stabilization of critically ill pediatric patients before they become pulseless non-breathing victims” (Zaritsky, 1987, p. 561). Years later, this same author described the PEARS course as providing the bridge needed

• Cardiopulmonary resuscitation—events in which compressions and/or defibrillation are delivered • Acute respiratory compromise—absent, agonal or inadequate respiration that requires emergency assisted ventilation1 including NEWBORNS receiving at least 2 minutes of assisted ventilation. Also significant was the increase in the utilization of the hospital's rapid response team (RRT) to assess and triage patients with changes in their clinical presentation (Figure 2). These trends demonstrate an improved ability of surgical inpatient unit nurses to recognize patients at risk for deterioration and act early to stabilize the patient prior to an arrest situation. The inclusion of PEARS as a training option was only one strategy employed as a result of participation in the CHCA 14 12 10 8 6 4 2 0 Qr 3 07

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PEARS Training to fill the gap between BLS and PALS (Ralston & Zaritsky, 2009). The need for adequate education and training related to the clinician's scope of practice is also discussed by Ralston and Zaritsky (2009). The guiding principles of PEARS rely on the nurse's ability to assess, categorize, decide and act as a mechanism to quickly recognize and stabilize patients with a changing clinical picture (Diagram 1). This concept reflects critical thinking skills necessary for the nurse to accurately interpret data, correctly analyze problems, quickly and completely identify viable options, implement these options and effectively evaluate the outcomes (Facione & Facione, 1996). It also aligns with the concept of situational awareness which is described by Jones and Endsley (2000) as the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future. The emphasis on early recognition and intervention is well documented in the literature. There is clear evidence supporting the development and implementation of RRT in order to reduce in-hospital mortality and improve timely response to patients exhibiting signs of clinical deterioration (Barbetti & Lee, 2008; Chen, Bellomo, Flabouris, Hillman, & Finfer, 2009; Tibballs & Kinney, 2009). Jones, DeVita, and Bellomo (2011) examined the effectiveness of RRT and found that it is reliant upon the ability of the bedside caregivers to identify signs of deterioration and quickly trigger a response. Buist et al. (2002) felt that these teams allow for a more considered and controlled approach to patient management rather than the chaos that typically results with a cardiac arrest event. In 2004, the Institute for Healthcare Improvement (IHI) launched the 100,000 Lives Campaign proposing six highly feasible interventions the first of which is the development and implementation of an RRT that can be summoned before an arrest situation occurs (Berwick, Clakins, McCannon, & Hackbarth, 2006).

Diagram 1 American Heart Association PEARS Provider Manual 2007 (p. 5).

269 In-hospital pediatric cardiac arrest is often preceded by signs of respiratory insufficiency or shock. Research has shown that 76% of patients exhibit identifiable respiratory or cardiac deterioration 1 hour prior to arrest (Buist et al., 1999) and 66% of patients show evidence of clinical deterioration up to 6 hours prior to arrest (Franklin & Matthews, 1994). Tibballs and Kinney (2009) studied the preventability of cardiac arrests and death in pediatric patients and described the inability of both medical and nursing staff at all levels to recognize and respond to signs of serious illness. A more recent study reported indicators of deterioration greater than 11 hours preceding these events (Akre et al., 2010). Also discussed in the literature is “failure to rescue” as a significant factor in many serious adverse events (Schmid, Hoffman, Happ, Wolf, & DeVita, 2007;Jones et al., 2011). This concept refers to not recognizing signs of patient deterioration and taking action to reverse these changes. A study conducted by the CHCA collaborative found that, although infrequent, pediatric cardiopulmonary arrest requiring compressions for pulselessness has a survival rate of only 27% which increases to 80% if patient deterioration is recognized earlier (Hayes, Dobyns, DiGiovine, Brown, & Jacobson, 2012). It is clear that the pre-arrest clinical status of the patient may provide indicators that when identified, can lead to early intervention (Cretikos & Hillman, 2003). The evidence shows that early recognition and intervention of changes in a patient's condition are essential to improving patient outcomes related to clinical deterioration. PEARS training is one method of supporting nurses working in non-critical care settings to strengthen their ability to assess, categorize, decide and act in a timely fashion to prevent cardiopulmonary arrests on inpatient units.

Planning and Implementation The potential benefit PEARS training could have on patient care was clearly demonstrated during the initial trial and expansion of the course to the inpatient surgical program's nursing staff. As a result, the hospital CPR committee made the recommendation to nursing leadership to support PEARS training for all non-critical care nurses. This recommendation was accepted by the leadership group resulting in the development of a policy requiring nurses practicing in non-critical care areas, both inpatient and ambulatory settings, to complete PEARS in addition to BLS training. Nurses in critical care areas, including the intensive care units, post anesthesia care unit, bone marrow transplant unit, intermediate care unit, emergency department, critical care transport team, inpatient cardiology and catheterization lab and those involved with patient sedation were still required to maintain PALS certification. The implementation of the PEARS training program required the support of the Department of Nursing as well as the financial backing of the institution. Additional funding to

270 support the training was granted to the Life Support Program's operating budget to cover the expense of course training materials, manikins and instructor salaries. Nurses were scheduled to attend the 1-day class as part of their work schedule, with the charge for the course absorbed by the nursing department. In March 2008, the PEARS course was opened to all nursing staff required to complete this specific training. As of August 2011, nearly 100% of the approximately 950 nurses working in non-critical care settings have participated in the 127 PEARS training courses offered at CHB. One third of those nurses have taken the training a second time to refresh their skills.

Implementation The PEARS course prepares nurses to assess, categorize, decide and act early to stabilize the child. The content zeros in on prevention, and specifically the assessment, recognition and stabilization of pediatric patients at risk of severe cardiopulmonary distress (http://www.heart.org). The training strives to empower nurses by enhancing their basic clinical knowledge and skills and enabling them to become confident active members of the team during response to emergency events. PEARS bolsters nurses' abilities to decide what they need to know, see, hear, assess and do in order to strengthen their scope of practice and improve patient safety and outcomes. The design of the course is based on the following two principles of adult learning: adults learn best when they actively participate in the learning process and instructors are most effective as facilitators of learning rather than lecturers (Russell, 2006). With these principles as a foundation, participants are actively engaged for as much of the course as possible. They are provided the opportunity to learn, practice and demonstrate proficiency in assessing a seriously ill or injured child as well as the appropriate actions for stabilizing the child. The content focuses on the management of the initial minutes of a worsening clinical patient condition while waiting for help to arrive. As a prerequisite, the PEARS student is expected to be proficient in performing CPR. Participants must be able to meet the following learning objectives: • Evaluate a seriously ill or injured child using the general and primary assessments • Describe the “assess–categorize–decide–act” approach to recognition and management of the child in respiratory distress or failure, shock, or cardiac arrest • Identify appropriate actions to take for stabilizing a critically ill or injured child during the initial minutes of response until the next level of care arrives • Recognize and take appropriate action for a child in cardiac arrest • Demonstrate element of effective communication as a team member

N. Famolare, J.C. Romano (adapted from the American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization Provider's Manual, 2007). As an intermediate course, PEARS falls under the umbrella of the PALS discipline and therefore, per AHA guidelines, is taught by a PALS instructor, with a course director who is responsible for the course logistics and quality assurance. Specialty faculty may assist in teaching a PEARS course under the supervision of a course director, however; only an AHA PALS instructor may evaluate a student's performance during a PEARS course. The PEARS instructor is critical to the success of the participants. The role of the instructor is to facilitate student discussion of core cases and coach nurses to perform appropriate actions during case simulation. The importance of teamwork and effective communication is fundamental to improve patient outcomes and is integrated into the curriculum of the course. The instructor provides both positive and constructive feedback to the nurses to ensure the desired outcomes and comprehension of the learning concepts. Thus, it is imperative that the instructor has a strong understanding of his or her own role as well as what is expected of the participants. To successfully complete the PEARS course, individuals must: • Actively participate in, practice, and complete all skills stations and learning stations • Pass skills tests in child 1-rescuer CPR/AED and infant 1 and 2-rescuer CPR • Pass a video-based written test with a minimum score of 84%.

Feedback and Evaluation Much of the feedback and evaluation related to the training are subjective in nature. Participants of PEARS courses are asked to voluntarily complete a paper presurvey that includes eight questions related to demographic and experiential data (Table 1). To date, about half the nurses who have completed the training (n = 494) filled out and handed in pre-surveys. A significant percentage of nurses reported having 10 years or less of nursing experience (46%) and pediatric nursing experience (56%). Sixty percent of the respondents reported they worked on one of the nine inpatient acute care units in the hospital. The remainder worked in inpatient psychiatry (2%), ambulatory clinics (22%), procedural areas (3%) and the operating room (13%). Thirty-six percent reported they had activated the RRT, with only 6% doing so based on family request. A high percentage of nurses felt that they were able to assess and determine the need for early intervention (67%), believed they had a good understanding of the emergency response system (70%) and were supported by nursing leadership (82%).

PEARS Training Table 1

PEARS Pre-Survey.

1. How many years of nursing experience do you have? a. Less than 1 year b. 1–5 years c. 6–10 years d. 11–15 years e. 16–20 years f. 21 years or more 2. How many years of pediatric nursing experience do you have? a. Less than 1 year b. 1–5 years c. 6–10 years d. 11–15 years e. 16–20 years f. 21 years or more 3. What area do you work in? a. Inpatient medicine b. Inpatient surgical c. Inpatient psychiatry d. Ambulatory clinic e. OR f. Procedural area 4. I have activated the RRT. a. Yes b. No 5. I have activated the RRT per request of a Family a.Yes b. No 6. I am able to effectively assess and determine the need for early intervention. a. Strongly agree b. Somewhat agree c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree 7. I understand the emergency response system. a. Strongly agree b. Somewhat agree c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree 8. I feel supported by my supervisors when activating the emergency response system. a. Strongly agree b. Somewhat agree c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree

Participants are also asked to respond to a similar online post-survey. Only 20% of the nurses (n = 222) completed the voluntary questionnaire. The results were similar to data yielded from the pre-course survey prompting an evaluation of the information collected for future review of the training. Since a significant number of the nurses reported they worked in an ambulatory setting (34%), some of the statements did not apply to their practice setting on a routine basis. For instance, the RRT is currently intended for

271 inpatient areas so ambulatory nurses activate the code team for assistance with changes in a patient's condition. Fortythree percent (95) of the post-test respondents reported that they worked in an inpatient medical or surgical unit. The majority of the nurses at the bedside (73%) felt that they routinely integrated the PEARS systematic approach of patient assessment into their daily practice while 26% felt they were able to integrate the concepts occasionally. The information gathered through this method of evaluation and feedback has provided important data and trends that will be used going forward. After completion of the training, nurses are required to complete a course evaluation from the AHA. Among other quantifiers, participants are asked to rate on a Likert-type scale of 1–5 (5 being strongly agreed) if the program content was relevant to their work and extended their knowledge. An overwhelming 98% strongly agreed or agreed that participation in the course enhanced their practice. Written comments on the evaluations highlighted the values of hands-on learning and the relevance to their practice versus PALS training. Many felt that the training should be required of all new graduate nurses and should be required yearly as a refresher. The evaluations and comments remain consistently positive. Another measure used to evaluate the effectiveness of PEARS training involved contacting nurses who had activated the RRT or code blue from August 1, 2009, through July 31, 2010. E-mails were sent to 184 nurses asking them to respond to a two-question survey regarding their experience with the specific emergent event. One hundred and forty nurses responded to the request. Of those who completed the survey, 81 nurses had participated in the PEARS course. An overwhelming majority of those who had completed the training (95%) felt that they were able to apply the PEARS systematic approach of assessment and early intervention to the situation. Objective evidence also exists that the training has positively influenced practice and outcomes. Since implementation of the change package of which PEARS was a critical component, there has been a reduction in cardiac arrests on inpatient units (Figure 3). In calendar years 2007 and 2008 the rate (per 1000 patient days) of these events on inpatient units was 0.06 and 0.04 respectively. Since the implementation of the strategies including PEARS training, the cardiac arrests rates decreased to 0.02 (2009), 0 (2010) and 0.02 (2011). Of note, there has been an increase in the number of respiratory arrests in these same areas which could be influenced by several factors. As stated earlier, in-hospital pediatric cardiac arrest is often preceded by signs of respiratory insufficiency or shock. The increase in the occurrences of respiratory arrests suggests an enhanced ability of staff at the bedside to recognize signs of clinical deterioration leading to the initiation of the appropriate steps to preventing progression to a cardiac arrest. It is also felt that the documented increase in respiratory arrests outside the ICU has been influenced by a more efficient and effective method of tracking events implemented as a result of

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participation in the initial CHCA collaborative discussed earlier. This trend will continue to be monitored and evaluated going forward. Also significant is a more appropriate use of the hospital's emergency medical response system focusing on early assessment and triage of patients showing signs of deterioration (Figure 4).

through staff meetings, computer screen savers, event debriefings and hospital orientation. • An existing pediatric early warning scoring system was modified to include the subjective aspects of staff and family concerns to the objective assessment criteria. The Children's Hospital Early Warning Score (CHEWS) was trialed by surgical program nurses during the CHCA collaborative and subsequently expanded to all inpatient areas in October 2008. The assessment criteria included on the CHEWS tool align with the strategies and concepts taught in PEARS training. The tool is currently pending validation. • The frequency of mock codes was increased and includes both low fidelity activities conducted on inpatient areas as well as high fidelity, multidisciplinary offerings in collaboration with the hospital simulation program. • The method of requesting ICU consults was streamlined through the assignment of a specific pager in an effort to more accurately track this mode of early assessment and intervention.

Supporting Early Recognition and Action The effort to eliminate cardiopulmonary arrests and associated mortalities on inpatient units requires more than one strategy to be successful. Other strategies implemented during the CHCA collaborative project include the following: • The formation of an RRT occurred in January 2006; however, trends showed a less than optimal utilization of this method of early assessment. Re-education regarding the purpose of the RRT was conducted 140 120

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PEARS Training • The addition of a nurse project manager for resuscitation quality establishing formalized tracking, evaluation and follow-up of all activations of the system. All these CHCA initiated strategies intertwine and support each other in order to achieve successful outcomes. They do, however, rely on a solid foundation of knowledge and skills such as those provided through PEARS training to be most effective. They all collectively support the nurse's ability to assess, categorize, decide and act on early signs of patient deterioration which are critical to the goal of eliminating pediatric cardiopulmonary arrest events outside the critical care environment.

Ongoing Challenges and Future Recommendations The implementation of the new level of training has been simple in some ways and challenging in others. The course is taught by current PALS instructors which simplified the task of preparing appropriately skilled clinician as educators. What helped keep the challenges at a minimum is a wellestablished, nurse directed life support program. The logistics of scheduling courses to suit the needs of a 24/7 workforce and securing space to teach those classes in a very busy pediatric teaching hospital can often be difficult. Instructors needed to become familiar with course content and requirements for the participants. The emphasis of PEARS is less on testing competency and more on building confidence in basic skills and knowledge. The key to success is in becoming more of a facilitator of learning and less an instructor. Currently, the AHA recommends PEARS training be done every 2 years. Initially, CHB policy followed the AHA recommendations; however, the Department of Nursing has decided to change the requirement of PEARS training from every 2 years to every 4 years. Basic life support certification for all nurses and PALS certification follow the 2-year recommended renewal date. The effects of this change on patient care and outcomes will be monitored closely by the Life Support Program in collaboration with the hospital's Resuscitation Quality Program. The Life Support Program is currently reviewing the preand post-course evaluations in an effort to strengthen the information gathered. Some vital trends were identified such as the high percentage of novice nurses practicing at the bedside. A study by Wynn, Engelke, and Swanson (2009) examined years of experience in relationship to activation of an RRT and found that nurses with fewer years at the bedside were less likely to recognize subtle changes in a patient condition, often leading to a delay in action. A similar study in 2008 also reported that nurses with less than 10 years' experience struggled with decision-making and implementing independent nursing interventions (Fero, Witsberger, Zullo, & Hoffman, 2008). The need for adequate training and support for these clinicians is evident. In addition, the high

273 number of ambulatory nurses who have completed the course warrants a closer look in order to determine how the training can best serve this unique practice area. A critical development to be examined moving forward is the documented increase in respiratory arrests since the implementation of the change package. Although it was hypothesized that the increase may have been due to an enhancement of the nurse's ability to recognize and act on a change in condition sooner, the ultimate goal is to reduce all type of pediatric arrests outside the critical care setting.

Conclusion The nurse at the bedside is most often the strongest link between the patient and the team of clinicians providing care (Pusateri, Prior, & Kiely, 2011). As a result, it is typically that nurse initiating the call for help when a patient's condition is worsening. In addition, the quality and timeliness of the initial actions of these nurses greatly influence the outcome of the event (Hunt, Walker, Shaffner, Miller, & Pronovost, 2008). To be effective and confident as first responders, nurses require appropriate systems and training. The implementation of the PEARS courses for nurses in non-critical care settings is a leap in the right direction to support practice and improve the safety net for hospitalized pediatric patients. The overall feedback from nurses related to PEARS training continues to be positive and is felt to enhance the nurse's ability to assess, categorize, decide and act when the clinical picture is changing. Most evident is the increase in a more accurate use of the emergency medical response system as well as the decrease in cardiac arrest events on general medical and surgical inpatient units since the implementation of a multifaceted change package. Since the best systems rely on human decision making in order to be most effective, PEARS training could be considered the cornerstone of that package. There are, however, clear opportunities for more extensive evaluation and research regarding the impact and potential of this training related to both patient safety and nursing practice.

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