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Work Redesign for Today's Surgical Patients: The Short Stay Surgical Program
e8
SPN 2010 Convention Poster Abstracts • Who: Tameron Mouser, Liz Cull, Deysi Augilera, Janice Mahaffey, and Lenora Poynter FNP-Interns, guided by a faculty advisor, developed tool for use by nurse practitioners, physicians, and health care providers.
Proposed Outcomes: Increased provider awareness in the local medical community is possible with the implementation of this tool. The long-term goal is to implement this poster as a national medical identification tool to be used in conjunction with the national protocol for known DEC. Practice Implications: Recognition of additional children as DEC is the first step to intervention. Providing practitioners with the tool and with information about how to proceed to get services for those children identified will be an asset to children's health. Future research should be aimed at a weighting symptom presentation to increase specificity and sensitivity of the tool. doi:10.1016/j.pedn.2009.12.023 Development of a Multidisciplinary Evidence-Based Framework for Sustaining Change in Pediatric Nursing Practice Shirley Martin BSN, RN, CPN, Suzanne Frey BSN, RN, C, Andrea Smith PhD, RN, CPNP Cook Children's Medical Center, Fort Worth, TX
Problem: Up to two decades may pass before the findings of original research become part of routine clinical practice. There are many strong EBP models available for initiating change in pediatric nursing practice, but the challenge remains how to sustain the change over time. The purpose of this EBP project was to identify the most effective concepts and strategies to sustain change from a variety of different disciplines and develop them into a framework for changing practice. Model: Iowa model of EBP (Titler, 2001) guided this project. Summary of Literature: Extensive search of multidisciplinary online databases provided summary evidence from (a) psychology: successful change related to congruent decisions; (b) neuroscience: changes in brain neuroplasticity related to repetition; (c) cognitive– behavioral therapy: successful change and axiomatic rules; (d) business: guidelines for making change stick; (e) nursing: change related to cultural assessment. These concepts were incorporated into an implementation framework and strategies for sustaining change in pediatric nursing practice. Outcomes: To pilot test and evaluate the framework, a multidisciplinary group of pediatric nurses and caregivers from the emergency department and postsurgical in-patient units were recruited to be part of a change team for needle stick pain prevention. Baseline data were collected prior to implementation. The project is ongoing and will be evaluated for the outcomes of initiation of change in needle stick practice, decreased needle stick pain, and changes in caregiver knowledge and attitude. Effectiveness of the framework and strategies for sustainment of change will be evaluated at 6 months and 1 year. doi:10.1016/j.pedn.2009.12.024 Get Going With Go-Bags Carol Murray BSN, RN, Abigail Riedel MS, RN, CPNP-AC/PC Dayton Children's Medical Center, Dayton, OH
Patients with tracheostomies are at risk for mucus plugging and accidental decannulation, thus requiring emergency suction and/or changing of the tracheostomy tube. These children are seen in many inpatient and outpatient areas of the hospital. The hospital implemented a standardized Go-Bag to ensure that patients with tracheostomies have the necessary emergency supplies with them at all times. We require the caregivers of patients with tracheostomy tubes to carry supplies that allow them to perform a tracheostomy tube change or suction should the child become distressed. We noticed caregivers carrying these supplies in plastic bags and having only some of the necessary supplies with them. Through a grant from the hospital, we were able to purchase bags and supplies. These Go-Bags are bright red so they are easily identified and highly visible. The bags have clear compartments that allow the supplies to be organized and easily visualized when needed. The Go-Bag remains at the bedside and is used for all out-of-unit transports. When the child is discharged, the Go-Bag is sent home with the caregiver to be kept with the child at all times. The caregivers and home nurses report positive feedback on the style, organization, and quality of the Go-Bags. With the adoption of the Go-Bags, we have seen increased compliance with caregivers using the Go-Bags on all social and medical adventures. The Go-Bags have improved care and safety for tracheostomy patients throughout the hospital. doi:10.1016/j.pedn.2009.12.025 It's a Little Nosey, Isn't It? Screening for Risk Behaviors in Adolescents Allison Nisbet MSN, RN, BC, CPN, AOCNS, Barbara Harrison RN, CPN Inova Fairfax Hospital for Children, Falls Church, VA
The purpose of the poster is to describe the quality improvement processes used to create and implement an evidence-based risk behaviors screening tool for adolescents aged 12–18 years admitted to the hospital and to report on pilot test outcomes relating to follow-up assessments, education, and referrals. In addition, the dimensions of inpatient risk assessments as guided by the literature review are presented, and the prevalence in the population overall for each area screened, as indicated by the literature search. Illness and injury associated with risk-taking behaviors comprise the area of highest mortality and morbidity for adolescents (CDC, 2006, 2008). In 2009, The Joint Commission (JCAHO, 2009) has identified a National Patient Safety Goal (#15), which requires health care organizations to identify risks inherent in their population. doi:10.1016/j.pedn.2009.12.026 Work Redesign for Today's Surgical Patients: The Short Stay Surgical Program Cindy Petro BSN, RN, Sonja Jones MSN, RN, CPN, Judith J. Stellar MSN, RN, CRNP The Children's Hospital of Philadelphia, Philadelphia, PA
Background: As surgical care advanced to include more minimally invasive techniques, the surgical population at The Children's Hospital of Philadelphia (CHOP) has evolved from a traditional inpatient length of stay (LOS) of 3 to 7 days, to a significantly shorter LOS—23 hours or less. Data regarding surgical patients
SPN 2010 Convention Poster Abstracts were analyzed from FY 2006 through FY 2008. Over this 3-year period, the short stay (SS) surgical population increased nearly 50%. Staffing and work design changes were indicated to keep up with this trend. In order to meet the needs of this changing surgical population, a work redesign project was developed. Clinical Question: Can care of short stay (SS) surgical patients be redesigned to improve efficiency without compromising quality? Program Development: A review of the literature and queries to pertinent List Servs revealed minimal results on this topic. An interdisciplinary team was formed. Components of the program included new staffing patterns, concise documentation, updated order sets, group classes for patient/family education, and a streamlined discharge planning process. A 2-week trial was conducted, and families and staff were surveyed pre- and postimplementation. The program was modified based on results of the trial and surveys. Practice Implications: Work redesign for SS patients fostered more efficient care without compromising quality. Because of the new staffing pattern, the program allowed for decreased patient nurse ratio for non-SS patients, improving care for that population as well. The program has been well received by both staff and families. An ongoing evaluation process is in place for continual improvement. doi:10.1016/j.pedn.2009.12.027 To Heparinize or Not to Heparinize Wanda Rodriguez RN Children's Hospital of Orange County, Orange, CA
Background: The use of normal saline or dilute heparin as a flush to maintain the patency of peripheral intermittent infusion devices (PIID) has been a controversy in medicine since the 1980s. Most children admitted to an acute health care facility require a PIID. Maintaining patency of the PIID is important to continue administration of intermittent IV medications, minimize number of IV catheter placements, and decrease number of supplies. Because of the side effects related to heparin use, it is important to evaluate the use of normal saline flushes as an alternative to heparin to maintain PIID patency in the pediatric population. Methods: Different nursing and medical databases were searched using dates ranging from the 1980s to 2008. Nonpublished and published articles have been researched. Most of the actual research was conducted in different hospitals throughout the world. The pediatric studies were predominantly double blind randomized controlled studies. The catheters studied ranged from 16 to 24 guage. The solutions studied ranged from 1 unit of heparin/1 ml NS to 100 units of heparin/1 ml NS compared to normal saline. Results: The evidence clearly shows that saline is as efficacious as heparin, and heparin has risks. It also showed that it is not just the solution but the technique that makes a difference. Conclusion: Heparin can be the cause of side effects and complications. Normal saline should be the solution of choice when flushing a PIID. By using normal saline, patients can be kept safe and have increased satisfaction with care and cost savings. doi:10.1016/j.pedn.2009.12.028 The More We Know the Less We Cancel Theresa Schultz MBA, RN, Denise Coan RN, CNIV The Children's Hospital of Philadelphia, Philadelphia, PA
e9 Pediatric patients often require sedation or anesthesia for radiology imaging and intervention. At The Children's Hospital of Philadelphia, over 200,000 examinations are performed annually. The goal of the nurse triage role is to call scheduled pediatric patients to obtain accurate history and educate patients and families about what they could expect on the day of service. Planning care according to unique needs minimizes day of service delays and cancellations. Our experiences were such that patients were being cancelled because of npo violations, medical issues requiring anesthesia when sedation was scheduled, and consent issues. Development of this role improved patient care planning; however, day of service cancellations remained significant. Through a quality improvement initiative, it was determined that often patients who cancelled their appointments were not reached by the triage nurse. This increased frustration between staff and parents resulted in inefficient use of radiology imaging. Data were collected daily reflecting the number of sedated outpatients reached. It became apparent that an alternate resource was needed to obtain valid contact information and modifications to methodology around how to reach families after the appointment was already scheduled were trialed. This included changing times of day to achieve higher reach rates. Significant improvement seen in reaching families prior to the day of service. Data were shown reflecting the increase in completed calls on a consistent basis. When this project started on some days, we were at 40%; today we are consistently above 90%, reaching 100% frequently. doi:10.1016/j.pedn.2009.12.029 Taking Sedation Assessment on the Road Theresa Schultz MBA, RN, Marianne Briggs MSN, RN, CRNP, Susan Maeder-Chieffo BSN, RN, PHRN, CCRN The Children's Hospital of Philadelphia, Philadelphia, PA
A hospital-based sedation service has become a standard of care in many settings. In our outpatient pediatric radiology and painful procedure setting, patients are evaluated by the nurse practitioner (NP). The appropriateness of sedation is determined through assessment of the patient's medical condition, test to be completed, duration, and pain associated. A plan of care is developed and executed on the day of service by the sedation team. In our current practice model, the NP is the primary provider. In select cases, consultation with the collaborating sedation attending occurs. Care is provided by the sedation nurse with intervention as needed from the NP. After years of success for outpatients, it was recognized that this model would benefit inpatients as well. By standardizing assessment, care delivery, and recovery of inpatients and outpatients, efficiencies would be gained and outcomes could improve. Expanded sedation services to include comprehensive NP-driven consultation program has proven beneficial in a pediatric health care system. Additional considerations for further improvement will include triage and provider assessment at the time of scheduling versus after they are scheduled. This may eliminate rework and need to reschedule. This expansion has afforded the opportunity to decrease cancelled procedures because of resource mismatch. All patients sedated by the Sedation Team for imaging and invasive procedures have standard approach regardless of inpatient/outpatient status.
SPN 2010 Convention Poster Abstracts • Who: Tameron Mouser, Liz Cull, Deysi Augilera, Janice Mahaffey, and Lenora Poynter FNP-Interns, guided by a faculty advisor, developed tool for use by nurse practitioners, physicians, and health care providers.
Proposed Outcomes: Increased provider awareness in the local medical community is possible with the implementation of this tool. The long-term goal is to implement this poster as a national medical identification tool to be used in conjunction with the national protocol for known DEC. Practice Implications: Recognition of additional children as DEC is the first step to intervention. Providing practitioners with the tool and with information about how to proceed to get services for those children identified will be an asset to children's health. Future research should be aimed at a weighting symptom presentation to increase specificity and sensitivity of the tool. doi:10.1016/j.pedn.2009.12.023 Development of a Multidisciplinary Evidence-Based Framework for Sustaining Change in Pediatric Nursing Practice Shirley Martin BSN, RN, CPN, Suzanne Frey BSN, RN, C, Andrea Smith PhD, RN, CPNP Cook Children's Medical Center, Fort Worth, TX
Problem: Up to two decades may pass before the findings of original research become part of routine clinical practice. There are many strong EBP models available for initiating change in pediatric nursing practice, but the challenge remains how to sustain the change over time. The purpose of this EBP project was to identify the most effective concepts and strategies to sustain change from a variety of different disciplines and develop them into a framework for changing practice. Model: Iowa model of EBP (Titler, 2001) guided this project. Summary of Literature: Extensive search of multidisciplinary online databases provided summary evidence from (a) psychology: successful change related to congruent decisions; (b) neuroscience: changes in brain neuroplasticity related to repetition; (c) cognitive– behavioral therapy: successful change and axiomatic rules; (d) business: guidelines for making change stick; (e) nursing: change related to cultural assessment. These concepts were incorporated into an implementation framework and strategies for sustaining change in pediatric nursing practice. Outcomes: To pilot test and evaluate the framework, a multidisciplinary group of pediatric nurses and caregivers from the emergency department and postsurgical in-patient units were recruited to be part of a change team for needle stick pain prevention. Baseline data were collected prior to implementation. The project is ongoing and will be evaluated for the outcomes of initiation of change in needle stick practice, decreased needle stick pain, and changes in caregiver knowledge and attitude. Effectiveness of the framework and strategies for sustainment of change will be evaluated at 6 months and 1 year. doi:10.1016/j.pedn.2009.12.024 Get Going With Go-Bags Carol Murray BSN, RN, Abigail Riedel MS, RN, CPNP-AC/PC Dayton Children's Medical Center, Dayton, OH
Patients with tracheostomies are at risk for mucus plugging and accidental decannulation, thus requiring emergency suction and/or changing of the tracheostomy tube. These children are seen in many inpatient and outpatient areas of the hospital. The hospital implemented a standardized Go-Bag to ensure that patients with tracheostomies have the necessary emergency supplies with them at all times. We require the caregivers of patients with tracheostomy tubes to carry supplies that allow them to perform a tracheostomy tube change or suction should the child become distressed. We noticed caregivers carrying these supplies in plastic bags and having only some of the necessary supplies with them. Through a grant from the hospital, we were able to purchase bags and supplies. These Go-Bags are bright red so they are easily identified and highly visible. The bags have clear compartments that allow the supplies to be organized and easily visualized when needed. The Go-Bag remains at the bedside and is used for all out-of-unit transports. When the child is discharged, the Go-Bag is sent home with the caregiver to be kept with the child at all times. The caregivers and home nurses report positive feedback on the style, organization, and quality of the Go-Bags. With the adoption of the Go-Bags, we have seen increased compliance with caregivers using the Go-Bags on all social and medical adventures. The Go-Bags have improved care and safety for tracheostomy patients throughout the hospital. doi:10.1016/j.pedn.2009.12.025 It's a Little Nosey, Isn't It? Screening for Risk Behaviors in Adolescents Allison Nisbet MSN, RN, BC, CPN, AOCNS, Barbara Harrison RN, CPN Inova Fairfax Hospital for Children, Falls Church, VA
The purpose of the poster is to describe the quality improvement processes used to create and implement an evidence-based risk behaviors screening tool for adolescents aged 12–18 years admitted to the hospital and to report on pilot test outcomes relating to follow-up assessments, education, and referrals. In addition, the dimensions of inpatient risk assessments as guided by the literature review are presented, and the prevalence in the population overall for each area screened, as indicated by the literature search. Illness and injury associated with risk-taking behaviors comprise the area of highest mortality and morbidity for adolescents (CDC, 2006, 2008). In 2009, The Joint Commission (JCAHO, 2009) has identified a National Patient Safety Goal (#15), which requires health care organizations to identify risks inherent in their population. doi:10.1016/j.pedn.2009.12.026 Work Redesign for Today's Surgical Patients: The Short Stay Surgical Program Cindy Petro BSN, RN, Sonja Jones MSN, RN, CPN, Judith J. Stellar MSN, RN, CRNP The Children's Hospital of Philadelphia, Philadelphia, PA
Background: As surgical care advanced to include more minimally invasive techniques, the surgical population at The Children's Hospital of Philadelphia (CHOP) has evolved from a traditional inpatient length of stay (LOS) of 3 to 7 days, to a significantly shorter LOS—23 hours or less. Data regarding surgical patients
SPN 2010 Convention Poster Abstracts were analyzed from FY 2006 through FY 2008. Over this 3-year period, the short stay (SS) surgical population increased nearly 50%. Staffing and work design changes were indicated to keep up with this trend. In order to meet the needs of this changing surgical population, a work redesign project was developed. Clinical Question: Can care of short stay (SS) surgical patients be redesigned to improve efficiency without compromising quality? Program Development: A review of the literature and queries to pertinent List Servs revealed minimal results on this topic. An interdisciplinary team was formed. Components of the program included new staffing patterns, concise documentation, updated order sets, group classes for patient/family education, and a streamlined discharge planning process. A 2-week trial was conducted, and families and staff were surveyed pre- and postimplementation. The program was modified based on results of the trial and surveys. Practice Implications: Work redesign for SS patients fostered more efficient care without compromising quality. Because of the new staffing pattern, the program allowed for decreased patient nurse ratio for non-SS patients, improving care for that population as well. The program has been well received by both staff and families. An ongoing evaluation process is in place for continual improvement. doi:10.1016/j.pedn.2009.12.027 To Heparinize or Not to Heparinize Wanda Rodriguez RN Children's Hospital of Orange County, Orange, CA
Background: The use of normal saline or dilute heparin as a flush to maintain the patency of peripheral intermittent infusion devices (PIID) has been a controversy in medicine since the 1980s. Most children admitted to an acute health care facility require a PIID. Maintaining patency of the PIID is important to continue administration of intermittent IV medications, minimize number of IV catheter placements, and decrease number of supplies. Because of the side effects related to heparin use, it is important to evaluate the use of normal saline flushes as an alternative to heparin to maintain PIID patency in the pediatric population. Methods: Different nursing and medical databases were searched using dates ranging from the 1980s to 2008. Nonpublished and published articles have been researched. Most of the actual research was conducted in different hospitals throughout the world. The pediatric studies were predominantly double blind randomized controlled studies. The catheters studied ranged from 16 to 24 guage. The solutions studied ranged from 1 unit of heparin/1 ml NS to 100 units of heparin/1 ml NS compared to normal saline. Results: The evidence clearly shows that saline is as efficacious as heparin, and heparin has risks. It also showed that it is not just the solution but the technique that makes a difference. Conclusion: Heparin can be the cause of side effects and complications. Normal saline should be the solution of choice when flushing a PIID. By using normal saline, patients can be kept safe and have increased satisfaction with care and cost savings. doi:10.1016/j.pedn.2009.12.028 The More We Know the Less We Cancel Theresa Schultz MBA, RN, Denise Coan RN, CNIV The Children's Hospital of Philadelphia, Philadelphia, PA
e9 Pediatric patients often require sedation or anesthesia for radiology imaging and intervention. At The Children's Hospital of Philadelphia, over 200,000 examinations are performed annually. The goal of the nurse triage role is to call scheduled pediatric patients to obtain accurate history and educate patients and families about what they could expect on the day of service. Planning care according to unique needs minimizes day of service delays and cancellations. Our experiences were such that patients were being cancelled because of npo violations, medical issues requiring anesthesia when sedation was scheduled, and consent issues. Development of this role improved patient care planning; however, day of service cancellations remained significant. Through a quality improvement initiative, it was determined that often patients who cancelled their appointments were not reached by the triage nurse. This increased frustration between staff and parents resulted in inefficient use of radiology imaging. Data were collected daily reflecting the number of sedated outpatients reached. It became apparent that an alternate resource was needed to obtain valid contact information and modifications to methodology around how to reach families after the appointment was already scheduled were trialed. This included changing times of day to achieve higher reach rates. Significant improvement seen in reaching families prior to the day of service. Data were shown reflecting the increase in completed calls on a consistent basis. When this project started on some days, we were at 40%; today we are consistently above 90%, reaching 100% frequently. doi:10.1016/j.pedn.2009.12.029 Taking Sedation Assessment on the Road Theresa Schultz MBA, RN, Marianne Briggs MSN, RN, CRNP, Susan Maeder-Chieffo BSN, RN, PHRN, CCRN The Children's Hospital of Philadelphia, Philadelphia, PA
A hospital-based sedation service has become a standard of care in many settings. In our outpatient pediatric radiology and painful procedure setting, patients are evaluated by the nurse practitioner (NP). The appropriateness of sedation is determined through assessment of the patient's medical condition, test to be completed, duration, and pain associated. A plan of care is developed and executed on the day of service by the sedation team. In our current practice model, the NP is the primary provider. In select cases, consultation with the collaborating sedation attending occurs. Care is provided by the sedation nurse with intervention as needed from the NP. After years of success for outpatients, it was recognized that this model would benefit inpatients as well. By standardizing assessment, care delivery, and recovery of inpatients and outpatients, efficiencies would be gained and outcomes could improve. Expanded sedation services to include comprehensive NP-driven consultation program has proven beneficial in a pediatric health care system. Additional considerations for further improvement will include triage and provider assessment at the time of scheduling versus after they are scheduled. This may eliminate rework and need to reschedule. This expansion has afforded the opportunity to decrease cancelled procedures because of resource mismatch. All patients sedated by the Sedation Team for imaging and invasive procedures have standard approach regardless of inpatient/outpatient status.