Repositioning Guidelines to Decrease Pressure Injury in the Pediatric Intensive Care Unit: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement repositioning guidelines that reduce pressure injury (PI) in hemodynamically unstable pediatric intensive care unit (PICU) patients. PARTICIPANTS AND SETTING: All PICU patient ages 0 to 36 months who required sedation for invasive mechanical ventilation and had a Braden Q score ≤ 18 were eligible for inclusion. The project was implemented in 116 patients preimplementation and 100 postimplementation. Their median t age was 5 months (interquartile range 2-13 months). The QI project setting was an academic hospital PICU with a Level I trauma center located in the Mid-Atlantic Region of the United States. APPROACH: A pre-post observational design was used to compare the at-risk population for 21 weeks before (August-December 2018) and after (August-December 2019) implementing repositioning guidelines. Turn attempts were undertaken every 2 hours. Repositioning attempts were defined as (1) full (30°); (2) partial (15°); (3) unable to turn owing to hemodynamic instability; or (4) noncompliance. The primary outcome was incidence of Stage II or higher PI. OUTCOMES: We found a significant reduction in the incidence of PI before and after implementation of the repositioning intervention (16.4% vs 2.0%, P = .0003). IMPLICATIONS FOR PRACTICE: A structured intervention for repositioning hemodynamically unstable PICU patients has the potential to significantly lower PI incidence in a group of hemodynamically unstable children.

Pain Assessment in the Outpatient Pediatric Burn Patient: An Integrative Review.

BACKGROUND: There is no standardized practice in pediatric pain assessment with burn injuries in the outpatient clinic setting. OBJECTIVE: This review aims to identify reliable, validated tools to measure pain in the pediatric burn clinic population. METHODS: The literature search for this integrative review was conducted using the databases of PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane, and Embase from 2011 to 2023. Quality and relevance were appraised using the Johns Hopkins Nursing Evidence-Based Practice Model. Reporting was done according to a Preferred Reporting Items for Systemic Reviews and Meta-Analysis checklist. RESULTS: Fourteen articles and two clinical practice guidelines met inclusion criteria and were included in this review. CONCLUSION: The Pain Observation Scale for Young Children and the COMFORT Behavior Scale tools have shown good reliability and construct validity and can be safely used to measure background and procedural pain in daily burn practice. Further research on reliable, validated pain assessment techniques in the pediatric burn population is needed.

An Integrative Review Regarding Knowledge and Self-Competency of Pediatric and Neonatal Critical Care Transport Nurses.

OBJECTIVE: As the health care setting has become more centralized, there has been an increased need for critically ill neonatal and pediatric patients to be transported to facilities for a higher level of care. These interfacility transports are possible through the utilization of highly specialized teams of health care providers. Unfortunately, there is currently a lack of consistency in training these teams to provide safe care. The purpose of this integrative review was to identify the best practice for improving nursing knowledge and self-competency in critical care neonatal and pediatric interhospital transport. METHODS: A literature search was conducted to answer the following question: What are the best practices to improve/assess nursing knowledge and self-competency in critical care neonatal and pediatric interhospital transport? The articles found were then appraised using the Johns Hopkins Evidence-Based Practice Model's appraisal tool. RESULTS: Eight articles were included in the final review and found to be of good quality. From these articles, 4 themes were identified that address the best practices in the education of critical care transport nurses: increased knowledge and skills with simulation, improved self-efficacy and satisfaction of nurses with simulation, knowledge assessment is feasible through tests and checklists, and the importance of debriefing among nurses with simulation. CONCLUSION: The incorporation of routine simulations that include knowledge tests, checklists, and targeted educational debriefings for interhospital neonatal and pediatric critical care transport teams improves and verifies nursing knowledge and self-competency. Future research should focus on the design and curriculum specifications of this educational plan within critical care interhospital transport.

Advance Care Planning in Chronically Ill Patients With an Episodic Disease Trajectory in the Acute Care Setting: A Quality Improvement Project.

INTRODUCTION: Advance care planning (ACP) is a fluid discussion between patients and providers to define preferences for future medical care. In the acute care setting, ACP is limited due to lack of structured process for identifying persons who may benefit from ACP. This quality improvement (QI) project aimed to increase the frequency of ACP discussions and documentation of preferences by targeting geriatric patients with an episodic disease trajectory for ACP. METHODS: This project used an intervention and comparison group design to target English-speaking, geriatric adults at a large academic medical center with a diagnosis of NYHA class III/IV HF and/or GOLD criteria III/IV COPD for ACP discussions. The intervention group was compared to a group with a range of diagnoses who were approached in a non-systematic way. RESULTS: Thirteen (n = 13) participants completed all aspects of the QI project. Results showed a non-significant increase in the number of patients with a diagnosis of HF and/or COPD who participated in an ACP discussion when compared to the comparison group (n = 20, p = 0.131), as well as a non-significant increase in the number of ACP tools documented in the HER (53.8% compared to 30%) (x = 1.877, p = 0.171). CONCLUSION: While this project demonstrated non-significant statistical results in the incidence and documentation of an ACP tool, this project increased the number of ACP discussions had, which is clinically significant.

Increasing Nursing Research Program Visibility: A Systematic Review and Implementation of the Evidence.

In healthcare, timely communication of critical information is imperative among workforce members. Nurse leaders struggle with how to reach clinical staff effectively when informing them of program updates, practice changes, or available resources. This article provides a review of the marketing and communication literature sharing best practices for improving visibility and program uptake for infrastructure supporting the conduct of inquiry projects among hospital employees using an evidence-based practice approach.

Work System Assessment to Facilitate the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use: A Case Study Using a Human Factors Engineering Approach.

BACKGROUND: Work system assessments can facilitate successful implementation of quality improvement programs. Using a human factors engineering approach, we conducted a work system assessment to facilitate the dissemination of a quality improvement program for optimizing blood culture use in pediatric intensive care units at 2 hospitals. METHODS: Semistructured face-to-face interviews were conducted with clinicians from Johns Hopkins All Children's Hospital and University of Virginia Medical Center. Interview data were analyzed using qualitative content analysis. RESULTS: Blood culture-ordering practices are influenced by various work system factors, including people, tasks, tools and technologies, the physical environment, organizational conditions, and the external environment. A clinical decision-support tool could facilitate implementation by (1) standardizing blood culture-ordering practices, (2) ensuring that prescribing clinicians review the patient's condition before ordering a blood culture, (3) facilitating critical thinking, and (4) empowering nurses to communicate with physicians and advocate for adherence to blood culture-ordering guidelines. CONCLUSION: The success of interventions for optimizing blood culture use relies heavily on the local context. A work system analysis using a human factors engineering approach can identify key areas to be addressed for the successful dissemination of quality improvement interventions.

Macrocognition in the Healthcare Built Environment (mHCBE): A Focused Ethnographic Study of "Neighborhoods" in a Pediatric Intensive Care Unit.

OBJECTIVES: The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition. BACKGROUND: In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, "macrocognition in the healthcare built environment" (mHCBE) addresses this relationship. METHOD: A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data. RESULTS: Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs). CONCLUSIONS: Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

Identifying Barriers to Delirium Screening and Prevention in the Pediatric ICU: Evaluation of PICU Staff Knowledge.

Delirium in the pediatric intensive care unit (PICU) setting is often unrecognized and undertreated. The importance of screening and identification of ICU delirium has been identified in both adult and pediatric literature. Delirium increases ICU morbidity, length of mechanical ventilation and length of stay. The objective of this study was to determine the current knowledge level about delirium and its risk factors among pediatric critical care nurses through a short questionnaire. We hypothesized that before a targeted educational intervention, PICU care providers do not have an adequate knowledge base for accurate screening and diagnosis of delirium in critically ill children. A 17 question online survey was given to all nurses in a tertiary 36-bed PICU to assess current knowledge about delirium in children. The response rate was 73% (105/143). When asked to identify the correct way to diagnose pediatric delirium, 11.4% of nurses surveyed (12/105) incorrectly believed that Glasgow Coma Score is the appropriate screening tool. A large proportion of respondents (40/105) believed that benzodiazepines are helpful in treatment of delirium. The results of the survey identified specific knowledge gaps about risk factors and treatment of pediatric delirium in the critically ill child. There is a critical need for education about pediatric delirium and its risk factors among PICU staff prior to unit-wide implementation of a delirium screening and prevention program, specifically with regards to screening methods and pharmacologic risk factors. These results are likely generalizable to all physicians, nurses and staff who care for critically ill children.