Sleeping Safe and Sound: A Multidisciplinary Hospital-wide Infant Safe Sleep Quality Improvement Initiative.

INTRODUCTION: Promoting safe sleep to decrease sudden unexpected infant death is challenging in the hospital setting. LOCAL PROBLEM: Concern for adherence to safe sleep practice across inpatient units at a large pediatric hospital. METHODS: Used quality improvement methodologies to promote safe sleep across all units. INTERVENTIONS: Development of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress. RESULTS: Adherence to safe sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a safe sleep environment. Safe sleep practices were less likely to be observed in infants with increased medical complexity (p = .027). CONCLUSIONS: Quality improvement methodology improved adherence to infant safe sleep guidelines across multiple units. Medically complex infants continue to be a challenge to safe sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary.

The acuity of pediatric neuroscience nursing using the Inpatient Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO© ) tool.

PURPOSE: The neuroscience nurse must possess advanced knowledge and skills to care for a wide range of unique congenital and acquired neurological diagnoses. For each of these clinical scenarios, the measurement of complexity and acuity of patient care is key to informing staffing models and patient assignments. The Inpatient Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO© ) acuity tool measures patient acuity in terms of nursing cognitive workload complexity. We describe the implementation and evaluation of the Inpatient CAMEO© in a pediatric neuroscience unit in a large free-standing children's hospital in the northeast United States. DESIGN AND METHODS: Using a quality improvement approach, the Inpatient CAMEO© was implemented and evaluated over a 12-month period by a neuroscience clinical lead and unit-based ambassadors. Monthly data reports evaluating unit-level completion and the level of acuity (I-V) were generated for unit leadership. Data were further stratified by type of admission to the neuroscience unit. Five categories of patients included neurology medical, epilepsy, neurosurgical, neurooncology, and other, which is defined as nonneurology patients, admitted to unit. RESULTS: The monthly proportion of Inpatient CAMEO© s Classified as III-V ranged from 62.3% to 83.3% with a median of 78.2%. The type of neuroscience admissions varied in level of acuity. Patients identified as neurology (68.7%) and epilepsy (67.5%) had the lowest acuity, patients identified as neurosurgery (82.8%) and other (80.2%) had moderate acuity, and neurooncology (94.5%) had the highest acuity. PRACTICE IMPLICATIONS: Using the Inpatient CAMEO© , the acuity of neuroscience pediatric care was demonstrated to be increased and variable across disease categories. Neurooncology patients were identified as having the highest acuity as compared to other pediatric neuroscience admissions.

Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting.

BACKGROUND: Evidence-based practice (EBP) is essential for clinical decision-making, improving care, reducing costs and achieving optimal patient outcomes. The Evidence-based Practice Mentorship Program (EBPMP) is a flexible, self-directed programme whereby participants carry out EBP projects guided by expert mentors. AIMS: To evaluate EBPMP effectiveness and participant experience. METHODS: To evaluate effectiveness, as measured by changes in EBP value, knowledge and implementation, participants completed pre- and post-EBPMP Quick-EBP-Value, Implementation and Knowledge (VIK) surveys. To understand participants' experiences individual and group interviews were conducted at the end of the programme and analysed using qualitative content analysis. RESULTS: Most participants were over 50 years old, Caucasian, inpatient staff nurses, baccalaureate prepared, with over 11 years' experience. Statistically significant improvements were observed in the post Quick-EBP-VIK knowledge and implementation domains. Individual and group participant interviews revealed four categories of importance to the experience: 1. perceived benefits of EBP, 2. time as a barrier to EBP, 3. desire for more cohort interaction and 4. positive mentee-mentor experience. CONCLUSIONS: EBPMP can improve participants' knowledge and implementation of EBP in an environment that values EBP; however, opportunities exist to implement programme modifications that address barriers identified by participants including project time and increased participant interactions.

The Measurement of Pediatric Inpatient Nursing Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) Tool.

PURPOSE: Physiologic measurement of patient acuity has been used to predict patient outcomes, length of stay, and resource utilization. To date, these tools are not sufficiently comprehensive to inform nurse staffing assignments and have limited practical application. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) acuity tool was initially developed and validated to quantify patient acuity in terms of complexity of nursing cognitive workload in pediatric intensive care units (ICU). This article describes development and implementation of the Inpatient CAMEO© in the pediatric inpatient setting. DESIGN AND METHODS: Utilizing a modified Delphi technique, an expert panel convened to scale and implement the Inpatient CAMEO© in the pediatric inpatient units through four Delphi rounds. RESULTS: The expert panel identified care items unique to the pediatric inpatient setting and assigned a cognitive workload scale of 1-5. To consolidate the tool, the panel identified items to be classified as "Standard of Care" and developed a new baseline score for the Inpatient CAMEO©. Expert panel members served as unit-based ambassadors to foster the expansion and implementation of the new Inpatient CAMEO©. CONCLUSIONS: The Inpatient CAMEO© describes and quantifies acuity beyond the intensive care setting. The implementation and use of the Inpatient CAMEO© was accomplished through unit-based ambassadors and the support of leadership. PRACTICE IMPLICATIONS: Quantifying nursing cognitive workload in both direct and indirect care is important to determining nursing assignments and comprehensive staffing models in the pediatric inpatient setting.

Extremity fractures in children: when is it an emergency?

Not all pediatric fractures require emergent orthopedic attention. The information needed to assess and provide the appropriate interventions to children and their families following an extremity fracture is discussed in this article. A case study is used to describe a fracture that requires emergent intervention. The role of the pediatric orthopaedic nurse practitioner in the emergency department, inpatient, and outpatient setting is also illustrated.

Physiology after pediatric splenic injury.

BACKGROUND: The splenic injury computed tomographic (CT) grade is used to guide nonoperative management. A study was conducted to determine whether this grade correlates with patient physiology. METHODS: Records of consecutive children with isolated spleen injuries were reviewed. Vital signs, fluids administered, urine output, and hematocrit values from the scene through 120 hours after admission were retrieved. A blinded radiologist reviewed CT scans. Statistical analyses were conducted to test for a linear relationship between injury grade and physiologic parameters. RESULTS: Eighty-two patients with isolated splenic injuries and available CT scans were located. CT injury grade correlated directly with pulse, systolic blood pressure, and diastolic blood pressure and inversely with hematocrit. No correlation was found with pulse pressure, urine output, or maximum temperature. CONCLUSION: The CT grade of splenic injury correlates directly with pulse, systolic blood pressure, and diastolic blood pressure and inversely with hematocrit. CT injury grade correlates with physiologic impact and may guide management decisions.

Application of the APSA evidence-based guidelines for isolated liver or spleen injuries: a single institution experience.

PURPOSE: In 1998, the American Pediatric Surgical Association (APSA) recommended evidence-based guidelines for the management of hemodynamically stable patients with isolated liver or spleen injuries. A clinical practice guideline (CPG) was developed using the APSA guidelines. This study analyzes the impact of the CPG on the care of these children in a single institution. METHODS: Patients treated with the CPG between September 1998 and June 2002 were compared with a similar cohort admitted from February 1992 to October 1997, before the CPG was instituted. Groups were analyzed for age, computerized tomographic organ injury grade, hematocrits obtained, Injury Severity Score (ISS), length of intensive care unit (ICU) and hospital stay, follow-up imaging studies performed, and outcome. RESULTS: CPG patients had a shorter ICU length of stay (0.4 +/- 0.6 v 1.4 +/- 0.6 days; P <.001), shorter hospital stay (3.8 +/- 1.2 v 7.2 +/- 1.4 days; P <.001), fewer hematocrits obtained (4.7 +/- 2.2 v 9.2 +/- 3.1; P <.001), and fewer follow-up imaging studies (0.3 +/- 0.4 v 2.1 +/- 1.1; P <.001). One patient in the CPG group was readmitted for delayed hemorrhage. No urgent operations were performed in either group. CONCLUSIONS: Application of an APSA-based CPG resulted in decreased length of ICU stay, decreased hospital stay, and decreased resource utilization without any noted effect on outcome.