A Randomized Controlled Trial Comparing Flat Times Versus Standard Care in Pediatric Patients Post Cardiac Catheterization.

BACKGROUND: Pediatric patients undergoing cardiac catheterization procedures are required to lie flat for 4 hours for femoral venous access and 6 hours for femoral arterial access. Authors of research in adults suggest the flat time for the same access can be safely reduced to 1.5 to 2 hours post procedure. No literature was found that flat times could be safely reduced for pediatric patients. OBJECTIVE: The purpose of this study was to determine whether decreased flat time for the post-cardiac catheterization pediatric patient would impact the incidence of site bleeding, additional sedation, and the need for a critical care admission. METHODS: A randomized controlled trial was designed and participants were randomly assigned to experimental or control group. The experimental group reduced flat times to 2 hours for venous and 4 hours for arterial. The control group was standard care of 4 hours for venous and 6 hours for arterial. RESULTS: A total of 119 participants were enrolled, 60 in the experimental group and 59 in the control group. Results suggest no difference in the incidence of site bleeding (P = .999), additional sedation (P = .653), or need for a critical care admission. CONCLUSIONS: For pediatric patients undergoing arterial or venous cardiac catheterizations, flat times can safely be reduced without increasing site bleeding, additional sedation, or critical care admissions.

Pain Control and Positioning in Children Following Selective Dorsal Rhizotomy Surgery.

BACKGROUND: A practice was changed to elevate the head of bed from day 1 to day 3 on children after selective dorsal rhizotomy (SDR) surgery to improve pain control. Multiple methods to address pain post SDR include a continuous epidural infusion, medication administration, and repositioning/distraction. The length of time for the patient to remain flat was increased to potentially improve pain management. However, no studies in the literature were found to support the practice change. Nurses inquired whether this change resulted in optimal pain control. The primary research aim was to determine whether the change in positioning resulted in a difference in pain control. METHODS: A retrospective cohort design was used to compare pain medication administered before and after the practice change. Patients between the ages of 2 and 15 years and admitted to the neuroscience unit after SDR surgery were included. Data were electronically retrieved to record the amount of medications given for pain. Descriptive and univariate statistics were used to detect differences. RESULTS: The retrospective component of the study analyzed a total of 385 patients. There were no statistically significant differences between the number of intermittent doses of medication administered for pain between the 2 groups (P = .661). DISCUSSION: Results support return to practice of 1 day of flat time. Nurses perceive that lying flat contributes to child and parent anxiety and limits options for distraction; therefore, decreasing flat time may lower anxiety without affecting pain control. These results are limited to postsurgical SDR patients but have implications for postoperative positioning and pain management. On the basis of these results, the neurosurgeon changed practice to zero days of flat time.

A Randomized Controlled Trial to Compare Pain Medications in Children Undergoing Strabismus Surgery.

PURPOSE: The purpose of this study was to investigate optimal intraoperative combinations of analgesia for children undergoing strabismus surgery. DESIGN: A randomized controlled trial was employed to compare the difference in pain after administration of hydromorphone versus fentanyl. METHODS: Participants were randomly assigned to either arm of the study. Pain was measured by the revised Faces, Legs, Activity, Cry, and Consolability Scale (rFLACC) tool postoperatively, and the parent was asked about the presence or absence of pain after discharge. FINDINGS: A total of 135 children were included in the study. The rFLACC pain score was found to be significantly higher postoperatively among patients receiving fentanyl (P = .011). Pain after discharge was reported more often among patients who received fentanyl (P < .001). CONCLUSIONS: Results of this study can be used to change practice to minimize the pain levels both postoperatively and after discharge for children undergoing strabismus surgery.

Improving the Discharge to Home Experience for Pediatric Heart Center Patients and Families.

PURPOSE: The purpose of this study was to determine if implementation of the discharge specialist role improves family perception of discharge readiness and determines whether the use of the role decreases the number of tasks needing completion on the day of discharge. DESIGN AND METHODS: A prospective descriptive study was designed to compare parent readiness for discharge from two groups of participants. One group had a discharge specialist the day of discharge. The other group did not have the assistance of the discharge specialist on the day of discharge. Participants were contacted after discharge and surveyed on their perception of readiness for discharge based on a modified version of the Care Transitions Method Survey. Patient responses were either Strongly Agree or Less than Strongly Agree. RESULTS: A total of 60 patients (30 in each group) were analyzed. There were no statistically significant differences in demographic variables between the two groups. The overall average score of the composite proportion responding with Strongly Agree was higher among caregivers using a discharge specialist (Mean = 88.2) as compared to those without (Mean = 55.9, U = 157.0, p < .001). CONCLUSION: The use of a discharge specialist on the day of discharge resulted in a higher parent perception of discharge readiness in this sample of children with complex cardiac diagnosis. PRACTICE IMPLICATIONS: The use of a discharge specialist in the heart center can assist with the successful transition from hospital to home. Future research should examine the effect of the discharge specialist on hospital re-admission rates and clinical outcomes.

Pediatric nurse practitioners effective in teaching providers the Asthma Action Plan using simulation.

Despite traditional education regarding the Asthma Action Plan (AAP), providers in the inpatient setting of a pediatric hospital reported lack of knowledge regarding the AAP and lack of confidence in teaching the AAP to patients and families. The purpose of this study was to assess the effect of a pediatric nurse practitioner (PNP)-led class incorporating simulation on resident physician knowledge of the AAP and confidence in teaching families the AAP. The study setting was a 250 bed Midwest academic pediatric hospital. The 26 participants were second year residents completing a four-week pediatric pulmonary rotation. The class consisted of a brief didactic component regarding the AAP, simulation to teach a patient/parent actor the AAP based on PNP-developed scenarios, and debriefing of the experience. The average composite score on the pre- and post-simulation knowledge assessment showed improvement from 44.8% to 80.4% (p<0.001). All participants answered favorably on questions regarding perceived benefit of the class and 80.8% strongly agreed that they felt more confident teaching the AAP after the class. This study demonstrates that resident physician knowledge of the AAP and confidence in teaching the AAP improved after a PNP-led simulation class.

Evidence-Based Practice and Quality Improvement in Nursing Education.

For more than a decade, nursing education has experienced several significant changes in response to challenges faced by healthcare organizations. Accrediting organizations have called for improved quality and safety in care, and the Institute of Medicine has identified evidence-based practice and quality improvement as 2 core competencies to include in the curricula for all healthcare professionals. However, the application of these competencies reaches far beyond the classroom setting. For nurses to possess the knowledge, skills, and attitudes to apply evidence-based practice and quality improvement to the real-world setting, academic-clinical institution partnerships are vital.

Beyond implementation: sustaining family-centered rounds.

Family-centered care encourages patients and families to participate in the planning and delivery of care based on personal preferences and individual needs. For pediatric patients and families, family-centered rounds (FCRs) represent a standard of care that involves patients and families partnering with the healthcare team to share information and make decisions about care. Our healthcare team strongly believes that FCRs are critical to providing excellence in care. Our initial attempt to implement and then sustain FCRs presented challenges that required changing the culture to one that consistently partners with patients and families and appreciates the role they play in the care of their children. Incorporation of observations and feedback from family advisors, a consistent process for rounding, and education for team members about expectations for participation were needed to revive and sustain FCRs. Through continued evaluation and collaboration, our unit worked to establish a standard approach to FCRs that benefits the patient and family as well as to the healthcare team.

Optimizing perioperative care for children and adolescents with challenging behaviors.

Pediatric perioperative nurses care for a wide variety of children and adolescents, some of whom have special developmental or behavioral needs. Providing care for this vulnerable population can be challenging because they may not express their level of pain or anxiety through behaviors commonly observed in typically developing children. This quality improvement project was conducted to enhance perioperative care delivered to children with challenging behaviors and to their families. A screening tool to individualize the plan of care was developed to identify specific behaviors, triggers, and communication patterns of these children prior to hospitalization. Interventions were identified to address these behaviors that could be used by nurses, child life specialists, and occupational therapists. Partnering with parents and other members of the interprofessional healthcare team has resulted in best practice care planning for these children, ensuring a much more successful perioperative experience for patients and families. Findings from parent surveys demonstrate that by using the tool, nurses and other team members are able to minimize stressors and implement interventions specific to the child. As a result, the adaptive care planning tool has expanded beyond the perioperative area and is now being used by direct care nurses, support staff, nurse practitioners, and physicians across the organization.

Psychosocial outcomes of a summer overnight recreational experience for children with heart disease.

Children with chronic heart disease (CHD) are often turned away from recreational summer overnight experiences because of complicated medical histories and medication regimens. The purpose of this qualitative study was to evaluate the psychosocial impact of a five-day overnight recreational experience for children with CHD and their parents. Thirty-six children with CHD between the age of 8 and 15 years and their parents participated in the study. Data were collected from the children using photovoice interviews. Parent data were collected using a post camp survey. Results included the following external outcome themes: inclusion in a peer group and the importance of friendship, fun, and safety. Internal or personal outcome themes included counselor as a role model, increased self-confidence, and the realization of life's possibilities. Parent themes included increased child independence, increased child confidence, and child feelings of normalcy related to belonging to a peer group. Findings from this study can be used to encourage families of children with CHD to allow participation in a well-supervised overnight recreational experience. Such an experience can foster the child's overall development, provide peer group support, and reduce parent anxiety about overnight separation from the child.

Evaluation of child and parent outcomes after a pediatric cardiac camp experience.

PURPOSE: This study evaluated the effects of a cardiac camp experience on children with heart disease and their parents. DESIGN AND METHODS: A repeated measures design was used with 49 parent-child dyads. Repeated measures evaluated the effects of camp on anxiety, attitude toward illness, and psychosocial functioning of the children. Parental anxiety was also evaluated. RESULTS: Results demonstrated decreases in parent anxiety, decreases in child trait anxiety, and positive psychosocial outcomes in the areas of self-esteem, social, physical, and emotional functioning. PRACTICE IMPLICATIONS: Findings can be used to support decisions for those contemplating a camping experience for the child with heart disease.

An outcome of evidence-based practice education: sustained clinical decision-making among bedside nurses.

This research described factors related to incorporating evidence-based practice for clinical decision-making by staff nurses who completed an evidence-based practice (EBP) scholars program. A phenomenological approach was used with focus groups to collect data. A semi-structured questionnaire and field notes comprised study instruments. Audio tapes were transcribed and semantic content analysis was used to code data. Programs to teach bedside nurses how to incorporate EBP into care delivery not only result in better outcomes for patients but also greatly contribute to the sustained enculturation of EBP as a foundation for nursing practice.

Nutritional screening and early intervention in children, adolescents, and young adults with cancer.

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

Collaborative research partnerships in support of nursing excellence.

Nursing leadership is committed to advancing the profession of nursing through research and evidence-based practice. Partnerships between the hospital and area academic institutions were formed to develop a comprehensive research program that supported active involvement for frontline staff and provide clinical research opportunities for area faculty. Through this collaborative model, the research program has continually expanded and provided clinical research that is making a difference for patients and families. The commitment of this service/academic research partnership is shown by the close involvement of each in future planning for studies and program development. A collaborative partnership is an excellent means to promote clinical research and support nursing excellence.

Teaching research and evidence-based practice using a service-learning approach.

Because nurses are expected to engage in evidence-based practice (EBP), nursing students must learn to critically evaluate and apply research findings to prepare for professional practice. To connect research and EBP, the focus of a baccalaureate research course was changed from a traditional format to one of evidence appraisal and synthesis. Using an approach that incorporated service-learning and collaborative learning resulted in a new hybrid course that provided students with an opportunity to apply concepts in the real world. Working with a community partner, students were able to develop PICO (Population, Intervention, Comparison, and Outcome) questions and critically appraise the literature to establish the evidence base for three pediatric programs. Students reported that working with a community partner was a meaningful experience because course assignments had a direct impact on current practice. Research courses taught from an EBP perspective can provide motivation for students to incorporate research into their practice as professional nurses.

Evidence Equals Excellence: The application of an evidence-based practice model in an academic medical center.

An evidence-based practice (EBP) program that is designed to develop mentors in both clinical and academic settings has the potential for transforming a health care organization. This article describes an innovative program, Evidence Equals Excellence, which consists of two components: a clinical practice component for health care clinicians and an academic program for baccalaureate and graduate nursing students. The development of EBP mentors creates a core group of clinicians who can assist fellow staff members apply evidence at the bedside. An academic program prepares new graduates to partner easily with clinical mentors to support and initiate successful practice changes.