Building Bridges From Hospital to Home: Understanding the Transition Experience for the Newly Diagnosed Pediatric Oncology Patient.

Caregivers of pediatric oncology patients are expected to understand and adhere to a complex medical plan of care while at home; yet little is known about how to assess and evaluate the caregivers' abilities to adequately meet these demands. The purpose of this study was to describe the issues and daily challenges faced by caregivers as they transition from hospital to home after their child's cancer diagnosis. Patients and caregivers received a home visit by an expert pediatric oncology nurse within 72 hours postdischarge after initial diagnosis. The nursing narrative notes from these visits were analyzed using content analysis. Four explanatory themes emerged: (1) "We're doing okay," (2) "This isn't going so well," (3) "I could use a little help with this," and (4) "An RN in the house makes you feel safe and know what is correct." These analyses revealed many caregivers achieved mastery of caring for the child at home; however, an overwhelming majority of caregivers expressed questions or concerns to the nurse during the home visit, even those achieving mastery of care. A home visit by an expert pediatric oncology nurse assisted the caregiver in transitioning to caring for the child at home. Such programs should be considered when planning transition programs from hospital to home.

Development of an outcome measure to monitor the effectiveness of pain management.

Attention to the pain that occurs during treatments and procedures for pediatric patients with cancer continues to be a priority. This article describes the development of a pain effectiveness outcome measure at an academic pediatric medical center in order to inform about the implementation of quality improvement strategies and evaluate the effect of these pain interventions within the hospital setting.

Linking equitability to quality: the development of a pediatric nursing e-quality measure.

Over the past decade, many initiatives have been directed toward eliminating racial and ethnic disparities in healthcare. Despite these efforts, the 2007 National Healthcare Disparities Report revealed that overall disparities in healthcare quality and access have not decreased. Although the disparities described vary in magnitude by category and population, they were identified in almost every aspect of healthcare. Improving the quality of care may not reduce disparities; therefore, ensuring the collection of better patient reported race and ethnicity data, whereas linking it to clinical performance may be one of the first challenges to overcome. Eliminating disparities in healthcare is particularly important in the provision of pediatric care because children of immigrant families are the fastest growing sector of the pediatric population in the United States. This article describes an approach to the stratification of nursing-sensitive measures by race, ethnicity, and insurance group, which integrally links cultural competence to quality of care, identifies disparities in patient outcomes related to nursing care, and informs the development of tailored interventions to meet the needs of diverse patients and their families.

An evidence-based approach to nasogastric tube management: special considerations.

Although there have been helpful literature reviews on pediatric nasogastric (NG) tube management, there is a lack of evidence with regards to special circumstances, such as at-risk patients with altered neurological status or developmental disabilities. At our hospital, an interdisciplinary Enteral Feeding Task Force was created to address the special needs and concerns of complex pediatric patients. We carefully weighed the evidence from the literature, incidents at our hospital and other children's hospitals, and a synthesis of expert opinion. This article describes our evidence-based process of policy revision, and it includes excerpts from our revised NG tube management policy.

Can end of life care for the pediatric patient suffering with escalating and intractable symptoms be improved?

Over twelve thousand children are diagnosed each year with cancer, and approximately 2200 children die each year from the disease. A percentage of these patients experiences escalating and intractable distress with symptoms that include pain, dyspnea, and agitation. These symptoms may continue for hours to days. Intractable symptoms of pain, agitation, and dyspnea can be very distressing to the patient, family, and staff and often a challenge for the physicians and nursing staff to treat. To meet this challenge, The Dana-Farber Cancer Institute/Children's Hospital Cancer Care Program has made it a priority to create a process of care that includes identifying barriers to care and the development of an end-of-life (EOL) rapid response model that includes guidelines and physician-templated orders for rapid escalation of opioids. The goal of this quality-improvement initiative was to develop a model of care that would enable the caregivers to provide effective comfort care to any patient experiencing symptoms of rapid escalation of pain, dyspnea, and agitation. A model of care was created to overcome barriers to care. The model includes role clarification, "Guidelines for the Management of Escalating Pain/Dyspnea/Agitation at the End of Life," and "Rapid Titration-Templated Physician Orders." Staff feedback was solicited relative to the content, format, and usability of the guidelines and templated orders. The physician and nursing staff reported that they found the templated orders and guidelines very helpful and effective and suggested only a few edits. A retrospective chart review is currently under way. The purpose of this chart review is to systematically document and compare the record of management of rapidly escalating symptoms of pain and/or dyspnea and/or agitation prior to and after instituting the EOL Rapid Response Model of Care. Care of the EOL patient experiencing symptoms of pain, dyspnea, and agitation is challenging. The EOL Rapid Response Model of Care outlines a process of care and provides recommendations and templated physician orders for rapid titration of opioids.