Nursing Posters

Follow

• 

  A Metabolic, Mechanical, Multi-Organ Masterpiece: Dural Device Support Bridge to En-Bloc Heart-Liver Transplantation in Propionic Acidemia

  Rebecca Juhl, Brian Birnbaum, Aliessa P. Barnes, William Gibson, Bhargava Mullapudi, Beth Lang, Megan Faseler, Daniel E. Heble, Victoria Urban, Ryan T. Fischer, Jennifer L. Gannon, and David Sutcliffe

  Introduction: Propionic Acidemia (PA) is a disorder related to abnormal protein and lipid metabolism resulting in progressive neurological injury and dilated cardiomyopathy (DCM). Interventions for PA and secondary disease manifestations can require multi-organ transplantation. Herein we report the case of a child with PA and end-stage DCM requiring left ventricular assist device (LVAD) support with eventual heart-liver transplant. Case Report: A 17 year old male diagnosed in childhood with PA developed chronically progressive DCM culminating in end stage heart failure with acute decompensations. In a recurrent admission, he progressed to require dual inotropic support and systemic anticoagulation for new LV thrombus. Heart-liver transplant eligibility was confirmed, and with further clinical deterioration requiring invasive mechanical ventilation and chemical paralysis he underwent durable, intrapericardial LVAD implant as bridge to candidacy. After accomplishing discharge, he achieved intense physical and metabolic-specific nutritional rehabilitation over the span of 3 months, and he was listed for combined heart-liver transplant. In preparation for the complexities related to dual organ transplant from LVAD support, collaborative operative simulations were completed as were adaptations of post operative immunosuppressive and medical management between transplant teams. After a 3 week waitlist duration, he underwent en-bloc heart-liver transplant with successful post operative recovery to discharge within 2 weeks. Summary: Even with effective and specialized nutritional management, DCM secondary to PA can progress to end stage heart failure requiring mechanical support and organ transplantation. Successful rehabilitation via VAD and bridge to multiorgan transplantation requires diligent collaboration across transplant teams. Despite both technical and clinical challenges, successful completion of en-bloc heart-liver transplant from VAD support can be accomplished.

• 

  Antibiotic Durations for Skin and Soft Tissue Infections in Pediatric Urgent Care Clinics

  Megan Hamner, Amanda Nedved, Holly Austin, Donna Wyly, Alaina N. Burns, Diana King, Brian R. Lee, and Rana El Feghaly

  Background: Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5-7 days for most diagnoses.
  
  
  Objective: To determine the baseline percentage of patients receiving antibiotic prescriptions for >7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations.
  
  
  Design/Methods: We built a report that extracted patient encounters from the three UCCs based on International Classification of Diseases (ICD)-10 codes for common SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Data was pulled from June 2019 through June 2020. The report included patient age, concomitant diagnoses, antibiotics prescribed and their duration. We excluded encounters if the patient was transferred to the emergency department or admitted, the patient was younger than 3 months of age, no antibiotics were prescribed, or if there was a concurrent infectious diagnosis affecting antibiotic duration. We sent a 22-question survey to UCC providers to understand prescribing habits particularly focusing on factors prompting administration of longer antibiotic courses.
  
  
  Results: From June 2019-June 2020, we reviewed 2,575 encounters; we excluded 208 of those (8%). 823 (35%) of patients received >7 days of antibiotics for SSTIs while 1181 (50%) received 5-7 days and 35 (1%) received <5 days of antibiotics. 328>(14%) received topical therapy only. Most common antibiotics prescribed included cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. A mild improvement in the 5-7 days duration was noted through our study period (Figure 1). The survey was sent to 50 providers with 27 responding (54% response rate) (Tables 1 and 2). Barriers for shorter treatment courses included concern for acute rheumatic fever development, parental pressure, fear of complications, and accustomed antibiotic duration.
  
  Conclusion(s): A third of children with SSTIs in our UCCs receive long courses of antibiotics. A mild improvement noted in our study period may be due to existing antibiotic stewardship interventions. Specific provider concerns leading to overprescribing will be targeted by quality improvement efforts.

  Presented at the 2021 PAS Virtual Conference

• 

  A SMARTer Way to Round

  Charles Maloy, Adrienne G. DePorre, Erica Adams, Jessica Olson, Amber Hunley, and Darcy K. Weidemann

  Background: Communication is a key driver of health care outcomes. Poor communication practices contribute to sentinel safety events, poor family/patient experiences, and delays in care. Use of checklists in the healthcare setting is important to the development of high reliability and is increasingly common, however, the development and implementation of medical checklists for the standard patient floor are inadequately described.
  
  
  Objective: To develop a sustainable rounding checklist for multidisciplinary discussion of patient safety measures and clinical plans.
  
  
  Design/Methods: Key stakeholders in the rounding process (subspecialty and general pediatrics physicians, resident physician, bedside nurses, and nursing leadership) created a rounding checklist tool for use on a medical unit at our tertiary care children’s hospital. This checklist was modified from an existing checklist used in the pediatric intensive care unit. It focused on reducing harm, improving quality of care, and facilitating communication. To foster open communication within the multidisciplinary team and project sustainability, bedside nurses owned the task to prompt daily review of checklist items with the team during rounds. We developed badge buddies as an aid and an audit tool to assess checklist compliance. Compliance with checklist use was assessed by iterative Plan-Do-Study-Act (PDSA) cycles. Acceptability and usefulness of the checklist was measured by a 6 month-post implementation survey of nurses, residents, and staff.
  
  
  Results: A five-item checklist entitled SMART (Situational Awareness, Medications, Access, Routine, and Transition) was created (Figure 1). Daily audits showed between 75%-88% usage of the checklist during rounds (Figure 2). Our first PDSA cycle showed improved compliance with implementation of a streamlined audit tool. 29% of eligible providers completed the survey (n=51). 77% of respondents perceived communication improvement with SMART card usage with 4% disagreement. 66% reported vital patient care details were discussed that would otherwise have been missed. Only 2% found the checklist led to delays in patient care with a majority responding that checklist completion took 30-60 seconds.
  
  Conclusion(s): This project emphasizes the importance of multidisciplinary teams in development and implementation of a daily rounding checklist for a pediatric floor. We demonstrate the feasibility and acceptability of inserting a rounding checklist into the workflow of a multidisciplinary pediatric care team. Further study is needed to determine long-term effects on this initiative on process of care outcomes.

  Presented at the 2021 PAS Virtual Conference

• 

  Assessing Early Use and Complications of Gastrostomy Blended Feeds.

  James Fraser, Kristen L. Sayers, Amy L. Pierce, Beth A. Orrick, Wendy Jo Svetanoff, Tolulope A. Oyetunji MD MPH, and Shawn D. St Peter

  Providers are hesitant to recommend using blended tube feeds (BF) after gastrostomy tube (GT) placement due to increased risk of bacterial contamination, nutrition inadequacy, tube blockages, and lack of data addressing clinical outcomes. Caregivers often feel that BF are more natural, better tolerated, and more cost-effective. We studied early use of BF, potential complications, and satisfaction among caregivers.

• 

  Simulation Based Clinical Systems Testing in the Pediatric Emergency Department to Prepare for COVID-19 Pandemic

  Christopher S. Kennedy, Marc Sycip, Lisa Ell, and Shautonja Woods

  Background: The COVID-19 prompted pediatric emergency departments (PED) to prepare for a surge in patients. In response, guidelines developed represent “work as imagined” and may not reflect work as done. In situ simulations could identify gaps and help to mitigate errors. Simulation-based clinical systems tests (SbCSTs) can detect latent safety threats (LSTs) in systems design.
  
  
  Objective: Our aim was to use SbCSTs combined with rapid cycle training to test hospital system modifications for ED preparation. This method represenst a new application of SbCSTs. The research questions were in 2 frames: 1. Can rapidly deployed SbCSTs identify LSTs and recommendations for improvement and 2. Do providers consider rapid SbCSTs a way to improve preparedness?
  
  
  Design/Methods: The study took place in a PED and was approved by the IRB as non-human subject research. SbCST scenarios tested guidelines/job aids, equipment, and ways to mitigate exposure. Each case used “tipping-point”(s) to test workflow. Short scripted debriefs reviewed guidelines, staff input, and the simulation repeated. Participants evaluated the SbCST with a survey. Three sim staff collected observations on a standardized form for which process was tested, staff response, and LSTs identified.
  
  
  Results: Question 1. LST identification: From the 44 simulations, 64 staff identified 103 unique LSTs. LSTs were categorized as follows: Job Aids/tasks 37 (36%), Isolation Measures (PPE) 30 (29%), Communication/personnel: 18 (17.5%), and Equipment 18 (17.5%). Common LSTs identified: In the Job Aid category: simplify intubation job aid, Isolation Measures: staff had concerns about PPE changes prior to generating aerosol, Equipment: adjust equipment needs to avoid delays, and change PPE, and Communication/Personnel: minimizing staff during resuscitations. Question 2. Staff evaluations (strongly agree, (SA) to strongly disagree, (SD)): Worth the time it took: 86% SA, 14% some what agreed (SWA). An acceptable way to improve: 92 % SA, 8% SWA. An effective way to test: 92% SA, 8% SWA. Debriefing allowed staff to share ideas: 86% SA SWA 8%, and Average 6%.
  
  Conclusion(s): This study showed that SbCST methods are adaptable for preparedness evaluation and training. Participant evaluations reveal a high regard for this method for practicing/improving the COVID-19 process. This work highlights a new application of SbCSTs that could increase system preparedness and reduce errors.

  Presented at the 2021 PAS Virtual Conference

• 

  6 Hall Team Norms: It's Our Patient

  Mallory Rittel, Markeyta Brown, Ron Chenoweth, Marcy Page, Chelsi Peterzalek, and Amanda Woldruff

  Aim Statement

  6 Hall will increase NDNQI RN-RN interaction scores from 5.06 to 5.45 to meet the 2019 National Magnet Facilities benchmark b August 1, 2019.

  6 Hall Team Norms

  • We strive for excellence: our work is complex, mistakes will happen.
  • We provide timely (<1>week) feedback, which includes positive, learning and interpersonal feedback.
  • We celebrate as a team and our environment feels like every individual matters.
  • When trust is broken, we ask ourselves: how did I contribute? What can I do to make it better? We are careful in not making assumptions.
  • Our behaviors are supportive and display respect.
  • We create a work environment that feels consistently awesome.

• 

  A Multifaceted Approach to Improve Quarterly Visit Rates at a Pediatric Cystic Fibrosis Care Center

  Paula Capel, Jessica Banks, Micaela McKenna, Ashley Andrews, and Christopher M. Oermann

  Standard quality improvement methodology was used to improve quarterly visit rates among cystic fibrosis patients at Children's Mercy Kansas City Cystic Fibrosis Center.

  • A family-centered, team-based approach was adopted
  • A change in culture led to sustained improvement

  Improved quarterly visit rates should drive improvement in outcomes including pulmonary function and nutritional status.

• 

  CLABSI Prevention through Prevention Huddles and CLABSI Risk Assessment and Prevention Form in Electronic Medical Record

  Tara Benton, Barb Haney, Lacey Bergerhofer, Yolanda Ballam, and Kaitlyn Hoch

  Our aim is to increase the awareness of high risks for central line associated bloodstream infection (CLABSI) and decrease the CLABSI rate with the implementation of CLABSI prevention huddles and an electronic medical record (EMR) "CLABSI Risk Assessment and Prevention" form.

• 

  Decreasing Length of Stay in Pediatric Urgent Care with Electronic Discharge Instructions

  Jennifer Wooster, Aimy Patel, Brian R. Lee, and Amanda Nedved

  Time spent waiting in the urgent care clinic is dissatisfying for patient and staff. This "wasted time" accounted for more than 52% of the urgent care visit at our urgent care.

  The aim of our project is to decrease length of stay by 10 minutes by April 30, 2019 for all patients discharged from Blue Valley Urgent Care by offering patients a paperless depart process. To be eligible for discharge without paper families must be enrolled in the online patient portal.

  Electronic discharge instructions significantly decrease length of stay and is associated with improved patient experience scores. Patients who received hardcopy discharge instructions also had short median LOS, likely due to overall improved urgent care workflow with the use of the portal.

• 

  Examining Nurse Resiliency & a Mindfulness-Based Stress Reduction Intervention to Prevent Nurse Burnout

  Allegra Grannell

  Nurses continually give of themselves at work, as well as outside of work. This results in extensive stress, physiological distress, and ultimately burnout for individuals in the nursing profession. Nurses that work in high-stress environments, such as critical care, pediatrics, and oncology, are at a significantly increased risk of manifesting physical and psychological symptoms of burnout syndrome, compassion fatigue, and post-traumatic stress disorder (PTSD). Many of these factors are leading to nurses leaving the profession prematurely, resulting in significantly high turnover rates. High burnout and turnover rates of nurses result in the lack of adequate nursing staff in hospitals, which in turn results in the inadequate ability to provide safe and effective care to patients. Resilience is a topic that has gained much discussion in recent years surrounding the significant burdens nurses are experiencing. Nurses with resilience exhibit a heightened awareness, internal stability, and flexibility that allow them to navigate high-stress situations. The goal of resilience training and education is to enable nurses to respond to clinically challenging situations in ways that will protect them against detrimental consequences. Mindfulness based stress reduction (MBSR) has gained significant headway in recent years as a valuable, evidence based intervention to increase resiliency in nurses, improve job satisfaction, and reduce burnout. The purpose of this quality improvement project was to implement a MBSR course for nursing staff to improve nurse resiliency in a mid-western freestanding Children’s hospital. This project examined nurse resiliency pre-intervention, and post-intervention utilizing the Connor-Davidson Resilience Scale, as well as compassion fatigue, compassion satisfaction, burnout, and secondary traumatic stress pre-intervention, and post-intervention using the Professional Quality of Life scale. Results of the project indicate that resilience scores improved, at a statistically significant level, from pre-intervention to post-intervention.

• 

  Identifying Structural Factors Associated with Central Line-Associated Bloodstream Infections (CLABSI) Risk in a Single-Center Pediatric Academic Hospital

  Elizabeth Monsees, Paul N. Bauer, Yolanda Ballam, and Brian R. Lee

  Objective: compare unit structure and process-related factors against unit-specific CLABSI rate.

  Conclusion: CLABSI mitigation requires more than individual competence with task-related practices; the unique work ecology of each clinical area may broadly influence CLABSI as an outcome; extending analyses to consider organizational structure can inform resource allocation and recalibrate traditional prevention strategies.

• 

  Implementing Treat to Target Approach in the Care of Children with Juvenile Idiopathic Arthritis

  Julia G. Harris, Jamie Holland, Emily Fox, Leslie Favier, and Ashley M. Cooper

  Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory disease seen in pediatric rheumatology. Despite advances in biologic therapy, many children with JIA will experience morbidity. Treat to Target is a treatment paradigm that involves setting a target of disease activity, using shared decision making, and incorporating clinical decision support. Our clinic aimed to set a treatment target on 50% of eligible JIA patients by December 31, 2019.

• 

  Improving Bedside Nurse Engagement in Quality Improvement (QI) Projects

  Beckie Palmer, Sarah Carboneau, Ashley Domsch, Barb Haney, Brandy Huitt, Ashley Lewis, Ashley Mirabile, Allison Ronco, and Dianne Wilderson

  Project Aims:

  • Improve nursing engagement in QI as evidenced by increasing nurse involvement to 40% of overall staff by December 2018, with a continual increase to >50% by June 2019.
  • Decrease the % of nurses who express "my opinion doesn't matter" as a reason they do not participate in QI by 30% by June 2019.

• 

  Improving Care of the Small Baby

  Beckie Palmer, Abdebayo Oshodi, Brandy Huitt, Kaylee Hurt, Pamela Kliethermes, Trudy Koons, Patricia Lanzer, Ashley Mirabile, Allyson Owen, Christian Anthony Schneider, Betsi Anderson, and Steven Olsen

  Hierarchy of Aims:

  • Global Aim: Create a Small Baby Unit for infants admitted to our NICU that arebirth, in which 90% of our patients are admitted to F pod on day of admission, by March 2019
  • Interim Aim: Staff 80% of our micropremie patients with a Small Baby Team nurse from admission until >32 weeks by May 2019.
  • Sub Aim: Increase rates of developmentally appropriate care (2 person cares, kangaroo care compliance) by 50% by August 2019.

• 

  Increasing Kangaroo Care in a New Small Baby Unit

  Dianne Wilderson; Barb Haney; Ashley Mirabile; Beckie Palmer; Jenny Heltzer; Erin Keith-Chancy BSN,CCRN; Brooke Smith; Christian Anthony Schneider; and Abdebayo Oshodi

  Project Aim: Increase the percent of eligible patients receiving kangaroo care from 19% to 30% by September 2019.

  Results:

  113 staff completed education

  OT consults completed on all SBU patients

  20 kangaroo wraps purchased

  Kangaroo care rate in NICU increased from 19% (prior to SBU) to 36% (Post SBU opening).

  Conclusion: Due to increased multidisciplinary awareness of importance of kangaroo care in the SBU more parents are completing kangaroo care.

• 

  Increasing Rates of Breastmilk Use at Time of Neonatal Intensive Care Unit (NICU) Discharge: An Improvement Project in a Midwest Level IV NICU

  Kathleen Hortenstine, Teresa Fulk, Stephanie Callis, Kyla Galate, and Beckie Palmer

  • Breast milk is the preferred food for all infants.
  • The rate of breast milk use at time of discharge was below the goal of the institution.
  • A gap was identified in bedside nursing education, limiting their ability to provide resources and education to mothers. Nursing involvement ensures skilled, comprehensive, and accessible breastfeeding support.
  • The aim of this project is to increase breast milk rates at time of NICU discharge to 95% of eligible patients by December of 2019.

• 

  Lighting the Way to Ensure Safe Transition Home

  Barb Haney, Ashley Mirabile, Dianne Wilderson, Beckie Palmer, Ashley Lewis, Cris Mills, and Eugenia K. Pallotto

  All aspects of discharge (education, screenings, appointments, plans and home services" must be completed and appropriately communicated prior to discharge to ensure safe transition to home.

  Goal: Standardize all aspects of discharge in a large, busy 84-bed Level IV NICU with >1000 admissions/year and >300 nurses, >60 NNPs, and >25 neonatologists.

  • 95% of patients with lengths of stay >3 days have all discharge planning completed prior to discharge/Parent Care Unit overnight stay

• 

  Making the Management of Acute Otitis Media a SNAP

  Cassandra Newell, Donna Wyly, Tanis Stewart, Alaina N. Burns, Brian R. Lee, and Rana El Feghaly

  AIM:

  To improve Watchful Waiting or Safety Net Antibiotic Prescription (WW/SNAP) in children >6 months old diagnosed with acute otitis media by Advanced Practice Nurses in the Emergency Department by May 2020.

• 

  Safe Sleep in the NICU

  Ashley Mirabile, Barb Haney, Dianne Wilderson, Beckie Palmer, Ashley Domsch, and Eugenia K. Pallotto

  Goal: To evaluate a staff education program on approach to improve in the rate of eligible NICU infants in safe sleep in a busy 84-bed level IV NICU.

  Outcome Measures; Improve safe sleep compliance for eligible patients to 90% or greater by December 2019.

  Process Measures: Audits from bedside RNs showing compliance with safe sleep.

  Planned Intervention: In December of 2018 a multidisciplinary work group brainstormed and implemented best practice safe sleep education for staff and parents. September 2019 a Safe Sleep Educational Toolkit was made available for staff.

  Results: Safe Sleep compliance has gone from 53% to 90% in September of 2019 after the initiation of a safe sleep toolkit.

• 

  Safe to Sleep in the ICN

  Megan Kelly, Alexandra (Lexi) Van Noy, Molly Kruse, Megan English, Hannah Culbertson, Brianne Truitt, Ziryan Salihparkhy, Jenny McKee, and Brecklyn Findley

  The CDC states that 1,545 infants passed away from SIDS in 2014. Safe sleep includes supine, in a crib, head of bed flat, firm sleep surface, tightly fitted sheet, no loose blankets, no toys or supplies in crib with infant. It is important for nurses to model safe sleep practices in the hospital setting. Current compliance with safe sleep in the Intensive Care Nursery is 50%.

  AIM Statement:

  By August 1, 2019 we want to increase the compliance of modeling safe sleep behaviors for patients who qualify for safe sleep from 50% to 90% in the Intensive Care Nursery.

• 

  Sepsis: Triage Triggers, Outcomes Quicker

  Rylee Ainge, Mackenzie Flaws, Natalie Heim, Emily Herndon, Hayley Norris, and Amy L. Scott

• 

  The Kanga-Croo: Nurse Resident Champions Creating Momentum for Improvement

  Brett Butler, Jacob Burden, Carly Creekmore, Blair Griffin, Taylor Godemann, Taylor Hagen, Theresa Koelling, Mary Anne Kucera, Halle Magid, Makenna Miller, Monica Page, Mary Riffel, Madison Stebbins, Sarah Stokes, and Skylar Suppes

  Topic Summary:

  Kangaroo Care (skin to skin care) is a parent-led, evidence-based intervention which improves outcomes in neonatal patients including: decreased apnea, increased weight gain, increased parent satisfaction and decreased length of stay.

  Results:

  Nurse resident team interventions to support parent engagement and remove barriers to Kangaroo Care (KC) through iterative PDSA cycles from January 2018 to July 2019 yielded positive results within a subset of ICN patients.

• 

  Trauma Informed Care: Improving Staff Morale on 6 Henson

  Kara Humphreys, Katherine Karstens, Kortney Neiderhauser, Briana Pina, Payton Tallent, Stephanie Assad, and Madison Dexter

  Six Henson staff reported feeings of burnout and compassion fatigue.

  Aim Statements:

  Decrease percentage of 6 Henson staff feeling sometimes or often "worn out because of [their] work as a helper" from 86% to 50% by August 1, 2019.

  Increase the number of KUDOS cards submitted by 6 Henson staff from 2-3 per week to 10 per week by August 3, 2019.

  Both aim statements were met and exceeded.

• 

  Who Codes in the NICU: An Analysis of Demographics and Factors that Place Neonates at Higher/Lower Risk of a Serious Code Event and Prognosis Post-Code

  Danielle N. Gonzales, Ashley K. Sherman, Jennifer Dremann, Staci Elliott, Amelia Gute, Amber Bellinghausen, Jessica Brunkhorst, and Danielle Reed

  This study analyzed resuscitation events in a level IV neonatal intensive care unit from 2012-2017 to determine whether there are identifiable differences between those who have a rapid response event and those with a short or long code and determine factors post-event that may impact survival to discharge.

• 

  An Innovation for Skin Integrity Risk Assessment SIRA Quality Metrics

  Kristina Foster, Michele Fix, and Lacey Bergerhofer

  Metrics for hospital acquired pressure ulcers over time, by stage, by device, and compared to other pediatric hospitals.