Pediatric SUMMER 2012 PERSPECTIVES ADVANCING PATIENT CARE SERVICES AT ST. LOUIS CHILDREN’S HOSPITAL EXPERIENCED, INNOVATIVE HEART TEAM See page 4 ON THE Cover The St. Louis Children’s and Washington University Heart Center maintains a strong referral base throughout Missouri and surrounding states. Five-yearold Porter Stone with Kelsey Wassmer, BSN, RN, 7 West (left) and Yvonne Renick, BSN, RN, CICU (right), is from St. Joseph, MO. Patients like Porter are referred to the center with complex conditions that require expertise and coordination beyond routine care. St. Louis Children’s Hospital is recognized among America’s best children’s hospitals by Parents magazine and U.S.News & World Report. For more information about nursing opportunities at a Magnet hospital, visit: StLouisChildrens.org/jobs SUMMER 2012 VOLUME 9, NO. 3 The Heart Center provides patients and families a collaborative approach to care involving physicians, nurse practitioners, physician assistants, nurses, dietitians, physical therapists, occupational therapists, speech therapists, pharmacists, respiratory therapists, social workers and child life specialists — all with specific education and clinical expertise in caring for heart patients. Editorial board Terry Bryant, MBA, BSN, RN, NE-BC Professional Practice and Systems Lisa Chapman, BSN, RN Emergency Unit Inside THIS ISSUE Emily D’Anna, PharmD Clinical Pharmacy Doing what’s right for kids with heart disease . . . . . . . . . . . . . . 4 Angie Eschmann, RN Clinical Operating Room The winter surge of 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Robin Foster, MSN, RN, CPNP-PC, CDE, CPN General Medicine Jeanne Giebe, MSN, NNP-BC, RN Newborn ICU Peggy Gordin, MS, RN, NEA-BC, FAAN Vice President, Patient Care Services Nutritional screening and early intervention in children with cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 What a “NAVA” idea! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Meet Lauren Yaeger, medical librarian . . . . . . . . . . . . . . . . . . . 12 Beth Hankamer, MSN, BS, RN, CAPA Clinical Education Lisa Henry, MSN, RN, PNP-BC Healthy Kids Express Dora O’Neil, BSN, RN, CCRN Cardiac ICU Christina Patrick, MSN, RN, CPN Clinical Education Lara Smith, MSN, RN, CPNP Pediatric ICU Lisa Steurer, MSN, RN, CPNP-PC, CPN Professional Practice and Systems Pediatric Perspectives is published by the St. Louis Children’s Hospital Communications and Marketing department. To add or remove a mailing address or make a direct inquiry, please contact Arvella Robinson, at 314.454.4086 or [email protected] © 2012, St. Louis Children’s Hospital The leadership team of the St. Louis Children’s and Washington University Heart Center includes (from left) Shelley Perulfi, MA, BSN, RN, NE-BC, director; and co-medical directors Pirooz Eghtesady, MD, PhD, chief of Pediatric Cardiothoracic Surgery, and George Van Hare, MD, director, division of Pediatric Cardiology. Not pictured is Allan Doctor, MD, director, division of Critical Care Medicine. See story on page 4. Pediatric Perspectives From Peggy Extraordinary people, remarkable acts What’s amazing to me is how the staff at St. Louis Children’s Hospital continue to serve patients and families. I’ve come to understand it’s just how we roll here. Challenge has nearly become routine, and the past nine months were an exceptionally demanding time for us. After the low volumes of 2011, we were faced with the surge of 2012 and had to ramp up our staffing on a dime. Every department across the entire organization pulled together and played a role — Materials Distribution, Child Life Services, Nursing, Respiratory Therapy, Pharmacy and Housekeeping — just to name a few. The surge arrived just as we were starting to use Teletracking for bed management and trialing a new Emergency Unit patient throughput process. Hospital volumes far exceeded what staff had planned for, so new plans were put in place. can take a great toll on employees and their families, and the surge required a tremendous amount of effort. I truly appreciate what each and every one of you did to get us through this challenging time. Throughout the weeks that turned into months, no patient was ever turned away. The staff knew that they had to take care of our kids, and employees stepped up to make that happen on every shift, every day. Staff worked longer, taking on more on-call duty and additional shifts. Times like these In early April the Trauma Program hosted a visit from the American College of Surgeons (ACS) to verify our application for designation as an ACS Level I Pediatric Trauma Center. This visit also went successfully, and we were recommended for verification. This was quite an achievement and required the Another note to recognize during the early days of 2012 was the presence of a survey team from the Commission on Accreditation of Rehabilitation Facilities (CARF). The hospital’s survey went very well and staff continued to maintain their commitment to patients and families throughout the survey. We were successfully re-accredited for another three years thanks to the efforts of that outstanding team! collaboration of services from across the hospital and Washington University School of Medicine. Not knowing what might lie ahead for us, I know that the St. Louis Children’s Hospital team will step up to meet any challenge. I encourage you to read more details about the surge plan on page 6. The other articles in this issue outline several other programs, which represent the kind of advancements St. Louis Children’s Hospital has been known for over the years. You continue to impress me with your dedication to being your best for every patient, every family, every day! Peggy Gordin, MS, RN, NEA–BC, FAAN, is SLCH’s Vice President of Patient Care Services. She can be reached at [email protected] 3 4 Pediatric Perspectives STRUCTURAL EMPOWERMENT Doing what’s right for kids with heart disease The St. Louis Children’s and Washington University Heart Center maintains the largest pediatric heart team in the region. The St. Louis Children’s Hospital and Washington University Heart Center is the influential voice in the hospital, the medical school and the region, representing the best interests of children with heart disease. Team goals are to offer excellent pediatric clinical cardiac care; advance the field through innovation; provide clinical research and laboratory investigation; and educate the next generation of academic physicians and clinicians. Background The Heart Center was established to encompass all aspects of the care that patients and families receive while dealing with heart disease. Previously, activities and decision making had taken place in multiple, disparate venues, including hospital units, divisions and departments. A broader perspective was needed to achieve an inclusive, efficient and transparent approach to care and to collaboratively plan for the future. The Center is led by co-medical directors Pirooz Eghtesady, MD, PhD, chief of Pediatric Cardiothoracic Surgery; George Van Hare, MD, director, division of Pediatric Cardiology; Shelley Perulfi, MA, BSN, RN, NE-BC, director; and Allan Doctor, MD, director, division of Critical Care Medicine. Moving forward St. Louis Children’s Hospital and Washington University are building upon an already robust and prestigious history of pediatric cardiac care. Enhancing this history through the development of the Heart Center positions the hospital as a leader in pediatric cardiac care for the future. Strengths include: • Active pediatric heart failure and transplant program with 25 to 30 heart transplants annually • Expanding pediatric ventricular assist device program provides a growing number of device implants each year, including the Berlin, HeartMate II and CentriMag. The program also offers both neonatal and pediatric Extracorporeal Membrane Oxygenation (ECMO) support • Continued expansion and development of a comprehensive adult congenital heart program • Strong quality improvement initiative related to patient safety through monitoring and evaluation of numerous indicators to enhance patient outcomes • Considered a high-volume center by Society of Thoracic Surgeons (STS) criteria with significantly better outcomes than the STS national average for complex cardiac surgical cases Pediatric Perspectives The Heart Center team crosses departments and includes all disciplines that provide care to pediatric patients with heart disease. Each individual and team collaborates with the Heart Center through participation on quality improvement projects, the nursing taskforce, and regular attendance at leadership meetings. The blending of the Cardiac ICU and 7 West patient care staff is one of the immediate challenges the team is facing to enhance continuity of care. To achieve its mission, the Heart Center is developing an organizational structure to enhance collaborative working relationships across the hospital and School of Medicine. Increasing the breadth and depth of pediatric heart services will help accommodate increasing volumes as the program’s national reputation grows. For example, the Heart Center received seven admits from Oklahoma in January 2012 when previously three admissions were the highest monthly number admitted from this state. For additional information, contact Shelley Perulfi at [email protected] Heart Center Team ❤ cardiac intensivists ❤ social workers ❤ perfusionists ❤ cardiac anesthesiologists ❤ cardiologists ❤ nurses ❤ child life therapists ❤ pharmacists ❤ respiratory therapists ❤ cardiothoracic surgeons ❤ pulmonologists ❤ patient care techs ❤ nurse practitioners A nursing task force meets regularly to guide Heart Center development and define the recent combination of 7 West and the Cardiac ICU (CICU). Members include (from left): Rachel Miller, MSN, RN, CPN, 7 West assistant manager; Elizabeth Risse, BSN, RN, CPN, 7 West; Colleen Murphy, RN, CCRN, CICU staff nurse; Kym Galbraith, BSN, RN, CICU assistant nurse manager; Anna Lawrence, BSN, RN, CICU staff nurse; Avihu Gazit, MD, CICU medical director; and Courtney Lazzara, MSN, RN, CCRN staff nurse. 5 Pediatric Perspectives TRANSFORMATIONAL LEADERSHIP The winter surge of 2012 Every winter, pediatric hospitals gear up for high census related to viral illnesses. In preparation for the winter of 2012, St. Louis Children’s Hospital proactively established a “surge” committee during 2011 to plan for these increased volumes. Based on the typical winter bed availability on the 10th floor surgical unit, the interdisciplinary team developed plans for patient placement, staffing, medical coverage and communication. During this time of the year, medicine over-flow beds are usually available on the 10th floor surgical unit; however, the historical challenge has been appropriate medical coverage in order to tackle this issue. A model was created that added 12 hours of advanced practice nurse (APN) day shift coverage to the 10th floor, providing care for up to 10 general medicine patients from mid-January through March. A patient profile was created to identify potential diagnosis and appropriate age for this location. Daily surge planning meetings were common on the 10th floor. From left, Madeline Martin, BSN, RN, Amy Becker, BSN, RN, and Mary Kay Scanlon, BSN, RN, administrative supervisor, discuss staffing issues to project needs for upcoming admissions. As surge plans were under development, other organizational changes were ongoing. Teletracking, the new electronic bed management application, went live in November 2011 to provide real-time views of beds, pending discharges and environmental services activities. In addition, the Emergency Unit (EU) was planning a “Fast Track” concept using pediatric nurse practitioners to facilitate EU patient flow. Both of these initiatives supported patient throughput efficiencies, especially in times of increased census. RESPIRATORY VIRUS DATA December 4, 2011 - March 3, 2012 # POSITIVE SPECIMENS 6 12/10 12/17 RSV 12/24 12/31 FLU A 1/7 1/14 1/21 1/28 2/4 2/11 HMPV Data reported weekly: week 1 is week ending Dec 10; week ends on Saturday 2/18 2/25 3/4 Then the winter surge hit, and plans had to be revised. Cases of Influenza A in the community peaked at the same Pediatric Perspectives DAILY MIDNIGHT CENSUS January 15, 2012 - March 12, 2012 300 JAN FEB MAR 250 Beginning in January, surge planning meetings were established weekly to review the census, required resources and equipment. After three weeks, these meetings were changed to daily meetings, when it was clear the surge was actually increasing and not stabilizing. Issues were identified with updates provided the following day. Peak census reached 262 patients at 10 a.m. on Feb. 22, 2012, but the census each and every day was unpredictable, requiring varying resources in each department. Ancillary departments such as Laboratory Services, Pharmacy, Respiratory Therapy and Dietary had to respond to the increase in tests, medications, treatments and patient meals. Additional physicians and staff were needed to provide patient care, but the volatility of the census each day made this very challenging. While increased demand on services was challenging for all, not one child was sent elsewhere for care. St. Louis Children’s Hospital staff recognized their unique role in the care of ill and/ or injured children as well as their commitment to the community. As with any plan and situation, there were lessons to be learned. Earlier VOLUME 200 150 100 50 0 15 17 21 23 CICU 27 29 PICU 31 2 4 6 8 NICU 10 12 14 16 18 20 22 24 26 28 1 3 5 7 9 11 Specialty Care Units SLCH EMERGENCY DEPARTMENT VISITS BY DAY December 4, 2011 - March 3, 2012 240 200 NUMBER OF VISITS time as Respiratory Syncytial Virus (RSV); (see chart on page 6). Changes included broadening the diagnoses admitted to the 10th floor to include respiratory illness. In addition, an overflow area for the Pediatric ICU (PICU) was created within the Newborn ICU (NICU) because of high PICU volumes. PICU nurse practitioners provided medical coverage in collaboration with PICU attending physicians while the NICU nursing staff provided patient care. Flexibility with ever-changing plans was essential. 160 120 80 40 0 12/10 12/17 12/24 12/31 1/7 1/14 1/21 1/28 2/4 2/11 2/18 2/25 Data reported weekly: week 1 is week ending Dec 10; week ends on Saturday recognition of equipment and patient furniture needs was needed. In addition, staff were not clear on the exact timing and process of supply distribution. For example, inventory par level information was sent to the warehouse at 1:45 p.m. each afternoon. If departments stocked their areas after this time, the need for replacement supplies was not known until the following day, leading to a lower inventory than required to meet the peak demand. Volumes continued to be strong even into April. However, the lessons learned during this surge season will be documented and used to plan the next sustained increase in census. It’s not “if” it happens again, but “when” it happens again…..and the staff will be ready! For additional information, contact Terry Bryant at [email protected] 3/4 7 8 Pediatric Perspectives NEW KNOWLEDGE, INNOVATIONS AND IMPROVEMENT Nutritional screening and early intervention in children with cancer The overall survival rate for a child or adolescent newly diagnosed with cancer is now almost 80 percent. Although cure rates are high, the side effects of chemotherapy are still significant and include nausea, vomiting, mouth sores and loss of appetite. These side effects, as well as pain and fatigue, can impact a child’s nutritional status. The risk of malnutrition associated with treatment for childhood cancer is estimated to be as high as 60 percent. Children are more vulnerable to malnutrition than adults due to their increased caloric requirement and decreased caloric reserve. Malnutrition during treatment for childhood cancer increases children’s risk of infection, decreases their tolerance to treatment, and can impact their overall survival. Published guidelines recommend children and adolescents with cancer be screened for malnutrition risk at diagnosis and monthly throughout treatment. Deborah Robinson, DNP, APRN, PNP-BC, CPON, 9 West, and Marsha Flowers, MHS, RD, LD, clinical nutrition manager, conducted a study funded by the American Cancer Society to assess nutritional screening performed at baseline and for the first six months of treatment for children and adolescents with cancer during active treatment with chemotherapy and/or radiation. In addition, the study determined if children with a positive screen (at risk for malnutrition) received timely intervention. Based on the published literature, a tool was developed to record monthly objective criteria to determine the risk of malnutrition. This included baseline weight, monthly weight, and percent Marsha Flowers, MHS, RD, LD, clinical nutrition manager, (center) and Deborah Robinson, DNP, MSN, RN, APRN, BC, PNP, CPON, 9 West, (far right) counsel Braden Darty and his mother Heidi about Braden’s daily diet, calorie intake and nutritious snacks. of weight loss from baseline. In addition, serum albumin was recorded. If children had a negative screen, no further data was obtained. If children had a positive screen, subjective data and co-morbidities were documented at the time of the visit, including documentation of mouth sores, pain, infection, nausea, vomiting, and reported decrease in oral intake. Disease status was recorded as stable or progressive (not responding to treatment). Seventy-nine children and adolescents met the inclusion criteria (age > one year and treatment > 6 months) in 2010. All children on active treatment plans had monthly visits with the pediatric oncology team, and objective measurements for risk of malnutrition (height, weight, body surface area (BSA), body mass index (BMI), and serum albumin) were recorded on all patients. Sixty-two percent (n = 49) of patients had a positive screen, which showed a risk for malnutrition defined as greater than or equal to 5 percent weight loss from baseline weight or previous month. In addition, a serum albumin less than 3.2 grams/dL was also a primary risk factor for malnutrition. Of the 49 patients with a positive screen, 38 received timely intervention (78 percent). Timely intervention (within 24 to 48 hours) included medical care or a referral to the Pediatric Perspectives • • • Children are more vulnerable to malnutrition than adults due to their increased caloric requirement and decreased caloric reserve. Malnutrition during treatment for childhood cancer increases children’s risk of infection, decreases their tolerance to treatment, and can impact their overall survival. • • • Since being diagnosed with acute myeloid leukemia in January, Braden has experienced multiple hospital stays including a month in the Pediatric ICU. A sixth grader at Wentzville Middle School, Braden has improved his nutritional status and hopes to return home soon to enjoy summer. dietitian for a full nutritional assessment and plan. Medical care included antiemetics, IV hydration, pain medication, or treatment for mouth sores or infection. In many cases, the medical intervention reversed the risk of malnutrition and the patient’s weight stabilized or improved. Nutritional interventions included nutritional counseling and oral supplements. Some children did require more aggressive nutritional support including total parenteral nutrition (23 percent) or enteral feedings (10 percent). Data from the participants who had a positive screen (n= 49) were analyzed further to determine if variables such as age, gender, diagnosis, treatment type, head and neck location and disease status impacted the risk for malnutrition. The only variable that was statistically significant was disease status. Children and adolescents with progressive disease had a significantly higher risk of malnutrition. In addition, individual risk factors were analyzed to determine if children with these factors were more likely to need a nutritional referral and nutritional plan. Children who had any one of these risk factors were more likely to receive a nutrition referral as compared to those children who had weight loss but no additional risk factors or symptoms present. In addition, the number of risk factors present increased the overall risk of a positive screen for malnutrition. Future studies will include determining what type of nutritional strategies are effective in reversing the risk of malnutrition and if early intervention for malnutrition impacts the patient’s quality of life and overall outcome. For additional information, contact Deborah Robinson at [email protected] or Marsha Flowers at [email protected] 9 10 Pediatric Perspectives TRANSFORMATIONAL LEADERSHIP Meet Lauren Yaeger, medical librarian Lauren Yaeger serves as the medical librarian at St. Louis Children’s Hospital in partnership with Washington University School of Medicine, providing information and research support to the hospital staff and the Department of Pediatrics at Washington University. What is your role? I am the go-to-person in the hospital for library resources and information support. I instruct clinicians, often one-on-one, about how to access evidence-based information to support their practice. I assist employees who are studying for advanced degrees and nursing students on rotation at the hospital. I also teach classes on library resources, such as searching skills, accessing full text articles, using PubMed and other specific needs. Lauren Yaeger, the go-to person for library resources and informational support. • • • It makes me happy when people have that ‘ah ha’ moment about using the right resources to get needed information to help them perform their job better. • • • I participate on multidisciplinary teams within the hospital, such as the Craniofacial and Cleft Palate Research team meetings. As a member of the Ethics Committee, I provide research support for the consult team and general information support. I am working with a multidisciplinary team that is running a pilot program integrating decision support tools and library resources into the electronic health record in the Emergency Unit. In addition, I support the residents, the 8 West Unit-Based-Joint-Practice team, and recently provided a two-part information series for the Physician’s Education Committee. Whenever possible, I attend clinical rounds to provide point-of-care information support as well as become better acquainted with the clinical environment, pace, language and needs. Another aspect of my role is to provide systematic review searching to the Department of Pediatrics. As a librarian, I have the skills and knowledge to perform the comprehensive search needed for a systematic review article where the goal is to have a “sensitive search,” not to miss any article. I recently partnered with Child Health Advocacy and Outreach (CHAO) to present a paper at the National Association of Children’s Hospitals and Related Institutions (NACHRI) conference; I also presented two posters and a paper at the national Medical Librarian’s Association (MLA) conference in May. What is your background and educational preparation? I have a Master of Arts (MA) in English Literature from Saint Louis University. Pediatric Perspectives EXEMPLARY PROFESSIONAL PRACTICE What a “NAVA” idea! Mechanical ventilation has seen significant advancements for the hospital’s pediatric and neonatal patients. The ultimate goal, however, has not changed; to provide effective ventilation with the least amount of trauma and extubate as soon as clinically indicated. Different forms of ventilation have been developed to provide adequate ventilation for patients. Initially, intermittent mechanical ventilation (IMV) was available. During IMV, a patient received a set number of breaths per minute, regardless of the patient’s own respiratory breath cycle. Improvement came with the use of synchronous intermittent mechanical ventilation (SIMV), in which the ventilator would be triggered to deliver a breath when the patient initiated a breath (began to inhale). However, many patients continued to experience asynchrony, which is thought to contribute to patient discomfort, alter a patient’s work of breathing and lead to diaphragmatic dysfunction. Research has shown as high as 25 percent of patients exhibit asynchrony, which can cause increased duration of mechanical ventilation, ineffective triggering resulting in ventilation mismatch, hypoxemia and ineffective diaphragm activity. For patients, this leads to an increased need for sedation, oxygen requirements and ventilator support. In spring 2008, a new mode of ventilation became available known as Neurally Adjusted Ventilatory • • • With NAVA, there has been a reduction in sedation use, and patients exhibit better tolerance and quicker recovery time. • • • —continued on back page It was there that I discovered my love of mining databases to find the jewels of information I seek. This discovery led to my decision to obtain a master’s degree in Library and Information Science (MLIS) at the University of Illinois at Urbana-Champaign and become a librarian. What brought you to your current position? Luck!! I was working at St. Luke’s Hospital as a librarian hoping for an academic librarian position to open where I could mix my love of literature and library sciences. During that time, I applied for my current position and cannot believe what a perfect fit it has become. I love working in the hospital and supporting the people who do so much good for kids. It’s humbling. What is the most rewarding part of your job? with a hundred opportunities every day, I want to do everything I can to help. Education. It makes me happy when people have that ‘ah ha’ moment about using the right resources to get needed information to help them perform their job better. In turn, being in the clinical environment is educational and teaches me how to better serve my customers. I learn something new every day, and I hope I do the same for my community. I really enjoy working with the residents; they are all amazing people with bright futures. For additional information, contact Lauren Yaeger at [email protected] What is the most challenging part of your job? Trying to be everywhere and support everyone. There is only one of me and 11 12 Pediatric Perspectives EXEMPLARY PROFESSIONAL PRACTICE What a “NAVA” idea! Assist (NAVA). NAVA synchronizes the ventilator to the diaphragmatic activity of the patient allowing for breath-tobreath variance based on the patient’s individual needs. Understanding how NAVA works In collaboration with a respiratory therapist, an individualized plan of care is first required, which requires at least 30 to 45 minutes for set up. A catheter, specifically designed for NAVA, is inserted nasally or orally by the bedside nurse to the level of the diaphragm. Placement is verified using the NAVA positioning screen, often requiring frequent reassessments to ensure catheter migration has not occurred. Once the catheter is in place, the type of NAVA support needed is determined by using the preview screen. Back-up settings and alarms are then determined. The ventilator in NAVA mode generates a peak continued from page 11 inspiratory pressure (PIP) based on the amount of electrical activity generated by the diaphragm. PIP is continued until the electrical activity of the diaphragm decreases by 40 to 70 percent, then the breath is terminated and the patient exhales. The patient will determine the PIP and the inspiratory time (i-time) of each breath on a breath-to-breath basis. Every breath can be different; this is normal. For example, it is known that suctioning may cause atelectasis. In SIMV mode, the patient is unable to receive larger breaths to recover after suctioning unless the actual ventilator settings are adjusted. NAVA allows for the patient to adjust himself or herself so once the positive end-expiratory pressure (PEEP) and oxygen level are set, all other parameters including the initiation of the breath, i-time, rate, PIP, and termination of the breath are controlled by the patient. The Newborn ICU began using NAVA in April 2011. With NAVA, there has been a reduction in sedation use, and patients exhibit better tolerance and quicker recovery time with care. Also noted was an improvement in oxygenation and blood gases. Several patients were successfully extubated directly from the NAVA mode of ventilation. As noted in previous studies, apnea was the biggest contributor to failure. There is a continued learning process related to all the intricacies of the system, including the fact that NAVA is not MRI compatible. NAVA is a new and exciting concept of ventilation for patients, continuing to help staff strive to do what’s best for every patient, every family, every day. For additional information, contact Julia Huck at [email protected] or Dan Murphy at [email protected] Who is a NAVA candidate? In order for a patient to be considered a candidate for NAVA, a patient must have an intact respiratory and neurological system and therefore, should not be heavily sedated. Backup modes are set initially to a pressure support mode in the event the patient becomes apneic and then full back-up if the patient’s diaphragm does not trigger a breath. Photo courtesy of MAQUET Medical Systems USA.
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