I am pleased to present the 2017 Nursing Annual Report. We have celebrated several key accomplishments this past year. Our South Tower construction is nearing completion and we have taken occupancy of several new units. Last spring we opened a new cardiac intensive care unit, cardiac catheterization labs, cardiac operating rooms, echocardiogram suites and behavioral health units (inpatient and day programs). Phased occupancy of the peri-operative areas occurred throughout this past year. We celebrated our neonatal intensive care unit's Level IV designation validating the extraordinary care provided to infants and their families. Our extracorporeal membrane oxygenation (ECMO) program was awarded the Center of Excellence Gold Status.
Our professional nurse practice model remains a focal point for our nursing teams. The center of our practice model is focused on patient- and family-centered care. Our practices are guided by principles of safety, quality, collaboration, accountability, respect, professional development and the art and science of nursing. In this year's annual report, you will learn more about these principles in action.
I am so proud of our nurses and all that they have achieved in 2017. Their innovation, exemplary professional practice, leadership, quality and research efforts make a difference at Cook Children's. We look forward to a year in which we will implement a new electronic health record, develop strategy to strengthen the patient and family experience and expand our innovative and professional nursing practice. The sky is our limit and the future is bright for nursing at Cook Children's!
Cheryl Petersen, RN, MBA, BSN, NE-BC
Vice-President and Chief Nursing Officer
Cook Children's Medical Center
Cook Children's launched the Nursing Professional Development Program (PDP) in January 2015. This program supports our nursing philosophy and promotes quality care. The PDP encourages and recognizes nursing excellence by rewarding professional development of registered nurses with an opportunity for career advancement. Eligible candidates apply to the program and embark on a two-year journey of professional growth, where they can earn level 1, 2, 3, or 4 placement, depending on the number of points earned and the education level achieved.
At the completion of the first two-year cycle in 2017, the review committee reviewed successful portfolio presentations from 54 registered nurses serving in the medical center inpatient units, clinics, palliative care, research, clinical education, transport and Emergency Department. Furthermore, nurses presented successful projects and quality outcomes as poster and podium presentations at local, regional, national and international conferences (for more detailed information, please visit the Research, Publications, and Awards section of this annual report). We look forward to the continued success of the PDP with 45 applicants scheduled to finish in 2018 and 140 on track to finish in 2019.
At Cook Children's, our goal is to eliminate central line associated blood stream infections (CLABSIs) by providing perfect line care to every patient every time.
Nurses at Cook Children's follow an evidence-based set of steps (bundle) when providing central line care. This bundle was developed by the pediatric collaborative, Solutions for Patient Safety (SPS). Cook Childrens has been a part of SPS, which now includes more than 130 hospitals nationwide, since 2009.
In an effort to reduce CLABSIs, the largest contributor to harm in pediatric hospitals, Cook Childrens began an incentive program called "making a bundle" in March of 2016. This program was implemented to improve reliability to the central line care maintenance bundle. Evidence-based research shows that reliability above 90% will reduce central line infections. During the 2016 program, nurses performed self-audits of line care by completing a central line bundle checklist. The 2016 program was successful in increasing hospital-wide compliance to above 90%, but the rate of central line infections did not decrease.
In January of 2017 an updated "making a bundle" program was employed to move from self-auditing with checklists to direct observation of line care. All units have employed Kamishibai card (K-card) rounding. Kamishibai is a Japanese term for "storytelling" using visual cards. K-cards provide scripting for a short interaction or observation and are used to discuss or observe central line care. K-card rounding is considered best practice by SPS. Frequent K-card rounding is performed by nurses and leaders to discuss challenges and barriers. This has increased the opportunity for feedback and coaching. Tracking, trending and sharing issues and concerns has removed barriers and streamlined processes.
Because of heightened awareness from observations and rounding, hospital-wide reliability to follow the central line maintenance bundle has remained well above 90% in 2017. In the first five months of direct observation auditing (versus auditing with checklists completed during the previous five months), Cook Children's has seen a decrease in central line infections of more than 78%. The steps taken through the "2017 making a bundle" program has moved Cook Children's toward achievement of perfect line care as well as our ultimate goal of Zero Harm.
Anxiety often runs high for pediatric patients in the perioperative setting. To help ease these patients' nerves, nurses in Cook Children's perioperative unit partnered with a Child Life specialist to try using non-pharmacological interventions to help calm surgical patients.
Nurses in the Post-anesthesia Care Unit (PACU) witnessed numerous patients, given preoperative oral midazolam, become irritable and agitated after waking from anesthesia. The nurses questioned if there was a way to improve the surgical experience for these patients and their families.
After a comprehensive literature review, a research team led by two clinical perioperative nurses, with 11 nurses from the preoperative and PACU areas, one Child Life specialist and one anesthesiologist, replicated a 2014 anesthesiologist-led study conducted at Lurie Children's Hospital in Chicago. The two lead nurse researchers attended two-day training sessions on the use of the child preoperative anxiety tool at the National Institutes of Health-funded Center for Stress and Health at the University of California in Irvine.
This first and only nurse-led study simulated the single-blinded randomized control design on the use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety and post-emergence delirium in children, 4 to 12 years old, having a surgery less than 1-1/2 hours long.
Each child selected a card from a whimsical hat to denote the study intervention: dinosaur (oral midazolam) or robot (tablet distraction with interactive age-appropriate games). PACU nurses were blinded to the intervention received by study participants. To ensure strong study power, each study group consisted of 51 children and their caregivers. Measurements included child anxiety (observed at baseline, separation and mask induction), caregiver perception of child anxiety (at baseline and separation), emergence delirium scores observed at emergence and 15 minutes post-emergence and length of time from PACU arrival to emergence, as well as discharge home.
Statistically significant results included: (1) interactive distraction group displayed significantly less preoperative anxiety at separation and mask induction than those who received oral midazolam; (2) interactive distraction group had significantly lower observed delirium scores 15 minutes post-emergence; (3) caregivers were satisfied at separation with both medication and interactive distraction; and (4) interactive distraction group were discharged 25 minutes sooner than oral midazolam group.
Due to intradepartmental collaboration across multiple disciplines, the use of interactive distraction has now been integrated and adopted into current practice within the perioperative setting. The research team has presented their completed research study results at Cook Children's Grand Rounds, a national perioperative nursing conference and an international nursing research congress. The leadership demonstrated by these frontline nurses in a clinically relevant research study has led to increased interest and participation by nurses in research projects across our medical center.
Cook Children's values the satisfaction of all of our employees, many of whom work the night shift. In partnership with our Nurse Practice Council, a taskforce was created to focus on engagement, retention and enhancing the lives of staff working to care for our patients at night.
The needs of this employee population was made a priority as part of the most recent Nursing Strategic Plan. Utilizing a review of current literature, the Nurse Practice Council taskforce identified ways to increase satisfaction for night shift nurses. Additionally, the council informally surveyed their staff members to determine what aspects were important to them. A list of ideas was generated and presented to the Nurse Executive Council. This list was reviewed for priority, applicability and feasibility for implementation.
The initial priorities identified by night shift staff members were for additional food options, night shift engagement events and the creation of a lifestyle resource list for night shifters, including:
In response to these requests, Cook Children's provided additional food and beverage options through an onsite café, Goodies to Go. Additionally, the hours were extended to increase hot food meal options throughout the night. The times of the annual employee picnic also were altered so the night shift employees could take part.
Currently, the taskforce is designing a webpage with resources specifically for night shift employees on Cook Children's intranet. The theme will be Cook Children's "Night Owls" and the page will include links to surveys aimed to enhance the experience for night shift employees. The page will feature announcements related to events/education that are during night-friendly times, multiple resource tabs for night shift healthy lifestyles and an email address for employee feedback.
Other programs that promote the health and work-life balance of this specific population are in the planning stages and a second, larger, systematic article review is being conducted to provide additional insight. Together, we are dedicated to exploring opportunities for Cook Children's to become an enhanced night shift-friendly organization.
Congratulations to Cook Children's employees and university partners who work together to make our nurse residency program a success. In 2017, the Pediatric Nurse Residency program obtained reaccreditation by the Commission on Collegiate Nursing Education (CCNE) through 2022. When the program started in 2009, Cook Children's was the first nationally accredited pediatric nurse residency and remained the only program until 2017.
Since the program launched eight years ago, the cohorts have doubled in size and have increased from two to three per calendar year. With these changes, the program has graduated 434 nurse residents to-date. Our nurse residents have a first year retention rate of 97%, which compares favorably with national averages. The nurses we retain are among the finest in the nation, evidenced by the first-time pass rates on the national certification exam for pediatric nursing. They consistently surpass both the national average score and the annual national pass rate. According to our Press Ganey survey, these nurses are also among the most engaged in our organization. In 2017, for the first time ever, a nurse resident received the DAISY Award while still in the residency program.
In 2016, specialty tracks were added to the residency program, including a perioperative track created to help meet the growing need for nurses in this specialty. Collaboration and support from clinical nurse educators, perioperative staff and leadership, led to the development of the unique curriculum for this specialized area. In just one year, 11 nurses entered the perioperative track and now serve in all clinical areas including pre-op, the operating room and post-anesthesia recovery.
The journey to support more than 400 nurses, from new graduates to certified pediatric nurses, required the expertise of 18 clinical nurse educators. These educators facilitate rotations within their nursing units and provide clinical consultation for the development of the case studies that build the new nurses' pediatric knowledge. Literally hundreds of staff nurses throughout our medical center serve as unit guides, building the new nurses' clinical skills and confidence. Additional partners, including Child Life specialists, a laboratory educator, respiratory therapy educators and chaplains, also support our nurse residents. During shadow week, nurse residents spend time with support departments including Environmental Services, Nutrition and the International program, where their eyes are opened to the depth and breadth of support required to care for our patients.
The example set and support provided by our nursing leadership from charge nurses to the chief nursing officer is evident. Currently, 161 (37%) of the 434 nurses who have entered the residency since 2009 are now in various leadership roles, such as charge nurses, trauma nurse leaders, nurse managers and clinical nurse educators, to name a few.
These new nurses make contributions to quality improvement with each evidence-based practice (EBP) project completed. Since 2013, under the guidance of the director for nursing research and evidence-based practice, nurse residents completed 48 EBP projects, with 16 (34%) resulting in policy, procedure or practice changes. One evolved to a research study, and 20 (42%) resulted in professional presentations at regional, state and national conferences, with two award winners.
If excellence occurs in an environment that demonstrates and expects it, Cook Children's can be very proud of their nationally recognized Pediatric Nurse Residency program, the nurses who complete it and the system that supports it.
In 2017, a group of Cook Children's pediatric intensive care unit nurses initiated a research project to address concerns about the reliability and validity of the Pediatric Early Warning System (PEWS) tool. The primary goal was to confirm whether PEWS consistently measures what it is intended to measure (clinical deterioration) and prevent delays in intervention.
Staff reported subjectivity and misinterpretation of scored items, including the criteria to score parent concern and dual diagnoses. Increases in false positive and false negative scores were also noted, leading to lack of support for the tool's reliability and validity. A literature review revealed an opportunity for data collection and analysis.
The research task force included nursing, respiratory therapy, pharmacy, Child Life, leadership, research, education, a librarian, biostatistician, informaticist and Risk Management.
To begin, the team conducted a literature review and synthesis of PEWS history, goals, definitions, variations and strategies for reliability and validity analyses was done. Next, vital sign parameters were changed to reflect evidence-based pediatric ranges. Then, the electronic medical record (EMR) template was modified to increase scoring clarity. Subjective criteria were removed or revised. Education included computer-based learning modules that were assigned to nurses on a 40-bed medical pilot unit. To collect interrater reliability data, charge nurses scored patients within five minutes of staff nurses scoring patients. For convergent validity analysis, data were collected on physical assessment EMR data and correlated with PEWS documentation for two categories: cardiovascular and respiratory.
Based on the results, psychometric properties of reliability and validity were established for a revised PEWS tool to measure clinical deterioration. Plans include data collection for sensitivity and specificity with further house-wide rollout and confident recommendations for rollout in other pediatric centers.
Within the United States, the number of self-harm or self-directed violence-related Emergency Department (ED) visits for adolescents has quadrupled over the past two decades. A recent Canadian study revealed 80% of youth who died by suicide visited a primary care provider or an ED within three months prior to their deaths. From 2015 to 2016, Cook Children's had a 44% increase in patients admitted after attempting suicide.
With suicide on the rise, one of the 2017 National Patient Safety Goals is to identify patient safety risks by suicide screening and provide safety for patients with high-risk behaviors in non-psychiatric units. Additionally, The Joint Commission recommends that EDs and primary care setting administer an evidence-based suicide screening assessment.
Based on this growing trend and national recommendations for pediatric suicide, one of Cook Children's ED nurses partnered with a nurse from psychiatry to create a suicide screening tool as part of an evidence-based practice project (EBP) fellowship program. Prior to this project, ED nurses asked just one question related to suicide risk upon admission.
To help determine the best way to proceed, a comprehensive literature review (32 current publications), including five articles on different pediatric suicide screening tools, was completed. The evidence-based four-question Ask Suicide/Screening Questions (ASQ) was selected for implementation in this EBP project. To kick-off the project, a pre-intervention ED nurse survey was administered to evaluate comfort and barriers to completing suicide risk assessments in the ED. More than 25% of the nurses surveyed reported that adding additional questions would be time consuming, but 33% were neutral. Up to 40% agreed that there is a stigma attached to being a mental health patient in the ED and felt they had inadequate training in screening patients for suicide risk.
Based on pre-survey results, education interventions included: (1) creation of a PowerPoint with audio to explain evidence behind and benefits of suicide risk screening in the ED; (2) video presentation depicting the administration of the ASQ with supporting rationale for new practice; and (3) handout guiding documentation in the electronic health record.
The go-live date for use of the ASQ tool for all ED pediatric patients (ages 10 and over) was July 3, 2017. A child answering "yes" to any of the screening questions, would prompt a psychiatric intake consult. Post-survey was administered two weeks post-practice change.
The impact from this nurse-initiated evidence-based practice project has helped identify children for suicide risk admitted to the ED for physical symptoms rather than behavioral health problems.
Our main goal is to decrease current suicide attempt numbers by assessing suicide risk with all admissions (10 years and older) and provide appropriate resources at that time.
At Cook Children's, our nurses continually go above and beyond to serve our patients. From obtaining an advanced degree to publishing research and presenting at national conferences, our nurses are leaders throughout Cook Children's. We are proud of our nurses and all that they've accomplished.