Pediatric Nursing Journal 2020

FALL 2020 | VOLUME IX

pediatric nurse journal

A note from the Nurse Executive In January 2020, as a new year and decade dawned, we looked forward to celebrating the “Year of the Nurse� in honor of the bicentennial birth of Florence Nightingale, the founder of modern nursing. The important role of the nurse became even more apparent as we quickly were confronted with the COVID-19 global pandemic. Despite the personal and professional challenges we all faced, the pediatric nursing commitment across Northwell Health to providing the very best care to our children and families never wavered.

You will see from the depth and breadth of the articles presented in this journal that we are resilient. We remain focused on our nursing strategic plan to reduce noise at night and promote a quiet, healing environment. Supporting and fostering the professional development of our pediatric nurses is a key priority as you will read about the impact of nursing fellowships on retention and the personal growth of nurses who emerged as leaders during the pandemic. Pediatric nursing across the care continuum is also highlighted in the work being done with short stay units and improving outcomes for children with asthma via home health visits.

As you read these stimulating articles and reflect on the challenges of 2020, please take a moment to take pride in your commitment to pediatric nursing as Northwell Health continues to lead the way in creating and providing innovative care of children and families.

Margaret (Peg) Duffy, PhD, RN, NEA-BC Chief Nursing Officer/Associate Executive Director

Letter from the Editor

From the Executive Director

In the year 2020, the world stood still and looked to nurses for guidance, love, and comfort. In the darkest of hours for many patients affected by Covid-19, it was the nurse who held their hand and comforted their fears. I am privileged to share the extraordinary stories of the nurses on the front line, the nurses who went into battle, and who themselves were forever changed. It is with great honor that I share their voices and sorrows.

Despite these trying times, they did not sit idle while the world stood still. They continued to improve the care we provide to our children. They moved as one to push the world forward and turn it right side up. This year more than any other, we saw that the power of love and compassion has no limits. Please enjoy these stories and never forget how together we shined brighter than we ever imagined possible in the darkest of times.

The year 2020 has been filled with unmeasurable sadness and loss. At the same time, it has been filled with extraordinary feats of courage and strength by countless healthcare team members. I have been astonished at the depth of care and the limitless love provided to patients during one of our most challenging times in history. With grace, they bared the weight of the world on their shoulders, caring for patients and one another with dignity and love.

In these pages, you will read introspections from extraordinary pediatric nurses who answered the call to care for adult patients with Covid-19. Through their voice, you can reflect on the uncertainty we all felt and take pride in the heroic character they exhibited. I am proud of the work we have done together, and it is an honor to walk shoulder to shoulder with each of you.

Sharon Goodman, MA, RN-BC, CPNP Nurse Educator, Pediatric Service line Editor-in-Chief PNJ

Cari Quinn RN, MSN, NEA-BC Executive Director

pediatric nurse journal Pediatric Nurse Journal is created by the pediatric nurse experts of the Northwell Health System.

269-01 76th Avenue New Hyde Park, New York 11040 718.470.3000 www.cohenchildrens.com Carolyn Quinn, RN, MSN, NEA-BC Deputy Executive Director, Cohen Children’s Medical Center Margaret (Peg) Duffy, PhD, RN, NEA-BC Chief Nursing Officer Associate Executive Director Cohen Children’s Medical Center Editor: Sharon Goodman, MA, RN-BC, CPNP Director, Clinical Professional Development Pediatric Service Line Editor-in-Chief, PNJ 718.470.3178 Layout Design: Erin Donohue Director, Operations Cohen Children’s Medical Center Cover photo credit: Nicole Ciccione, BSN, RN Nurse Manager, Pediatric Emergency Department Cohen Children’s Medical Center

In this issue 2

Adult Patients Were Not as Different from Pediatric Patients as I Once Assumed - Renata Schillizzi MSN, CCRN, FNP-BC

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Community Flowers are Blooming with STEM Education Yvonne Hernandez, MSN, RN, CPEN

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Stepping into Care for Adult Patients – A Pediatric Nurse’s Experience During COVID - Maryann Peterson BSN, RN, CPN, C-NPT

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Quiet at Night: Bringing Down the Noise - Tania Wang BSN, RN, CPN, Laura Dunac MSN, RN, CPN and Camille Cipriano BSN, RN, CPN

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One Less Stick – Improving Lab Practices and Patient Satisfaction Zack Shapiro BSN, RN, Noelia MaGowan MSN, RN, CPNP and Geraldine Shikora CLT, MS Ed.

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Leadership During COVID-19 and Supporting Redeployed Pediatric Nurses: An Introspective - Renee Sanchez MSN, RN, NE-BC

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Improving Outcomes for Children with Asthma through Home Health Visits - Shari Bernstein MSN, RN, AE-C and Judith Jeanty MSN, RN, AE-C

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The Impact of Nurse Fellowships on Retention in a Pediatric Intensive Care Unit - Maria Marchelos MSN, RN, CCRN-K, NEA-BC

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Changing the Culture in the Pediatric ASU: One Stick at a Time Haley Holcman BSN, CCRN, Carol Creeron BSN, CPN, Fran Weingartner BSN, RN and Melissa Duffy MSN CPNP-PC

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Promoting Self-Care in an Uncertain World: A Comprehensive Program Sofia Agoritsas MPA, FACHE, Phyllis S. Quinlan PhD, RN, NPD-BC and Cari Quinn RN, MSN, NEA-BC

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Learning and Growing Through a Pandemic - Samantha Snyder BSN, RN

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SSUP Short Stay Unit/ Pediatrics Team Inspirational Work Board, Northern Westchester Hospital - Beatrice M. Kwasnaza BSN, RN SSUP

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Empowering Families to Advocate for their Children in the PICU Mary Schafer MSN, RN, CCRN, CPNP

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Adult patients were not as different from pediatric patients as I once assumed

believe they always hear me. By week two, I began to become familiar with some of the family members. They would recognize me over the phone from my voice and name. They started As a nurse practitioner primarily trained in pediatrics, asking me to deliver a message without me asking them; this working with critically ill adult patients, I have learned so much. felt wonderful and so gratifying. Despite a grim prognosis and I found that the knowledge I acquired in the PICU with ventia devastating pandemic, we tried our best to keep these families lators and interpreting blood gasses could easily be applied to as close to their loved ones as possible. It was unbelievable to patients of all ages. The biggest surprise to me was how tidal see how many people would walk around with iPads to connect volume was calculated, by height – fascinating! Drips were families with the patients; surgeons that I have never met, some calculated by kilograms, the same way we would do for our peI have known for 18 years, volunteers, social workers, nurses, diatric patients. Many medications utilized were the same, and the list is endless. These small acts of kindness, connecting peosome were different with similar indications. Sedation medicaple, holding a patient’s hand for a minute, praying at their bedtions, paralytics, diuretics, and anticoagulants were all familside, regardless of faith, all meant so much to everyone involved iar. Medications to maintain hemodynamic stability were also in a scary and unknowing situation. It wasn’t just about treating familiar, with a few extra options that I learned about during my the patient and the things that I could control-I felt most fulfilled redeployment. Continuous venovenous hemofiltration (CVVH) as a nurse practitioner by delivering a simple message of love orders were completely controlled by the nephrology team. The during an unforeseen perfusionists would round on time. the extracorporeal mem“You treat a disease, you win, you lose, you During the brane oxygenation (ECMO) Covid-19 pandemic, patients, making changes to treat a person, I guarantee you, you’ll win, no the phrase “healthcare the machines in collaboramatter what the outcome” tion with the physician and – Dr. Patch Adams hero” was born. Cernurse team. In the PICU, Physician, activist, diplomat, and author tainly, the world had gone mad, me a hero? both CVVH and ECMO are I rounded with the managed day to day by the attendings, replaced electrolytes, interpreted blood gases, made physicians and PICU nurses. Managing an adult patient with ventilator changes, adjusted drips, and this made me a hero?

Diabetic Keto Acidosis (DKA) after their levels are corrected This was simply my job to help sick people and care for them is harder than a pediatric patient, as any nurse or physician that to the best of my ability. Walking in and out of the hospital, I has worked in an ICU would understand. What I found most often felt as if no matter how hard we tried, people continued interesting overall was that there were more similarities than to pass away. Does that constitute a hero? Don’t heroes save differences. Thanks to the wonderful people I worked with, lives? Many lives were saved, but my only experience was including the Nurses, Physician Assistants, Nurse Practitioners, within the confines of the ICU, and the truth is, most of us felt a Attendings, Respiratory Therapists, Fellows, and Residents, I sense of defeat. I began to wonder what the definition of a hero was able to use my knowledge to help as much as I could. truly was, so I began my internet search. This coming from What I began to realize during my time caring for adult someone who researches the afterlife, hoping to find more scienpatients was that in a way, they were just big pediatric patients, tific studies daily, so it wasn’t so far-fetched. According to the maybe not from a medical standpoint, but a human standpoint.

Merriam-Webster (2020) dictionary, there are many definitions Adults still needed care and to be treated with dignity and huof the word hero. First, a mythological or legendary figure often manity. Pediatric specialists are experts in ensuring this type of of divine descent endowed with great strength or ability; well, care. Even with all of the intensive care interventions that I orthat’s not me. Second, an illustrious warrior; also, not the words dered and performed when I brought things back to the basics of I would use to describe myself as. Third, a person admired for holistic nursing care, I believe my impact was most significant. achievements and noble qualities, still not me. The fourth defiI began developing relationships with families over the phone, nition, one who shows great courage- Bam, that was it, that’s despite the grave situation I often conveyed to them about their why we are all healthcare heroes. loved one’s condition. Despite the grim news, family mem After a few months in the adult COVID ICUs, I came back bers thanked me profusely and blessed me many times. At the to the Children’s Hospital, and besides it being a bit more deesend of our conversation, I always asked the family member if calated and seeing everyone in a mask, everything seemed the they wanted me to deliver a message to their loved one, and same. Upon entering the elevator in the main lobby, a mother the initial response was usually, “can you do that, can he/she was there with her child in a stroller. The little girl gazed at hear you?” I would tell them that their loved one is receiving me with her head turned sideways, whether she was terrified or sedation medication and resting comfortably, but I would still be continued on page 31 more than willing to deliver a verbal message to them and that I Renata Schillizzi MSN, FNP-BC, CCRN

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Community Flowers are Blooming with STEM Education Yvonne Hernandez MSN, RN, CPEN

Introduction The St. Agnes Academic High School is an all-female catholic school located in the heart of Queens, New York. When the school was expanding its Health Sciences Program, the administration was interested in starting an after-school health club to promote the program. The club’s objective was to give the students additional healthcare experiences that would ignite a passion for nursing and allied healthcare fields. St. Agnes recognizes the importance of providing its young women opportunities in the sciences using professional female role models as mentors to nurture their educational curiosities.

Purpose The Health Sciences Program curriculum at St. Agnes Academy provided various experiences and opportunities in healthcare to empower students to move into nursing and allied health professions. The specialized track is part of the broader Science, Technology, Engineering, and Math (STEM) Program.

St. Agnes High Schools strategy was “to educate and motivate math and science students… [because they] know that increasing STEM opportunities for young women is the first step towards achieving success in high school, college and ultimately, economic success in the workforce” (St. Agnes Academic High School, n.d.).

Significance Northwell Health is dedicated to inspiring young minds to choose clinical and non-clinical careers within healthcare through their various community outreach programs. Northwell understands that helping students ignite interests in STEM will “establish/enhance relationships between Northwell and our future [community] workforce” (Northwell Health, 2014).

STEM education is currently utilized in academia to increase science and math literacy using innovative strategies to help students connect to concepts. Unfortunately, most western countries still find that females have higher incompletion rates in STEM education, and they are still under-represented in STEM careers (Van den Hurk et al., 2018).

Of the STEM research that has emerged, Kennedy and Odell (2014) note that one effective way to approach learning is to connect students with professionals within the STEM fields.

They also believe that “project-based learning provides formal and informal learning experiences” (Kelly & Knowles, 2016).

Other studies confirm that providing female role models from STEM professions motivates young girls to continue in STEM studies (Van den Hurk et al., 2018).

Initiative Details A Clinical Pediatric Nurse from Cohen Children’s Medical Center (CCMC) leads the St. Agnes Healthcare Club. CCMC

is a free-standing Children’s Hospital located ten miles from St. Agnes in New Hyde Park, NY, and is part of the Northwell Health system. The Clinical Nurse, Yvonne Hernandez, MSN, RN, CPEN, is a master’s prepared nurse who volunteers her time to run the program. The program is in addition to the established curricular as an after school club that focuses on health professions while highlighting the role of the nurse. The club curriculum concentrates on the treatment of illness and injury to others. It serves two important goals in nursing. First, it develops creative and critical thinking skills. These skills are proven to be essential for academic success and serve as a basis for continued growth in nursing education. Second, the curriculum fulfills the ANA Code of Ethics provision that requires nurses to promote health, safety, and programs that develop the profession (American Nurses Association, 2015).

The curriculum was designed to introduce the students to basic first aid over thirteen weeks and includes: • Fundamentals of anatomy and physiology • Fundamentals of infection control • Fundamentals of medical emergencies • How to obtain vital signs • How to manage simple fractures and lacerations The blended learning curriculum allows the students to develop self-learning strategies at home while keeping them engaged with in-class activities that will require developing practical skills and critical thinking skills. The classes involve hands-on demonstrations and practice time for practical skill development and simulations, case studies, role-playing, and Socratic questioning to develop critical thinking skills. Critical thinking skills are necessary for the registered nurse because nurses need to “identify essential data and distinguish between problems that require urgent intervention and those that are not life-threatening” (Shirazi & Heidari, 2019, p. e38).

During the program, the students receive Stop the Bleed and American Heart Association CPR certifications. Stop the Bleed is a nationally recognized program developed by the American College of Surgeons to teach life-saving bleeding control techniques to the average citizen. American Heart Association is the leading organization for fighting heart disease and stroke. Attaining these certifications allows the students to be proactive community healthcare citizens.

Another meaningful aspect of the curriculum includes the importance of self-care and body confidence. This section was added to fulfill the ANA “Healthy Nurse Healthy Nation” initiative that calls for nurses to focus on improving their own overall mental and physical health (American Nurses Association, 2020). It is critical to teach these life-affirming skills to young women to help them develop into confident, healthy women that will go out into the world and become our future leaders in STEM careers. continued on page 28

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Stepping in to care for adult patients A pediatric nurse’s experience during COVID Maryann L. Peterson, BSN, RN, CPN, C-NPT

How can I describe two months of my life in the middle of a pandemic? What I can tell you is that the word “pandemic” isn’t grandiose enough to paint the picture. I had always thought that it seemed like a word with a lot of magnitudes, but until I experienced it, I don’t think that I appreciated the word for what it really is. A pandemic is undefinable. The dictionary tells me that it can be a noun or a verb, synonymous with an outbreak that is prevalent in a whole country or the world, but this definition is just not enough.

In April of 2020, I volunteered to deploy from my Pediatric RN job to the adult COVID intensive care units where I learned a lot about myself as a professional nurse and as a resilient human. Nursing is my second career and I have been a pediatric nurse for six years now. So, when I say that I’ve never seen anything like the COVID ICU’s, I want you to understand that I have some years of experience from being a struggling dancer/actor/performer working job to job to pay bills to being a pediatric critical care nurse.

The funny thing is that I don’t need to quantify my experience because one hundred percent of all nurses who took care of COVID patients you poll will tell you the same thing: “I’ve never seen anything like it.”

The way I conceptualize it in my mind is like a Pendaflex of large memories, a folder of organized photographs and when I see the image in my mind, then I remember sounds, smells, feelings, etc. After deciding to write about my experiences, I then stared at a blank page while the images in the file cabinet of my mind swirled past me. I can see the walls of multiple pop-up ICUs lined with patient after patient, mostly intubated, some in a prone position, all with multiple tubes invading their bodies, like foley catheters, flexi-seals, nasogastric or orogastric tubes, central lines hooked up to continuous dialysis machines, and the list goes on and on. A cacophony of sounds fill the air and makes it hard for you to focus. All you can really smell is the inside of your n95 mask, especially if you had been wearing it for a few days. Sweat beads roll down your face because you are wearing more personal protective equipment than you have ever worn (and I’ve worn a full PPE level C suit with Powered Air Purifying Respirators (PAPR) for over two hours before).

The entire unit is considered a “dirty” unit, so you leave your gown on all day and put multiple gloves on to care for your patients as you try your hardest to be as clean as possible, but with 3 to 4 patients all on multiple vasoactive and sedative drips,

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you have to be sure you maintain their vitals before worrying about small things like turning or bathing your patients. I can hear families on the iPads, worried sick for their loved ones that they cannot visit, praying, singing, or even just taking one last look at them before they pass on to whatever is next. On some units, there isn’t anyone to answer the phones, so you try to, but you really don’t have time either. I can’t imagine how they feel, but I don’t really have time to think about it. You go home and wish you had more hands, more feet, more hours in the day to give them. I would work for days without taking a break because I just couldn’t leave my patients. We were all too busy to relieve each other anyway. Those patients who didn’t make it would get sent to the morgue and as soon as that space was clean and available, another patient would be on their way. It was, for lack of a better word, horrifying.

During the first few weeks of New York becoming the epicenter of SARS-CoV-2, I was still working on the Neonatal/Pediatric Transport Team where the children’s hospital’s census had dropped dramatically. Outside hospitals weren’t calling us to come to pick up patients and a significantly fewer number were walking into our Pediatric Emergency Department. My job transporting children became less busy as the sound of the overhead pager consistently rang out for adult patients like an ominous omen. For the same patient, it would start as a “Medical Rapid Response” and then a few minutes later progress to “Code Blue” and then “Anesthesia STAT.” You knew this patient wasn’t doing well, but then they would call another “Medical Rapid Response” in a different part of the hospital and the cycle would start again. The calls had a familiar, dark tone. The overhead paging system became all too familiar. Some days, it felt like they barely turned their microphone off in between calls. As our census in pediatrics dropped, we knew that our adult compatriots were drowning in patients who were decompensating quickly. There’s an expression called “circling the drain” that you hear when a patient is dying, but the problem was that every single COVID ICU patient was spinning towards that drain at an alarming rate.

That was when several nurses, providers, and other medical professionals from Cohen Children’s Medical Center found themselves in the middle of the pandemic at our sister adult hospitals. It was comforting to walk through the unknown hallways and run into a familiar face. I was provided an orientation and then took my own assignment as they needed more nurses

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Quiet at Night: Bringing Down the Noise Tania Wang BSN, RN, CPN Laura Dunac MSN, RN, CPN Camille Cipriano BSN, RN, CPN Introduction Noise in the environment is a known stressor that can affect a person both physically and psychologically. The body’s response to repeated noise exposure can negatively impact a person’s overall health. Hospital noise levels often exceed the recommended noise level and can increase complications in patients leading to longer hospital stays, increased cost of care, and decreased satisfaction rates (Choiniere, 2010).

This article investigated the noise level on a busy pediatric medical-surgical unit and the impact of maintaining recommend noise levels for this patient population. Medicine 3 (Med 3) is a high turnover Pediatric Medical-Surgical unit, located at Cohen Children’s Medical Center (CCMC) in New Hyde Park, New York. The unit is comprised of twenty-two semi-private inpatient rooms consisting of two, three, and four-bedded rooms. The majority of patients on this unit are discharged within forty-eight hours of their admission.

In the first quarter of 2018, it was noted that only 37% of patients reported on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey that the noise around their child’s room was quiet at night, and they were able to have a restful night of sleep. This presented an opportunity to provide an environment that promotes a restful night to parents and children in this hospital setting.

Background To evaluate the Med 3 unit’s noise level, an electronic audio monitoring device, “the ear” was utilized. The device was strategically placed on the unit in high traffic areas, including the nurse’s station, hallways, and outside patient rooms. Decibel (dB) sound levels were collected over four months, and sustained noise levels as high as 85.4 dB were noted on the unit. This decibel level is the equivalent noise level made from a vacuum cleaner (Choiniere,

2010). In the year 1960, the average noise in hospitals during the day was 57 dB, and at night it was 42 dB. Today the average noise during the day is 72 dB and 60 dB at night (Choiniere, 2010).

The data on Med 3 was consistent and slightly higher than these noted averages.

The data gathered on Med 3 showed an increase in noise level between 6 am to 10 am and 6 pm to 10 pm. During this time, multiple disciplines change shifts such as nursing, housekeeping, medical providers, and residents. Also, during this time, it was noted that the floors were cleaned at about 6 am with the Zamboni machine, causing a significant spike in noise levels. An inter-professional team was formed to implement changes that would reduce this noise level. This team aimed to create an environment conducive to healing and sleep by reducing the noise level at night.

The interprofessional task force realized there was an opportunity to improve the care provided on the unit by reducing the noise level and allowing patients and families to have a more restful night. Many studies have shown increased patient satisfaction scores directly related to decreased sound within the hospital setting (Joseph & Ulrich 2007). The team also recognized the impact the noise level had on the staff working on this unit. According to Noise Control regulation, it is dangerous for one’s health to work eight hours with a noise level of 85 dB (Yarar et.

Al., 2019). The taskforce posed the question, “How could the Med 3 staff promote a quiet and, therefore, healing environment for their patients, families, and staff?” The task force reviewed the comments on the HCHAPS responses for specific factors on the unit reported to impact the noise level and prevent restfulness of the stay. The common

figure 1, above

themes extracted were noise from the TV of the patient’s roommate, cell phone conversations of the roommates or their parents, staff talking at the nurse’s station, and the use of lights in the room at night.

Interventions After the information from “the ear” was gathered, several changes were made to promote Quiet at Night. First was to bring awareness to all the staff members regarding the unit’s current level of noise as determined by the electronic ear device.

Next was to educate the staff on the dangers of these levels and their impact on patients. Education was performed on the unit, and many staff expressed surprise at the findings of the high noise level. They reported that they felt the level of noise on the unit was “normal.”

The next step was to come up with a plan to reduce the noise level in the unit. The Med 3 team decided to implement “Quiet Time” from 9 pm to 6 am daily. Quiet times in the hospital

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cohen children’s medical center

One Less Stick Zack Shapiro BSN, RN Noelia MaGowan MSN, RN, CPNP Geraldine Shikora CLT, MS Ed.

Purpose Cohen Children’s Medical Center (CCMC) cares for approximately 60,000 children annually in the Pediatric Emergency Department (ED). Every child has the potential for phlebotomy needs during their visit.

These blood draws are often difficult and involve several factors that may lead to poor outcomes. One of these undesirable outcomes is called a ‘short draw.’ This occurs when an insufficient volume of blood is filled into an individual test tube. This can lead to a lab technician needing to run the test by hand instead of on the automated system. This is very time consuming and can back up other specimens waiting to be processed. If the specimen amount is entirely inadequate, the specimen cannot be processed, and the test cannot be performed. In this situation, the blood sample must be redrawn and often requires additional needle sticks to the child. This can be very upsetting and stressful for the child, parents, and staff obtaining the blood specimen. It can also contribute to delays in results and treatment.

In November 2017, members of the CCMC Pediatric Emergency Department’s Collaborative Care Council (CCC) decided to explore the issues they were having with short draws.

The team discovered that the Pediatric ED made up approximately 11.7% of all short draw samples processed by the central lab. The team resolved to investigate the department’s practices further and implement actions that would achieve two results: reduce the percentage of short draws and the number of sticks performed on children.

Methods In December 2017, the task force from the ED CCC was formed and began a literature review of evidence-based practices. The review revealed some valuable insight from multiple professional bodies to help guide the group in its pursuit to im-

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Improving Lab Practices and Patient Satisfaction prove outcomes. The American Academy of Pediatrics (AAP) notes that best practice recommendations are to utilize microtubes when possible in pediatric patients to reduce phlebotomy excess (Steffen et al., 2017). Repeated blood draws on a patient can lead to adverse patient outcomes as this is a source of unintended iatrogenic blood loss and induction or exacerbation of anemia (Meybohm et al., 2017). The development of a bedside reference guide for minimal blood volumes for laboratory testing is advisable in blood conservation strategies while still obtaining the appropriate amount needed for testing (Steffen et al., 2017).

While the literature review was underway, data analysis of short draws began in collaboration with the lab educator. First, a definition of a short sample was identified to be when the automatic testing probes of the processing machines could not reach the sample inside the tube.

When this occurs, the tube would need to be removed to see if the test could be performed by hand. If not, the sample would be discarded, and the sending nurse would be notified that the sample was insufficient for testing.

The CCC identified that blood volumes less than two milliliters in a regular blood tube would trigger a short draw. Next, the team performed site visits within the Northwell system to assess current lab practices. Upon visiting these sites, it was determined that microtubes were standardly utilized for testing on pediatric patients. The team next examined the current stock of microtubes available within the system and found two microtubes in use. These tubes were only being utilized for two specific lab tests. Through collaboration with the laboratory educator, it was discovered that these microtubes had the capability of running additional tests. However, these microtubes would have to be processed manually, which could have a negative effect on lab efficiency.

The team further investigated tubing options and identified a new microtube that was designed for automatic processing.

This microtube had the same 1mL sized sample as the current microtubes and had a fuller outside casing. This casing allowed for easy use during phlebotomy and allowed it to fit in the lab’s automatic testing machines. It was recommended that any lab draws performed that would result in less than two milliliters of blood should be processed in this new microtube. If greater than eight tests are being ordered, a huddle with a lab representative to determine the least amount of tubes possible to carry out each of the requested tests.

Next Steps Since this process improvement, the lavender microtube for automated processing was implemented hospital-wide. The ED is currently piloting a 3mL mint green tube to sustain the short draw reduction. While this tube is not a microtube, it is a significantly smaller version of the commonly used ‘mint green’ vial. We are in the process of creating a reference guide listing minimal blood volumes needed for greater than fifty percent of the most common lab tests ordered. This will help prevent overdrawing of blood volume on pediatric patients and distribute the blood specimen volume more effectively.

Discussion Small changes made to the phlebotomy and laboratory practice in this busy pediatric ED reduced short draws by 65% and prevented unnecessary needle sticks for pediatric patients. Laboratory efficiency was also positively impacted, as less short draw resulted in fewer specimens being processed by hand.

Before this initiative, the culture was only to utilize microtubes as a “back-up” when a patient was a particularly difficult stick or if it was a particularly small child. The unit culture changed once it was discovered the wide range of tests that could be performed using the microtube . The new microtube was used

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Outcomes The Pediatric Emergency Department incorporated the process of utilizing the new microtube. Before the initiative, the short draw rate was 11.7%. Post-implementation, this was decreased to 5.94% representing a 65% reduction, figure 1, above. Continued decline was seen in 2020, figure 2, bottom right.

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An introspective:

Renee Sanchez MSN, RN, NE-BC Friday, March 20, 2020, was a day I will never forget. I had to huddle with my pediatric team to inform them that Pediatrics at Lenox Hill Hospital (LHH) was going to close until further notice due to the novel coronavirus COVID-19 pandemic.

The hospital was running out of space and beds to admit adult patients who fell ill to COVID-19. I was asked to then open up and manage an adult COVID unit with nurses who were also redeployed from perioperative services. I was nervous, scared, stressed, and overwhelmed all at the same time but I knew I had to figure out a way to lead both my displaced pediatric team and to lead a new team of nurses who are displaced.

Constant Checking in on the Team After establishing a routine on the new “pop-up” COVID-19 unit a few weeks into the pandemic, I sent a group text to have a virtual meeting for pediatrics to touch-base and check in on the team. The response was overwhelming, and the clinical nurses and physicians all responded positively and stated how much they would appreciate a check-in meeting. I set up the virtual link and held our first pediatric team meeting since the start of the pandemic. The virtual meeting was not structured. I believed it was important to allow a space for our team to connect and share the experiences we were all having during this time. It was a place to share fears and a safe space to decompress. I also asked the team what I could do to better support them. They responded that they wanted more virtual meetings to allow them to feel connected. There were so many emotions shared, questions asked, and compliments made of how thankful they felt to have a way to connect with each other.

As a pediatric team, we normally hold a daily huddle between day and night shift to connect each day. With the unit closed and these huddles not occurring, the team, including myself,

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felt so disconnected over these weeks that this virtual meeting was greatly appreciated. Some of us laughed, and some of us cried, but in the end, we felt connected again. I made sure to do these virtual meetings a few more times during the pandemic.

Additionally, every morning, I would send a group text to the team on both days and nights to check in on them. During downtimes, which was not often, I would physically make a point to find them in the units they were assigned to say hello and ask how they were doing. I would do this early in the morning for the night shift and during the day with the day team.

Many of the pediatric staff had past experience in adult practice and volunteered to work in the COVID-19 units; some also volunteered to care for patients on the adult units I was managing, which was nice and made me feel like I had my team with me.

Most of the ancillary staff reached out and asked if they could be assigned to the unit I was managing so that they felt some form of semblance and a way to feel secure under my leadership, which made me feel so appreciated.

Ensuring Emotional Support As nurses have to don personal protective equipment (PPE) while caring for patients, this set-up a barrier and challenge to make the end of life transition special for patients. Nurse leaders need to understand this challenge for the nurses they are leading who are on the frontlines caring for patients in their final moments of life. Many of the pediatric nurses were all dispersed and working in adult COVID-19 units where patients were extremely sick and dying. As clinical nurses, our desire and need to provide holistic and empathetic care to our patients can be challenged when we are in PPE in patient’s rooms.

Nurses have to minimize exposure to the patient. They may not have readily available resources such as support staff like pastoral care available to help with the transition to death for patients who have COVID-19. This can be very hard emotion-

pediatric nurse journal

Leadership during COVID-19 and supporting redeployed pediatric nurses ally for the nurse to burden the sadness and toll this virus takes on the patient.

The difficulty of providing truly holistic care day after day as patients die is something that will remain with these nurses for years to come.

As leaders, it is important to recognize the emotional trauma from caring for extremely ill patients. Ensuring there is the support provided is very important. I called upon a team called “team lavender” consisting of a holistic nurse, psychiatric nurse and physician, nursing leadership, pastoral care, and human resource to come to the units I was managing for COVID-19. During the code lavender, I would make sure to include the pediatric team to join and participate. Team lavender is a response team for the staff that will host an emotional debrief and safe space to talk and share thoughts to reflect all the team’s challenges during a crisis occurring both at work and home. Team lavender also brought resources, including essential lavender oils, chocolate, prayer books, and lotions to the staff to help comfort them. The pediatric staff appreciated it when I included them. It helped them know that I was also ensuring their needs were being met even if I was afar.

Celebration and Remembrance On June 15, 2020, the pediatric unit at Lenox Hill Hospital reopened. This was such a special day for our team.

The pediatric unit was one of the first units to close down during the start of the pandemic and one of the first units to reopen. The unit, while closed, reopened as a COVID-19 adult ICU in which I managed. The patients on the unit were on ventilators and extremely ill and often did not survive. Many of the pediatric staff helped me to convert the unit back to pediatric. This meant we needed to move all our furniture and pediatric-specific supplies out of storage back onto the unit and put up our child-friendly artwork to make the unit pediatric-focused. Before we opened, we held a remembrance for all the

patients that had died on the unit during COVID-19. I felt it was important to honor the lives lost on the unit before we reopened and especially important for the pediatric staff to close the chapter of displacement to feel home again on the pediatric unit. I reached out to pastoral care, and one of the Rabbis agreed to perform a blessing on the unit with the entire interdisciplinary team for pediatrics. It was a beautiful ceremony.

The Rabbi wrote out the most heartfelt prayer and blessing specific to pediatrics. Afterward, we hugged, and tears were shed. There was such a noted moment of release after the blessing was performed. In commemoration, we framed the blessing and hung it up on the wall for the team to reflect and have a place to always remember. The pediatric team appreciated this and made them feel like they could move on to the next journey with the reopening of the pediatric unit.

Recognition I wanted to make sure the pediatric nurses felt appreciated for all the work they had done caring for patients during the COVID-19 pandemic. The ANA declared 2020 the “year of the nurse,” and nurse’s week is traditionally celebrated at the beginning of May. However, this past May, due to COVID-19 and social distancing restrictions, there was no celebration. Lenox Hill’s leadership gave a thoughtful gift to each of the nurses. I wanted to show my gratitude towards the team. I put together a small care package with a handwritten note to each of my pediatric staff members.

I wanted them to know how much I appreciated them personally. I also used the myRecognition platform that Northwell provides to recognize every pediatric staff member with points and a personalized note of appreciation.

On August 12, 2020, I was awarded the “Storey Award,” named after one of the ancillary staff who came up with the award, which is an award based on one of the core values for Northwell that the division of Maternal Child Health

(MCH) and Pediatrics awards every week to a staff member in the division.

In addition, the recipient receives a Northwell sports jacket embroidered with the awardee’s name. The pediatric staff specifically nominated me for my leadership during COVID-19. They stated that I always made them feel connected to pediatrics even though the unit was closed. They said that they always felt supported, and their emotional needs considered. They recognized me for the long hours and the time I put into ensuring the team stayed connected. I was the first leader in the division to be awarded the “Storey Award.” I was so honored, humbled, and grateful for their recognition of my leadership.

It allowed me to realize my efforts and support for the pediatric team were noticed and appreciated during the pandemic.

References: Edmonson, C., Samagaysay, D., Cueman, M., Chappell, S., (2016) “The Nurse Leader Role in Crisis Management,” JONA Vol 46, Number 9, PP417-419.

Sanchez, R., O’Flaherty, Smith, E. (2020), “Supporting Nurses when patients die during a disaster: Wheat leaders can do,” American Nurse.

O’Grady, T. (2011), “Leadership at all levels,” Nursing Management.

Renee Sanchez MSN, RN, NE-BC Nurse Manager, Lenox Hill Hospital

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Improving Outcomes For Children with Asthma through Home Health Visits Shari Bernstein MSN, RN, AE-C, Judith Jeanty MSN, RN, AE-C.

Introduction Bringing Resources for Effective Asthma Treatment through Health Education (BREATHE) was initiated in 2012 and has evolved into a multifaceted program aimed to reduce readmission rates for children treated for asthma. In collaboration with the interdisciplinary team, the program driven

by Certified Asthma Educators empowers patients and their families to manage their asthma safely at home to decrease emergency department (ED) visits and hospital admissions. The recent incorporation of a homecare referral for patients in the BREATHE program has shown added success in achieving the program goals. This article will explore this unique component of the program and its benefits in keeping children with asthma out of the hospital setting.

The National Asthma Education and Prevention Program (NAEPP) has six priority asthma management goals that have been successfully incorporated into the BREATHE program.

These goals include: 1. Assessment and monitoring of asthma control 2. Assessment of asthma severity 3. Prescribing appropriate inhaled corticosteroids 4. Using an Asthma Action Plan 5. Controlling environmental exposures 6. Discussing the importance of follow up visits with primary care physician and asthma specialists Literature Review A literature review was conducted to show the benefits of home visits for children with asthma. Numerous studies have linked asthma exacerbations to indoor housing conditions and exposure to allergens or irritants. Studies have also shown that homecare visits lead to a decrease in asthma symptoms and the utilization of hospitals, EDs, and urgent care centers. (Campbell et al., 2015) Bracken et al. (2009) studied the importance of nurse-led home visits and focused on children who were known to be poorly controlled. They found many issues in the home that the hospital education did not capture. In some homes, asthma medications could not be found or was being misused by young children without parental supervision. In addition, many psychosocial issues impeding proper asthma management were uncovered by the nurse in the home. The home visit provided invaluable information that benefitted the future asthma management of these children.

The National Center for Healthy Housing provided case studies on the benefits of home visits for children with asthma in several U.S. states. In Portland, Oregon, a homecare program was developed for asthmatics, resulting in participants being two and a half times less likely to use the ED after the intervention.

In Baltimore, Maryland, a similar program was instituted, re-

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sulting in statistically significant decreases in asthma symptoms and ED visits. The Neighborhood Health Plan was formed to promote asthma education in the home of asthmatics in Boston and resulted in a dramatic decrease in hospitalizations. Finally, a healthy home program in Seattle, Washington, had their home care visits add twenty-one more symptom-free days per year in children who participated (National Center for Health Services Research 2011).

All of the homecare initiatives reviewed involved developing an individualized plan to reduce and, when possible, eliminate the triggers in the patient’s home and environment. A key element reinforced in the homecare visit was the importance of the child’s adherence to asthma medication and consistent follow-up care. Additionally, in the case of smoke exposure, homecare nurses would provide information and resources for cessation programs and referrals.

Several additional studies regarding the effectiveness of homecare visits for asthma patients and their families revealed significant benefits of care continuity from ED visits and hospital admissions. The overall outcomes from homecare visits, according to various studies, have shown to reduce asthma symptoms. There was a decreased need for urgent health care facilities (admissions, ED visits, and urgent care visits) and improvement in the family’s knowledge and skills to manage the child’s asthma. (Anderson et al., 2020; Bhaumik et al., 2017; Fernandes et al., 2019; (Marshall, et al., 2020.

Methods Project BREATHE is driven by Certified Asthma Educators (CAE) that work closely with the inter-professional team. The CAE’s provide education to the asthmatics that meet the Project BREATHE criteria. These criteria include: 1. Patients with a primary diagnosis of asthma, status asthmatics, asthma exacerbation, or reactive airway disease 2. Greater than or equal to 2 years old 3. History of asthma or prior wheeze responsive to albuterol For all the asthmatics enrolled in Project BREATHE, CAE’s complete a thorough asthma history, provide standardized asthma education utilizing the Project Breath flipbook, and help to ensure completion of the asthma action plan prior to discharge.

Before discharge, the CAE offers home care visits to all of the families in the program and prioritizes the patients with multiple ICU admissions, non-compliance with follow-up appointments, and those who have several environmental triggers. Once the family accepts the home care visit, the CAE contacts the case manager and notifies the patient’s primary care provider. The case manager processes the referrals to the homecare department. During the home visit, the home care nurses go through specific asthma training that aligns with the inpatient teaching provided to ensure information consistency. During the visit, environmental triggers are assessed within the home, and families are provided with the needed supplies. Supplies include HEPA vacuum cleaners, hypoallergenic cleaning products, and

pediatric nurse journal

mattress covers. Resources are also offered for any structural repairs needed in the house that may be contributing to the asthma triggers. Typically the home care nurse will conduct two visits and then follow-up as needed. Documentation of the visit is sent to the primary care provider to facilitate continuity of care.

A home visit provides an opportunity to reinforce the hospital’s education to ensure proper administration of medications, assess environmental triggers and confirm adequate understanding of the asthma action plan. The visit also ensures follow-up care with the primary physician or asthma specialists is occurring.

both residences.

Next Steps continued on page 34

Outcomes: Fifty-seven children admitted for asthma and entered into the BREATHE program received home visits. Five were readmitted to the hospital yielding an 8.7% readmission rate for this group.

Two participants returned to the emergency department for care, yielding a 3.5% rate for emergency visit post-intervention (Figure 1, at right).

Limitations Limitations encountered included the recruitment of participants for the home visit. One obstacle identified was the requirement to have a parent/guardian present on the visit day.

Parents had difficulty scheduling a home visit due to their work schedules. Additional challenges arose when parents had shared custody in two different residences requiring visits to

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cohen children’s medical center

The Impact of Nurse Fellowships

on Retention in a Pediatric Intensive Care Unit Maria Marchelos MSN ,RN, CCRN-K, NEA-BC Kathleen Schmidt MS, RN, PNP, CCRN Purpose: Novice nurses are challenged by their lack of experience, self-confidence, and unfamiliarity with the practice environment.

As a result, our Pediatric Intensive Care Unit (PICU) was experiencing low retention rates. New graduate nurses were having difficulty transitioning to independent practice and were leaving the unit within the first two years of employment. Although all new hires received an extensive twelve-week orientation consisting of a precepted experience, the turnover rate remained high. It was determined that a change was needed, and the leadership team made a long-term investment in implementing a nurse residency/fellowship program. A yearlong nurse fellowship program was designed to help decrease turnover and help novice nurses successfully transition to independent nursing practice.

Relevance/Significance: The PICU is a dynamic work environment in which the sickest of children are provided care. Proper training of new nursing hires is essential to their transition to safe and independent practice. New graduate nurses often lack self-confidence in performing clinical skills, critical thinking, prioritizing, and communicating with their colleagues. It is estimated that 35% to 60% of nurses leave their first employment place within one year of hire. Nurse fellowship programs are seen as a way to transition new graduate nurses into practice by providing them with a comprehensive educational experience and the support they need to succeed in their practice environment (Van Camp & Chappy, 2017). Nurse residency or fellowship programs are commonly used to support new graduate nurses and effectively reduce vacancy and turnover rates (Garrison et al., 2017).

Dr. Patricia Benner’s Novice to Expert Framework identifies the progression of clinical nurse competence and was used to develop a nurse fellowship program in this PICU. Benner (1982) described five stages of clinical competence: novice, advanced beginner, competent, proficient, and expert. The transition from novice nurse to expert occurs in the clinical setting because it provides the nurse with opportunities to continuously develop and expand their knowledge.

According to Benner’s framework, the new graduate nurse enters the practice environment as an advanced beginner. During this stage, nurses need support in the clinical setting. They need guidance in prioritizing care, and they must be supported by competent nurses who can assist them in their clinical decision-making. Advanced beginners take in little of a situation because it is so new to them, and they are focused on following the rules and guidelines they have been taught. They lack the experience required to recognize whole situations (Benner, 1982). Benner’s framework is valuable in developing fellowship programs because successful programs should expound onto

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new graduate nurses an educational base while offering various experiences to assist them in moving towards the stage of an expert nurse (Bradley, 2017).

Leaders in healthcare organizations focus on nurse fellowship programs to attract, retain, and socialize novice nurses into practice. The Institute of Medicine (IOM), among other organizations, recommends that healthcare organizations develop nurse residency or fellowship programs to support new registered nurses as they transition into their new role. The IOM also recommends that organizations evaluate these nurse residency programs to determine their impact on retention and patient outcomes (Bradley, 2017).

Additional factors to consider are the amount of time and resources required to orient new graduate nurses. Also, high nurse turnover rates can negatively impact staff morale and engagement. There are financial aspects to consider, as well.

According to the 2016 National Healthcare Retention and RN Staffing Report, the average cost of turnover for a nurse ranges from $37,700 to $58,400. The expense can be even more significant when orienting a new nurse to a specialty area such as the PICU and further emphasizes the need for a fellowship program to help new nurses transition to the practice environment.

Strategy and Implementation: The nursing care of critically ill children is a specialty that requires a systematic orientation framework to potentiate the successful transition to practice. A Pediatric Critical Care Nurse Fellowship Program (PCCNFP) was created to meet this specialized need. PCCNFP is a comprehensive orientation that prepares new graduate nurses for practice in the pediatric critical care environment. The program consists of three semesters to aid in the transition to practice: Semester one fosters clinical knowledge through multimodal education methodologies such as didactic knowledge, simulation learning, and hands-on experience. Semester two places the fellow in the care setting alongside a designated preceptor to acquire clinical skills/competencies and develop critical thinking skills. Semester three is the transition wherein the fellow cares independently for the critically ill child with a dedicated resource nurse’s support.

A central component of the PCCNFP is the fellow’s support through each semester of the structured program. The fellow, associate fellow, and master fellow collaborate to individualize the orientation experience. This enables individual goals and growth opportunities to be identified and enhance clinical improvement and critical thinking. The support provided through each semester is tailored and individualized to the needs of each fellow. In semester 2, the RN Orientation Pathway and Weekly Progress Records allow for goal setting and providing necessary feedback to aid in the transition. During Semester 3, the fellow is caring for their patient assignment. A clinical resource nurse (CRN) is assigned to the fellow to support growth during their shift.

This can be a very challenging time for the fellow as they are

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pediatric nurse journal

Changing the culture in the Pediatric ASU:

One stick at a time Haley Holcman BSN, CCRN Carol Creeron BSN, CPN Fran Weingartner BSN, RN Melissa Duffy MSN, CPNP-PC

Introduction At Cohen Children’s Medical Center in New York, in the Pediatric Ambulatory Surgery Unit (PASU), a decision was made to change the current practice regarding peripheral intravenous (PIV) catheter placement. Through collaboration with unit nurse managers, anesthesia, PASU nurses, and Nurse Practitioners (NPs), it was determined that a change in current practice was necessary to improve the perioperative throughput. The plan was to have the PASU Registered Nurse (RN) place PIVs in patients 12-years-old and older prior to entering the operating room (OR). This plan disrupted the longstanding unit culture that did not encourage this practice and required the nurses to change their usual routine. Previously, the nurses had a limited skill set in PIV placement, and the anesthesiologist was responsible for insertion. Prior to this initiative, patients who required interventions before entering the OR would have to wait for the anesthesiologist to come out of the OR and place the PIV. This led to OR delays and delays in preoperative intervention, such as lab work or administration of medications or blood products. Placing PIVs before going into the operating room not only facilitates a smoother transition into the operating room and anesthesia induction, it also allows for parental support during PIV placement. Additionally, it enables appropriate dosing of intravenous pre-sedation medication for older children for which the oral version may not be as effective due to weight-based dosing.

Background Before introducing a new way of doing things, it is crucial to identify the culture that already exists within the organization (Johansson et al., 2014). This initiative had previously been attempted and was faced with barriers, including lack of support from surgical services or the anesthesia team and a limited skill set of the RN to place PIVs. The group decided to initiate the RN PIV placement process again after requests from the perioperative leadership to help with throughput. Initially, we encountered some resistance from PASU nurses, as many nurses were comfortable with the current practice. Resistance to change has been shown to delay improvements in patient-centered care and often limits the ability to place new ideas into practice (Johansson et al., 2014). This culture change was a disruption to the conventional way that preoperative patients were cared for in the PASU, and it required the nurse to step out of their comfort zone to adjust their routine practice. When the status quo is not disrupted, it is easy to become stuck in routine practices, which may not necessarily be best for the patient (Nisbet et al., 2013).

Method/Initiative

To initiate this change in practice, the Nursing Professional Development Department provided PIV insertion classes to all PASU nurses, and competency was attained after three successful PIV insertions. During the pre-surgical testing visit, the patient and families meet with the Child Life and Creative Art Therapy team, who prepares the children through anticipatory guidance about what to expect the day of surgery, including PIV insertion.

This step in the process aids in identifying patients prone to experience anxiety from having a PIV placed. In addition, patients who are 12-years-old or older are assessed by the RN on the day of surgery to ensure IV placement is beneficial and would not cause unnecessary anxiety. While making this change in the culture, it was essential for the nursing staff to make this a pleasant experience for the patient and not cause undue anxiety. Therefore placing a PIV is always a collaborative effort with the child life specialist, parents, patient, and nurse. It is also important to take into account the specific surgery the patient is undergoing.

For example, if the patient is having surgery on the right side of the body, the PIV is placed on the left side of the body. When continued on page 20

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Promoting Self-Care in an Uncer

Sofia Agoritsas MPA, FACHE Phyllis S. Quinlan PhD, RN, NPD-BC Cari Quinn RN, MSN, NEA-BC

Background The challenges in healthcare of adapting to new care models, stricter quality benchmarks for optimal reimbursement, increased agency oversight, transitioning to an electronic medical record (EMR), hospital mergers and acquisitions, over the course of the past thirty years, has resulted in a significant percentage of healthcare professionals experiencing burnout as a consequence of this unrelenting stress.

Organizations began to search for interventions and programs to address this new and disconcerting syndrome of caregiver burnout.

Raising awareness, education, and focusing on the need for increased attention to self-care began to surface. Over the years, these health-living and self-care programs were housed in a by variety of departments. These programs have ranged from health insurance incentives, cellphone apps and onsite holistic and chaplain services. We finally appreciated the importance that resilience and an agile mindset play in caregiver well-being and positive clinical outcomes.

However, in 2020 our heroic response to COVID-19 changed everything. We now had to work within our demanding professions and an atmosphere of uncertainty. There are few things that will tax a person’s resilience more than navigating uncertainty. As professional caregivers, we rely on evidence, protocols, and procedures to guide us every minute during the workday. The anxiety and threat around what we were dealing with, how we would deal with it, and the unpredictability of how long we would need to mount a response to this pandemic was disturbing and draining. We could no longer look upon self-care programs as added value niceties to help sustain us in our demanding professions. We needed a comprehensive program that targeted caregiver well-being needs in order to maintain a healthy body, mind, and spirit during persistent, uncertain times.

Understanding the Issue In his article, The Most Underrated Management Skill, Nelson Repenning (2019) declared that “There are few management skills more powerful than the discipline of clearly articulating the problem you seek to solve before jumping into action” (p. 39). Early on, the Cohen Children’s Medical Center’s

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(CCMC) executive team, led by Cari Quinn, MSN, RN, NEABC, acknowledged that while space and resources for promoting well-being were available, our existing services were siloed and lacked a unified message of promoting self-care as essential.

The resulting strategic initiative was based on the observations and insights gained through leadership rounding during the CCMC interprofessional team COVID-19 response. Listening to the staff share their challenges, fears, and concerns illuminated for the executive team that a one-size-fits-all program would not offer the desired outcomes. The feedback was self-evident. Different staff members had different experiences, both personally and professionally, during the height of the pandemic.

Those on the front lines faced stressful realities beyond comprehension. The challenge for pediatric nurses deployed to care for adult and geriatric patients diagnosed with COVID-19, some of them in critical condition, was unique. Several shared that they had never lost a patient, let alone provide post-mortem care. Many of our physicians, advanced care practitioners, and nurses had not cared for the adult/geriatric populations since medical/nursing school.

Our respiratory therapists were tested beyond what many of us would think humanly possible. The chaplains, child life, and creative arts therapists were dedicated to keeping the human touch palpable throughout critical clinical situations. The word essential doesn’t even approach a clear description of the role our environmental services teams provided. Others needed to find a way to carry out their roles remotely or were furloughed. Many juggled the needs of caring for frail parents, home-schooling, and working remotely. Others were ill with COVID-19 and struggled to regain their health. All had different needs.

It fell to the leadership representing Administration, Human Resources, Nursing, Nursing Education, Social Work, Behavioral Health, Child Life and Creative Art Therapy and Creative

rtain World: A Comprehensive Program

pediatric nurse journal

Arts Therapy, Communication, Chaplaincy, Holistic Services, Concierge Services, Engineering, and others to examine the programs currently offered and sort them into different levels of staff support. A comprehensive program was needed that was clear and easily understood by all.

In June 2020, The Cohen Children’s Medical Center Restoration Program was established. The Restoration Program is a curation of all internal and external interventions and services offered to our interprofessional team as a key component of the CCMC Comprehensive COVID-19 Restoration Plan. As we began reimagining the children’s medical center postCOVID-19, these programs were refocused on the common goal of rebuilding resilience and assisting each staff member in sustaining their joy in what they do.

The CCMC Restoration Program: Revive, Resilience, Restore This comprehensive program repackaged our existing internal and external resources into three levels of services, Revive, Resilience, and Restore. Each service is targeting a different wellness need and desired outcome.

The Revive Programs These programs are intended to offer the staff member a brief respite from the stress of the day in order to revive, lift, and renew the spirit. They are also offered to provide more opportunities for staff to connect and engage with each other.

The Oasis Space and Rejuvenation Cart are examples of where the executive team identified a need to expand programming. The Oasis Space is a Zen-like space opened on May 12, 2020, in part to celebrate the conclusion of nurse recognition week (Florence Nightingale’s birthday) and, in part, to signal the end of our emergent COVID-19 response phase. It is a place that encourages all members of the interprofessional team to take a moment, breathe, and begin to let go.

The Oasis Space is an extension of our Serenity Suite. Its footprint includes three rooms on our Med2 Unit. One room is a place where staff can come, grab some water and a snack and go, or linger a while to decompress in the essential oil aromatherapy and pleasant company. Since May 12, this space has seen greater than 6000 total visits from both CCMC and LIJ staff members. The room is open for enjoyment Monday through Friday and staffed by our wonderful concierge partners. The second room serves as an extended area for our holistic practitioners to offer Reiki. Our dedicated Holistic Team has offered this wellness modality to over 500 employees since May. The third room is our new Recharge Room. This room offers the staff member an opportunity to lounge in our new electronic massage chair while viewing the beautiful nature scene projected onto the wall. More than 450 staff members have taken advantage of this sanctuary since May. When the staff cannot getaway to the Serenity Suite or Oasis Space, our new Rejuvenation Cart, manned by our Child Life-Creative Arts Therapy colleagues, come to them. The Rejuvenation Cart is a welcomed sight as it brings cold drinks, a snack, and other inspirational and donated items right to the units for all to enjoy.

The feedback from the staff has been gratifying to receive.

They share that they try to get to the Oasis Space at least once a week. They are so thankful and appreciative of all the community donated items they’ve received. Most remark that these programs are a welcomed addition to the workplace.

The Resilience Programs These ongoing programs, comprised of training, holistic services, and peer support groups, promote the enrichment of the staff’s stamina and ability to recover from work-related stress. The programs are designed to address individual and group/team needs. Resilience is an active, dynamic process, according to the Centre for Confidence and Well-being (2006).

The Stress First Aid Sessions are our newest addition to our Resilience Programs. These peer-support groups (performed remotely) were offered specifically to provide a forum for our frontline clinical staff to tell their COVID-19 response stories in a safe and accepting space. These sessions were facilitated by a team of healthcare professionals that included licensed mental health counselors, professional coaches, and licensed psychologists. The program was based on the content from the Center for Traumatic Stress Recovery and Resilience (CTSRR) program developed by the Zucker Hillside Hospital team of psychologists. The staff’s response to these 90-minute remote sessions was very positive and validated the need and importance of peer-support.

The Restore Programs As healthcare professionals, we recognize that mental health is the foundation of all well-being. This third component

continued on page 24

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Changing the culture in the Pediatric ASU from page 17

potential blood loss is a consideration during the surgical procedure, a larger gauge angiocatheter is placed. Patients’ preference for location is also taken into account.

To facilitate this process, patients that were 12-years-old and older have PIV orders placed on hold the day before surgery by the NP. The assistant nurse manager would arrange for appropriate staffing to provide the extra time needed for the procedure. This initiative improved perioperative throughput for patients in the PASU. Anesthesiologists, surgeons, patients, and families recognized the impact of this change practice immediately. After receiving positive feedback, the nurses felt empowered to maintain this practice and validated that a small change in practice can make a substantial impact.

Results A survey was sent out to our pediatric anesthesia team and surgical attending’s, which received 21 responses. Based on the survey results, 57.14% thought PIV placement in PASU improved patient experience, 80.95% felt the PIV placement prior to going to the OR decreased the time to induction, and 85% felt the PIV placement in PASU facilitated premedication prior to entering the operating room. Open communication was the key to the success and real-time evaluation of any issues with a PIV that was placed in PASU; whether the PIV was placed in an undesirable location or was not functioning in the OR, having a constructive dialog with the staff led to improved future practice.

Input received from a lead pediatric anesthesiologist led to the understanding that “certain surgeries may require a certain location or size of IV.” Based on this assessment, the anesthesiologist provides guidance on the size and location needed for specific surgeries.

Since initiating this culture change, preoperative interventions such as bloodwork and IV medication administration have improved. Patient experience preoperatively and in the operating room has improved. Patients experiencing anxiety in the perioperative area with PIVs in place were able to receive IV sedation prior to entering the OR. For patients who verbalized having a negative prior

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experience with mask induction of anesthesia, the placement of a PIV allows for a more comfortable anesthesia experience.

With continued support from nursing leadership, the NP, and the Nursing Professional Development team, we were able to successfully implement this practice change, which was well received by the staff. Once the nurses felt comfortable placing the PIVs, and more staff were participating, a shift in the unit culture was noted. Many anesthesiologists and surgeons praised the initiative for helping move patients in and out of the operating room more efficiently.

The PASU nurses have embraced this challenge and continue to proactively seek opportunities to place PIV’s.

The patients are supported throughout the process by their parents, nurses, and child life therapists. Anesthesiologists can administer IV sedation prior to the patient entering the OR (if necessary), and initiation of anesthesia in the operating room is faster.

Outcome There has been a dramatic increase in the number of PIVs placed by the nurses in the preoperative area. After initially tracking our volume over the summer months, we noticed that 46% of PIVs in July and 42 % in August were successfully placed (graph 1, above top).

Some of the issues encountered were time constraints for the first case to have a PIV placed, difficult sticks, extremely fearful patients, or developmentally delayed patients. In the months immediately prior to this initiative, 0% of our targeted patients received preoperative PIVs in May and only 5% in June. The

number of PIVs placed in the PASU by the RN has increased monthly, with 64.7% of patients receiving PIVs in the PASU in December 2019. This culture change has improved the flow and efficiency in the OR and improved patient experience. The overall patient experienced increased by 17.4% for patients 12 years-old to 21-years in the perioperative setting (graph 2, above).

Conclusion We have experienced overall success with the implementation and results of this initiative.

This initiative introduced a shift in practice that ultimately led to a change in unit culture among the staff from various disciplines. Nurses are now more comfortable placing PIVs and are empowered to implement this new skill. Additionally, the anesthesiologists have expressed their satisfaction with this culture change, and when surveyed, 61.9% of them “strongly agreed” that they would like the PIV to be placed by the PASU RN. The child life specialists have also been an integral part of this culture change. They provide anticipatory guidance and prepare the children during their pre-surgical testing appointments about the day of surgery and PIV placement.

Future Goals

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pediatric nurse journal

Learning and Growing Through a Pandemic Samantha Snyder RN, BSN

Being a nurse during the Covid- 19 pandemic has challenged me in ways that I never could have imagined. When I graduated nursing school, my goal was to work in pediatrics.

For as long as I could remember, I have been passionate about working with children and their families and making their difficult time in the hospital just a little bit better. A little over a year and a half ago, I began working at Lenox Hill Hospital in the pediatric unit. It was a fulfillment of a long-time dream, and I could not have been happier. Shortly after Covid-19 hit New York, the decision was made to close our unit to accommodate the anticipated surge of patients and protect the more vulnerable pediatric population. There was so much uncertainty from that point on, as we did not know how long this would last. Fortunately, our leadership and team were strong, and we were all in it together.

Since our unit was closed, we each needed to make a decision individually as to what we would do. We were given the choice to either float within the maternal-child health units, float to the newly opened Covid units as “runners,” or to float to the Medical/Surgical (Med/Surg) units and take on an adult assignment. After some thought, I felt that the right thing to do was to orient to adult Med/Surg and take assignments. I had some experience working in a PACU and decided that I was going to use that knowledge to go where I was most needed.

I believe that as nurses, we are equipped with the tools to confront challenges no matter how hard. Floating to unfamiliar units in a period of chaos and uncertainty became one of the most difficult challenges in my short nursing career. Taking care of adults with Covid and other pre-existing comorbidities tested every single skill I had, mentally, clinically, or physically. Despite these challenges, there was always a strong feeling of teamwork amongst those of us working together. Every unit I worked on was a “pop-up” unit, and every single nurse had been floated from somewhere else within the hospital. Being that we were all in unfamiliar territory, caring for patients with a new and unknown illness, we all had to rely on each other for guidance and support. We had to use our collective skills and strengths to safely care for each patient. Each shift we worked, we had the potential to either sink or swim, and with strong teams, we were able to rise up and swim.

After returning to the pediatric unit, I saw how much my experience impacted my work with adults. Because kids are so vulnerable and usually cannot advocate for themselves, we rely on their families to be an integral part of their care. It is also incumbent on us as nurses to be their voice. The adult patients for whom I had cared for were alone in the hospital. They were critically ill and often could barely talk because of difficulty breathing. I needed to become their voice and advocate for

them, just like we do for our pediatric patients. My experience on the adult unit also impacted my work on the pediatric unit.

Typically, our patients do not have multiple comorbidities like the adult population. I learned to take an even deeper holistic approach to care for patients, and I hope that I will be able to continuously grow as a pediatric nurse from this experience.

When I look back at my time working on Covid units, I see it as a time of tremendous growth and learning. I learned that as nurses, we need to be flexible and sometimes go not where we had intended, but where we are most needed. As Sheryl Sandberg, COO of Facebook, discusses in her book Option B, we can build resilience based on how we respond to adversity or hardships in our life. It is like a muscle and can be either strengthened or weakened based on our response. Covid was, and still is, a time where we are living far from what we envisioned as option A, and possibly not even option B or C. However, we have the choice every day to make the most of option B. While this has been a time of extreme challenge and hardship, I believe that we have the potential to come out stronger as medical professionals and people.

Resources: Sandberg, S. & Grant, A. (2017). Option B: facing adversity, building resilience, and finding joy. Knopf Doubleday.

Samantha Snyder RN, BSN, Clinical Nurse, Pediatrics Lenox Hill hospital

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Stepping in to care for adult patients from page 8

to take care of the growing demand. My first day on my own, I had four patients who were intubated, sedated, some paralyzed, and on multiple vasoactive drips. One of my saving graces was that my nurse buddy next to me was a nurse that I had known for a long time from the Pediatric ICU. I knew that even though we were both keeping our heads above water if one of us started to drown, the other would be there.

We were in one of the pop-up ICUs, so it was difficult to find supplies, not that we didn’t have any but more that I had no idea where they were. There were technicians from the operating rooms who would restock the tables of supplies in our areas. They could find me anything I needed, so I nicknamed them “The Unicorns.” The unit was previously a psychiatric care unit, so the medication Pyxis initially didn’t have enough bags of fentanyl and versed to get us through the day. I would have to run to another Pyxis in a different unit to get bags of Phenylephrine or call the pharmacy for a new bag of Vasopressin, both vasoactive drips that if they ran out, would be detrimental to my patient’s blood pressure. As the weeks went on, our medications became more available since we were all trying to figure out what the best workflow would be, pharmacy included. I’m sure having multiple nurses from units that were not typically ICUs calling for immediate, lifesaving medication was probably stressful.

Much like a bowling ball, I figured out how to take care of these patients as best as I could because I had to keep rolling down the alleyway. There was no opportunity to feel uncomfortable because there was a mighty to-do list that I had to get done, even if that meant no break, no water, no bathroom. These patients had become my responsibility and so even though I was out of my element, I had to give them 110% because that is what we do as nurses.

One of the adult travel nurses started calling me “the hostess with the “mostess” because I never stopped. If I had a question related to adult care, one of the nurses would help me, so I never felt like I couldn’t take on the medicine, but

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it was more an issue of time. I remember during my first year of nursing the exact minute I realized that I was one person with two hands and that I could only be in one place at a time. Seems like an amazingly simple concept, right? Eight months into my first year of nursing was when I figured it out.

During coronavirus, you had to be in more than one place at a time because of how sick these patients were and how many you were responsible for at once.

It was exhausting, but in hindsight, I am surprised and proud of how hard the work was and that I could do it. Putting aside what makes a pandemic horrible, I learned a great deal about myself as a nurse. I would have never known that I could take care of that many sick people at once because that isn’t common practice in the hospital setting and I hope it is never the practice again.

Retaining my humanity was very important to me during this time. It would have been very easy to get washed away by the tide of how much needed to get done and forget that these patients are humans just like me. They could have been my parent, my sibling, my cousin, or my grandparent. While I would focus on the care, I would talk to my patients who are intubated and sedated because I believe wholeheartedly that they can hear me. I had times where I remember becoming awash with emotion because I was quickly reminded about the human in the bed in front of me. I was searching for a foley catheter on the other side of one of the units because I couldn’t find one on my side and I looked up and saw three of the functional nurses (nurses who didn’t take assignments that helped with tasks, in other words-angels) standing next to a dying patient. They were holding his hands as his blood pressure and heart rate dropped on a silenced monitor because they didn’t want him to be alone.

With no family allowed at the bedside, this happened all too often, but the patients were never alone because they had us. At that moment, I had almost forgotten what I was looking for as tears flooded my eyes. In the midst of the chaos, that was such a moment of love that I was honored to witness.

I met so many talented, amazing

nurses, providers, and medical professionals in my two months caring for adults. Much like the first day of school, I was nervous about what kind of reception I would get upon arriving in the Surgical ICU. As a pediatric nurse who tends to look on the positive side of practically everything, I figured I would stick out like a sore thumb, but the nurses were happy for the help and very welcoming. We were in the mud shoulder-deep together, so I was accepted. There were many travel nurses as well. So many of them came to New York because they said that they knew they had to come to help us. I remember being teary-eyed with one who gave me report after her last night shift and was headed to the airport after a shower. I tried to tell her that I was so grateful that she jumped out of her life to help these patients and how special that was.

I worked alongside teams of people out of their element, and everyone was professional and just wanted to do the best for the patients.

There were teams of people who came around with iPads and they would make sure to call families so they could see their loved ones at least once a day.

I was taking care of a man in his 60s who was on the verge of being extubated, so he was pretty awake. He had been intubated for weeks, much longer than the regular, pre-COVID intubation time. There was nothing really entertaining for him to watch so he would track me with his eyes all day and I would say to him, “You are doing great.

Keep taking those slow, deep breaths.”

He would nod to me. Since he was so awake, whenever the iPad team walked by, they would FaceTime his wife, and whenever he saw her and heard her voice, his eyes welled up and you could plainly see the recognition on his face.

She told him that he needed to get better so they could hold hands and watch movies. I think he was extubated the next day. The people on the iPad teams were amazing and I don’t envy the job that they were tasked with. They were just as invested in these patients as we were, if not more because they got to know their families. They were unsung heroes.

continued on page 24

pediatric nurse journal

SSUP Short Stay Unit/ Pediatrics Team Inspirational Work Board Northern Westchester Hospital Beatrice M. Kwasnaza BSN, RN SSUP As a member of the Holistic Committee at Northern Westchester Hospital, led by Susan Raskin MS, RN, AHN-BC, Manager of Integrative Medicine Program, I was motivated to find a way to inspire our fast-paced short stay unit, Pediatrics (SSUP). The SSUP is impacted daily by several departments, including the emergency department, PACU, and ASC. This unit can quickly start at full capacity of twenty patients and can discharge these same twenty patients, and within a 12 to 24-hour period, they can be back at a twenty patient census.

To say that the stress level at times on the unit is elevated is an understatement. Nonetheless, my colleagues are excellent caregivers and handle our unit’s speed and stress with grace and expertise. I am honored to be amongst this unit’s staff.

We are skillfully led by Carolyn Oates MSN, RN, Patient Care Manager, and Christine Odell BSN, RNC, CNML, Pediatric Coordinator.

On the journey to obtaining my BSN in September of 2019, I learned through my education that the best way to deliver quality patient-centered care was through the self-care of the caregiver. As part of the holistic committee’s effort to work on our nurses’ self-care and build on camaraderie, morale, and incorporate our patients, we came up with the idea of establishing a team/inspirational board on the SSUP unit. Every few months, we would put up some new ideas, whether it be inspirational quotes or motivational ideas. The board did not have to follow any formal pattern, and all staff ideas were welcome.

Some themes incorporated both staff and patient input. Thus, the SSUP Short Stay Unit/ Pediatrics Inspirational Work Board was born.

The Team/Inspirational Work Board has been uplifting to staff, patients, and visitors. Some boards had staff bring in pictures of their family members so that they could see their loved ones every day and share the people who bring them joy at home with their work family. Another board asked any staff member, patient, or guest to leave an inspirational thought (feather) for a patient, colleague, friend, or even oneself. The 2019 Holiday Board spread joy to the unit and loved ones alike by acknowledging the staff’s diversity as snowflakes. Each member appropriately named and recognized what greatness

can be accomplished when everyone works together. The gratitude board went up at the end of February and has been up throughout the COVID-19 pandemic. The goal was for the staff to show their gratitude. Its message was to offer ways to be grateful to one another. As we moved through the chaos of COVID-19, it evolved to staff placing notes of what they appreciative of throughout the pandemic, as we came out of the darkness back into the light.

It brings me great joy to share these powerful messages with my unit and to encourage self-care in any capacity amongst staff, patients, and family members. Words are very powerful. They can motivate people to greatness, which is what this team board accomplishes. It sparks dialogue and conversation and brings to light topics that need recognition.

When we gauge success in the nursing profession, it is not defined by how much theoretical knowledge a nurse retains, but how resilient they are to apply all they have learned, including self-caring principles.

Beatrice M. Kwasnaza BSN, RN, Clinical Nurse, SSUP, Northern Westchester Hospital

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Promoting Self-Care in an Uncertain World from page 19

of the Comprehensive Restoration Program has the most intensive interventions. These vital services are offered to ensure that the mental health needs of the interprofessional staff are addressed.

The combined training and services available within three programs comprise the full spectrum of the Cohen Children’s Medical Center Restoration Program. It is how CCMC is meeting the unique needs of its interprofessional staff member.

Marketing and Communication To assist staff in identifying these programs, we create a visual icon that would communicate the three categories of services now housed in one comprehensive program. We decided upon the sunflower. Our Restoration Program Sunflower icon is visible throughout the facility, included in our education materials and organization’s newsletters.

The yellow Sunflower Petals represented the variety of services and programs offered to REVIVE the staff member The green Sunflower Stem represents the training programs, services, and peer support groups focusing on building and sustaining staff RESILIENCE The red Flowerpot represents the mental health services available to anchor and RESTORE our caregiver heroes The next step was to communicate this new initiative to all members of our CCMC family. The message was rolled out at a CCMC department Teams Meeting on June 25, 2020. The department heads were then charged with the responsibility to

begin to cascade this message. We provided them with a Tool Kit that included program resources and tools from CCMC and additional resources available from the Corporate Northwell Health Programs. In addition to some meet and share marketing events held in our Atrium, we began to disseminate the message via the weekly CCMC Newsletter, the monthly CCMC Wellness Newsletter, and the weekly CCMC Employee Activity of the Week Bulletin.

A formal presentation was also offered to our CCMC Central Collaborative Care Council. However, as most people know, word of mouth is the best form of advertising. Our service providers and practitioners are relied upon heavily to chat up the program when the opportunity presents itself, and our concierge partners do an amazing job walking the staff through some of the program spaces and encouraging people to sign up for services. However, there is nothing like a satisfied, happy staff member encouraging their colleagues to participate

Stepping in to care for adult patients from page 22

After a while, some of the patients became well known to us all. A few of the patients had tracheostomies placed as well as feeding tubes so that they could heal without an endotracheal tube in their throat for months and months. There was an older woman with fancy nails who we all got to know well. At first, I remember taking care of her and honestly thinking she would not survive, but I got to see her sitting in the chair the day before she was transferred out of the ICU. A grandfather from Uruguay who we affectionately referred to as “Coco” since that is what his family calls him. He would smile whenever you called him that or whenever I subjected him to my unpracticed Spanish. He went to a rehabilitation facility. A rowdy woman who would shout at you as you walked by her curtained off area “Can you help me?” and then when you asked her what she needed; she wouldn’t tell you. She was transferred to the medical floor. There was a young man who would seem fine one minute and then try to get out of bed, or take off his face mask, the next minute. He was reintubated after I went back to

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continued on page 29

my job. Another man, my age, who was on ECMO, or extracorporeal membranous oxygenation, for several days, now has a trach and G-tube and a severe clotting issue. I took care of him several times. I wonder how he is doing.

I will also always remember the people who didn’t make it.

I will remember little things about each of them. One man, who I got to meet before he was reintubated, loved Whitney Houston and would hold my hand so tight. Even though I saw him deteriorate, I told him when I left that he needed to get better so we could dance to Whitney Houston again. He died four days later. Another woman, whom I referred to as Miss Mary because I couldn’t say her last name had such a kind son and daughter-in-law. I didn’t get to meet them, but I imagine that they could hear me chatting her ear off. The first patient that actually died on my watch was a man who we weren’t escalating care on. I said goodbye to him the day before because I didn’t think he would survive the night shift, but he was there when I returned. He died at noon. There was so much loss that is was continued on page 35

pediatric nurse journal

Empowering Families to Advocate for their Children in the PICU Mary Schafer MSN, RN, CCRN, PNP

Background: The ABCDEF bundle (Table 1, top right) is an initiative from the Society of Critical Care Medicine aimed to minimize the harmful effects of pain, agitation/sedation, delirium, immobility, and sleep disruption during the patient’s stay in the intensive care unit (ICU). The bundle’s overall goal is to empower the multi-professional team to improve patient and family outcomes through evidence-based care to reduce the risk of long-term consequences associated with an ICU stay.

Each letter of the ABCDEF bundle represents an area of focus when caring for critically ill patients. The A represents Assess, prevent and manage pain; B is for Both spontaneous awakening and spontaneous breathing; C is Choice of analgesic and sedation; D is for Delirium; E is for Early mobility, and F is for Family engagements. In this article, we will examine the adaption of Family Engagement and Empowerment. The Pediatric Intensive Care Unit (PICU) had previously incorporated families into care through family-centered rounding; however, there was an opportunity for improvement. A representative from the Family Advisory Council was recruited to assist with strategies to improve family engagement, empowerment, and support. Family input was elicited as to what interventions could improve the ICU experience. After several meetings and performing an evidence-based literature review, the decision was made to create a PICU brochure and a PICU Diary.

Evidence: Critical Illness can be overwhelming for patients and their families and can lead to adverse psychologic outcomes such as anxiety, acute stress disorder, posttraumatic stress, and depression.

This combination of complications has been entitled Post-intensive Care Syndrome- Family (PICS-F).

Family-centered care supports the presence of family in the ICU and their involvement in their child’s care. Family-centered care encourages timely and effective communication between ICU staff and can help manage the family’s stress associated with a critical illness. Studies have shown that family engagement plays a crucial role in reducing the long- and short-term consequences of an ICU stay (Davidson et al. 2017). Although we cannot change the demographic risk factors of PICS-F, we can change our culture to decrease the risk factors that increase the family’s potential for developing PICS-F. Research shows that family members of critically ill patients who talked about their feelings and had social support had lower anxiety levels. Parents, who perceive ICU staff communication as open, complete, and comforting had a positive experience. (Coats, 2018.)

The PICU had open visiting hours for primary caregivers and family-centered rounds that improved family satisfaction and increased family engagement. The ABCDEF team’s literature review revealed that education programs, support programs, and spiritual/integrative therapies helped reduce the family’s stress level. The ABCDEF workgroup decided to start by developing an

informative brochure called “Caring for you and your child in the Pediatric Intensive Care Unit.” A PICU diary was also created to help reduce the family’s anxiety, depression, and stress. This diary allows the family to track their child’s progress, especially when they needed to leave their child alone in the PICU. Initiative Details: Family-centered rounds have been part of our PICU culture for many years. The multi-professional ABCDEF Team decided to start with a PICU Brochure and a PICU Diary to enhance patient and family engagement, empowerment, and support. The brochure, once finalized by the workgroup, was brought to the Family Advisory Council and the marketing department. The final version was entitled Caring for you and your Child in The Pediatric ICU and includes: • PICU team composition and culture of support • Promotion of self-care of the caregivers • Resources for Family Support including information regarding our siblings club and Integrative Therapies • Guidance to the family on how to assist in their child’s recovery • Encouragement to participate in rounds, request family meetings, and state what matters to them.

• Encouragement to speak up for safety on essential aspects of care such as medication reconciliation, allergies, isolation precautions.

• Information on ICU strategies to improve neurocognitive and functional outcomes in critically ill patients utilizing the elements of the ABCDEF bundle and how parents can participate and advocate for their child The ICU Diary was created for families to have a place to keep track of their child’s care. The diary is a composition book divided into two sections, with the first section filled out by the parents.

The first page has open-ended questions, including “I like to be called,” “My normal bedtime is,” “My favorite food is,” “My favorite color is,” and “My favorite TV show/movie is.” On the second page of the diary, parents are asked to write any information about their child that they think may be helpful when they are not by the bedside. The next pages are for the interprofessional team to write updates, test results, questions, and answers to questions parents had previously asked. Parents are encouraged to personalize the diary to meet their specific needs.

continued on page 34

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cohen children’s medical center

Achieving Zero Harm

through Prevention of Peripheral IV Infiltration and Extravasation Lianna Mashkovich MSN, RN, CPNP-PC Introduction Cohen Children’s Medical Center (CCMC) admits over 11,000 pediatric patients annually. More than 90% require peripheral intravenous (PIV) access. PIV access can lead to complications that affect patient safety, increase patient length of stay, and decreases patient satisfaction. A common PIV complication, peripheral intravenous infiltration, and extravasations (PIVIEs) occur at a rate of 3.64 per 1,000 inpatient admission days. In January 2017, CCMC detected an increase in harm to patients due to PIVIEs. This discovery prompted a response in training healthcare providers who were knowledgeable in

identifying, categorizing, and treating PIVIEs. In April 2017, a Hospital-Acquired Condition (HAC) Team was assembled with the mission to mitigate complications and harm associated with PIVIEs. Solutions for Patient Safety (SPS) is a national organization of pediatric hospitals that share an objective to eliminate harm children experience during their hospitalization. SPS collects data, shares methods, and highlights interventions with negative and positive outcomes to find appropriate solutions for safety issues affecting pediatric patients. Working in conjunction with SPS, CCMC began adopting the best practices to identify, prevent, and treat the occurrence of PIVIEs. SPS has defined the categories of harm caused by injury due

The Impact of Nurse Fellowships from page 16

taking on independent care. CRNs do not have their own patient assignment. They mentor, coach, and supervise the fellow on the unit for six months. CRNs oversee assignments, workload, time management, prioritization, documentation, and skill development. Their primary function is to offer support, guidance, and feedback to assist the fellow in acclimating to their role. The fellow is evaluated using documentation that defines clinical practice expectations and is given feedback regarding these expectations. Utilizing weekly resource records, the fellow is provided feedback about progress, ongoing goals, and specific competencies. Evaluation of the fellows, by the CRN, incorporates ongoing discussion of the orientation goals, assistance with successful completion of nursing competencies, and consistent dialogue regarding the fellow’s process. This process fosters collaboration and teamwork, helping sustain the fellow as they evolve to independent practice.

Results: The PCCNFP yielded a 91% retention rate for those who completed the fellowship in the past three years. Prior to this initiative the retention rates was at 50.1%. This represented an overall 81.6% increase. Additionally, RN satisfaction and engagement scores remained in the top “Team Index 1” ranking for five years. These factors all contributed to positive patient outcomes evident by this PICU receiving the American Nurses Credentialing Center (ANCC) Silver Beacon Award for Excellence in 2017 and 2020.

Discussion: The implementation of a fellowship program in the PICU helps novice nurses transition to safe, independent practice. Understanding that most nursing recruits are new graduates, nurse leaders need to provide them with a formal, evidenced-based program. Additionally, most nursing students are not allowed to train in a PICU while in school. For many of our new nursing hires, this was their first time experiencing the PICU. Fellowship programs not only improve retention rates but posi-

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tively impact nurse satisfaction and engagement in their practice area. They foster a successful transition into independent practice by increasing the competence and confidence of a novice nurse. Further studies are required to determine long-term retention rates for graduate nurses completing a nurse fellowship program and determine their impact on patient outcomes.

References Benner, P. (1981) From novice to expert. The American Journal of Nursing, 82(3), 402-407.

Bradley, V. (2017). The effect of a new graduate registered nurse residency program on retention. Nursing Theses and Capstone Projects.

Garrison, F. W., Dearmon, V., & Graves, R. J. (2017, March). Working smarter: Building a better nurse residency program. Nursing Management, 50-54.

Van Camp, J. & Chappy, S. (2017). The effectiveness of nurse residency programs on retention: A systematic review. The Association of periOperative Registered Nurses, 106, 128-144.

Maria Marchelos MSN, RN, CCRN-K, NEA-BC Nurse Manager, PICU CohenChildren’s Medical Center

Kathleen Schmidt MS, RN, PNP, CCRN Nurse Educator Cohen Children’s Medical Center

pediatric nurse journal

to a PIVIE as mild, moderate, and serious.

Serious (Severe) Harm includes, for example, PIVIE requiring fasciotomy or with deep partial thickness. Moderate PIVIEs include those with partial-thickness burns and those with between thirty to sixty percent swelling. Mild harm consists of swelling of less than thirty percent.

In response to increased harm from PIVIE, SPS has developed a prevention bundle, a set of guidelines that have shown to mitigate harm. Some of these bundle components include, assessing PIVs every sixty minutes and measuring the infiltrate for the percentage of swelling. The assessment consists of touching, looking, and comparing the limb. The PIV site is compared to the opposite limb to determine if there is swelling. Measuring the PIVIE included measure the length of the limb that the PIV is placed, and the longest portion of swelling of the PIVIE and calculating a percentage. Education to families is the last piece of the bundle and included educating families to touch, look, and call if they think there is something wrong with the PIV. In January 2018, the PIVIE HAC team at CCMC conducted a literature review to find a treatment that could reduce the severity of the injury caused by PIVIEs. In the review, it was noted that hyaluronidase had multiple purposes in the patient care setting. Hyaluronidase can be used for subcutaneous rehydration therapy when it is difficult to obtain a peripheral IV. It was also noted that when injected subcutaneously around an infiltration area, hyaluronidase helped facilitate the reabsorption of fluid into the capillary bed from the surrounding tissue. It can be used as an antidote for infiltrates of IV fluids and a wide variety of IV medications. This helps decrease tissue damage and reduces the risk of tissue necrosis. It was concluded that hyaluronidase would be used as the first-line treatment of PIVIEs and continues to be the most common antidote used at CCMC for infiltrations.

Starting in February 2018, the PIVIE HAC co-chairs trained the PIVIE HAC champions in hyaluronidase administration for PIVIEs. In turn, the PIVIE HAC champions trained nurses and providers on the inpatient units of CCMC in hyaluronidase administration. Hyaluronidase’s adoption for the treatment of moderate and serious infiltrates has decreased the rate of morbidity, length of stay, and need for invasive interventions.

Methods To ensure guidelines and methods were being followed, the PIVIE HAC team created a “Post PIVIE Data Collection Tool.”

Nurses and providers have been instructed to utilize the tool to document the incidence of PIVIEs. The data collected by the tool is analyzed in several ways.

The data collected by the tool is • Used to monitor the efficacy of the HAC’s efforts to mitigate the occurrence of moderate and severe PIVIEs • Submitted to SPS for national analysis and tracking • Provide training and feedback to nurses and providers when the PIV Prevention Bundles and treatment are not followed properly In addition, PIVIE HAC champions conduct real-time audits of PIV assessment documentation, inspection of PIV insertion site, and family education. These audits identify the need for re-training the staff to follow the SPS PIV Prevention Bundle guidelines.

Results Since the PIV Prevention Bundle implementation, there has been a significant reduction in Moderate and Serious PIVIE Harm. CCMC’s Moderate infiltrates centerline has decreased below the national average as reported by SPS (Figure 1, above).

CCMC has dropped the centerline of the average number of Moderate infiltrates from 2.4 per 1,000 patient days in 2018 to 1.351 per 1,000 patient days in 2019. The national average of Moderate infiltrates per SPS statistics is 1.889 per 1,000 patient days.

The serious infiltrates centerline has decreased below the national average, as reported by SPS (Figure 2, below). The centerline of the average number of Serious infiltrates also decreased from 0.6 per 1,000 patient days in 2018 to 0.193 per 1,000 patient days in 2019. The national average of Serious infiltrates per SPS statistics is 0.428 per 1,000 patient days.

Discussion The PIVIE HAC has been instrumental in the efforts to achieve SPS’s objective of zero harm. The PIVIE HAC has successfully educated nurses and providers in properly assessing PIVs, identifying infiltrates early, and providing timely and appropriate interventions, including hyaluronidase administration.

These interventions have decreased the number of Moderate and Serious harm that patients sustain, improving patient safety and patient satisfaction. continued on page 30

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cohen children’s medical center

Community Flowers are Blooming

from page 7

Outcomes The St. Agnes Healthcare Club has been running successfully for three years, and the outcomes for promoting nursing to a new generation are promising. The first year the club was introduced saw a very enthusiastic group of juniors and seniors who had a significant interest in following either nursing or an alternative healthcare tract. The entire first cohort of students entered college in either a nursing or an undergraduate medical program. The second-year saw a younger cohort of students, mostly in the 10th grade, interested in nursing, or were curious about the program. Many of these participants are still in High School and have not applied to college thus far. In time we will see how effective the program was in solidifying their STEM connection. A good indication of these second-year cohort girls’ continued interest is that some have come back during the third year to act as facilitators. Unfortunately, with the Covid-19 outbreak and closure of in-person teaching, the third cohort of students could not finish the program. However, the first half of the year successfully reflected a high attendance record and enthusiastic participation.

Conclusion As a STEM education leader, it is important that the students are excited about what they are learning. Through this program, students learn that nursing is much more than a job.

They learn that it is a lifestyle that is conveyed by what nurses do as professionals, as community leaders, as educators, and as mentors. Hopefully, through the STEM connection, they will be inspired to become the nurses of the future.

References American Nurse Association. (2020). Healthy Nurse Healthy Challenge. HNHN | home. https://www.healthynursehealthynation.org/ American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. ANA. https://www.nursingworld. org/coe-view-only Kelley, T. R., & Knowles, J. G. (2016). A conceptual framework for integrated STEM education. International Journal of

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STEM Education, 3(1), 1-11. https://doi.org/10.1186/s40594016-0046-z Northwell Health. (2014). SPARK Challenge. https://vportal. northwell.edu/cvpn/aHR0cHM6Ly9pbnRyYW5ldC5ub3J0aHdlbGwuZWR1/employees/PulseDocuments/Spark%20 Calendar%20of%20Events.pdf. https://vportal.northwell.edu/ cvpn/aHR0cHM6Ly9pbnRyYW5ldC5ub3J0aHdlbGwuZWR1/ employees/PulseDocuments/Spark%20Calendar%20of%20 Events.pdf Shirazi, F., & Heidari, S. (2019). The relationship between critical thinking skills and learning styles and academic achievement of nursing students. Journal of Nursing Research, 27(4), e38. https://doi.org/10.1097/ jnr.0000000000000307 St. Agnes Academic High School. (n.d.). Science, technology, engineering, and math. https://www.stagneshs.org/apps/ news/show_news.jsp?REC_ID=416593&id=1 Van den Hurk, A., Meelissen, M., & Van Langen, A. (2018).

Interventions in education to prevent STEM pipeline leakage. International Journal of Science Education, 41(2), 150164. https://doi.org/10.1080/09500693.2018.1540897 Yvonne Hernandez MSN, RN, CPEN, Clinical Nurse, Pediatric Emergency Department, Cohen Children’s Medical Center

pediatric nurse journal

Promoting Self-Care in an Uncertain World

from page 24

in these programs.

Funding and Support of the Initiative While all our providers and practitioners are on staff, there is limited funding available for these programs, which poses an ever-present challenge to our executive team to find creative solutions to support these programs and events. We rely heavily on the generous donations from the community and any available grant funding. We were recently awarded a $1000 grant from the Beryl Institute. These welcomed funds will go toward purchasing a second electronic massage chair for our Recharge Room, which will be available to all in early 2021.

Discussion The personality trait of hardiness has been found to buffer or lessen the negative effects of stressful events or adversity (Liu, 2019). Leaders must fully appreciate and analyze how the heroic response to COVID-19, mounted by our interprofessional teams, changed everything. Each healthcare organization is challenged today (post-COVID) with creating a healthy work environment for all to work and practice. Each organization must accept the challenge of creating a culture in which staff can actively engage in self-care and mental health activities as openly as they have been encouraged to participate in ongoing professional development programs.

As Dr. Jean Watson, PhD, RN, teaches in her nursing theories, we must show ourselves the same loving-kindness as we do our patients and families. We must place ourselves (the caregivers) at the center of the model of care and “Minister to our Basic Physical, Emotional, and Spiritual Human Needs” if we are to “Co-Create a Healing Environment for the Physical Self which Respects Human Dignity.”

References and Resources American Association of Critical Care Nurses. AACN Standards for standards for establishing and sustain a healthy work environment; a journey to excellence 2nd edition. 2016: www.aacn.org Bailey, K., Madden, A. Research Article, What makes work meaningful or meaningless. MIT Sloan Management Review.

2016: Summer: 52-61.

Bernhard, T. Self-care in an uncertain world. Tricycle.

2020: 30 (1) 36-37.

Bogue, R., Carter, K. A model for advancing nursing well-being: future directions for nurse leaders. Nurse Leader.

2019: (17): 526-529.

Centre for Confidence and Wellbeing http://positivepsychology.org.uk/centre-for-confidence-and-well-being/ Craig. H. Resilience in the workplace: how to be more resilient at work. (2020). An online article found on the world wide web. https://positivepsychology.com/resilience-in-the-workplace/ Kennedy, K., Campis, S., Leclerc, L. Human-Centered leadership: creating change from the inside out. Nurse Leader.

2020: 8 (3): 227-236.

Kobayashi, M. Nurse leader rounding: a view from the

front. VOICE of Nursing Leadership.2020: 18 (4): 20-21.

KPGM. COVID-19 and the American worker. (2019) An online article found on the world wide web. https://advisory. kpmg.us/articles/2020/covid-american-worker.html?utm_ source=google&utm_medium=cpc&mid=m-00003181&utm_ campaign=c-00088586&cid=c-00088586&gclid=Cj0KCQjwtZH7BRDzARIsAGjbK2b3el6pi20t9OxlG-j8ESHdCFCPdb1mRnb3z4q9gsXSriqD-m6CbOEaAhgiEALw_wcB&gclsrc=aw.ds Liu, A. Making Joy a Priority at Work. Harvard Business Review. (2019). An online article found on the world wide web. https://hbr.org/2019/07/making-joy-a-priority-atwork?utm_campaign=hbr&utm_source=linkedin&utm_medium=social Repenning, N., Kieffer, D., Astor, T. The most underrated management skill. MIT Sloan Management Review. 2019: 58 (3): 39-48.

Richardson, J., Ingoglia, C. Building Organizational Resilience in the Face of Covid-19. The National Council for Behavioral Health. An online article found on the world wide web. file:///C:/Users/Phyllis/Downloads/Building_Organizational_Resilience_in_the_Face_of_COVID-19.pdf Steinbinder, A., Sisneros, D. Achieving uncommon results through caring leadership. 2020: 18 (3):243-247.

The Watson Caring Science Institute. https://www.watsoncaringscience.org/

Phyllis S. Quinlan PhD, RN, NPD-BC Program Manager for Clinical Transformation, Internal Coach, Administration Cohen Children’s Medical Center

Sofia Agoritsas MPA, FACHE Associate Executive Director Hospital Operations Cohen Children’s Medical Center.

Cari Quinn RN, MSN, NEA-BC Executive Director Cohen Children’s Medical Center

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Achieving Zero Harm

from page 27

Next Steps The PIVIE HAC will continue educating champions, staff nurses, and providers on the PIV Prevention Bundle, proper assessment and interventions when PIVIEs occur, and proper administration of hyaluronidase. In collaborating with the Pediatric Pharmacy, the creation of a new hyaluronidase order-set is in development. The team has also put together an interactive virtual learning module to standardize training and communication throughout the Northwell Health Pediatric Service Line.

References Children’s Hospitals Working Together to Eliminate Harm. (n.d.). Retrieved August 19, 2020, from https://www.solutionsforpatientsafety.org/ Lexicomp Online, Pediatric, and Neonatal Lexi-Drugs Online, Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Retrieved from http://online.lexi.com/lco/action/home Odom, B., Lowe, L. & Yates, C. (2018). Peripheral infiltration and extravasation injury methodology. Journal of Infusion Nursing, 41(4), 247-252.

Taylor, J.T. (2014). Implementing an evidence-based practice project in the prevention of peripheral intravenous site infiltrations in children. Journal of Infusion Nursing, 38(6), 430-435.

Lianna Mashkovich Treadwell, T. (2012). The management of intravenous infiltraMSN, RN, CPNP-PC tion injuries in infants and children. Ostomy Wound ManageClinical Nurse ment, 58(7), 40-44.

Cohen Children’s Wilt Major, T., & Huey, T.K. (2016). Decreasing iv infiltrates Medical Center in the pediatric patient – system-based improvement project.

Pediatric Nursing, 42(1), 14-20.

Changing the culture in the Pediatric ASU Our future goal is to expand this initiative and place PIVs on all patients above 10-years-old or greater than 40 kg. We will continue to work with the anesthesiologists to ensure that we are placing appropriate gauge PIVs in preferable anatomical locations.

Acknowledgments: We would like to express our appreciation to all of the people who were instrumental in making this initiative a success; most importantly, we would like to thank the PASU nurses; this project would not have been possible without your enthusiasm and willingness to participate.

Special thanks to the Anesthesiologists for educating and encouraging this change, especially to Michelle Kars, MD, who was the inspiration behind this initiative and always an excellent resource for us. Also, to Alison Beach, MSN, RN, from nursing professional development for assisting with educating the PASU staff for PIV competencies.

Additional appreciation to Ann Shea, MSN, RN, for facilitating and supporting this project.

References Nisbet, G., Lincoln, M., & Dunn, S. (2013). Informal inter-professional learning: an untapped opportunity for learning and change within the workplace. Journal of Interprofessional Care, 27(6), 469–475. doi:10.3109/13561820.2013.805735z.

Johansson, C., Åström, S., Kauffeldt, A., Helldin, L., & Carlström, E. (2014). Culture as a predictor of resistance to change: a study of competing values in a psychiatric nursing context.

Health Policy, 114(2-3), 156-162. doi: 10.1016/j.healthpol.2013.07.014

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from page 28

Carol Creeron BSN, CPN, Clinical Nurse, PACU, Cohen Children’s Medical Center

Haley Holcman BSN, CCRN, Clinical Nurse, PASU, Cohen Children’s Medical Center

Fran Weingartner BSN, RN, Assistant Nurse Manager, PASU Cohen Children’s Medical Center

Melissa Duffy MSN, CPNP-PC, Pediatric Nurse Practitioner, PST Cohen Children’s Medical Center

Artwork by Tasfia Suha, New Hyde Park High School donated as part of a school project for healthcare workers.

Adult patients were not as different as once assumed from page 5

confused was up in the air. I bent down to be at her level and smiled, wearing my mask, of course. The most unbelievable thing happened - she smiled back, without seeing my mouth smile. When the elevator door opened, I waved her goodbye. I went to the ladies room and stood in front of the mirror, smiling with my mask on; whether it’s my scrunching cheeks or my eyes, my face smiled, despite wearing a mask. The way she looked at me, maybe for that tiny moment in time, I was her hero. She may have been frightened initially, but we shared a smile, and her expression was no longer questionable; she looked happy. What I am learning every day is that we are all heroes. Every single employee in our facility was a hero for walking into this building during the pandemic. Being a hero does not mean that extraordinary measures have to be taken.

Being a hero could be as simple as helping a lost visitor in the hallway or making a frightened girl smile. For that moment in time, they needed help, and you were there and potentially their hero for that moment. We were all nervous and scared to leave our families. We were so worried to spread the virus to our loved ones. Homeschooling our children was challenging, and we have no idea what will happen in the next six months. What we do know is that we have each other, and once you enter this building, we are all surrounded by heroes, brave, and courageous healthcare heroes.

As you get dressed and put on your badges day in and day out, remember you have the potential to be someone’s hero today, and you already are to your coworkers, simply by showing up. I am so thankful for all of my coworkers. I felt such support in the adult hospital when I saw multiple nurse educators and even my Chief Nursing Officer from Cohen’s. This bought a smile to my face on some of the most difficult days. The comradery and teamwork I felt was extraordinary. I do not look forward to another pandemic, but if it happens to come back, I am confident that we are ready and all willing to fight again.

I also want to thank all of the LIJ staff that supported me and believed in my skills, especially Kevin Cunningham and Garry Ritter.

Renata Schillizzi MSN, FNP-BC, CCRN, Family Nurse Practitioner, PST Cohen Children’s Medical Center

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Quiet at Night: Bringing Down the Noise from page 9

setting had proven effective in decreasing noise and improving patient experience related to a restful night (Boehm, H., & Morast, S. 2009).

Quiet time on the unit was initiated with an overhead announcement to the entire unit. The team collaborated with the Unit Receptionists (UR) to implement these changes by creating a script (figure 1). The script prepared the patients and families for “Quite Time” in the evening before the overhead announcement. The development and incorporation of the UR script was a unique component to the interventions. Unit receptionists were a part of the team developing the script, and all URs received education on the script before implementation. The script allowed for standardization throughout the unit. This consistency of information to all families was reported to be helpful, especially when in a shared room. Also noted to be beneficial was alerting families ahead of time to ensure that the message was clear, understood, and received well. The Unit receptionist also offers amenities at the time of delivering the script. These amenities include, eye masks, headphones, and the option of white noise/ soothing sounds on the patient’s TV in the room. These helped relieve some of the common issues raised in the patient survey, such as using headphones to prevent hearing the noise from a roommate’s TV and eye masks when lights are used at night to perform patient assessments.

As part of the admission process, parents are alerted that if they are admitted into a shared room that does not currently have a roommate, there is a possibility of an admission coming in during the night. The parent is asked if they wanted to be woken up at night if a patient is admitted into the room. The nurse admitting a new patient in the middle of the night to a shared room uses a quiet voice when speaking and encourages the patient and parent to do the same. Quiet time is discussed upon admission and is an ongoing conversation throughout the stay.

Cell phone use and TV volume are monitored by the staff and they gently remind families to be courteous of their roommates.

Since staff conversations outside the room was also an area needing improvement, according to the HCAPS scores, all staff members were made to feel empowered to alert others when the noise level became too loud. As a quiet way to alert staff to decrease the noise level, the lights are turned on and off to make everyone aware that it was getting too loud. Conversations outside and inside the patient’s rooms were minimized during the nursing handoff at the shift change.

Lastly, since it was previously notFigure 1

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ed that the housekeeping staff cleaning the floors at 6 am caused a significant spike in noise level during the designated quite time, through interprofessional collaboration, the team was able to change the time of the Zamboni cleaning to after 7:30 am.

Cleaning the floors later prevented a disruption within the quiet time hours.

Results Pre-data noted that 37% of patients reported on the HCAHPS survey that the noise around their child’s room was quiet at night, and they were able to have a restful night of sleep.

Post-implementation during the 1Q19 Press Ganey survey question regarding the patient’s room’s perceived noise level at night increased to 52%, representing a 36% overall improvement.

2Q19 and 3Q19 showed sustained improvement at 50% and 49% respectfully.

The staff also noticed a change in Med 3 since Quiet at Night was implemented. One Nursing Assistant said he noticed a decrease in direct patient complaints when it came to noise at night.

pediatric nurse journal

Next Steps As a result of the Quiet at Night program’s success on the Med 3 unit, next steps include expanding the project to the additional units of this hospital. To maintain sustainability, Quiet at Night monthly meetings have continued. These meetings now include representatives from the additional units to provide support and guidance as they implement the new process on to their units. Lastly, periodic spot checks performed with the mechanical ear to evaluate the noise level are planned to aid in the continued awareness and success of this initiative.

Conclusion Sleep within the hospital setting is vital for the promotion of healing and wellness. This can prevent additional complications and prevent the increased length of stay for patients and families. This initiative’s impact is far-reaching in the improvements for patients, families, and the overall health of the staff.

References Boehm, H., & Morast, S. (2009). Quiet time. AJN The American Journal of Nursing, 109(11), 29-32.

Choiniere, D. B. (2010). The effects of hospital noise. Nursing administration quarterly, 34(4), 327-333.

Joseph, A., & Ulrich, R. (2007). Sound control for improved outcomes in healthcare settings—the Center for Health Design, 4, 2007.

Yarar, O., Temizsoy, E., & Günay, O. (2019). Noise pollution level in a pediatric hospital. International Journal of Environmental Science and Technology, 16(9), 5107-5112.

One Less Stick from page 11

appropriately and frequently. Unfortunately, there is currently only one microtube that can be processed by the automated machine, and this tube cannot run every type of blood test.

We are hopeful that additional tubes will be produced that will allow many other tests to be processed in the same efficient manner.

References Maybohm, P., Richards, T., Isbister, J., Hofmann, A., Shander, A…Zacharowski, K. (2017). Patient blood management bundles facilitate implementation. Transfusion Medicine Reviews, 31, 62-71.

Steffen, K., Doctor, A., Hoerr, J., Gill, J., Markham, C… Spinella, P.C. (2017). Controlling phlebotomy volume diminishes PICU transfusion: Implementation process and impact.

Pediatrics, 140(2), e1-e9.

World Health Organization. (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0005/268790/ WHO-guidelines-on-drawing-blood-best-practices-in-phlebotomy-Eng.pdf?ua-1

Tania Wang BSN, RN, CPN Assistant Nurse Manager, Med. 3 Cohen Children Medical Center

Noelia MaGowan MSN, RN, CPNP, Nurse Educator Cohen Children’s Medical Center

Laura Dunac MSN, RN, CPN Clinical Nurse, Med 3 Cohen Children’s Medical Center

Geraldine Shikora CLT, MS Ed., Educator Clinical Lab Long Island Jewish Medical Center

Camille Cipriano BSN, RN, CPN Assistant Nurse Manager, Med 3 Cohen Children’s Medical Center

Zack Shapiro, RN-BC Assistant Nurse Manager Peds Emergency Department Cohen Children’s Medical Center

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Empowering Families to Advocate from page 25

Outcomes: Pre-implementation data collected over three months showed the patient experience Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for overall Nursing communication domain at 90.7% and post-implementation over three months at 94.4%, representing a 4.4% increase.

Next Steps: First, the ABCDEF workgroup needs to find a reliable process for replicating and distributing the brochures and diaries in the PICU. The brochure is also being translated into Spanish to meet the needs of more patients and a survey is being developed to capture the impact on family participation in care, rounds, requesting family meetings, and advocating for patient safety.

of Implementing Family-Centered Care in Pediatric Intensive Care Units. Am J Crit Care 2018; 27(1): 52-58.

Davidson et al. Family response to critical Illness: Post-Intensive Care Syndrome-family. Crit Care Med 2012.

Davidson et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med 2017; 45: 103-128. https://www.sccm.org/ICUliberaton Mary Schafer MSN, RN, CCRN, PNP Clinical Nurses, PICU Cohen Children’s Medical Center

References: Coats H. Nurses Reflections on the Benefits and Challenges

Improving Outcomes For Children with Asthma from page 15

The success of Project BREATHE has been a multidisciplinary approach to asthma education. The addition of home care visits has shown to increase the adherence to the medication regimen, improve patient’s asthma control, and decrease readmissions and ED visits. To continue to build on the success of Project BREATHE going forward, we would like to maintain readmissions and ER visits at less than 10% for those who accepted a homecare visit. Also, we aim to incorporate additional follow-ups at three months and six months.

Conclusion Overall, homecare visits, combined with inpatient asthma education, provide a unique opportunity to empower the patient and family to manage asthma. The one-on-one instruction within the family’s own environment allows for a true partnership and personalized care. This leads to fewer asthma exacerbations and has the potential to break the cycle of recurrent hospital and emergency room visits across a child’s lifespan.

References Anderson, M. E., Zajac, L., Thanik, E., & Galvez, M. (2020). Home visits for pediatric asthma-A strategy for comprehensive asthma management through prevention and reduction of environmental asthma triggers in the home. Current Problems in Pediatric and Adolescent Health Care, 100753.

Bhaumik, U., Sommer, S. J., Giller-Leinwohl, J., Norris, K., Tsopelas, L., Nethersole, S., & Woods, E. R. (2017). Boston children’s hospital community asthma initiative: Five-year cost analyses of a home visiting program. Journal of Asthma, 54(2), 134-142.

Bracken, M., Fleming, L., Hall, P., Van Stiphout, N., Bossley, C., Biggart, E., ... & Bush, A. (2009). The importance of nurse-led home visits in the assessment of children with problematic asthma. Archives of disease in childhood, 94(10),

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780-784.

Campbell, J. D., Brooks, M., Hosokawa, P., Robinson, J., Song, L., & Krieger, J. (2015). Community health worker home visits for Medicaid-enrolled children with asthma: effects on asthma outcomes and costs. American Journal of Public Health, 105(11), 2366-2372.

Fernandes, J. C., Biskupiak, W. W., Brokaw, S. M., Carpenedo, D., Loveland, K. M., Tysk, S., & Vogl, S. (2019).

Outcomes of the Montana Asthma Home Visiting Program: A home-based asthma education program. Journal of Asthma, 56(1), 104-110.

Marshall, E. T., Guo, J., Flood, E., Sandel, M. T., Sadof, M. D., & Zotter, J. M. (2020). Peer Reviewed: Home Visits for Children with Asthma Reduce Medicaid Costs. Preventing Chronic Disease, 17.

National Center for Health Services Research. (2011).

Health, United States. US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics.

Shari Bernstein MSN, RN, AE-C, Asthma Educator, Cohen Children’s Medical Center

Judith Jeanty MSN, RN, AE-C, Asthma Educator, Cohen Children’s Medical Center

pediatric nurse journal

Stepping in... from page 24

disheartening and it made you start to wonder if we were going to save any of them. I had to consistently remind myself and others that the majority of persons with a positive COVID swab didn’t end up in the ICU, but it was hard to remember.

Going over to the adult side in the middle of a pandemic wasn’t something I ever thought I would experience. There were beautiful and horrifying moments. Every day, I went home and would decontaminate as best I could. Clean my shoes, badge, bag, face shield, pens. The next step would be a sizzling hot shower. Decompression was always very important to me post-shift, which could mean an array of activities including yoga, cooking, watching Schitt’s Creek over and over again, or even just laying directly in bed.

One night I called an emergency Zoom meeting with my girlfriends because I had missed contact with people who weren’t in the hospital. Days off were also very important.

I did pick up extra shifts, but I had learned fast that I needed my days off. My mother and I started a tradition of doing a FaceTime workout on my off days at 2 pm. It was a way to stay in contact, and it was important for my sanity.

This time in my life will never be forgotten. It was a time when not only my skill as a nurse was tested, but my humanism and resilience were tested as well. A quote that I love from poet and samurai Mizuta Masahide goes like this, “My barn having burned down, I can now see the moon.” I find this incredibly fitting when reflecting on the two months I spent in the adult COVID ICUs. A great percentage of my memories are of a very scary, uncertain time, but if I look very closely, I can see the smallest of a silver lining.

Maryann L. Peterson BSN, RN, CPN, C-NPT Clinical Nurse Pediatric Transport Team Cohen Children’s Medical Center

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