2009 Projects
Protecting Fragile Skin: Nursing Interventions to Decrease Pressure
Ulcer Development in the Pediatric Intensive Care Unit
The incidence of pressure ulcer development in
the pediatric population is 18%- 27%. Pressure ulcer development
in the pediatric population has been associated with increased health
care costs, increased length of stay, and increased morbidity1.
The estimated cost of managing a single full-thickness pressure ulcer is
as high as $70,000: and the total cost for treatment of pressure ulcers
in the United States is estimated at $11 billion per year. The
purpose of this project was to identify the incidence of pressure ulcers
in critically ill children, describe at-risk populations, and to
identify the prevention strategies associated with less frequent
pressure ulcer development. We found skin integrity incidence rate
of greater than 10% in PICU patients. We identified basic nursing
interventions associated with a lower incidence of pressure
ulcers.
- Published Article: Schindler C., Mikhailov T., Fischer K.,
Lukasiewicz G., Kuhn E., Duncan L. Skin integrity in critically ill and
injured children. American Journal of Critical Care, 16 (6),
568-574.
- Poster presented, March 2009, at NACHRI Creating Connections
Conference
- Manuscript submitted to American Journal of Critical Care,
July 2009, Protecting Fragile Skin: Nursing Interventions to
Decrease Pressure Ulcer Development in the Pediatric Intensive Care
Unit
Skin
Integrity Updates
Skin Integrity Documents
Prevalence and Incidence of Venous Thromboembolic Events in PICU
Patients
Venous thrombotic events (VTE) are recognized as a significant cause
of morbidity in critically ill children, with a reported incidence as
high as 36% in some patient populations. This prospective, multisite,
descriptive study was undertaken to determine the prevalence and
incidence of clinically relevant thrombotic events in PICU
patients. In our study the incidence of VTE was 0.77% and no
geographic region or specific site reported a notably higher or lower
incidence. In patients with documented VTE the average length of stay
was longer (31.43 vs. 4.79 days) and the average PIM2 (Pediatric Index
of Mortality 2) was higher (0.084 vs. 0.031) in the VTE patients
compared to the overall PICU population.
DVT-Thrombosis In Children Documents
Reduce PICU Discharge Delays
Excessive discharge delays, due to issues within the PICU or systemic
issues outside the PICU have challenged PICUs across the country. PICU
is one of the costliest levels of inpatient care with delays in
discharge increasing PICU LOS and therefore cost. This project
identified benchmark institutions, practices that impacted low discharge
delay rates and developed a tool kit of those practices. Utilizing this
tool kit, one site has been able to decrease their discharge delay rate
by nearly 2hrs or 22% (from average rate of 8.54 hrs in 4th qt 2006 to
6.68hrs in 3rd qtr 2008) and continue to work toward a goal of discharge
delay rate of < 4hrs. The goal of this group is to see if the
same impact can be achieved if these practices are implemented in
multiple institutions.
- Initial work of this group presented at NACHRI Annual meeting
2007
- Poster presented, March 2009, at NACHRI Creating Connections
Conference and won top poster in their class
Discharge
Delay Documents
Ventilator Associated Pneumonia Registry (VAPoR)
This is a multi-institutional observational study to define the
incidence of pediatric ventilator associated pneumonia (VAP) in the PICU
utilizing the CDC clinically defined pneumonia (PNU1) definition of
VAP. The goal is to formalize a process of VAP detection and data
collection to facilitate further multi-institutional research regarding
pediatric VAP using a consistent, reliable definition. The
expectation is that there will be variance in VAP rates with this
prospective surveillance compared to the usual retrospective
method. Interim analysis from 12 of 16 sites shows a VAP rate of
8.9/1000 ventilator days(current reported PICU rates
2.5-12/1000ventilator days) and association of VAP with several
collected variables. Data collection is near completion with
complete analysis by early 2010.
Abstract accepted for oral presentation at AAP, Critical Care Division,
October 2009.
VAPoR
Documents
Unplanned Extubation Phase II
Maintaining a critical airway is of utmost importance in pediatric
patients. This multi-institutional analysis of factors associated
with unplanned extubations in the PICU will describe factors most
commonly associated with unplanned extubation events including; patient
management practices; identify clinical staffing practices; and identify
additional care needs associated with an unplanned extubation event.
Unplanned
Extubation Roster
Unplanned Extubation Subgroup Interviews
Do Rapid Response Teams Make a Difference?
Implementation of Rapid Response Teams in adult hospitals has been
shown to reduce non-ICU cardiac arrests 26% to 50%, mortality 24%-37%
and unplanned ICU transfers 7%-30%. Similar studies for pediatrics exist
in the literature only for single centers. In addition to the
publication of a multi-institutional pediatric study, this project will
explore the most successful models of RRT’s among the participants
in order to establish best performance guidelines for pediatric
RRT’s.
Rapid
Response Teams Documents
Does Nurse Staffing Affect Patient Outcomes?
An increase of one RN FTE per patient day in adult ICU’s has
been associated with a 30% decrease in the risk of hospital acquired
pneumonia, and a 51% decrease in unplanned extubations. Estimates of the
cost of adverse events to healthcare were as high as $8.8 billon in
2007, and hospitals are already facing cuts in Medicaid payments related
to nosocomial events. This pilot study, the first in a series, compares
nurse sensitive outcomes to determine whether favorable outcomes are
related to acuity-based staffing in pediatric ICU’s.
Nurse
Staffing Documents
Nurse Practitioner Programs in the PICU
Utilization of nurse practitioners in acute care areas results in
$1-2.4 million in cost savings as a result of decreases in ventilator
days, length of stay and mortality. In addition, nurse practitioners
provide a cost-effective solution to gaps in provider coverage as well
as promoting excellence in nursing. This survey details the
characteristics of nurse practitioner programs across the country from
the perspective of both the NP’s themselves and the medical
directors who run them.
-
Poster presented at Creating Connections 2009
-
Manuscript in progress for submission to JAMA by November,
2009.
Nurse
Practitioner Documents
Compression Project
Although full cardiopulmonary arrest is a rare event in children,
previous studies have reported survival rates in children ranging from 9
to 47%. This is a multi-institutional retrospective study to delineate
survival for pediatric code resuscitation based on duration of chest
compressions for the initial resuscitation event requiring compressions
longer than 1 minute. The pilot data collected at Children’s
Hospital of Wisconsin showed a statistical difference in survival after
receiving 10 minutes of compressions regardless of all events.
Compression Project
Documents
Compression
Project
Compression
Tracking
End of Life Care
This is a multi-institutional bi-lingual qualitative study that will
explore the various experiences and perceptions of parents regarding end
of life care in pediatric critical care units. The second purpose
is to compare their experiences and perceptions with previously
determined key end of life care (EOLC) domains and quality indicators
for pediatric critical care.
End of Life Care Documents
Nutrition & Outcomes in PICU
The influence that undernutrition has on mortality and morbidity of
children admitted to hospital, and in particular, to the PICU is
unknown. This project will examine if early enteral/parental nutrition
administered within 48 or 72 hours of admission leads to better PICU
outcomes such as mortality, LOS, duration of mechanical ventilation and
complications.
Poster presented, March 2009, at NACHRI Creating Connections
Conference.
Nutrition
& Outcomes Documents
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Champions for Children’s Health
