Best of ONS Abstracts: Successful Training to Impact Care

1. Using a Pediatric Radiation Therapy Training 2. A Successful Multifocal Team-Based Initiative to Pre- Program to Avoid the Use of Anesthesia in Pediatric vent CLABSI: Outcomes From the Engagement of Nurses, Patients ages 3-12 Years Nursing Assistants, Patients, Families, and Physicians Danielle Crump RN, BSN, OCN Jordan Oliver RN, BSN, OCN Nurse Clinician III/RN, BSN, OCN Assistant Nurse Manager Johns Hopkins Hospital UCI medical Center [email protected] [email protected]

Oncology Nursing Society 42nd Annual Congress Clinical Practice May 4–7, 2017 • Denver, CO 1 ONS 42nd Annual Congress

Using a Pediatric Therapy Training Program to Avoid the Use of Anesthesia in Pediatric Patients ages 3-12 years

Danielle Crump, BSN, RN, OCN

Disclosures

• The author has no financial relationships to disclose.

Ethan’s Experience

Clinical Practice (D. Crump) 1 ONS 42nd Annual Congress

Past Practice

• Craniospinal irradiation • General anesthesia for kids <10y (no standard) • 30-33 treatments • Immobilization device • NPO after midnight • Early arrival to clinic • Port access daily or weekly • Recovery • Time in the department ~2-3 hours daily

The Vision

• Literature Review – Behavioral Training (Scans) – Play Therapy – Audiovisual – Reward System • Best Practices of Other Hospitals – Child Life – Music Therapy/relaxation techniques – Technology – Reward System – Valium – Anesthesia

Johns Hopkins Pediatric Anesthesia Training Program

• Target age group: 3-12 yo • Treatment diagnosis: CNS tumors, neuroblastoma, Wilms tumor, ALL, lymphoma, sarcoma • Training program includes: assessment/screening, acclimation, play, practice

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The Team

Consult: Screening

• Multidisciplinary team meets with family • Build rapport • Specific questions asked: – Eating habits – Sleeping – blanket, pillow, stuffed animal – Favorite things (i.e. super hero, cartoon, fairy tale) – Coping • Tour of the Radiation Department • Tools for preparation and training

Developmental Milestones

For children 3-5 years of age: • Initiative; confidence • Questions things; ritualistic; magical thinking • Has conversations; masters new skills and tasks; can modify behavior with rewards, plays cooperatively • Use dolls or puppets to help explain procedures; reassure child; allow child to make reasonable choices; offer rewards (stickers); praise appropriate behavior; provide privacy

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Simulation

Training Process

• Education • Engagement – Time in clinic, treatment, and sim rooms – Time to play with materials • Encouragement • Training Tools – Mask painting – Manipulatives – Rewards – Use of dolls

Training Process Complete

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Treatment

• Routine • ‐Help patient maintain consistency • Reinforcement • ‐Child Life or Nursing presence daily • ‐Same therapy team daily

Pediatric Patients Ages 3‐12y Receiving Radiation Therapy with or without Anesthesia 100%

90%

80%

70%

60% No Anesthesia 50% Anesthesia 40%

30%

20%

10%

0% 2011 2012 2013 2014 2015 2016

Pediatric Patients Receiving Radiation Therapy with no Anesthesia

100%

90%

80%

70%

60% 7‐12 y

50% 3‐6 y

40%

30%

20%

10%

0% 2011 2012 2013 2014 2015 2016

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Financial Implications

Approximate Cost Savings Anesthesia $40,000 RN Time $2,000 Approximate total $42,000

Note: This does not include cost of supplies, monitors, anesthesia cart/equipment, anesthesia tech, etc).

Benefits of No Anesthesia

Patient Benefits: – Eat anytime – Less time in the department – Less restrictions – No port access – Lower cost of treatment – Safer/less risk – Parent involvement/less stress on family – Relief

In Conclusion

Happiness All Around!

Clinical Practice (D. Crump) 6 ONS 42nd Annual Congress

References

• Beagley, L., & Smith, R. (2014). A competency based orientation and credentialing program for the registered nurse in the perianesthesia setting. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses. • Bucholtz, J. (1992). Issues concerning the sedation of children for radiotherapy. Oncology Nurses forum, 19(4), 649-655. • Bucholtz, J. (1994). Comforting children during radiotherapy. Oncology Nurses forum, 21(6), 987-993. • Haeberli, S., Grotzer, M., Niggli, F., Landolt, M., Linsenmeier, C., Ammann, R., & Bodmer, N. (2008). A psychoeducational intervention reduces the need for anesthesia during radiotherapy for young childhood cancer patients. Radiation Oncology, 3(17), 1-6. • Klosky, J. L., Tyc, V. L., Tong, X., Srivastava, D. K., Kronenberg, M., de Armendi, A., & Merchant, T. (2007). Pediatric Distress during radiation therapy procedures: The role of medical, psychosocial, and demographic factors . Official Journal of The American Academy of Pediatrics, 119, 1159-1166 • Mcgee, K. (2003). The role of child life specialist in a pediatric radiology department . Pediatric Radiology, 33(7), 467-474.

References

• Pressdee, D., May, L., Eastman, E., & Grier, D. (1997). The use of play therapy in the preparation of children undergoing mr imaging. The Royal College of Radiology, 52, 945-947. • Schlund, M. et al (2011). Pediatric functional magnetic resonance neuroimaging: tactics for encouraging task compliance. Behavioral and Brain functions, 7(10), 1- 10. • Scott, L. (2002). Minimising the use of sedation/anaesthesia in young children receiving radiotherapy through an effective play preparation programme. European Journal of Oncology Nursing, 6(1), 15-22. • Slifer, K. J. (1996). A video system to help children cooperate with motion control in young children undergoing radiation treatment without sedation. Journal of Pediatric Oncology Nursing, 13, 91-97. • Tyc, V., Klosky, J. L., Kronenberg, M., De Armendi, A., & Merchant, T. (2002). Children's distress in anticipation of radiation therapy procedures . Children's Health Care , 11-2 • Willis, D., & Barry, P. (2010). Audiovisual interventions to reduce the use of general anaesthesia with paediatric patients during radiation therapy. Journal of Medical Imaging and Radiation Oncology, 54, 249-255.

Clinical Practice (D. Crump) 7 ONS 42nd Annual Congress

A Successful Multifocal Team‐Based Initiative to Prevent CLABSI : Outcomes From the Engagement of Nurses, Nursing Assistants, Patients, Families and Physicians

Jordan Oliver BSN, RN, OCN, Assistant Nurse Manager ‐ Oncology Jennifer Hoff MSN, RN, OCN, CMSRN Medical‐Surgical Nurse Educator Deborah Boyle MSN, RN, AOCNS, FAAN, Oncology Clinical Nurse Specialist Jennifer Yim BSN, RN, CIC, Nurse Infection Preventionist Cynthia Reyes BSN, RN, OCN, Nurse Manager ‐ Oncology

• No Disclosures

UC Irvine Health

• 400+ bed tertiary care academic medical center • Magnet‐designated • NCI Comprehensive Cancer Center • 30‐bed oncology and medical telemetry unit • Diverse patient population • > 50% of patients are hematology/ oncology

Clinical Practice (J. Oliver) 1 ONS 42nd Annual Congress

PROBLEM

Initiative Development

• Multidisciplinary Team  Bedside staff  Unit nursing leadership  Oncology Clinical Nurse Specialist  Nurse Educator  Nurse from ‘Epidemiology and Infection Prevention’ (EIP)  Hematology/Oncology physicians & fellows  EIP physicians

• Support from Leadership  Nursing Administration

• Developed bundled interventions rolled out in 3 phases

Three Phase Plan

Line Care & Assessment

CHG Count Bathing with Me

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Phase 1 : Central Line Assessment, Maintenance and Care

Challenges and process gaps identified:

 Line care and dressing changes inconsistent

 RN to MD communication of problematic sites inconsistent

 Physicians unaware of high risk lines

 No standardized way to assess or respond to ‘At Risk’ lines

Phase 1 : Central Line Assessment, Maintenance and Care Unit Central Line Champions  RN peer‐peer evaluation of line care Central Line Rounds  Daily  Weekly Nurse/Physician Collaboration  Team approach  Hospital line assessment tool (CLISA)

Central Line Insertion Site Assessment (CLISA) Score

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Outcomes

 Improved quality of documentation  Improved RN‐MD communication  Facilitated early recognition of localized inflammation and removal of high risk lines

Phase 2 : CHG Bathing Challenges and process gaps identified:  Baths typically performed by NA  Knowledge deficit of purpose  Inconsistent technique  Patient refusals  Documentation challenging

Phase 2 : CHG Bathing Improvements

 Comprehensive education and training for all nursing assistants (including documentation):  ‘Hand’s On’ teaching format  Small group or ‘One –One’ only to encourage discussion  Daily compliance checks  Patients who refused were visited/educated further by leadership

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Outcomes

 Bathing participation improved to average > 83% per month (from 66%)

 Of the 2 CLABSIs in early 2016, only 1 was a skin organism (occurring early post intervention)

Phase 3 : Scrub the Hub Initiative ‐ “1,2,3…Count with Me”

Challenges in ‘Scrub the Hub’ practice identified:  Variable compliance  Difficult to monitor  Patients unaware of best practice

Phase 3 : Scrub the Hub Initiative ‐ “1,2,3…Count with Me”

 Adapted practice shared from Johns Hopkins Cancer Center* regarding engaging patients & families in scrubbing the hub  Patients and families taught to count along when nurses scrub the hubs  Engages patient’s active participation in their care and safety

 Front line staff involved in development of campaign  Included PICC RN team to introduce concept

*Special thanks to Mikaela Olsen for her consultative advice

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Black light demonstration of scrubbing quality & duration

Phonetic Language Card

Laminated and placed in every room at the head of the bed; languages based on UCI diversity information

Sustainability of ‘Best Practice’

 Daily compliance checks • Charge Nurse shift audits • Unit nurse leadership rounding

 Incentives

 Celebrating Milestones

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Implementation Beyond In‐Patient Oncology

Initial Patient Engagement in Oncology Acute Care Reinforces ‘Best Practice’ In Other Settings

Outcomes

 Engenders staff accountability  Culture change = proactive vs. reactive approach  Patients and families fully embraced initiative  Launched house-wide in November 2016  Due to launch in 6 local area SNFs in coming months

Outcomes

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Keys to Success

1. Strong clinical, education and leadership support 2. Utilize all 3 phases for maximum benefit and outcome 3. Integrate patient engagement into each intervention

References

• Central Line Insertion Site Assessment (CLISA) Score – Gohil, S.K., Yim, J. Quan, K., Espinoza, M., Thompson D., Kong, Tjoa, T., Bahadori, B., Paiji, C., Rashid, S., Hong, S., Dickey, L., Alsharif, M., Amin, A.N., Chang, J., Khusbu, U., Huang, S.S. Impact of a Standardized Central Line Insertion Site Assessment (CLISA) Score on Localized Inflammation and Infection. Infectious Disease Society of America, October, 2016, San Diego, CA

• Daily CHG Bathing: Evidence Based Practice – “Targeted verses Universal Decolonization to Prevent ICU Infection” Susan S. Huang, M.D., M.P.H., Edward Septimus, M.D., Jen Kleinman, Sc.D., Julia Moody, M.S., Jason Hickok, M.B.A., R.N., Taliser R.Avery, M.S., Julie Lankiewicz, M.P.H., Adrijana Gombosev, B.S,m Leah Terpsta, B.A., Fallon Hartford, M.S., Richard Platt, M.D., for the CDC Prevention Epicenters Program and the AHRQ DECIDE Network and Healthcare‐Associated Infections Program

• For more information or ways to incorporate the CLISA scoring into your practice, please contact : Jennifer Yim RN, BSN, CIC Infection Preventionist [email protected]

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