A biomedical device to improve pediatric vascular access success

PURPOSE

to evaluate the effectiveness of a vein-viewing device on the success of venipunctures performed by staff nurses on a pediatric surgical unit.

METHOD

this prospective, non-randomized study examined pediatric inpatients from the age of newborn to 17 years requiring vascular access at a tertiary care center in northeast Florida. The number of attempts, age of the patient, and time required to establish successful vascular access using a vein-viewing device were self-reported by nursing staff (experimental group, n = 91, mean age 9 years, range 3 days to 17 years) as well as staff, patient, and parental comments about the device. These data were compared to baseline data (control group, n = 150, mean age 5.7 years, range 11 days to 17 years) previously collected on the same unit without using the device. The outcome variables were first-attempt success rate, the number of attempts per patient, and the time to procedure completion.

FINDINGS

when comparing the two groups, the first-attempt success rate increased from 49.3% to 80.2%, the mean number of attempts per patient decreased from 1.97 to 1.29, and the percentage of procedures completed in 15 minutes or less increased from 52.8% to 86.7%. Results were statistically significant for all outcome variables between the two groups and also when re-analyzed in subgroups controlling for age.

CONCLUSIONS

use of a vein-viewing device significantly improved first-attempt venipuncture success rate, decreased the number of attempts per patient, and decreased procedure time for the study population. The device was well received by patients, families, and staff.

Seizure precautions for pediatric bedside nurses

Seizures are a common neurologic disorder of childhood, and many pediatric nurses will care for children with epilepsy during their careers. The term "seizure precautions" is used frequently in nursing practice; however, its definition varies among institutions. Childhood epilepsy has many phenotypes, and while some children require airway clearance and ventilatory support in the event of a seizure, many will not. The bedside equipment for a child with seizures should reflect the patient's symptoms. To that end, an algorithm based on seizure classification and current practice in seizure precautions is presented to aid bedside nurses in safely caring for children with seizures. The algorithm may also be used to assist in educating parents about the safest way to care for their child at home, without sending contradictory messages about different needs for equipment in the hospital and in the home.

Reliability of a computerized version of the Pediatric Canadian Triage and Acuity Scale

BACKGROUND

The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.

OBJECTIVES

To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).

METHODS

A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using kappa score.

RESULTS

Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg kappa score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS kappa score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (kappa score of 0.72 vs. 0.55 for level 1; kappa score of 0.70 vs. 0.51 for level 2).

CONCLUSIONS

A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.

The Health Utilities Index 3 invalidated when completed by nurses for pediatric oncology patients

When health-related quality of life instruments developed for and validated in 1 respondent group are completed by a different respondent group, findings could be invalid. The purpose of this study was to summarize the instrument outcomes when a widely used health-related quality of life instrument (the Health Utilities Index 3 [HUI3]) created from a population-based strategy was completed by pediatric oncology nurses for their patients during cancer treatment. Fifty-four nurses completed the HUI3 a total of 261 times at 1 to 3 sequential data points (106, 94, and 61, respectively) for pediatric patients who were enrolled on a frontline therapeutic clinical trial for acute lymphoblastic leukemia. Data were collected at 2 children's hospitals. HUI3 scores could not be calculated for 52% to 61% of the nurse reports at each of the 3 data points because of nurses' use of the "do not know" response option. Missing data of this proportion indicate that the nurse serving as a proxy rater independent of directly soliciting responses from the patient will not be able to rate certain attributes of the HUI3 more than half of the time despite having ongoing familiarity with the patient. Because of this, use of the HUI3 by nurse proxies for patients with pediatric acute lymphoblastic leukemia is not recommended.

Handwashing practice and policy variability when caring for central venous catheters in paediatric intensive care

It has been estimated that there may be as many as 150,000 healthcare associated infections (HCAI) in Australia each year, contributing to 7,000 deaths, many of which could be prevented through the implementation of appropriate infection control practices. Contact with contaminated hands is a primary source of HCAI. Intensive care staff have been identified as one of the least adherent groups of health care professionals with handwashing; they are less likely to practise hand antisepsis before invasive procedures than staff working in other patient care specialties. The study examined the self-reported clean and aseptic handwashing practices of nurses working in paediatric intensive care units (PICUs) across Australia and New Zealand, the patterns in variation between nurses' reported handwashing practices and the local policies, and patterns in the duration of procedural handwashing for specific procedures. A survey was undertaken in 2001 in which participating tertiary paediatric hospitals provided copies of their infection control policies pertaining to central venous catheter (CVC) management; five nurses on each unit were asked to provide information in relation to their handwashing practices. Seven hospitals agreed to participate and 30 nurses completed the survey. The study found an enormous level of variation among and between nurses' reported practices and local policies. This variation extended across all aspects of handwashing practices - duration and extent of handwash, type of solution and drying method used. The rigour of handwashing varied according to the procedure undertaken, with some evidence that nurses made their own risk assessments based on the proximity of the procedure to the patient. In conclusion, this study's findings substantiate the need for standardisation of practice in line with the current Centers for Disease Control and Prevention Guidelines, including the introduction of alcohol handrub.

Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children

STUDY OBJECTIVE

We compare the mean tidal volumes per weight and peak pressures generated by the 1- and 2-person techniques of bag-valve-mask ventilation in a pediatric model.

METHODS

This was a prospective, descriptive study in which postgraduate year 1, postgraduate year 2, and postgraduate year 3 pediatric residents, postgraduate year 2 emergency medicine residents, pediatric emergency department nurses, transport personnel, and paramedics were asked to perform 1- and 2-person bag-valve-mask ventilation on infant and child manikins. Participants were randomly assigned a partner and performed both techniques. Tidal volume and peak pressure were recorded every 15 seconds for 3 minutes by a blinded assistant.

RESULTS

Seventy participants, 10 in each group, completed the study. Overall, for the infant- and child-manikin groups, the 2-person technique generated higher mean tidal volume per weight than the 1-person technique (infant: 7.2 versus 5.9; child: 8.8 versus 6.1). Overall, the 2-person technique generated higher mean peak pressures than the 1-person technique (infant: 27.4 versus 22.0; child: 27.2 versus 21.8). Similar results were found among all provider groups. Paramedics were the only providers able to generate a recommended median tidal volume per weight of 10 mL/kg in the child manikin group when using either technique and were the only providers, when using the 2-person technique, to generate a mean tidal volume per weight of 10 mL/kg in the infant group.

CONCLUSION

Two-person bag-valve-mask ventilation provided greater mean tidal volumes per weight and peak pressures in the infant- and child-manikin model compared with the 1-person technique.

Tracheostomy management

Even though care of children with tracheostomies may differ between hospitals, there are basic principles and procedures that all nurses should be aware of including how to respond in an emergency.

Assessing ambiguity at the family-nurse boundary interface in pediatric health crisis

This article discusses the conceptualization and measurement of family-nurse relationships in pediatric intensive care unit (PICU) from the perspective of family systems and boundaries. The 14 items for the Family-Nurse Boundary Ambiguity Scale for PICU (FNBAS-PICU) were developed from a qualitative study. Nurse panels established face and content validity. Parents (156) from four PICUs participated in reliability estimates (Cronbach's alpha = .81) and validity testing with measures of illness uncertainty and role alteration stress. Principal components analysis confirmed the conceptual intent of the FNBAS-PICU.

The use of a pressure ulcer risk assessment tool for children

The need for pressure ulcer risk assessment has been acknowledged in adult nursing for many years. However, in paediatrics there is a misconception that children do not develop pressure ulcers (Mills, 1998). This misconception has been challenged in recent years with a growing awareness that children have specific risk factors that predispose their skin to pressure damage (Willock et al, 2000; Mills, 1998; Waterlow, 1998, 1997; Jones, 1997; Pickersgill, 1997; Zollo et al, 1996; Bedi, 1993).

Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS)

Children's Hospital Boston began a major pain assessment and management initiative 3 years ago: Pain assessment and management are considered one of the institution's primary standards of care. The initiative included State of the Science meetings with internationally renowned nursing pain researchers and clinicians. These meetings generated nursing staff interest in specific applications of what is known about pain; how evidence-based knowledge can be used to ask population-specific clinical questions; and how an evidence-based approach can be applied to systematically develop, implement, and assess interventions that suit a population's clinical needs. This article is an example of an evidence-based pain assessment project at Children's Hospital Boston that focused on nonverbal children with cognitive impairments. After developing a clinical question, the authors did a literature review and a benchmarking analysis of best practice. The pilot of an adapted, existing pain assessment tool is described in this article.

Life span of peripheral intravenous cannula in a neonatal intensive care unit of a developing country

The use of peripheral intravenous cannulas (IVCs) in the care of sick newborns is a common practice. IVCs, priced five times higher than conventional steel needles, can be more cost effective if insight is available on the variables affecting their life span in situ. The present report summarizes the efforts made to ascertain these factors in a neonatal intensive care unit (NICU) of a developing country. A total of 186 peripheral IVCs (24-gauge teflon) were used in 78 newborns amounting to 7,583 hours of IV therapy (mean, 40.8 hr per cannula; range, 1-136 hr). Of these, 25 cannulas were removed selectively and 84, 50, 17, and 10 were removed for swelling, dislodgement/leakage, blockage, and local erythema, respectively. The median survival time of IVC as expressed by Kaplan-Meir survival analysis was 40 hours (SE, 2.49; 95% confidence interval, 35.12-44.88). Birth weight, gestation, application of splint, fluid and glucose infusion rate, site of cannulation, and administration of ampicillin, gentamicin, amikacin, vancomycin, phenobarbitone, blood products, or calcium gluconate did not influence the median life span of IVCs. Children receiving cefotaxime had a significantly lower median survival time as compared with those not receiving it (36 vs 47 hours, p =.007). Median survival time of IVCs in our set-up was comparable with those in developed countries and was not governed by the cannula or patient variables. Cefotaxime use led to decreased survival of IVCs; though this effect appeared to be related to the mode of administration rather than to the drug per se.

Clinical governance and assessing and managing clinical risk

Joshua worked in paediatrics and was concerned about the frequency of injuries caused to babies as a result of intravenous fluids being pumped into the tissue. It appeared that the mechanical pumps were not sufficiently sensitive to cut out when the vein tissued and there had been several cases where it appeared that serious harm had been caused to a baby.

Clinical benefits of 3M Tempa.DOT thermometer in paediatric settings

Single-use clinical thermometers provide a safe alternative to the traditional mercury in glass thermometers for routine temperature taking. This article examines the 3M Tempa.DOT Single-Use Clinical Thermometer and discusses its use in the paediatric setting.