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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 5 

Magnet LogoContributions to New Knowledge - Nursing Research 


Nursing research and evidence-based practice (EBP) provide a foundation for evaluating and developing nursing practice. Nurses are using a scholarly approach to study and explore existing knowledge and contribute new knowledge to patient care and the professional practice of nursing. Nursing research projects in Fiscal Year 2009 included:

California Nursing Outcomes Studies (CalNOC)

Principle Investigator: Carole Cooper, BSN, MHA, RN, CPN, NE-BC

Purpose: This is a statewide nursing quality measurement program which provides hospitals with unit level performance reports for pediatric falls and pressure ulcer prevalence.

The CalNOC study has two primary goals:

1) To provide comparative information to healthcare facilities for use in quality improvement activities.

2) To develop statewide data on the relationship between nurse staffing and patient outcomes.

Design/Methods: Multi-center study which uses medical record review to retrieve data on patient falls and prevalence studies to gather data on pressure ulcer prevalence.

Clinical Relevance: Participation in the CalNOC study provides statewide comparative data to support patient safety and quality care for our patients. Data obtained will be utilized in developing quality improvement initiatives.


Child Health Corporation of America (CHCA) Pediatric Inpatient Fall Study

Principle Investigator: Carole Cooper, BSN, MHA, RN, CPN, NE-BC

Co-Investigators: Donna Wesenberg, BSN, RN, CPN, Explorer

                                     Anne Rowles, AS, RN, CPN; PACU, Perioperative Services

                                     Mona Weaver, BSN, RN, OR, Perioperative Services

Purpose: This study’s aim is to address the knowledge gap in pediatric inpatient fall prevention, specifically the incidence of inpatient pediatric falls, falls with injury and risk factors associated with in-patient pediatric falls. 

Design/Methods: A multi-site sample of CHCA children's hospitals in North America participated in this prospective, descriptive, exploratory study.

Clinical Relevance: This study is one of the first multi-center studies evaluating contributing factors associated with pediatric inpatient falls. Data gathered is currently being analyzed to identify the incidence of inpatient pediatric falls as well as a consensus on the risk factors.  Information will be utilized to identify best practices for preventing and reducing falls in hospitalized children.


Home Care Management of Pediatric Pain

Principle Investigator: Kimberly Sutters, PhD, RN

Purpose: To determine whether around-the-clock (ATC) dosing of pain medication, with or without nurse coaching, increases the effectiveness of pain management (i.e. decreased pain intensity scores with and without swallowing, increased use of pain medication, improved sleep, increased oral intake of fluids, decreased negative behaviors, and the same degree of side effects), over time, compared to standard care with “as needed” (PRN) dosing.

Design/Methods: Treatment, Single Group Assignment, Open Label, Randomized, Active Control.

Children 6 to 15 years of age were randomized to receive acetaminophen and hydrocodone (167 mg/2.5 mg/5 mL) for 3 days after surgery: Group A—every 4 hours PRN, with standard postoperative instructions; Group B—every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C—every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log and recorded the presence and severity of opioid-related adverse effects and children’s reports of pain intensity using a 0 to 10 numeric rating scale.

Clinical Relevance: This study is one of the first to evaluate in a systematic fashion the use of around-the-clock dosing of a weight appropriate dose of a nonopioid/opioid combination analgesic compared to as needed dosing. The study evaluates the effectiveness of both a behavioral intervention and two different pharmacologic interventions, and provides important information that has a direct clinical application in the management of children’s pain following tonsillectomy.


Multi-Agency Identification and Investigation of Severe and Fatal Child Injury:
Guidelines for Networking, Communication and Collaboration

Principle Investigator: Christine Kozub, RN, BA

Purpose: To advocate for a systematic review of severe child injury by communities and individual hospitals. This project focuses on nonfatal injuries. It is meant to influence better policies, practices and overall understanding of injuries in children to achieve the maximum rate of child abuse detection, intervention and prevention. 

Design/Methods: A multi-agency collaborative approach with the top 20 hospitals in California that see the majority of its children is involved.  Beginning with known hospital data on injuries for children under the age of 3 based on ICD9 coding, each case is retroactively reviewed for red flags for abuse or neglect. Cases that have suspected child welfare reports are reviewed for documentation and follow up differences. The focus on non-fatal child injuries results in medical professionals serving a prominent role in any community multi-agency collaboration. 

Clinical Relevance: The project will promote the building of inter- and intra-agency networks, especially to facilitate the sharing of information and expertise. It will strengthen hospital and community management of severe child injuries through data collection and case review. It will clarify roles of responsibility, authority and leadership of each agency in order to promote better prevention practices. The project will outline best practices and models for hospitals with pediatric services to strengthen their child protection protocols, combine lessons learned from multi-agency child fatality review teams with those learned from multi-disciplinary investigation teams and present them in a concise manner for all hospitals that serve children.


National Database Nursing Quality Indicators (NDNQI)

Principle Investigator: Carole Cooper, BSN, MHA, RN, CPN, NE-BC

Purpose: This is a national nursing quality measurement program which provides hospitals with unit level performance reports with comparisons to national averages and percentile rankings.

The NDNQI study has two primary goals:

1) To provide comparative information to healthcare facilities for use in quality improvement activities.

2) To develop national data on the relationship between nurse staffing and patient outcomes.

Design/Methods: Multi-center study which uses monthly medical record review, as well as, monthly prevalence studies to gather data on nursing outcome indicators to include: peripheral IV infiltrates, pain management, catheter associated blood stream infections, ventilator associated pneumonia, and catheter associated urinary tract infections.  

Clinical Relevance: Participation in the NDNQI study provides national comparative data to support patient safety and quality care for our patients. Data obtained will be utilized in developing quality improvement initiatives within the organization. Data information will help to investigate the link between nurse staffing and quality of care.


Neonatal Quality Improvement Initiative California Children’s Services (CCS)/California Children’s Healthcare Association (CHCA) Neonatal Prevention Project in Association with California Perinatal Quality Care Collaborative (CPQCC)

Principle Investigator: Stacie Venkatesan, MSN, RNC-NIC, CNS

Purpose: The CCS-CHCA Neonatal Infection and Prevention Project 2008 is a collaborative which aims to reduce central line associated blood stream infections (CLABSIs) in the neonatal population by at least 25 percent for the new facilities participating in the initiative; maintain or increase the 29 percent reduction in CLABSIs achieved in Year 1 of the project for currently participating facilities; and, reduce the number of other serious infections in NICU patients, including Ventilator Associated Pneumonia, surgical site infections and clinical sepsis events, by 25 percent over 12 months.

Children’s Hospital’s aim was to reduce by 50 percent the incidence of Central Line Associated Blood Stream Infections (CLABSI) in all weight strata by November 1, 2008. 

Design/Methods: Twenty-one NICUs, recognized by the state CCS program as providing care for the most complex medical and surgical patients, participated in the collaborative. The collaborative evaluated the Center for Disease Control and Prevention (CDC) bundle of best practices for reducing CLABSI and developed neonatal specific strategies. Participants implemented elements of the bundle based on organizational priorities utilizing a Plan Do Study Act (PDSA) process. Best practices were implemented, tested, added and changed as needed. Participants in the collaborative reported their findings to share knowledge to promote best practice and monitored for quality outcomes using the PDCA process.

Clinical Relevance: Participation in the collaborative provides comparative data and best practices to support patient safety and quality care through reducing infections in the neonatal patient. Infection rates have significantly decreased for CLABSI. The collaborative as a group showed a 20 percent decrease in CLABSI per 1,000 line days for all weights and Children’s Hospital demonstrated a 47 percent decrease.


NICQ 2009 Vermont Oxford Network (VON) – Performance Improvement Collaborative

Principle Investigator: Jennifer Norgaard, MSN, RNC-NIC, CNS

Purpose: This is a multi-center quality improvement collaborative coordinated through VON. The NICQ program allows for more intensive, face-to-face collaboration. VON has developed the Four Key Habits of Improvements, which are the basis of each collaborative. These key habits emphasize change, collaborative learning, evidence-based practice and systems thinking.

Design/Methods: Prior to the start of the collaborative in January 2009, teams chose from nine specific topic areas for improvement: medication safety, discharge management, respiratory care, resuscitation, nutrition, nosocomial infection, neonatal encephalopathy, and electronic health records. Each topic group has an identified content expert, quality improvement facilitator and clinical leader. The NICU is working with six other NICU teams from across the U.S. to decrease bronchopulmonary dysplasia rates in infants born with a birthweight less than 1,500 grams. NICQ participants attend two meetings annually where they participate in plenary sessions, group work and poster sessions. NICQ teams continue their quality improvement (QI) work between meetings via regular local team meetings, interest group conference calls and a dedicated email listserv.

Clinical Relevance:Participation in the collaborative supports enhanced patient care through the NICQ goals of achieving measurable improvements in quality and safety, engaging families as team members for improvement and fostering a worldwide community of practice for newborn care in which knowledge, tools and resources for improvement are developed, managed, shared and applied.


Nurses Perceived Knowledge, Beliefs, Skills and Needs Regarding Evidence-Based Practice Survey

Principle Investigator: Carole Cooper, BSN, MHA, RN, CPN, NE-BC

Purpose: To identify the current beliefs, knowledge and usage of evidence-based practice (EBP) among nurses at Children’s Hospital. 

Design/Methods: Descriptive Survey conducted using Survey Monkey during November 2008.

Clinical Relevance: Evidence based practice (EBP) has been advocated to support quality healthcare. This study was conducted by members of the Children’s Hospital Nursing Research Committee to evaluate the percentage of Children’s Hospital nurses who understand the steps of EBP and apply EBP to their clinical practice. Information obtained from the survey will be utilized to identify strategies to enhance care through the use of evidence based practice.


Retrospective Case Matched Study to Evaluate the Predictability of the Toronto Children’s Hospital Pediatric Early Warning (PEW) Tool and Bristol Children’s PEW Tool Identifying Acute Care Patients at Risk of Developing Critical Illness.

Principle Investigator: Mary-Ann Robson, BSN, RN, CCRN

Co-Investigators:  Carole Cooper, MHA, BSN, RN, CPN, NE-BC, Mary Jo Quintero, RN, CCRN, CPN

Purpose: To determine if the PEWS tool is a reliable and valid predictor of acute care pediatric patients developing critical illness and therefore provide an effective early warning trigger system for children at risk for respiratory or cardiopulmonary arrest for Children’s inpatient acute care areas.

Design/Methods: A retrospective case matched study design was used to review 204 medical records of inpatients. Demographic data and clinical data from a 24-hour period abstracted from the medical records of patients who met the inclusion criteria and randomly selected control subjects was used to calculate the patient’s PEW score in six hour intervals using the Toronto Children’s Hospital PEW Tool and the Bristol Children’s PEW Tool. Case patients had triggered an Emergency Medical Response Team (EMRT) or Code Blue call in the acute care areas due to: a cardiac arrest or respiratory arrest; neurological compromise; hemodynamic instability; death; increased monitoring or interventions; or need for transfer to the PICU. Case-matched control subjects were randomly selected by age, diagnosis, gender, residing patient care unit and month of occurrence. Variables included: vital signs; serum potassium lab values; medication administration, documented physical exam by bedside registered nurse, respiratory clinical practitioner, or physician; and clinical narrative descriptions.

Clinical Relevance: Tools have been developed to identify children at risk of deterioration known as Pediatric Early Warning Scores (PEWS), although only two have been previously validated. This study was undertaken to determine which tool could most reliably predict adverse outcomes in our patients.

In This Issue

Nursing Rights and Responsibilities

Nurse of the Year 2010

PICU Beacon Award

Critical Care Transport Excellence

A Culture of Inquiry

Nursing Governance Outcomes

Parents As Partners In Care

Professional Development

Contributions to Practice

Contributions to New Knowledge - Nursing Research

Leadership In Professional Nursing Organizations

Patient Satisfaction Comments