Pediatric Clinical Case Synopsis

A. Brenner, L. Collis, C. Ngo, A. ONeil, A. Reyes, K. Roman, J. Sahakian, N. Sanaee, L. Sarkisyan, K. Schultz

CNL Role: Clinician

The CNL assumes accountability for client care outcomes Understands rationale for care they are providing Utilizes most recent evidence-based practice Emphasizes health promotion and risk reduction
(American Association of Colleges of Nursing, 2007)

Population Overview
What did we see? Really sick kids!
Out of approximately 50 patients: 19 patients had central lines 18 patients were on TPN 14 patients were on isolation precautions 10 patients needed an organ transplant 2 patients were rejecting their transplant/had rejected in the past 3 patients had a history of multiple organ transplantation 20 patients were on immunosuppressive medications 10 patients were recovering from surgery Common Theme - At Risk for Infection

Recurring Problems
Patient Problems
Risk for rejection post multi-organ transplant Immunocompromised secondary to immunosuppressive therapies Immunocompromised secondary to chemotherapy At risk for infection secondary to surgery or invasive procedure Risk for complications due to infection in patients with autoimmune disorders

Recurring Problems

Unit Based Problems

Non-uniform use of PPE by clinicians and visitors Central line infections Inconsistent scrub-the-hub procedures Inconsistent patient hygiene practices Inconsistent clinical adherence to infection control policies already in place

Patient #1: CVC Infection

Patient: 2-year old female, 12.2 kg Diagnosis: D-Transposition of the great arteries, ventrical septal defect, atrial septal defect, heart failure, tricuspid valve, dysplastic aortic valve Reason for admission: CVC infection, r/o endocarditis

CVC Infection: Assessment

Assessment: BP 95/70, HR 102, Temp 38, O2 sat 90% on room air Resp 36 Redness, tenderness, warmth, edema Purulent drainage from exit site Positive blood cultures Fever, chills, malaise Thrombosis Diagnosis Decreased cardiac output r/t congenital heart defects Acute pain r/t systemic effects of infection Risk for sepsis

Seen on the Unit

Sometimes Seen

Washing hands

Strict sterile technique

Dressing & cap changes

More consistency is needed!

(Miller, 2010) (Ritter et al., 2013)

Patient #1: Implementation & Evaluation Central line infection CVC

Correct hand washing During insertion use proper aseptic technique Use sterile barrier precautions during CVC insertion mask, cap ,sterile gown, sterile gloves Scrubbing should be followed by 30 to 60 seconds of air drying No iodine skin prep or ointment is used at the insertion site. Use only polyurethane or Teflon catheters. Conduct insertion training for all care providers, including slides and video. Early removal! 2012 study demonstrated that daily needs assessments to expedite removal of central catheters reduced CLABSIs
(Miller, 2010) (Ritter et al., 2013)

CVC Implementation & Evaluation

Catheter-site care No iodine ointment. Use a chlorhexidine gluconate scrub to sites for dressing changes

Catheter hub, cap, and tubing care

Replace administration sets Q72h unless they are soiled or suspected to be infected. Replace blood, blood products, or lipid tubing within 24 h of initiating infusion. Change caps no more often than 72 hr Caps should be replaced when the administration set is change

Change gauze dressings Q2d unless they are soiled, dampened, or loosened. Change clear dressings Q7d unless they are soiled, dampened, or loosened. Use a prepackaged dressing-change kit or supply area

(Miller, 2010)

Pt. #2- Cancer Immunosuppression

Patient 13-year-old male Diagnosis: Acute lymphoblastic leukemia (ALL) Reason for admission: Relapsed, waiting for bone marrow donor

Pt. #2- Cancer Immunosuppression

Assessment PMH: Antineoplastic chemotherapy, preauricular lymphadenitis Pancytopenia r/t chemotherapy Neutrophil count <500 WBC 0.06! Low RBC (2.66), Hgb (8.3), Hct (23.1) DVT in left arm r/t peripheral IV

Pt. #2- Cancer Immunosuppression

Diagnosis Immunosuppression r/t chemotherapy treatment Risk for infection r/t depressed body defenses

Pt. #2- Cancer Immunosuppression

Interventions/Evaluation
Seen on unit Continuous temperature monitoring Minimize use of invasive procedures Mouth care/oral hygiene Screen all visitors for signs of infection Teaching about infection prevention Not seen on unit

Oral Hygiene in Cancer Patients

Research Study at the Oncology Ward of Womens and Childrens Hospital in Australia Implemented new oral care protocol
(Qutob et al., 2003)

Oral Hygiene in Cancer Patients

Oral Care Protocol Brushing with fluoridated toothpaste and soft toothbrush 2 x per day Rinsing or swabbing w/ chlorhexidine mouthwash 2 x per day 3 monthly dental visits Protocol posted in patients rooms, nursing station, & staff lounge
(Qutob et al., 2003)

Oral Hygiene in Cancer Patients

Results: Staff compliance with implementing the oral mucositis protocol improved from 41% to 87% Referrals to dental department increased from 53% to 100% Nursing practice implications: provide frequent oral care to prevent infection and make referrals for cancer patients when necessary

(Qutob et al., 2003)

Pt #3: Right Practice; Isolation Precautions

Assessment: 4 y/o Male Has a PICC line with NS TKO, TPN and lipids G and D tube that act only as drains Incision across lower right abdomen droplet precautions for adenovirus

Pt #3: Right Practice; Isolation precautions

Diagnosis: megalocytosis, microcolon, non-functioning bowel, liver failure and had bowel and liver transplant Total Rejection, subtotal enterectomy and small bowel resection

Pt #3: Right Practice; Isolation precautions

Plan, Intervention and Evaluation: airborne and contact precautions d/t suspected highly transmissible pathogen prevent transmission of infection, decreasing nosocomial acquired pathogens No sig. difference was found between the average time spent and quality of care for isolated versus non-isolated patients.
(Cohen et al, 2008) (Chen & Chien, 2006)

Hand Hygiene/Gloving
Most important measure in the prevention of hospital acquired infections Universal gloving decreases the chance of hand contamination from a patient by 70 - 80 %. gloves should not be re-used always work from clean to dirty Mandatory gloving associated with lower risk of bloodstream infections especially in the PICU and NICU
(Rezai, 2010) (CDC, 2007) (Chen & Chien, 2006)

Gowning
The units we were on used reusable gowns. 37 % of healthcare workers gowns were contaminated with VRE after patient contact There is a problem with healthcare staff and visitors not following the guidelines when it comes to gowning. Remember a lot of these children are also immunosuppressed and are more susceptible to infection.
(Rezai, 2010) (CDC, 2007)

CNL Core Competency: Illness and Disease Management Evaluate and anticipate risks to client safety using risk analysis tools Synthesize data, information, and knowledge on client outcomes and modify interventions to improve healthcare outcomes Application: Track the units hospital-acquired infections like CLABSIs, C. Difficile, and MRSA (run charts) against benchmarks Implement root cause analysis when there is an increase Address practice/policy changes where needed
(American Association of Colleges of Nursing, 2007)

CNL Specific Interventions

CNL Core Competency: Designer/Manager/Coordinator of Care - Intervene or modify nursing care, based on risk anticipation analysis and other evidence-based information to improve health care outcomes Application: Standardize infection control protocol unit-wide. Ensure alignment with hospital policies and procedures Participate in hospitals Infection Control Committee Keep up on latest infection control literature and employ or advocate for the latest evidence-based practice (unit based journal club) (American Association of Colleges of Nursing, 2007)

CNL Specific Interventions

CNL-Specific Interventions
What we saw on the unit...
BUG BUSTER COMMITTEE Interdisciplinary team of nurses Focus on infection control Periodic meetings Evaluate current practice and develop evidence-based interventions Educate staff, track compliance with interventions, & report patient outcomes

Who ya gonna call? (Saint et al., 2010)

CNL-Specific Interventions
How can we improve?
INTERVENTIONS * Lines up, tubes down * Scrub the Hub for 15 seconds * Standardized day & shift for caps/dressings * Caps/dressings observed by 2 nurses EVALUATIONS * Not changing caps & dressings until designated day, even though soiled & loose * Day-shift leaving dressing changes for night-shift IMPROVEMENTS * Bedside report * Initial/date/time all dressings * Increase # of days to change dressings * Alternate between day & night shifts

CONCLUSION
Unit Based Problems
Central line infections Inconsistent patient hygiene practices Non-uniform use of PPE by clinicians and visitors Inconsistent clinical adherence to infection control policies already in place

CNL Interventions
Standardize infection control protocol unit-wide. Participate in hospitals Infection Control Committee Keep up on latest infection control literature and employ evidence-based practice (unit based journal club) Track the units hospitalacquired infections Implement root cause analysis

References
American Association of Colleges of Nursing. (2007). White Paper on the Education and Role of the Clinical Nurse Leader. Retrieved from http://www.aacn.nche.edu/publications/white-papers/cnl Centers for Disease Control and Prevention. (2007). 2007 guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. Retrieved from: http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html Cohen, E., Austin, J., Weinstein, M., Matlow, A., Redelmeier, D.A. (2008) Care of Children Isolated for Infection Control: A prospective Observational Cohort Study. Pediatrics, 122, 411-415. doi: 10.1542/peds.2008-0181 Comoli, P., Genevri, F. (2010). Monitoring and managing viral infections in pediatric renal transplant patients. Pediatric Nephrology, 27. 705 - 717. Retrieved from: http://download.springer.com/static/pdf/305/art%253A10.1007%252Fs00467-011-1812-2.pdf? auth66=1385587856_4162c0f738b0095b54eb092840059ee0&ext=.pdf Miller, M.R. et. al (2010). Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. Journal of the American Academy of Pediatrics. 206 - 213. Retrieved from: http://pediatrics.aappublications.org/content/125/2/206.full.pdf+html

References (ctd.)
Pallock-BarZiv S.M. et. al (2010). Variability in tacrolimus blood levels increases the risk of late rejection and graft loss after solid organ transplantation in older children. Pediatric Transplantation, 14. 968 - 975. Retrieved from:http://onlinelibrary.wiley.com/store/10.1111/j.1399-3046.2010.0140.x/asset/j.1399-3046.2010.01409. xpdf?v=1&t=ho6af4za&s=5f3941671dddeb1eabb3a32decefd6c97b549e61 Qutob, A.F., Alle, G., Gue, S., Revesz, T., Logan, R.M., & Keefe, D. (2013). Implementation of a hospital oral care protocol and recording of oral mucositis in children receiving cancer treatment: A retrospective and a prospective study. Support Care Cancer, 21(4), 1113-20. doi: 0.1007/s00520-012-1633-2 Rezai, K., Weinstein, R. (2010). Reducing antimicrobial- resistant infections in health care settings: what works? Antimicrobial resistance, 6. 89 - 101. Retrieved from http://www.karger.com/Article/Pdf/298758 Rinke, M.L., Chen, A.R., Bundy, D.G., Colantuoni, E., Fratino, L., Drucis, K.M., Miller, M.R. (2012). Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics, 130 (4). doi: 10.1542/peds.2012-0295

References (ctd.)
Ritter, G., Kuncewitch, M., Roditi, A., Bily, T., Lennon, L., Wolff, E.Barrera, R. (2013). A Central Venous Catheter Line Protocol by the Surgical Continuum of Care and Nursing Decreases Line Infection/Complications in All Hospitalized Patients: Two Steps Beyond a Checklist. ICU Director, 4 (3), 121-127. doi 10.1177/1944451613480180. Saint, S., Kowalski, C.P., BanaszakHoll, J., Forman, J., Damschroder, L., Krein, S.L. (2010). The importance of leadership in preventing healthcare-associated infection: Results of a multisite qualitative study. Infection Control and Hospital Epidemiology, 31(9), 901-907. doi: 10.1086/655459 Wilson, M., Deeter, D., Rafferty, C., Comito, M., Hollenbeak, C. (2013). Reduction of central line-associated bloodstream infections in a pediatric hematology/oncology population. American Journal of Medical Quality, 28(6). doi 10.1177/1062860613509401 Yin, J., Shwaizer, M.L., Herwaldt, L., Pottinger, J.M., Perencevich, E.N. (2013). Benefits of universal gloving on hospital-acquired infections in acute care pediatrics units. Journal of the American Academy of Pediatrics, 131 (5). 1515 - 1520. doi: 10.1542/peds.2012-3389