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Purpose The purpose of this project was to design, develop, implement, and manage a sustainable process for pediatric preoperative COVD-19 testing and use the test results to determine the level of personal protective equipment and infection control required for each patient for optimal surgical scheduling and preservation of resources. Design This quality improvement project used the Plan-Do-Study-Act methodology. Multiple cycles of re-evaluation refined this process which was standardized across the enterprise. Methods A process for preoperative testing for all patients undergoing procedures requiring anesthesia was developed and implemented. Findings A safe, feasible, timely process was developed and piloted to obtain COVID-19 test results to guide individualized interventions. During the pilot, 1,707 patients were screened, and five tested positive for COVID-19, eliminating the need to manage 1702 patients as COVID-19 positive. Conclusion To continue to safely re-open, knowledge of the patient's COVID-19 status is imperative to ensure a safe journey through the perioperative area.

INTRODUCTION: There are a growing number of civilian mental health providers who are treating active duty service members (ADSM) from referrals of local emergency rooms, directly from military installations, or when a military mental health program is unavailable. Civilian providers may be unprepared to address issues that are unique to this population. AIM: The purpose of this quality improvement project was to develop and implement a survey-based knowledge assessment, in order to assess civilian psychiatric advanced practice nurse’s (APN) perceptions, knowledge, and practice of treating ADSMs. METHOD: The investigator developed and validated a survey that was posted on the American Psychiatric Nurses Association All-Purpose Discussion Forum, and the snowball technique was utilized to enhance psychiatric APN colleague recruitment. RESULTS: Seventy-eight participants scored extremely low with average score of 40.4%; however, the psychiatric APNs who received formal training from the Department of Defense on unique mental health issues of ADSMs scored significantly higher (49.6%) than participants without the formal training (38.2%; p = .03). CONCLUSIONS: Understanding the knowledge gap of psychiatric APNs as it relates to the care of ADSMs will allow educators to recommend available trainings or develop trainings that are tailored to meet their needs.

Nurse leaders have a responsibility to nurture a work environment that prioritizes meaningful recognition. This quality improvement project explored the perceptions of meaningful recognition of inpatient pediatric surgical nurses. Meaningful recognition provides a chance to honor all voices, particularly those that have not been previously heard. To be heard is to be honored and to be recognized is to be valued.

Introduction Current pediatric PACU practice administering low dose IV haloperidol for post-operative nausea and vomiting (PONV) unresponsive to other interventions for specific pediatric populations varies by anesthesia team. Identification of the problem Anecdotally, low dose haloperidol had been used safely in pediatric PACUs. Formulary recommendations for intensive monitoring were based on higher dose haloperidol used for the treatment of psychosis and the potential for QTc prolongation. QI question/Purpose of the study To clarify the magnitude of both QT prolongation and therapeutic benefit for PONV in pediatric PACU patients given low dose haloperidol. Those data would inform potential changes to the hospital formulary to differentiate guidelines for low dose IV haloperidol in the PACU from higher dose haloperidol used for psychiatric intervention. Methods An interdisciplinary QI project was developed to provide evidence to support proposed changes in the formulary. Data were collected over a six month period including pre- and post-haloperidol administration QTc and BARF scores. Descriptive statistics were used to analyze this data. Outcomes/Results During the project period, pre therapy QTc was 430±43msec (range 480-355) with heart rates of 82±16. Two patients had dosing deferred because of clinical QTc ≥ 480 (N=29). Post treatment QTc readings had an average increase of 2±22 msec, with 1 ECG exceeding the QTc cutoff of Discussion It is critical for nurses to question and evaluate practice using evidence based guidelines and quality improvement methodology. Conclusion Low dose IV haloperidol is effective at limiting PONV and has a low incidence of QT prolongation. The high monitoring environment of a pediatric PACU suggests that it can be used safely in that setting for select populations. Implications for perianesthesia nurses and future research This work resulted in developing evidence based changes to the formulary that are consistent with clinical practice. Further research is needed to determine if low-dose haloperidol can be administered safely for a younger population.

Background Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented. Methods Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours. Results Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months. Conclusions Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.

Approximately 300 children in the United States are diagnosed yearly with retinoblastoma. For a generation, it has had the highest cure rate among pediatric solid tumors, allowing reduction in side effects of management to become important determinants of therapy. Priorities of treatment are saving life, eyes, and vision. Standard treatment involves enucleation, multiagent systemic chemotherapy, and radiation and intra-arterial chemotherapy (IAC). IAC is a treatment option to deliver chemotherapy locally to the eye while minimizing systemic exposure. Research in the treatment of retinoblastoma has led to new treatment protocols for children. The purpose of this article is to define retinoblastoma, introduce the goals and priorities of retinoblastoma treatment, and describe the standard of care treatment options with a focus on IAC, which is administered in interventional radiology. It also highlights important nursing issues including the administration of chemotherapy in a clinical area where it is not traditionally administered and the challenges faced in caring for children and families with retinoblastoma.

Summary Introduction/background The Nurse Practitioner (NP)-Led Newborn Circumcision Clinic (NCC), developed in 2016, provides clamp-style circumcision to newborns without general anesthesia. There is a paucity of research regarding outcomes, satisfaction, and the cost benefit of such NP-led clinics. Objective The purpose of this descriptive study was to describe the impact of the NCC including family satisfaction, clinical and demographic characteristics, and cost. Study design This study utilized a mixed-method approach to describe the impact of the NP-led NCC using survey methodology to describe family satisfaction, a single center retrospective chart review to describe clinical and demographic characteristics and outcomes, and investigation of charges in NCC versus operating room (OR) circumcisions. Descriptive statistics were used to present survey results and chart review data. Results Results of the patient satisfaction survey revealed 89.8% of patients rated the overall quality of care as excellent or very good. Of the 234 patients reviewed, the median age and weight of patients was 4.30 weeks and 4.39 kg, respectively. Of the patients with comorbidities (30.3%), the most common were related to prematurity (12.8%). The most common reason for referral was concern for anatomical abnormality of the penis (53.8%). The median length of procedure was 20 minutes. No patients in our cohort experienced penile amputations, infections, strictures, intraoperative bleeding, or wounds. Ten patients (4.3%) had bleeding events during the recovery period which were treated with a topical medication (StatSeal). Two patients (0.9%) had bleeding after discharge requiring Emergency Department evaluation and application of a pressure dressing. Two patients (0.9%) required circumcision revision. Investigation of charges revealed a savings of 92.9% for circumcisions in the NCC versus OR. Discussion This study reveals that the NP-led NCC has high family satisfaction, few adverse outcomes, and cost benefits as compared to OR circumcision. There are a limited number of publications presenting outcome data for circumcisions and even fewer for NP- led circumcision clinics. Furthermore, a lack of standardized definitions for adverse events makes comparison difficult. Conclusions Critical to the success of the NP-led NCC is appropriately selecting patients, a NP training program, and intra-professional collaboration. This ambulatory clinic offers another option for select infants who were not immediately circumcised in the newborn period. By expanding opportunities for NPs to practice to the full extent of their education and expertise, our institution continues to develop opportunities to improve access to care, control costs, and increase patient and family satisfaction. Summary Table . NP-led Newborn Circumcision Clinic Clinical Outcomes NCC Clinical Outcomes Median [IQR]/n (%) During Circumcision Procedure N = 234 Length of Procedure Events that Occurred 20.00 min [13.00 - 28.00] Sutures by MD for Skin Separation 2 (0.9) None 232 (99.1) During Recovery Length of Recovery Events that Occurred 60.00 min [60.00 - 60.00] Bleeding Treated by StatSeal Topically 10 (4.3) None 224 (95.7) Post-procedural Day 0 to Day 6 Events that Occurred Unplanned Emergency Department Visit for Bleeding 2 (0.9) Treated with Pressure Dressing 2 (100) None 232 (99.1) Follow-up Visit: Post-procedural Day 7 N = 228 Events that Occurred Adhesions 10 (4.4) Treated with Betamethasone Topically 9 (90.0) Noted without Treatment 1 (10.0) None 218 (95.6) After Follow-up Visit Unplanned Clinic Visit Adhesions 7 (3.1) Treated with Betamethasone Topically 2 (28.6) In-Office Lysis of Adhesions 5 (71.4) Parental Concern/Normal Anatomy 1 (0.4) Cicatrix Treated with Betamethasone 2 (0.9) Circumcision Revision 2 (0.9)

Introduction Clinical inquiry is vital to safeguard nursing practice and ensure optimal outcomes for our patients and families. The innovative Nursing Science Fellowship (NSF) was developed to provide structured mentorship for pediatric nurses by nurse scientists to design and conduct clinical inquiry generated from their practice. Methods Each fellow is paired with a nurse scientist mentor to receive support for timely project completion. Dedicated mentors guide the immersion of fellows in nursing science by providing them with didactic content detailing the process of clinical inquiry and bi-monthly one-on-one mentorship sessions. Throughout their journey, fellows learn the appropriate method by which to address their clinical inquiry question and complete a scholarly project that contributes to the science of nursing. On a quarterly basis, fellows share their progress and achievements with peers, mentors, and senior leadership. Results Since 2011, 84 fellows have enrolled in this two-year program. Sixty-two nurses have graduated from the NSF and 22 fellows are currently active. Collectively, the fellows have received 46 grants to support their projects. Twenty-one fellows have received promotions and 22 fellows have furthered their education in a masters, clinical or research doctorate program. There have been 78 external disseminations highlighting their clinical inquiry work, including poster and podium presentations and peer-reviewed published manuscripts. Lastly, there have been 26 new or updated clinical practices implemented across the enterprise as a result of completed projects. Conclusions Combined these efforts have ensured a sustained commitment to advancing the science and practice of pediatric nursing.

Facilitating Empowerment and Stimulating Scholarly Dialogue Using the World Café Model Student empowerment is the best vehicle for critical thinking and optimal learning, and enhances the development of nurses with the knowledge and skills required to navigate their way through the complex, shifting terrain of current nursing practice. Central to this process is scholarly dialogue, in which conversations are guided by an understanding of the state of the science in nursing. When conducted within the context of respect, such dialogue leads to student empowerment. Freire (2000) called such an approach to teaching a liberation pedagogy, in which professors are no longer the only source of knowledge in the classroom but rather help students move from being passive recipients to active creators of knowledge and ideas. [more...]