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Dallas, TX • November 2–4, 2012
Using Simulation to Improve
CLABSI Prevention in
PediatricsKarla M. Abela, RN, CPN
Duke Children’s Hospital and Health Center
Duke University Health System
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Dallas, TX • November 2–4, 2012
Objectives
• Discuss pediatric CLABSI prevalence and the impact on patients and families.
• Identify benefits of simulation in pediatric blood stream infection education.
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Dallas, TX • November 2–4, 2012
Duke Children’s Hospital
• Hospital-within-a-hospital
• 190 inpatient beds
• 28 subspecialties
http://www.dukechildrens.org/about_us/overview/#facts
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Dallas, TX • November 2–4, 2012
Our Story
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Dallas, TX • November 2–4, 2012
Discovering the Problem
• Duke Children’s Performance Improvement Oversight Committee (PIOC)
• Readmission rates
• Most common cause for readmission
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Dallas, TX • November 2–4, 2012
Readmissions
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Dallas, TX • November 2–4, 2012
Questions, Questions, Questions
• What are we teaching our families when they are discharged from the hospital?
• How do we evaluate the education we’ve provided?
• What is the scope of our problem?
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Dallas, TX • November 2–4, 2012
Simulation
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Dallas, TX • November 2–4, 2012
What is Simulation?
• “The technique of imitating the behavior of some situation or process (whether economic, military, mechanical, etc.) by means of a suitably analogous situation or apparatus, especially for the purpose of study or personnel training.” http://dictionary.oed.com
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Dallas, TX • November 2–4, 2012
Aviation and Simulation Training
The Wright FlyerDec 17th, 1903
French Simulator circa 1907
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Dallas, TX • November 2–4, 2012
Improving Safety and Outcomes in High
Risk Industries
Ressler EK et al. Military Mission Rehearsal in:Tekian et al eds. Innovative Simulations for Assessing Professional Competence. 1999;157-174
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Dallas, TX • November 2–4, 2012
Simulation and Anesthesia Training
• Complex “realistic” simulations in OR-like setting
• Simulation training has been shown to:– improve acquisition
and retention of knowledge
– decrease unplanned errors
– improve correction of problems
Chopra V et al. Br J Anaesth 1994;73:287-292DeAnda A et al. Anesth Analg 1991;72:308-315
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Dallas, TX • November 2–4, 2012
Simulation in Nursing
PRE-LICENSURE
• Initial skill acquisition• Patient assessment• Safety training• Enhances teaching
STAFF DEVELOPMENT
• Further development of critical thinking
• Familiarization with core competencies
• Skills revalidation• Team training• Mock codes• Architecture• RCAs
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Dallas, TX • November 2–4, 2012
Literature Tells Us…
• Agreement regarding use of simulation– Academic settings– Practice settings
• Simulation plus debriefing builds confidence and performance
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Dallas, TX • November 2–4, 2012
What Can We Simulate?
• Technical skills– Psychomotor
• Non-technical skills– Decision-making– Cognitive rehearsal– Teamwork– Situational awareness– Communication
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Dallas, TX • November 2–4, 2012
Types Of Simulation
• Low Fidelity – Role Play
– Mannequins
• High Fidelity– HPS
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Dallas, TX • November 2–4, 2012
Part-Task Trainers
Laerdal – 1960’s - present
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Dallas, TX • November 2–4, 2012
Simulation: Past
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Dallas, TX • November 2–4, 2012
Potential applications of simulation
•Routine basic training of individuals and teams
•Practice of complex clinical situations
•Rehearsal of serious and/or rare events
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Dallas, TX • November 2–4, 2012
Potential applications cont.
• Rehearsal of planned, novel or infrequent interventions
• Design and testing of new clinical equipment
• Performance assessment of staff at all levels
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Dallas, TX • November 2–4, 2012
Advantages/Benefits
• Safe learning environment
• Student-focused – may be individualized
• Patient safety not compromised
• Immediate structured feedback
• Flexible teaching methodology
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Dallas, TX • November 2–4, 2012
Disadvantages
• High capital cost
• Staff development intensive
• Mechanical, environmental and psychological limitations– Suspension of disbelief– Hyper-vigilance
• Evidence in practice?
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Dallas, TX • November 2–4, 2012
Simulation: Present
• Neonatal Resuscitation• Using Simulation to
treat Oncologic Emergencies
• Critical Thinking• ACLS – Mega Code
Teach/Testing• Critical Care Core
Classes• Preceptor Development
classes• Unit-Based Initiatives
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Dallas, TX • November 2–4, 2012
High Fidelity Simulators
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Dallas, TX • November 2–4, 2012
Implications For Practice
• Recommendations from the IOM report:
– Use simulators to ensure that clinical training is safe for patients
– Develop simulators for use in skills assessment
– Use simulation technology to improve individual and team performance through interdisciplinary team training
– Use simulation for problem solving and recovery from problems — “crisis management”
To Err is Human: Building a Safer Health System, Institute of Medicine, Committee on Quality, National Academy Press, 1999
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Dallas, TX • November 2–4, 2012
Another Potential Application
• Patient Education!
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Dallas, TX • November 2–4, 2012
Patient and Family Education
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Dallas, TX • November 2–4, 2012
The Role of the Nurse
• Florence Nightingale (Nigthingale, 1860)
• Virginia Henderson (Henderson & Nite, 1960)
• National League for Nursing Education (1918)
• American Nurses Association (1975)
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Dallas, TX • November 2–4, 2012
Challenges
• External– Changes in health care delivery– Adequacy of resources
• Internal– Nurse’s values and beliefs– Patient’s and caregiver’s values and beliefs– Educational level– Teaching and learning styles
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Dallas, TX • November 2–4, 2012
Teaching the Family
• Patient education in pediatrics
• Special considerations– Environment– Workload– Resources– Learning Process
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Dallas, TX • November 2–4, 2012
Theories of Learning
• Condition – Behavioristic– B.F. Skinner
• Apperception– J.F. Herbart, E.B. Titchener
• Interpersonal – Social Learning– A. Bandura
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Dallas, TX • November 2–4, 2012
Future Implications• Incorporate patient and family education into the
mission and strategic priorities
• Create an environment that rewards patient and family education efforts and outcomes
• Create a structure that supports patient and family education
• Incorporate patient, family and staff education into policies and procedures
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Dallas, TX • November 2–4, 2012
Implications for Nursing Practice
• Motivate staff nurses and experts to teach
• Promote recognition and documentation of patient and family learning outcomes
• Streamline teaching protocols
• Promote a team approach
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Dallas, TX • November 2–4, 2012
Need for Innovation
• Present challenges to patient and family education– ?
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Dallas, TX • November 2–4, 2012
Caregiver Education Using Simulation
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Dallas, TX • November 2–4, 2012
Background
• Inequities accidentally created
• Caregiver anxiety and fear
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Dallas, TX • November 2–4, 2012
Significance
• Printed education material (PEM)
• Simulation as a valid teaching-learning strategy
• Readiness for discharge
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Dallas, TX • November 2–4, 2012
The Team• Vascular Access Team Coordinator• Staff Educators• Hospitalists• Pediatric Intensivists• Pediatric BMT Attending• Clinical Nurse Educators• Nurse Managers• Clinical Operations Director• Clinical Nurses• Clinical Practice Council• Infection Control Nurse
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Dallas, TX • November 2–4, 2012
Setting the Expectations
• Review of our current practice
• Standardizing practice
• Setting the policy
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Dallas, TX • November 2–4, 2012
Change Management
• Getting the clinical staff involved
• Unit-based champions
• Collaborative meetings
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Dallas, TX • November 2–4, 2012
Education
• Collaboration with Clinical Nurse Educator– Lesson plan– Measures of success
• 2 Mini-Expert Training Sessions
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Dallas, TX • November 2–4, 2012
Role of the CVAD Mini-Expert
• Change management
• Expert knowledge
• Just-In-Time training for staff nurses
• Provide the staff with updates to policy and practice
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Dallas, TX • November 2–4, 2012
Role of the Infusion nurse
• Content expert for best practices
• Leadership for identifying complications and trends
• Setting the research agenda to improve the specialty body of knowledge
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Dallas, TX • November 2–4, 2012
Measuring Success
• Balanced Score Card
• Infection Control Surveillance
• Routine unit-based audits
• Routine organizational-level audits
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Dallas, TX • November 2–4, 2012
Future Implications
• Engage multi-disciplinary team members
• Expand to other areas of Children’s
• Embed education into core curriculum
• Research!
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Dallas, TX • November 2–4, 2012
Central Venous Access Device (CVAD) Discharge Teaching Randomized Control
Trial
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Dallas, TX • November 2–4, 2012
Design
• Randomized controlled trial, compared to case-matched controls using prior CVAD content
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Dallas, TX • November 2–4, 2012
ArmsArm 1: current caregivers of children who received CVAD teaching based on old content and unit-based delivery methods.
Arm 2: caregivers of children who will receive CVAD teaching based on the new CVAD protocol. Delivery of content is unit-based.
Arm 3: caregivers of children who will receive CVAD teaching based on the new CVAD protocol. Delivery of content is structured using PEM and a task-simulator.
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Dallas, TX • November 2–4, 2012
Research Question 1
• What is the difference in BSI rates between individuals who have received the content from the previous Central Venous Line Management Protocol for Pediatrics and the individuals randomized to Arm 2 and Arm 3?
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Dallas, TX • November 2–4, 2012
Research Question 2
• What is the difference in re-admission rates between individuals who have received the content from the previous Central Venous Line Management Protocol for Pediatrics and the individuals randomized to Arm 2 and Arm 3?
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Dallas, TX • November 2–4, 2012
Research Question 3
• How do Readiness for Discharge and Post-Discharge Coping Difficulty scores differ between individuals in Arm 2 and Arm 3?
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Dallas, TX • November 2–4, 2012
Instruments
• Weiss Readiness for Discharge Parent Form (RHDS)
• Weiss Post-Discharge Coping Difficulty Scale – Parent Form
• Pre- and Post-Test Knowledge Assessment
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Dallas, TX • November 2–4, 2012
Subject SelectionINCLUSION
• Parents or caregiver(s) of a patient on any pediatric service
• > 18 years old• CVAD must be a
PICC/implanted port/tunneled catheter
• Consent given related to treatment plan
• English-speaking• Able to complete education
prior to discharge
EXCLUSION• Vascath/perm-a-cath, PIV
• Patients under the care of a governmental agency
• Patients whose time of departure does not allow completion of either intervention
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Dallas, TX • November 2–4, 2012
Next Steps
• Form the Research Team
• Institutional Review Board
• Recruit Participants
• Collect Data
• Analyze Data
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Dallas, TX • November 2–4, 2012
Our Vision
• To provide our patients, their families and their loved ones with excellent discharge preparation– Evidence-Based– Safe– Sustainable
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Dallas, TX • November 2–4, 2012
It Takes A Team…
• Britt Meyer, RN, MSN, CRNI, VA-BC
• Kathleen Little, BS, RN
• Julia Aucoin, DNS, RN-BC, CNE
• Duke Vascular Access Team
• Duke Clinical Practice Council
• Clinical Education and Professional Development
• Duke Children’s Nursing
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Dallas, TX • November 2–4, 2012
Thank You!