trends and changes in pediatrics

7/29/2019 Trends and Changes in Pediatrics

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TRENDS AND CHANGES INPEDIATRIC NURSING CARE
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INTRODUCTION

Changes in the standard of care for pediatricpatients are not something the medicalcommunity takes lightly. In the world of

medicine, clinical care guidelines are typicallydeveloped around sound clinical research;however, there is an exception to this rulewhen developing clinical care guidelines for

use with the pediatric patient. Although this iscounterintuitive, it does make sense; there arefewer research projects involving children and,as a result, less science to support changes inclinical care guidelines.


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1.Understanding Healthcare Design:Designing Patient Care Spaces that Work Nearly $200 billion of healthcare construction is

expected by the year 2015. There are 600documented studies that show hospital designcan significantly influence patient outcomes. The

environment in which we work affects ourperformance and the health and well-being ofpatients. Standardization and designing for caregiving processes impacts patient safety. Spaceand design that supports family involvement

promotes patient's and families well-being. Thepresenters will share their experiences as nurseleaders in promoting healthy hospital design forChildrens National Medical Center's patients andfamilies.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1A.pdf


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2.Critical thinking in AmbulatoryCare Nursing: Making Decision inComplex Practice Situations Critical thinking in nursing is paramount to

providing safe and effective patient care. Thepresenter will focus on developing critical

thinking framework which could be applied incomplex ambulatory practice situations.Developing personal characteristics of acritical thinker will be emphasized which are

necessary in developing empathy, andanalysis of dealing with the perspectives ofpatients, families and the multi-disciplinaryteam.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1B.pdf


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3.Complementary Enteral Nutrition viaNocturnal Nasogastric Feeding InPatients with Anorexia Nervosa Anorexia nervosa (AN) is a complex medical-psychiatric

disorder characterized by abnormal eating patterns, dramaticweight loss, body image distortion, unrealistic fear of weightgain and a refusal to maintain an ideal bodyweight. Nutritional rehabilitation and attainment of an ideal

body weight is paramount to recovery. It is known that weightrestoration leads to improved outcomes over the course oftreatment. Recent research has demonstrated that the use ofcomplementary nocturnal nasogastric refeeding (NNGR) ismore effective than oral refeeding alone in weight restorationin hospitalized adolescents. In 2006 Childrens National

Medical Center implemented an eating disorder pathway withNNGR which has confirmed that this methodology can besafely and successfully used within the context ofmultidisciplinary treatment plan, augmenting the chance oftreatment progress through earlier weight optimization.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session1C.pdf


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4.Teaching and Learning with Simulation:

An Avenue for Establishing and

Sustaining Safe Work Environments In an effort to align with CNMCS mission related

to safety transformation and meet therecommendations of the Institute of medicine, in ahighly complex healthcare environment, Nurse

and Physician Educators are challenged toemploy innovative and creative methods toprovide clinicians with extensive learningopportunities. Over a decade of aviation research

has demonstrated that effective teamwork isessential to flight safety. Simulation allowsteamwork lessons learned in aviation to beorganized into training for healthcare teams.


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Contd

Teaching and learning through simulation isused to provide both introductory andadvanced skills and competencies. Through

the enactment of case scenarios, using ahuman simulator, participants will have theopportunity to improve assessment andintervention skills, problem-solving and critical-thinking skills, crisis management andinterdisciplinary collaboration andcommunication skills, concepts of patient

safety and reflection skills.


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5.Integrating the Child with ChronicIllness into General Pediatric NursingPractice: The Model of Childhood CancerSurvivorship. Medical innovations and improved treatments are not

only increasing the survival rates of pediatricmalignancies, but also of many other childhood

illnesses including cystic fibrosis, sickle cell disease,hemophilia, congenital cardiac defects, as well asmany others. It is essential that these children, allwith unique issues, be successfully integrated intogeneral pediatric nursing practice. Childhood cancersurvivorship can serve as a model of integration for allchronic illnesses of childhood. This presentation willfocus on how nurses can help patients and familiesnavigate the heath care system and integrate the lateor chronic effects of illness to live productive andmeaningful lives.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session2A.pdf


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6.Family Presence in the ED Code

Room

Parents in the code room? Can it really besuccessful? This lecture will discuss onepediatric emergency departments journey to

bring family presence to trauma and medicalalerts using evidence based practice. How toovercome obstacles, prepare and educate amulti-disciplinary staff, document the event ,and collect data to ensure positive outcomeswill be detailed in this step by step guide toimplementation.


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7.Emerging Trends in Pediatric Nursing

Practice: A Panel Presentation

The panel presenters will share with theparticipants their specific journey to nursing

excellence through their individual case

scenarios of challenging diagnoses andtreatment modalities. Their innovative nursingpractice in pediatric cardiac care, nursing inradiology, transport, and neonatal intensive

care has achieved successful patientoutcomes and role-modeled evidence-basedpractice nursing.


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8.Translation of Nursing Practice

into the Electronic Healthcare

Record Systems: Now & In Our Future The use of Healthcare Information Technology

(HIT) will enable us to bridge this gap, and has thepotential to fundamentally change healthcare

delivery. The impact on nursing practice and thenursing role could be considerable, requiringchange in the way we educate nurses, the way weinteract with patients and members of thehealthcare team, and how we work. Nurses, asvital members of the healthcare team who standat the interface of the patient and the healthcaresystem have a unique opportunity to influencehow nursing practice is translated into the HIT of

the future. To take advantage of this opportunity,


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9.Keeping it Simple: Making the connectionbetween health literacy and patientsafety Health Literacy is the ability to read,

understand, and act on health careinformation. Nearly 20% of Americans are

functionally illiterate, unable to read andunderstand. This workshop will give anoverview of health literacy, how to assess forlow health literacy, and provide tools and

methods to use in clinical practice to promotesafety and positive health outcomes.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3A.pdf


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10.From Pain to Sleep: Listening toPatient-reported Outcomes The ability of pediatric patients to report their

symptom experiences is increasingly beingrecognized in clinical care and research

efforts. Being consistently at the point of care,nurses are well positioned to monitor andstudy pediatric patients symptom reports and

to alter care based on the study of those

reports.
http://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdfhttp://www.childrensnational.org/files/PDF/nursing/conferences/PediatricTrends/2009Trends/Session3C.pdf


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11.Advances in Genetic Medicine:Addressing the future now Since the mapping of the human genome in 2001,

substantial progress has brought a focus on genetics inthe media and medicine. The roadmap put forth byFrancis Collins, for genetics in medicine addressedsome of these advances but some progress has

occurred in unexpected ways. This presentation willaddress these current advances, the integration ofgenetics in medicine and the need for a translationalapproach. In order to facilitate a true translationalapproach of genetic medicine, a multidisciplinary

approach is necessary. Because nurses are at thefrontline of the healthcare system, they need to beaware of these advances and how they can beintegrated into patient care.


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12. Evidence-Based MedicineEvidence-based medicine (EBM) is defined as judicious useof the best current evidence in making decisions about thecare of an individual patient. The intent of EBM is to integrateclinical expertise with the best available research evidencewhile observing the psychosocial needs of the child.

Evidence-based medicine follows four steps: Formulate a clear clinical question from a patient's problem>

Conduct a literature search of peer-reviewed journals forrelevant clinical articles

Evaluate the literature for its value to EMS practice and

collaborate with your medical director Implement changes to the patient care protocols.


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13.Family-Centered Care The concept of family-centered care was initially introduced byFoote Hospital in Michigan and prompted former U.S. Surgeon

General C. Everett Koop's initiative for family-centered, community-based, coordinated care for children with special healthcare needsand their families in 1987. Family-centered care suggests thathealthcare providers acknowledge and utilize the family'sknowledge of their family member's condition and make use of thefamily's abilities to communicate with their family member.

Although the concept of family-centered care is not new, it is newto EMS. This initiative is championed by EMS for Children (EMSC).EMS providers must garner an appreciation and understanding offamily-centered care, of which a major principle is the need tounderstand normal growth and psychosocial development. With a

comprehensive understanding of the principles of growth anddevelopment, EMS providers will be able to anticipate thephysiologic needs of children based on the effects of illness orinjury. Furthermore, family-centered care advocates opencommunications with family members throughout the assessmentand management of the child.


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14.Pediatric Trauma Care One of the most important considerations in management of the pediatric

trauma victim is transport destination. It is critically important for EMSproviders to understand that there are significant differences between adultand pediatric trauma centers. Although we recognize that certain parts ofthe country do not have readily available access to a pediatric traumacenter, many do have access to rapid air medical capabilities that canprovide transport to a pediatric trauma center.

A significant number of traumatically injured children across the country are

being treated in non-trauma facilities. For years, there have been numerousdebates on the real impact of pediatric trauma centers over adult traumacenters in the management of critically injured children. The debate is over:Pediatric trauma centers do make a difference. As with any clinical practice,the findings of a single study cannot and should not change practice, butwe have identified four studies that concluded that injured children treatedat pediatric trauma centers have better outcomes and are more likely to

survive than those treated at adult trauma centers. It is important to notethat one of these studies also concluded that children treated at a pediatrictrauma center or an adult trauma center with a pediatric commitment hadsignificantly better outcomes compared with those treated at adult traumacenters. The single greatest variation between pediatric trauma centers andlevel I adult trauma centers with a pediatric commitment was nonsurgicaltreatment of injured children compared with treatment in a pediatric trauma

center.


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Contd..

While it is important to recognize the value

of pediatric trauma centers, it is equallyimportant to recognize the need for rapid careof a trauma patient. If the child requires traumacare and a pediatric center is reasonably

close, he should be taken to the pediatriccenter. If transport to a pediatric trauma centercan be rapidly accomplished through airmedical resources, it should be attempted,

with the understanding that waiting on scenefor a helicopter is not appropriate. An optionwould be to have the helicopter meet theambulance at the local hospital or adult trauma

center for transfer as necessary.


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15.Changes in AHA Standards

The first major change in the CPR guideline forchildren is a change in compression-to-ventilationratio. The previous 3:1 and 5:1 ratios, which no longerexist, have been replaced with the 30:2 ratio. Thesechanges occurred because there was no evidence-based medicine to support the variations incompression-to-ventilation ratios between various agegroups.

An additional change to the CPR guidelines is therecommendation to limit the time of ventilation deliveryto one second, rather than up to two seconds. Thisrecommendation occurred as a result of EBM's findingthat too much ventilation actually promotes limitedblood return to the heart because of higher pressuresinside the chest.


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Contd..

The previous ECC guidelines recommended three stackedshocks in the event of cardiac arrest. The new guidelinesrecommend that only one shock be delivered by an AEDbecause of the time required (30-60 seconds) to reanalyzethe cardiac rhythm. If three stacked shocks were stillimplemented, the patient would be without oxygen or

circulation for one to two minutes while the AED analyzed.This is not an option, since the majority of cardiac arrests inchildren occur as a result of hypoxia. In addition, researchhas demonstrated that in most cases of ventricular fibrillation(a rare rhythm in children) cardiac arrest, the first shock willterminate the VF and therefore the two latter shocks will not

be warranted. The guidelines also suggest that CPR beconducted for two minutes before attaching the AED to thepatient because of the child's sensitivity to hypoxia. The mostimportant consideration in the AHA standards remains BLSmaneuvers and assurance that hypoxia does not develop.Hypoxia kills kids!


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16.The Pediatric Airway

Airway management is the single mostimportant skill of an EMS provider. This isespecially true with regard to managing a

pediatric patient. Children are highly sensitiveto changes in oxygen saturation; without anadequate airway, they will rapidly deteriorateand die.


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17.BVM

Bag-mask ventilation is the preferred meansfor ventilating and oxygenating pediatric patients.It is often difficult to distinguish betweenrespiratory distress and failure without providing

bagged ventilation. A child with respiratorycompromise who responds well to bag-valvemask ventilation and quickly returns to the priorstate of distress should be considered to be in

respiratory failure. If the child remains inrespiratory failure despite appropriateresuscitative interventions, intubation or anotherform of invasive ventilation should be considered.


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18.Intubation

If intubation is necessary, it is still recommended in the prehospitalsetting to use an uncuffed ET tube. In recent changes to the PALSguidelines, there has been some discussion about whether a cuffed oruncuffed ET tube is preferred. While there are valid concerns on both sidesof the argument, the reason that an uncuffed ET tube currently remainspreferred in the prehospital setting is because of the concern foroverinflation of the cuff and, ultimately, damage to the airway. During the in-

hospital phase of care, cuffed tubes may be appropriate because cuffpressures can be better controlled and are advocated because they protectthe airway from aspiration and are more appropriate for high airwaypressures, as in the case of asthma. One study at Children's Hospital LosAngeles involving 210 children intubated with cuffed endotracheal tubesdemonstrated no significant difference in the airway, regardless of whetherthe tube was cuffed or not.

For many years, EMS providers have utilized the three-times tube size todetermine the appropriate depth for ET tube placement. A recent studyshowed that using this formula has contributed to 15%-25% tubemalposition. The study further suggested that the reliability of this formulacould be improved through utilizing the recommended ETT size assuggested by pediatric resuscitation guides (Broselow tape, crash cards,

etc.). Remember, however, that BLS rules. Above all else, when you ensuresolid BLS airway care, you are doing well for your pediatric patient.


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18.LMA

The laryngeal mask airway (LMA) was introduced in

1983, but was not used in clinical practice in theUnited States until 1992. The LMA is a tube with aninflatable mask designed to occlude the esophagus,while allowing for adequate, but low-pressure,ventilation. In EMS, the LMA is used by BLS providers

not trained in tracheal intubation and by ALS providersas a rescue device. The role of the LMA is variable from region to

region due to the lack of adequate science and clearprehospital practice guidelines. In one study involving

paramedic and medical students, 94% of traineeswere able to successfully insert an LMA in a manikinon the first attempt, compared with 69% with an ETtube. Furthermore, five students were unable to placean ET tube after three attempts, compared to noneusing the LMA. The overall time to adequatelyventilate the manikin with an LMA was 39 seconds


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Contd..

When compared to a bag-valve mask, theLMA is thought to be easier to insert and hasbeen shown to produce more effectiveventilation with less gastric insufflation, since

excess pressure is vented upward around theLMA rather than forced down the esophagus,as in the case of BVM ventilation.Unfortunately, there are few studies in the

prehospital use of LMAs and none inprehospital pediatrics.


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19.Should Parents Be Present DuringResuscitation?

Some EMS providers are afraid of having parentspresent when managing a pediatric patient. This maybe the result of perceived intimidation or distraction,resulting in procedural performance anxiety and aresultant deleterious outcome. Other fears may be of

litigation in the event of a complication or badoutcome, or that the presence of parents mayadversely affect the child's behavior.

There are several studies, however, that suggestthe opposite is true. In one study, parents actually

appeared to be more accepting of the death of theirchild when they were present during the resuscitation.This may be because they were able to see thateverything possible was done for their child and theycould achieve closure.


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Contd..

In another study involving emergency medicine physicians,researchers also did not find that the presence of parents hada deleterious effect on performance. This result suggests thatprocedures can be performed without much change insuccess rate despite the fact that parents are present.Interestingly, children were also found to be more cooperativeand less fearful when their parents were present. Thissuggests that procedural success rates may actually behigher if parents are with the child.

Yet another study demonstrated that, when given the option,most parents preferred to remain with their child during a

resuscitation or procedure and, as a result, viewed theexperience as favorable. Even in the case of pediatric death,the majority of parents were thankful for their involvement inthe process. Your rationale for excluding parents (whether toprotect them or you) may do more harm than good.


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20.Pediatric Traumatic Brain Injury

Prehospital providers have the distinct advantageof being first on scene in the event of a pediatricbrain injury. As discussed earlier in this article,evidence-based medicine needs to be the basisfor everything we do, but, in children, it is oftenhard to come by. Initial studies involving clinicaltherapy intended for children are often conductedon animal models. Many studies havedemonstrated that much of the damage to a brainoccurs within the first few hours after the initial

head injury and is known as primary injury.Therefore, prehospital providers shouldconcentrate their efforts on preventing secondarybrain injury that occurs hours to days after theprimary injury.


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Contd..

Future research in TBI will likely include prevention ofhyperthermia in the prehospital setting with the use of rectalantipyretic agents (drugs that reduce fever) and other coolingmodalities. Therapeutic hypothermia has shown somepromise in animal and adult models. Antioxidants have alsoshown promise in preventing secondary brain injury.Hypertonic saline (7.5% NaCl) is another therapy that hasbeen shown to potentially improve survivability in the earlymanagement of severe TBI. Hypertonic saline has greatervalue than mannitol in TBI management, because itdecreases cerebral edema while conserving the circulatingvolume to prevent hypotension. Regardless of what the futureholds, effective oxygenation and ventilation will eitherdecrease the potential for or completely protect the child fromsecondary brain injury.


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21.Pediatric Seizure Management

Prolonged seizure activity in a child can provide significantchallenges for the prehospital care provider. It is well documented

that the duration of seizure activity has a direct impact on death anddisability. Management of seizures in the prehospital setting isaccomplished through administration of benzodiazepines likeValium, Ativan and Versed.

Unfortunately, traditional medication delivery routes are routinely

difficult for prehospital providers to access due to their lack ofexperience and competence in intravenous access. Thesedifficulties can be exponentially increased if the child is activelyseizing. In the majority of cases, IV access may be attemptedwithout success and is often followed by administration of rectalValium. Although an appropriate therapy, Valium administeredrectally has been shown to be less effective in managing seizurescompared with intravenous medication administration. Recentstudies have suggested that intranasal Versed is safe and easy toadminister to the actively seizing child and works better than rectaland intravenous drug delivery. Intranasal medication administrationensures that the drug is delivered directly to the blood andcerebrospinal fluid via the nasal mucosa. The key to pediatric

seizure management is rapid cessation of seizure activity

trends and changes in pediatrics

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