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12 September 2017

12 September 2017

Tuesday 12 September 2017 Ella Latham Auditorium

8:30 AM Symposium Welcome

8:43 AM Session 1 - Service delivery

Implementing a Single Session Nurse-led assessment clinic into a child & adolescent gender service

Donna Eade

Pre-hospital care in childhood arterial ischaemic stroke Belinda Stojanovski

Clowns in the Mist Naomi Brockenshire

The role of the Nurse Practitioner in specialty areas Sonja Elia

Gaining consensus in multidisciplinary research: use of the e-Delphi technique Chris Williams

10:02 AM Break

10:28 AM Session 2 – Consumer engagement and communication

Immunisation in specialist schools research: Early findings Jenny O'Neill

Parental Experience of Prenatal Diagnosis of Lymphatic Malformation Zerina Tomkins

Development of a Childhood Cancer Survivorship Repository

Alice Wheller, Tegan Dunmall and Antoinet Arokiasamy

Using high fidelity simulation to provide Management of Clinical Aggression Training - a pilot study

Marijke Mitchell

Investigating the experience of parents who have given their children enoxaparin at home Hollie Gilmore

Recognising deterioration in the Newborn – case studies from the field Jen Sloane

12:02PM Lunch

12:35 PM David Danks ’Leaders in Science’ Seminar

What is supportive care research and is it a helpful construct for clinical inquiry?Professor Meinir Krishnasamy

Chair in Cancer Nursing|Department of Nursing

University of Melbourne Centre for Cancer Research

VCCC Research and Education Lead – Cancer Nursing

1:30 PM Poster Session

1:58 PM Session 3 - Patient safety 1

The Push to Pause: optimising theatre staff participation in team timeout Grace Mercado

Optimizing alarm safety practices to improve detection of clinical deterioration

Yvonne Enersen and Pip Cosgrove

Understanding young people who self-harm – the lived experience of young people in an inpatient mental health service Samantha Gronow

The association between Central Venous Catheter placement and Central Venous Catheter related Thrombus Sophie Jones

3: 02 PM Break

3:23PM Session 4 – Patient Safety 2

An EPIC Challenge Janine Furmedge

Renal Care in Children with Spina Bifida: A Retrospective-Cohort Study Jemimah Freeman

Trends in paediatric medication errors and the influence of a new hospital design Sharon Kinney

'Can I have a check?' RCH Nurses Understanding and Self Reported Practices of Medication Checking

Stacey Richards

4:27 PM Award of prizes and closing comments

4:45 PM Symposium closing

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Oral Presentation Book of Abstracts

Implementing a Single Session Nurse-led assessment clinic into a child and adolescent gender service _____________________________________________________________ 4

Pre-hospital care in childhood arterial ischaemic stroke __________________________ 5

Clowns in the Mist __________________________________________________________ 6

The role of the Nurse Practitioner in specialty areas ______________________________ 7

Gaining consensus in multidisciplinary research: use of the e-Delphi technique. ______ 8

Immunisation in specialist schools: Early findings _______________________________ 9

Parental Experience of Prenatal Diagnosis of Lymphatic Malformation _____________ 10

Development of a Childhood Cancer Survivorship Repository ____________________ 11

Using high fidelity simulation to provide Management of Clinical Aggression Training - a pilot study ______________________________________________________________ 12

Investigating the experience of parents who have given their children enoxaparin at home ___________________________________________________________________ 13

Recognising deterioration in the Newborn – case studies from the field. ____________ 14

David Danks ‘Leaders in Science’ Seminar: What is supportive care research and is it a helpful construct for clinical inquiry? _________________________________________ 15

The Push to Pause: optimising theatre staff participation in team timeout ___________ 16

Optimizing alarm safety practices to improve detection of clinical deterioration ______ 17

Understanding young people who self-harm – the lived experience of young people in an inpatient mental health service ____________________________________________ 18

The association between Central Venous Catheter placement and Central Venous Catheter related Thrombus _________________________________________________ 19

An EPIC Challenge ________________________________________________________ 20

Renal Care in Children with Spina Bifida: A Retrospective-Cohort Study ____________ 21

Trends in paediatric medication errors and the influence of a new hospital design ___ 22

'Can I have a check?' RCH Nurses Understanding and Self Reported Practices of Medication Checking ______________________________________________________ 23

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Implementing a Single Session Nurse-led assessment clinic into a child and adolescent gender service

Author(s)

Eade, Donna

Affiliation(s)

The Royal Children’s Hospital

Keywords

triage, wait times, transgender

Background

The Royal Children’s Hospital Gender Service (RCHGS) provide multidisciplinary support, assessment and medical care for transgender children and adolescents. New referrals have increased rapidly, from 40 in 2013 to 220 in 2016. This demand has resulted in increased wait-times for an initial consult.

Aim

To reduce wait-time and improve health outcomes for transgender adolescents a Single Session Nurse-led assessment clinic (SSNac) was introduced as the initial clinical contact.

Research Method or Innovation Plan

Historically the initial patient consult with the RCHGS was in multidisciplinary assessment clinic (MDAC), comprising of a psychiatrist and paediatrician. With an exponential increase in demand for the service wait-times extended to 12 months. In 2016, a SSNac was introduced as the first clinical contact to the RCHGS clinical pathway. In SSNac, the Clinical Nurse Consultant (CNC) undertakes an adolescent bio-psycho-social assessment, triages, educates and supports adolescents awaiting assessment regarding their gender.

Results or Data about the Innovation

SSNac provides a one-off face-to-face, first point of contact consult with a CNC. Even though referral numbers are anticipated to increase in 2017, with the introduction of SSNac, patients are now seen within 5 months. Furthermore, a fortnightly triage clinic has been created whereby all patients assessed in SSNac to meet triage criteria are fast tracked for medical assessment. Whilst outcomes data are not yet available an outcomes evaluation is underway.

Conclusion

The introduction of SSNac has reduced the wait-time for a face-to-face consult at RCHGS from 12 months to 5 months and patients are now efficiently triaged, educated and provided more timely support.

5

Pre-hospital care in childhood arterial ischaemic stroke

Author(s)

Belinda Stojanovski, Paul Monagle, Fiona Newall, Leonid Churilov, Ian Mosley, Grant Hocking, Mark Mackay

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, The University of Melbourne, La Trobe University, Ambulance Victoria

Keywords

Paediatrics, Stroke, Emergency

Background

Ambulance usage is the most important factor resulting in shorter time to hospital arrival in adult stroke. Pre-notification and bypass to stroke centres are associated with increased thrombolysis rates. Sensitivity of paramedic stroke identification in adults varies from 44-66% but there are no published data in children.

Aim

We hypothesised that emergency medical services call-taker (EMSDCT) and paramedic identification of childhood arterial ischemic stroke (AIS) is suboptimal and contributes to prehospital delays. The aims of this project were to (i) determine sensitivity of EMSCT and paramedic diagnosis, (ii) to describe patterns and timelines of paramedic care in childhood AIS.


Retrospective study of ambulance transported children <18 years with radiologically confirmed AIS, from 2008-2015. Direct admissions to the ward were excluded.


Ambulance records were reviewed for 19 children. Four children were excluded because records were unavailable. 58% were female, median age was 8 years (IQR 3-14) and median PedNIHSS score was 8 (IQR). EMSCT and paramedic diagnoses were stroke in 21% and 26% of children respectively. A Code 1 (lights and sirens) ambulance was dispatched for 72% of children. Pre-notification occurred in 42% of children and 64% were transported to adult (6) or pediatric (6) hospitals meeting criteria for primary stroke centres. Median prehospital timelines were: onset to 000 call 13 minutes, call to scene 12 minutes, time at scene 14 minutes, call to ED arrival 54 minutes. Total pre-hospital lag time 71 minutes (IQR 60-85) whereas post-arrival time to radiologically confirmed AIS diagnosis was 568 minutes (IQR 144-799).

Conclusion

Sensitivity of EMSCT and paramedic childhood AIS diagnosis and pre-notification rates are much lower than adults. However pre-hospital factors contribute less to delayed diagnosis than in-hospital factors, representing an important difference to adult stroke.

6

Clowns in the Mist

Author(s)

Naomi Brockenshire, Helen Shoemark, Richard Chenhall and Fiona Newall

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, The University of Melbourne

Keywords

Clown doctors, humour, paediatrics

Background

Clown doctors are a feature in paediatric hospitals, visiting children and families, providing a welcome escape from the reality of hospitalisation. Whilst the use of humour to improve health and wellbeing has been widely researched, limited exploration of the role of clown doctors has occurred.

Aim

This research aims to elucidate the role of clown doctors within a paediatric hospital.


In this ethnographic study, participants included the clown doctors and every person with whom they had a meaningful encounter. The narrative of the clown doctors was captured through 1,500 hours of participant observation documented over one year. Interviews and visual methods were utilised, with key informants drawing and explaining their experience of the clown doctors. A constructivist framework was used to analyse emergent themes.


The nature of the clown is inherently low status. For clown doctors, this perceived lack of power coupled with their position within the hospital system as ‘outsiders’ allows them to forge deep, considered relationships, becoming privy to emotions often not disclosed to healthcare professionals. Clown doctors use their freedom to flip the hospital paradigm, reflecting back system imperfections. Whilst almost universally acknowledged as a positive addition to the hospital, most people who encounter clown doctors have little conception about their role.

Conclusion

The results of this descriptive study provide valuable insight and a comprehensive understanding of clown doctors and the complexity of human relationships within a major paediatric hospital, uncovering a profound, nuanced culture cheerfully highlighting the need for a more person-centred approach to healthcare.

7

The role of the Nurse Practitioner in specialty areas

Author(s)

Sonja Elia

Affiliation(s)


Keywords

Nurse practitioner, immunisation

Background

A Nurse Practitioner (NP) is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The Victorian NP Program funding currently focuses on applications in aged care, emergency care and chronic disease management. There appears to be less guidance and support for nurses working in specialty areas.

Aim

The aim of the NP endorsement In Immunisation is to enable the Immunisation nursing team at the Royal Children's Hospital to offer a more timely service and provide better continuity of care for patients.


Endorsement as an NP requires successful completion of an approved Masters level program of study, plus the equivalent of three years (5,000) hours full-time experience in an advanced clinical nursing practice level, within the past 6 years. This paper will describe the process involved in obtaining Nurse Practitioner endorsement in the specialised field of paediatric Immunisation.


Departmental and Organisational support for an NP role in immunisation was confirmed. A Masters qualification (NP stream) was obtained in 2008. Completion of monthly Advanced Practice Nurse professional reporting provided evidence of 5000 hours advanced clinical practice. Evidence of academic qualifications and advanced clinical practice was submitted to the Australian Health Professional Registration Agency and NP endorsement was obtained.

Conclusion

The NP profession has come along way since the pilot projects of 1993. The endorsement of NP's in specialty areas continues to be an area for growth, ensuring that specialised health care is consumer focussed and of a high quality standard. Greater awareness of NP Innovations In paediatric health care has the potential to influence other specialty area nurses to pursue this important role In the health care system.

8

Gaining consensus in multidisciplinary research: use of the e-Delphi technique.

Author(s)

Chris Williams

Affiliation(s)

The Royal Children’s Hospital, Paediatric Integrated Cancer Service

Keywords

consensus methodology, electronic

Background

Undertaking consensus research amongst busy multidisciplinary teams within and across sites can be timely, expensive and is traditionally associated with high levels of attrition. Using face-to-face meetings raises societal and contextual factors that influence the ability to achieve consensus.

Aim

To test and generate knowledge of a consensus methodology process that could be successfully used to guide future initiatives in multisite research.


E-Delphi consensus methodology was chosen to set priorities in developing context-appropriate information for nurses providing paediatric oncology telephone triage and advice (TTA). Strict sampling of an expert panel of 65 multidisciplinary participants from two paediatric hospitals was performed. Three iterative rounds of surveys aimed at prioritising symptoms experienced in this population were built into an electronic data capture tool (REDCap) and distributed via email to use via computer or smartphone.


The three-round process of surveys (data from each round was collated and sent back out for comment) was completed on time, over a six-week period. Participation rates at each round were 37/65, 32/37 and 29/32, respectively. Fifteen symptoms met a pre-defined consensus level of 75% to progress to round two. Feedback of results from round two enabled the group to independently finalise a prioritised list of the five most important symptoms to develop into TTA guidelines for nurses.

Conclusion

This research was able to demonstrate that using e-Delphi research methodology can provide rapid analysis of information in real time, across multiple sites, result in acceptable levels of attrition and provide equally weighted, participatory democracy in establishing clinical priorities.

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Immunisation in specialist schools: Early findings

Author(s)

Ms Jenny O'Neill, Dr Margie Danchin, Dr Giuliana Antolovich, Dr Sally Lima, Prof Fiona Newell

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, The University of Melbourne, Bendigo Health

Keywords

specialist schools, immunisation, adolescents

Background

The Australian government-funded immunisation program includes school immunisations given in early adolescence. Local councils are mandated to offer this to all schools, including mainstream and specialist schools. Uptake, acceptance and delivery of school-based immunisations in specialist schools in Victoria is not known.

Aim

The aim of this study was to measure uptake and explore the barriers and enablers to delivery of immunisation in Victorian specialist schools for young people with disabilities.


A prospective cohort study was conducted to collect immunisation uptake data from specialist schools in 2017. Twenty-eight (38%) of 74 eligible schools consented to participate. Quantitative data collection is ongoing, and in addition, qualitative findings have been recorded in a journal maintained by the researcher capturing communications with schools and the immunisation sector of the Department of Health and Human Services.


Early findings of this study include: (i) absence of official uptake data from specialist schools due to reliance on Year 7 enrolment data which does not exist in ungraded schools, (ii) Identification of different support needs for students and staff, (iii) difficulty in determining assent for immunisations to be given when a student has a disability, and (iv) the non-participation of some specialist schools in the school immunisation program.

Conclusion

The provision of immunisations to students with disabilities in specialist school setting is challenging and multi-faceted. An exploration of the logistical, ethical and policy factors that contribute to the provision of this service is vital to ensure that both young people with and without disabilities have the same access to immunisations.

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Parental Experience of Prenatal Diagnosis of Lymphatic Malformation

Author(s)

Zerina Lokmic, Lucie Hallenstein, Tony Penington

Affiliation(s)


Keywords

Prenatal diagnosis malformation

Background

Lymphatic malformations arise during foetal development due to a mutation in the lymphatic endothelial cells.

Aim

The aim of this study was to investigate maternal and paternal experiences associated with prenatal diagnosis of lymphatic malformation.


Parents of 5 children diagnosed prenatally with lymphatic malformation were recruited from the Vascular Anomalies Clinic at the Royal Children's Hospital, Melbourne. Ten in-depth semi-structured interviews were conducted with each parent separately to explore their experiences. Transcribed interviews were coded and thematically analyzed.


Parents experienced prenatal diagnosis of lymphatic malformation as an unexpected and traumatic event. The lack of adequate information and clear care pathway created confusion and added to the difficulty of understanding the impact of the condition on the unborn child and what to expect after the child was born. Parents used the internet as the primary source of additional information. Some parents found that information distressing. Differences between mothers and fathers emerged in terms of roles that each parent played and their emotional responses during pregnancy and the prenatal diagnosis.

Conclusion

Closer connection between obstetric centers and specialized paediatric treatment clinics are suggested to facilitate better understanding of the lymphatic malformation impact on the unborn child and available treatment options after birth.

11

Development of a Childhood Cancer Survivorship Repository

Author(s)

Jess Fullerton, Ruth Harrap, Alice Wheller, Tegan Dunmall, Antoinet Arokiasamy, Amy Shelly, Jane Williamson, Peter Downie

Affiliation(s)

Paediatric Integrated Cancer Service

Keywords

oncology, survivorship, research

Background

The Paediatric Integrated Cancer Service (PICS) Long Term Follow-up Program (LTFP) provides tailored follow-up care to survivors of childhood cancer within Victoria.

Aim

To create a clinical repository of treatment received and clinical outcomes, including physical and psychosocial late effects, of Victorian childhood cancer survivors that will enable benchmarking of clinical outcomes of survivors nationally and internationally, and support interrogation of the data to monitor incidence of late effects.


Potential data entry fields were identified from review of registries and databases. The LTFP clinical repository comprises key data entry fields including treatment details and late complications. Clinical information is obtained from patient medical records by LTFP nurses. Patients’ data is captured on entry and exit into the PICS LTFP.


The repository was built in Access. The repository has 152 fields including the clinical trial protocol, chemotherapy received and cumulative dose, radiation dose/site, genetic and molecular abnormalities, fertility preservation, major clinical events (relapse, secondary diagnosis and death) as well as a systematic physical and psychosocial review of late effects. To date, a small cohort of patients’ clinical data has been entered into the LTFP clinical repository.

Conclusion

As of May 2017, LTFP has 1329 patients referred to the program. The repository is a valuable tool, providing a robust mechanism to highlight late effects within this patient population, and as an information source or starting point for future research. The LTFP will collate clinical data in order to assess the late effects seen within our patient population.

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Using high fidelity simulation to provide Management of Clinical Aggression Training - a pilot study

Author(s)

Marijke Mitchell, Katrina Williams, Fiona Newall, Jenni Sokol, Colin White

Affiliation(s)


Keywords

aggression, simulation, training

Background

Children and young people often exhibit challenging behaviours which can be magnified in the hospital environment. Hospital staff are not routinely trained to understand and effectively respond to aggressive behaviour from patients.

Aim

The aim of this study was to determine if participation in a high fidelity 2 hour simulation training program designed to provide the participants with experience in managing challenging behaviours in a hospitalised young person increase confidence and perceived competence in managing challenging behaviours.


Two separate simulation exercises were delivered in the Simulation Centre utilising a professional actor to play the role of the young person as part of the Management of Clinical Aggression (MOCA) training days. A structured debrief at the completion of each exercise is led by a trained member of the Simulation Faculty.

Participants complete a written survey prior to the commencement of the first simulation exercise and at completion of the simulation training program.


Four training days have been conducted since February 2017 with a total of 79 participants. Preliminary data suggests that more than 70% of participants have experienced clinical aggression as part of their routine work. Following completion of this training participants reported a 20% increase in confidence in managing clinical aggression and 93% stated that they now felt they would be able to manage a situation with clinical aggression. This training format was acceptable to participants with 100% stating they would recommend this training to colleagues.

Conclusion

This study demonstrates that high-fidelity simulation training results in increased confidence in participant’s ability to manage challenging behaviours in the clinical setting.

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Investigating the experience of parents who have given their children enoxaparin at home

Author(s)

Gilmore H, Monagle S, Lima S, Newall F

Affiliation(s)


Keywords

enoxaparin, parental experience, home

Background

Enoxaparin is commonly used for the outpatient treatment and prevention of paediatric thrombosis. Parents are responsible for the safe preparation and administration of enoxaparin when their child goes home; however, little is known about the parental experience of administering enoxaparin to children post-discharge.

Aim

To explore the experience and educational needs of parents whose children require enoxaparin anticoagulation at home.


A qualitative, descriptive methodology employed two focus groups of 12 parents who had administered enoxaparin to their child post-discharge. The groups were facilitated by an experienced moderator. Sessions were recorded, transcribed and thematically analysed.


Parents felt overwhelmed and distressed at the reality of giving their child clexane injections at home. Many reported that they felt insufficiently trained and had particular difficulty preparing the correct dose from manufactured stock solutions. Parents also reported problems with communication, and felt that they were not adequately educated on the practicalities of enoxaparin administration, including the supply of weight-appropriate equipment and dosages and rationale for use of subcutaneous injection catheters versus direct injection, prior to discharge by clinical staff.

Conclusion

Parents felt unprepared and expressed significant trauma when discussing their experience of administering enoxaparin to their child at home. Further research is needed regarding the psychosocial impact of parental administration of enoxaparin post-discharge and the optimal approach to supporting this extension of parent care-giving.

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Recognising deterioration in the Newborn – case studies from the field.

Author(s)

Sloane J & Kinney S

Affiliation(s)

The Royal Children’s Hospital, The University of Melbourne, Victorian Paediatric Clinical Network

Keywords

Newborn, Early Recognition, BirthSuite/Postnatal

Background

Following the success of the Victorian Children’s Tool for Observation and Response (ViCTOR) charts, the Victorian newborn sector requested a set of early warning charts to better assist in the early recognition of the deteriorating newborn. In 2016, two types of ViCTOR Newborn charts were developed and piloted. This report focuses on the ViCTOR Birth Suite/Postnatal (BSPN) chart.

Aim

To describe via two case studies how the development and implementation of the ViCTOR standardised BSPN charts assisted in the detection and management of deterioration in newborns.


The newly designed BSPN chart was piloted in 11 Victorian hospitals from August to November. The trial chart defined, frequency of vital signs and observations, trigger thresholds to prompt intervention and introduced a newborn risk assessment and a spot post-ductal saturation screen prior to discharge.


Case One describes an otherwise well newborn, born at term. In preparation for discharge, 12 hours post birth, a low post ductal saturation was detected promoting medical review and subsequent transfer to a higher level of care for an undiagnosed cardiac condition.

Case Two describes an otherwise well newborn, born at term who at the 3rd set of observations had respiratory distress, prompting medical review and intervention. A diagnosis of Group B Streptococcal was confirmed.

Conclusion

The introduction of a standardised observation and response chart in the BSPN environment has assisted in the earlier detection and intervention of the deteriorating newborn. The finalised BSPN charts have subsequently been released for Statewide use.

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David Danks ‘Leaders in Science’ Seminar: What is supportive care research and is it a helpful construct for clinical inquiry?

Professor Mei Krishnasamy

B.A. RN, MSc. PhD

Mei is Chair in Cancer Nursing at the University of Melbourne and Nursing Research and Education Lead for the Victorian Comprehensive Cancer Centre. She is Honorary Senior Research Fellow at the Olivia Newton John Cancer, Wellness and Research Centre at Austin Health, and at the Peter MacCallum Cancer Centre, and Honorary Professor of Nursing with the Royal Melbourne Hospital. Mei is chief investigator on collaborative grants that focus on improving patient experiences and health care outcomes totaling approx. $13.5m. She is actively involved in the work of the International Society of Nurses in Cancer Care and is immediate past President of the Clinical Oncology Society of Australia and past President of the Cancer Nurses Society of Australia.

The goal of supportive care has been defined as the prevention or treatment of symptoms of a disease, side effects caused by treatments and psychological, social, and spiritual problems related to a disease or its treatment. Also commonly referred to as comfort care, palliative care, and symptom management, supportive care is a broad construct that spans all domains and professional groups involved in the provision of health care. In effect, supportive care is an umbrella term for the essentials of quality care provision. This paper will consider the challenges and opportunities presented by application of the "supportive care" label for clinical inquiry, and will consider a series of questions about the currency and credibility of inquiry labelled "supportive care research" in an era of new opportunities through revised NHMRC and emerging MRFF funding.

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The Push to Pause: optimising theatre staff participation in team timeout

Author(s)

Grace Mercado, Sharon Kinney

Affiliation(s)

The Royal Children’s Hospital, The University of Melbourne

Keywords

Surgical, Safety checklist, Team

Background

The surgical safety checklist (team timeout) is a safety and communication tool prior to surgery. However, there is no standardised process to the way it is implemented within theatre at the Royal Children’s Hospital, Melbourne.

Aim

This study sought to determine the current ways the team timeout was performed regarding team member participation and completion of checklist questions, as well as ascertaining whether the introduction of a physical pause would improve the quality of team timeout performance.


Data was collected through two prospective observational audits – one prior to and following the implementation of a new process to help ensure all staff paused during team timeout. Focus groups were also conducted with theatre staff following each of the observational audits to gain an understanding of their experiences of the team timeout procedure, both before and after the implementation of the pause.


During the first observational audit (n=53), the timeout was mostly initiated by nursing staff with only 26% of the time all present staff respectfully silent and attentive. Common themes of the first focus group included staff frustration regarding the language of the checklist questions not reflecting current processes. The trial of a pause was an opportunity to change current behaviour. The second observational audit (n=50) post “pause implementation” saw anaesthetists initiate the timeout more frequently and staff were respectfully silent 36% of the time with a small increase in the frequency of each individual question being asked. The second focus group showed themes of improved staff awareness of the timeout process as well as showing more respectful behaviours.

Conclusion

By standardising this process, theatre staff’s behaviour changed in relation to participation and respect for each other during team timeouts. This is an improved outcome for both staff cohesiveness and patient safety. Future project work should consider revision of the timeout questions, continue repeated cycles of observational audits and feedback to determine further strategies for improvement.

17

Optimizing alarm safety practices to improve detection of clinical deterioration

Author(s)

Phillipa Cosgrove, Yvonne Enersen, Adebisi Faniyi, Emily Duboisee, Sarjana Muthusamy. Dr Sharon Kinney, Annabelle Santon, RN

Affiliation(s)


Keywords

Alarm fatigue; monitoring

Background

Alarm fatigue can lead to potential adverse effects for patients by nurses taking longer to respond to sounding alarms. Without further investigation around appropriate monitoring and alarm management there is potential for compromised patient safety.

Aim

To determine the number of actionable versus non-actionable alarms in paediatric patients receiving continuous monitoring (cardiac or saturation) and to measure the nurses’ response time to alarms.


The study was a prospective cross-sectional design completed over the month of December 2016 with 80 observational hours in the Koala ward. The researchers counted the alarms and classified as actionable (correctly identifying physiological status and warranting clinical intervention/consultation) or non-actionable (longer than 10 seconds and not requiring an intervention). Nurse response time to turning off the alarm was measured with a stop watch. Data were analysed using Microsoft Excel and summarised using descriptive statistics.


155 patients with 1,510 alarms were recorded providing an average of 18.9 alarms per hour; 5.6% were actionable and 94.4% were non-actionable. The average response time for actionable and non-actionable were 45.2 and 56.7 seconds, respectively. 71.8% of actionable alarms and 80.4% of non-actionable alarms were answered in under a minute. The average response time when a family member was present was 41.4 seconds. The correct age-related alarm settings were selected 65.2% of the time.

Conclusion

Alarms occurred at high rates in a paediatric cardiac ward, the majority were non-actionable and response times were acceptable. Strategies to reduce non-actionable alarms are required; ensuring the correct age-related alarm setting is selected may minimise their frequency.

18

Understanding young people who self-harm – the lived experience of young people in an inpatient mental health service

Author(s)

Samantha Gronow and Dr.Sally Lima

Affiliation(s)

The Royal Children’s Hospital, The University of Melbourne, Bendigo Health

Keywords

Self-Harm, Adolescent, Mental Health

Background

Understanding experiences of young people who self-harm in hospital will help inform and improve practices and care outcomes. However, there is little research conducted around adolescents in the setting of an inpatient ward.

Aim

The aims of this study are to record experiences of hospital from a young person’s perspective and their own personal narrative, and to gain an understanding of how a young person understands the role of hospital in their recovery in order to better design management strategies for young people who self-harm.


Six young people (aged 15-17 years) who consented and met the inclusion criteria were interviewed using a semi-structured informal technique, about their lived experiences inside an acute adolescent mental health inpatient unit. The interviews were transcribed and a phenomenological thematic analysis of the qualitative data was completed.


Several themes were identified, with the overarching theme of feeling “safe” within hospital. The young people identified positive therapeutic relationships as the main positive experience, followed by environment and routine. Negative experiences included feeling as though they were not being heard, or events that triggered distress linked to past trauma. The young people also identified as almost feeling “too safe” within hospital, and acknowledged that it was challenging and stressful transitioning back into the community. The themes found were discussed and related to developmental and psychological theory, including attachment theory.

Conclusion

It was concluded that the young people’s experiences enabled a greater understanding of their experiences within hospital. Implications for practice include a greater emphasis on staff and family education, family therapy, and outpatient supports.

19

The association between Central Venous Catheter placement and Central Venous Catheter related Thrombus

Author(s)

Sophie Jones, Paul Monagle, Warwick Butt, Fiona Newall

Affiliation(s)


Keywords

central venous catheter, thrombosis, risk factors

Background

Over 50% of thromboses in children are related to central venous catheters (CVCs). Recently, an increased focus upon concomitant risk factors for CVC-related thrombosis has emerged.

Aim

To describe the contribution site of CVC placement has upon the incidence and sequelae of CVC-related Venous-Thromboembolism (VTE) in acutely unwell children during their pediatric intensive care unit (PICU) admission.


A prospective cohort study recruited children admitted to a PICU requiring a CVC in the jugular or femoral veins. The study was approved by the hospital ethics committee and informed consent was obtained. Each child had a (blinded) ultrasound of the blood vessel in which the CVC was placed during their admission (Phase I). A second ultrasound was performed approximately 24 months following CVC placement (Phase II).


21.9% of the children developed a CVC-related VTE of which 6.2% (n=2) were symptomatic (both femoral CVCs). This study showed a significantly higher incidence of VTE in children with a femoral CVC at phase II (p=0.002). The incidence of clinically significant Post Thrombotic Syndrome (PTS) in was 1.6% (n=2), occurring only in children with femoral CVCs. Despite 18.5% of children with jugular CVCs having radiologically confirmed thrombosis at Phase 1 (all asymptomatic), none developed clinically significant PTS.

Conclusion

Children with a femoral CVC have a greater risk of residual CVC-related VTE approximately 2 years post-CVC placement. The study demonstrated no risk of clinically significant PTS in children with asymptomatic jugular vein thrombosis. These findings suggest that children with femoral CVCs present a higher risk of clinically significant thrombosis and associated morbidity at follow up 2 years post CVC.

20

An EPIC Challenge

Author(s)

Janine Furmedge

Affiliation(s)


Keywords

electronic medical record, medication safety, clotting factor concentrate

Background

Clotting Factor Concentrates (CFCs) are administered to patients with inherited bleeding disorders to treat or prevent haemorrhage. CFCs are located in Blood Bank at The Royal Children’s Hospital, Melbourne and were therefore incorporated into the transfusion workflow of the new Electronic Medical Record (EMR). In practice, this was complex and prone to confusion.

Aim

To monitor patients receiving CFCs in order to identify safety issues and staff concerns associated with their use within the EMR transfusion workflow.


Use of CFCs within the EMR was closely monitored. Feedback was obtained from clinical staff. Problems and errors were reported via the Victorian Health Incident Management System (VHIMS) and to the EMR team.


Ordering and documentation of CFCs in the EMR was non-intuitive and error prone. Scheduled dosing (e.g. 2 hourly) was particularly problematic leading to staff confusion, multiple orders being placed and missed doses. Other errors included under and over dosing and inability to document administration. Despite several modifications to the EMR workflow, a significant risk of error remained. The workflow requirements for CFCs were in fact more ‘medication-like’ than those required for the transfusion of fresh blood products (e.g. red cells). Once informed of the risks, the RCH Patient Safety Committee supported moving CFCs from the transfusion workflow to the Medication Administration Record. This work is ongoing.

Conclusion

Reporting errors associated with CFCs in the EMR transfusion module was critical in order to highlight a workflow that placed children at risk of error and significant morbidity and to inform and support change.

21

Renal Care in Children with Spina Bifida: A Retrospective-Cohort Study

Author(s)

Ms Jemimah Freeman RN BN(Hons) BPubHlth - The Royal Children's Hospital and The Murdoch Children's Research Institute, Professor Paul Bennett RN PhD - Satellite Healthcare Inc., California, Professor Alison Hutchinson RN PhD - Centre for Nursing Research - Deakin University and Monash Health Partnership, Dr Lilian Johnstone MBBS FRACP - Monash Children's Hospital, Monash Health and The Royal Children's Hospital, Ms Yogarani Jeyakumar RN MN - Monash Children's Hospital, Monash Health, Dr Helen Rawson RN PhD - Centre for Nursing Research - Deakin University and Monash Health Partnership

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, Deakin University, Monash Children's Hospital, Monash Health & Satellite Healthcare, California

Keywords

Spina Bifida, Renal Nursing, Chronic Illness

Background

Spina bifida is a congenital abnormality as a result of a neural tube defect with many affected children suffering renal complications.

Aim

The aim of this study was to explore associations between the nursing care of children with myelomeningocele spina bifida and the progression of renal complications.


This was a retrospective cohort study of the medical case notes of children diagnosed at birth with myelomeningocele spina bifida between 1993-2008 at a Victorian paediatric hospital. To explore changes in practices over time, children were stratified into three 5-year groups: 1993-1998, 1999-2003, 2004-2008. Demographic, hospital admissions, surgery, diagnostic and psychosocial data were recorded. Descriptive statistics were performed and Kruskal-Wallis tests to determine differences between groups.


Forty five cases met inclusion criteria: 53% female; 16% deceased at 2013. Without early intervention using clean intermittent catheterisation, patients experienced increased renal associated complications: urinary tract infections (51%), hydronephrosis (13%), deteriorating neurogenic bladder (27% in age 1-5; 13% in age 6-10), pyelonephritis (13%), and renal/bladder surgery 17.8%. A secondary finding was feelings of anxiety, grief, deconditioning and low self-esteem amongst children. Parents/caregivers experienced anxiety and depression associated with responsibility of caring for the child.

Conclusion

This study provides evidence that nurses providing timely and effective clean intermittent catheterisation can prevent long-term renal deterioration in children with spina bifida. Furthermore, multidisciplinary support and ongoing education for patients and parents/caregivers is paramount in long-term care for children with spina bifida. The importance of folic acid supplementation before and during pregnancy has been proven to prevent neural tube defects.

22

Trends in paediatric medication errors and the influence of a new hospital design

Author(s)

Kinney, S., Newall, F., Cranswick, N. & Manias, E.

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, The University of Melbourne, Deakin University

Keywords

medication errors, hospital design

Background

Children are at high risk of experiencing medication errors. Little is known about the impact of a new hospital design on medication errors.

Aim

To examine reported medication error trends in a tertiary paediatric hospital, and determine the effects of person, environment and communication-related factors on the severity of medication outcomes.


A retrospective clinical audit was undertaken over a five-year period of medication errors submitted to an online voluntary reporting system, between July 1, 2010 and June 30, 2015.


3,340 medication errors were reported, corresponding to 5.39 medication errors per 1000 bed days. The most common patient outcomes related to errors reaching patients that did not cause patient harm (n=979, 29.3%), and errors requiring monitoring or an intervention to ensure no harm occurred (n=1631, 48.8%). The new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95%CI 0.298-0.421, p <0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95%CI 1.028-1.568, p = 0.027) while problems with clinical handover had 2.042 increased odds in causing medication errors associated with possible or probable harm (95%CI 1.652-2.523, p <0.0001).

Conclusion

Future interventions need to focus on encouraging patient and family involvement, facilitating hospital redesign, and improving communication in effort to reduce harm associated with medication errors.

23

'Can I have a check?' RCH Nurses Understanding and Self Reported Practices of Medication Checking

Author(s)

Stacey Richards, Fiona Newall, Sharon Kinney, Meaghan Hawley

Affiliation(s)


Keywords

Medication errors, independent double checking, medication safety

Background

Paediatric patients are at high risk of medication errors, which can have severe consequences. Strategies to decrease medication errors include independent double checking.

Aim

To gain an understanding of RCH nurses’ knowledge and self-reported practices regarding medication checking.


An electronic survey was sent to RCH nursing staff working in clinical roles. Utilising Likert scales, nurses’ understanding of medication checking, self-reported practices of independent double checking and perceptions regarding causes of medications errors were explored. Preliminary data has been summarised with descriptive statistics.


272 nurses completed the survey at the time of this analysis, four days before it closed.

60% of respondents chose the correct definition of the term ‘independent double check’.

Nurses ‘always’ completed all elements of medication checking 69% of the time they were preparing/administering a medication requiring an independent double check. In comparison, when conducting an independent double check of a medication prepared by another nurse, all elements of the independent double check were ‘always’ completed 55% of the time.

Incorrect medication order (57%) and workload stress (55%) were the two most commonly cited contributors to medication errors. Inaccurate independent double check was rated the 6th (of 21) most important contributors to medication errors (35%).

Conclusion

Preliminary findings suggest a disparity in nurses’ practice of completing an independent double check. The checking process appears more thorough when nurses prepare medications for their own patients compared to when providing an independent double check for another nurse. Nurses did not rate an inaccurate double check as being a major contributor to medication errors.

24

Poster Presentations

Throughout the month of September the HELP corridors will be lined with 35 posters for the 2017 Nursing Research and Clinical Innovations Symposium. The abstracts are listed in hanging order with their position number indicated.

25

Poster Book of Abstracts

To reduce harm and pressure areas to hands caused by mitten restraints __________ 27

Implementing the ‘rights’ of the adolescent patient in an inpatient unit _____________ 28

Do you know me? Caring for children with autism spectrum disorder and intellectual disabilities in hospital ______________________________________________________ 29

"Hello My Name Is..." Therapeutic Relationships in a Paediatric Hospital ___________ 30

Education Outreach – A New Approach for Victoria _____________________________ 31

Aiming the scanner: Comparing teaching methods for nurses ____________________ 32

The incidence and assessment of post-thrombotic syndrome in critically ill children two years post-central venous catheter placement _________________________________ 33

Intravenous Immunoglobulin (IVIg) - planned change from Intragam P to Intragam 10 _ 34

SCIG - A new way of life for immunodeficient patients ___________________________ 35

SMS: an effective tool for follow up with young people __________________________ 36

Annual reviews and clinical recommendations in children with cystic fibrosis: an observational audit ________________________________________________________ 37

Neonatal nurses’ utilisation of the Pain Assessment Tool (PAT) score______________ 38

Establishing consensus about the frequency of observations for the well newborn: “That shouldn’t be too hard!” _______________________________________________ 39

The Practice of Routine Post-Anaesthetic Observations at the Royal Children's Hospital ________________________________________________________________________ 40

Implementation of an oxygen cessation algorithm for infants aged 0-24 months with Bronchiolitis _____________________________________________________________ 41

"It's still a big deal": Parent experiences following liver transplantation ____________ 42

The Nurse’s role in the multidisciplinary management of patients on Enzyme Replacement Therapy ______________________________________________________ 43

Australian Rules Football in Children _________________________________________ 44

Long-Term Benefits of Intravenous Epoprostenol in Idiopathic Pulmonary Arterial Hypertension _____________________________________________________________ 45

Reducing anaesthetic risk in children with idiopathic pulmonary arterial hypertension utilising a clinical practice guideline (CPG) ____________________________________ 46

The juxtapostion of end of life care and organ donation in the PICU _______________ 47

Auditing CVAD management in PICU - a fight against CLABSI's ___________________ 48

External Ventricular Drains: How to reduce infections, a systematic review _________ 49

Transmission Based Precautions: Knowledge and Practice ______________________ 50

Paediatric cardiac surgery - who gets the wound infections? _____________________ 51

From abstracts to nurse doctorates: the work of the Nursing Research Department __ 52

26

Travel Tips _______________________________________________________________ 53

An Advanced Practice Nurse roadmap to reduce clinic wait times _________________ 54

Building Capacity: Introduction of a Simulation Fellowship Program _______________ 55

Regional outreach: expanding capacity for telehealth in paediatric oncology care ____ 56

Developing a paediatric oncology care pathway for acute leukaemia _______________ 57

Improving Neonatal CVAD management through targeted education intervention ____ 58

The incidence, assessment and management of mental health issues in young people on anticoagulation therapy secondary to idiopathic venous thromboembolism ______ 59

RCH BEST Practice Program: achieving outcomes for nurses ____________________ 60

27

To reduce harm and pressure areas to hands caused by mitten restraints

Poster location: 1

Author(s)

Melissa Maxey; Fiona Newall

Affiliation(s)


Keywords

Restraint, Hands, Children

Background

Little has been reported on the practice of using crepe bandages as hand mittens, to restrain or prevent a child from interfering with treatment. Pressure injury to hands from crepe mittens is in the top 3 pressure issues for RCH, as reported on the Victorian hospital incident management system (VHIMS).

Aim

This innovation aimed to identify if a practice change could decrease harm caused by restraining children’s hands, and be acceptable to staff.


Dolphin Ward nurses ceased the use of crepe bandages to restrain or prevents children’s interference with treatment. Instead, nurses applied a 2-way stretch bandage for this purpose, allowing for greater range of hand and finger movement. A product change evaluation form was distributed to staff to assess their knowledge of and satisfaction with this product’s performance.


After 3 months of using the new technique, 54% (n=44) of staff completed the evaluation form. 100% of respondents reported this innovation was exceptional or superior to using a crepe bandage based on ease of use, ease of removal, patient having some movement of fingers and hands and no signs of pressure areas. All respondents recommended continued use of this product and only 4% felt they would require further education on this innovation. The VHIMS has shown a decrease in reported incidents of harm caused when restraining hands since implementation of this innovation.

Conclusion

This clinical practice innovation successfully met staff expectations of a restraint device, with 100% of staff responses indicating their preference for this innovation over the current accepted practice.

28

Implementing the ‘rights’ of the adolescent patient in an inpatient unit

Poster Location: 2

Author(s)

Melissa Anania and Fiona Newall

Affiliation(s)


Keywords

Adolescent inpatient rights

Background

The Australian Charter of Healthcare Rights covers seven basic rights including: access, safety, respect, communication, participation, privacy and opportunity to comment. These rights are pivotal to family centred care at The Royal Children’s Hospital (RCH). This study will determine how these rights impact adolescent inpatients.

Aim

This study investigates how patient’s rights are valued by nursing staff and patients on an adolescent ward at RCH. Identifying and acknowledging the rights of adolescent patients and changes that need to be implemented in clinical practice to maintain best practice.


This qualitative study will identify themes arising from individual adolescent patient interviews and nursing staff focus groups. A sequential analysis process will be followed to code themes and subthemes that emerge. Themes will be compared and analysed against the Australian Charter of Healthcare Rights.


Adolescent patients and nursing staff identified rights consistent with the Australian Healthcare Charter. Privacy, respect & advocacy were key themes for adolescent patients. Holistic, caring and sensitive communication was valued by both groups. Communication considerations for empowering and engaging adolescent patients and the importance of building trust & rapport were highlighted. Further themes for nursing staff related to differences in patient cohorts, acute versus chronic illnesses and ethical challenges in managing emerging patient autonomy versus adult opinion.

Conclusion

Communication is a key theme for both adolescent inpatients and nursing staff. Nursing staff are leaders in implementing and maintaining adolescent patient rights. The voice of individual adolescent patients’ needs to be acknowledged to inform best practise.

29

Do you know me? Caring for children with autism spectrum disorder and intellectual disabilities in hospital

Poster Location: 3

Author(s)

Emily Cull, Sally Lima, Sharon Kinney

Affiliation(s)


Keywords

Autism, Intellectual Disability, Patient Care

Background

The number of children with autism spectrum disorder (ASD) and intellectual disabilities (ID) continues to increase. These children require additional considerations during hospitalisation (eg. sensory processes and communication barriers), yet this is rarely incorporated into care and there is little evidence to guide practice.

Aim

To understand the attitudes of staff working in an inpatient ward caring for children with ASD or ID and the experiences of the parents of these children during admission.


Staff were surveyed using a tool with 4 point Likert scale questions on their experiences caring for patients with ASD and ID. Parents of children with ASD or ID were interviewed on their experiences.


A total of 54 nurses, 8 doctors and 9 allied health completed the survey. While 74% of staff felt confident caring for children with ASD or ID, only 16% believed there were enough resources to facilitate these patients’ care and 19% were aware of the clinical practice guideline (CPG) on ASD and ID. Parent interviews (n=13) highlighted the provision of great care with suggested improvements around individualising care. Parents often felt their suggestions were not being listened to, frequently identifying that “no one asked.”

Conclusion

Staff identified the need for more resources and better promotion of the current CPG may improve care. Parents want to be listened to and involved in decision making. These findings will inform the development of an admission tool to gather appropriate patient information that helps to individualise care and improve the experiences of patients and families.

30

"Hello My Name Is..." Therapeutic Relationships in a Paediatric Hospital

Poster Location: 4

Author(s)

Henry Clark, Elsa Sorensen, Sora Gwak, Jack Snowball, Ananta Homagain, Sally Lima, Melisa Glogolia

Affiliation(s)


Keywords

Therapeutic relationships, paediatric

Background

Effective therapeutic relationships are a key contributor to successful clinical outcomes. However, little research has been conducted on this in the paediatric setting.

Aim

To investigate how successfully staff and volunteers build therapeutic relationships, and to identify the qualities patients and families consider to be most important in therapeutic alliance.


Face-to-face interviews were conducted with patients and families using a survey instrument, which consisted of 16 Likert-scale statements and an open-ended question. Patients' and families' responses were inputted directly into an online survey tool. Descriptive analysis was performed on categorical data, producing frequencies (n) and percentages (%). Content analysis was conducted on the qualitative data.


102 complete responses were obtained. Responses to Likert-scale statements demonstrated that staff and volunteers were rated very highly in their abilities to build therapeutic relationships. In 15 of the 16 statements, at least 90% of responses were positive. A statement focusing on task-orientation produced a broader range of responses. From the open-ended question data, in addition to interpersonal qualities traditionally associated with therapeutic relationships, "positivity" was a novel quality that emerged. Furthermore the category of "cognitive and professional attributes", incorporating professionalism and clinical competence, emerged as a prominent factor in the conception of the therapeutic alliance.

Conclusion

The establishment of effective therapeutic relationships in the setting under investigation was strong. In the paediatric setting, a degree of task-orientation is seen as important by parents, aligning to inclusion of professionalism and competence as part of the therapeutic relationship.

31

Education Outreach – A New Approach for Victoria

Poster Location: 5

Author(s)

Helen Codman, Melody Trueman, Ruth Nicholls

Affiliation(s)


Keywords

Education, Outreach, Victoria

Background

Over a quarter of a million Victorian children live in regional and rural areas. Current models of paediatric education delivery do not meet the requirements of allied health and nursing professionals based outside metropolitan Melbourne. As a result of this children are often required to travel long distances to access the clinical expertise they require.

Aim

To scope, develop and deliver a new and unique program offering teams the opportunity to receive education and training in their place of work, based on their identified learning and professional development needs.


A state-wide scoping exercise was undertaken to engage consumers about their desire for tailored education. Flyers were distributed to all existing providers of paediatric care in both public and private domains across Victoria.

Response to this initiative led to the augmentation of a consumer based framework and the development of a sustainable costing model for outreach education provision. Subsequent strategic direction centred on the development and delivery of specific content.


Metropolitan, regional and rural organisations provided feedback and significant common themes were identified from sites similar in size and population served. Of interest, clinicians from the two craft groups demonstrated very different approaches to communicating their needs, reflecting the diversity of their professions.

Conclusion

Response to this innovative new program has been overwhelmingly positive. Program delivery has commenced and initial evaluation demonstrates that recipients rate the content of education received as being of high quality and relevance to their area of practice.

32

Aiming the scanner: Comparing teaching methods for nurses

Poster Location: 6

Author(s)

Abbey Lee, Clinical Nurse Consultant, Children's Pain Management Service, RCH, Melody Trueman, Director of Nursing Education, RCH

Affiliation(s)


Keywords

Simulation, teaching, nursing

Background

An Electronic Medical Record (EMR), was launched at the Royal Children’s Hospital in April 2016. The potential for drug errors whilst preparing medications can be significant, if not detrimental for patient health. One of the aims of the EMR is to decrease medication errors by introducing bar coding at the time of preparation and administration. Didactic teaching methods were challenged with simulation learning, providing hands on practice with the new scanning equipment in a realistic non-clinical environment, encouraging the development of motor memory skills acquired through practice.

Aim

To determine the effect of simulation learning in comparison to didactic methods of learning while implementing the EMR to nursing staff.


In the months prior to launching the EMR, nurses from the surgical unit (Platypus Ward) participated in dedicated simulation sessions that included the correct methods of medication scanning and administration, in the way they would be doing once the EMR was launched. This was in addition to the didactic teaching sessions provided to all nurses at RCH, where computers and workbooks were used to practice general nursing tasks.


Reports generated through EMR show (12 months since launch) Platypus ward has a combined compliance (medication and patient bar code scanning) of 73% compared to Cockatoo ward (65.5%) and Koala ward (53%).

Conclusion

The results suggest that simulation learning methods to acquire motor memory skills through practice in comparison to didactic learning alone, nurses were more compliant during preparation and administration scanning of medications, therefore potentially decreasing medication errors.

33

The incidence and assessment of post-thrombotic syndrome in critically ill children two years post-central venous catheter placement

Poster Location: 7

Author(s)

Sophie Jones, Paul Monagle, Warwick Butt, Fiona Newall

Affiliation(s)


Keywords

central venous catheter, thrombosis, post-thrombotic syndrome

Background

Central Venous Catheters (CVCs) are associated with over 50% of thromboses in children. Post-thrombotic Syndrome (PTS) is a long-term complication of thrombosis in children, which can impact quality of life. There is limited data regarding the epidemiology of PTS in children with CVC-related thrombosis.

Aim

To determine the frequency and severity of PTS two years following CVC placement in critically ill children and to optimize the scoring criteria for the severity of PTS in children.


205 children admitted to a pediatric intensive care unit (PICU) with a CVC in situ participated in a prospective cohort study. Approximately 24 months after PICU admission and CVC placement, a PTS assessment was performed. Two validated pediatric PTS tools were used independently in conducting PTS assessments: the Manco-Johnson instrument (MJI) and the Modified Villalta scale (MVS).


126 Children underwent PTS assessment. The same 13 children were classified as having PTS using the MJI and MVS. Two children met the criteria for clinically significant PTS using the MJI, whilst the MVS assessed all PTS cases as mild.

Conclusion

The incidence of clinically significant PTS was 1.6% in this cohort, despite 10.3% of children having some degree of PTS. Only the MJI assessed children to have clinically significant PTS, raising the possibility that published estimates of PTS incidence in pediatric populations may overcall the clinical significance of this outcome measure, particularly in younger children. As the MVS is less dependent on measuring pain, it may be more suitable for use in younger children.

34

Intravenous Immunoglobulin (IVIg) - planned change from Intragam P to Intragam 10

Poster Location: 8

Author(s)

Anne Kinmonth

Affiliation(s)


Keywords

Intravenous Immunoglobulin, IVIg

Background

IVIg is manufactured from human plasma and used to treat various illnesses. The Royal Children’s Hospital (RCH) infused over 2,600 bottles of IVIg during 2015 to 2016. In 2016, manufacture of the IVIg product, Intragam P ceased and was replaced with a new product, Intragam 10.

Aim

To develop, implement and evaluate the strategy for changeover of IVIg product administration at RCH.


To attempt a smooth transition a number of actions were planned:

1. A new Intragam 10 blood order set was built into the EMR

2. The RCH IVIg guideline was updated

3. Emails detailing proposed changes to IVIg administration were disseminated

4. Training and education was provided to Nurse Educators

5. Patient information for IVIg was developed

6. An audit of IVIg infusion management and outcomes from the EMR


Action items 1 to 5 were completed as planned. 107 infusions audited, with an adverse event rate of 29% (n=29) however only 41% (n=12) of these were reported to the Blood Bank. Of the 12 events reported 59% (n=7) were moderate or severe. 41% of fluid balance charts were accurately completed with respect to Intragam 10 requirements

Conclusion

Evaluation of the development and implementation of a plan for IVIg change of product raised the profile for IVIg at RCH. This may have contributed to some of the adverse events reported. However, the severity of some of these events were moderate to severe warranting investigation. Accuracy of fluid balance charting warrants further investigation.

35

SCIG - A new way of life for immunodeficient patients

Poster Location: 9

Author(s)

Ben Van Dort

Affiliation(s)


Keywords

SCIG, immunoglobulin, immunedeficiency

Background

Subcutaneous immunoglobulin (SCIG) is an alternate way of giving patients immunoglobulin replacement compared with IVIG. Parents are trained to administer SCIG at home. Home administration of SCIG has proven benefits for patients & families.

Aim

Demonstrate the growing need for SCIG at RCH, its benefits and value of utilizing other centres models of care and expertise and adapting them to suit our patient cohort.


The SCIG program at RCH was developed as pilot for immunology patients. An immunology CNC was identified as imperative to adequately care for this cohort and the role has moved from part time to full time due to increasing demand. Overseas centres with established SCIG programs were contacted for advice to ensure the best care could be provided at RCH.


SCIG rather than IVIG reduces hospital admissions and allows patients to receive essential therapy at home. Regularly parents note the improvement in their child's health and quality of life since starting SCIG (currently anecdotal). Results are supported by literature and studies that have been conducted overseas with SCIG programs running much before RCH.

Currently number of patients on SCIG n=42 and successfully ceased SCIG due to disease resolution n=15. There are 22 patients remaining on IVIG which have been offered SCIG but declined (personal preference). Retrospective data supporting growth at RCH will be included in the presentation.

Conclusion

Development of the SCIG program at RCH has been a success, utilizing experience from other facilities is beneficial and positive patient outcomes, impact on hospital access and flow are evident.

36

SMS: an effective tool for follow up with young people

Poster Location: 10

Author(s)

Christine Parrott, Dot Henning, Stuart Cook

Affiliation(s)


Keywords

Hepatitis, vaccination, SMS

Background

Hepatitis B is a largely preventable condition and, if left untreated, can lead to liver disease and cancer. Many at-risk young people have incomplete vaccination histories. However their transience means that it can be challenging to complete vaccination courses.

Aim

The aim of this intervention was to see if YPHS could improve the uptake, and completion, of the three course Hepatitis B vaccinations, by recalling at-risk young people using SMS.


We undertook a clinical audit of historical practice for 2015. From January 2016 we began to use SMS to contact clients. We would text them if: 1) their titre was < 10, 2) to return for next vaccine, or 3) they have past or current infection. We are determining if text messaging increases the rate of return and completion of the Hepatitis vaccination. Data is collected in excel spreadsheets and dates are transferred into Outlook calendars. Initial analyses has occurred through simple calculations.


This project is ongoing. Over 2015/16 we had 174 clients who had a Hepatitis B screen or vaccination. While approximately the same number received the first vaccine in both years, there was a 4% increase in 2016 in those having their second and third vaccine. Of those who returned, 40% stated that it was because of SMS. Overall, Australian born and age 19-24 were the largest groups.

Conclusion

We have seen positive signs that SMS is a useful tool. This is an important step to investigate means of increasing vaccine coverage in high risk groups.

37

Annual reviews and clinical recommendations in children with cystic fibrosis: an observational audit

Poster Location: 11

Author(s)

Charlotte Krones, Clare Pratt, Wisan Kesuma, Natasha Mezhov, Madeleine Rode, Michelle Frans, Judith Glazner, Nicola Reardon, Shivanthan Shantikumar, Jo Harrison, Ajay Kevat

Affiliation(s)


Keywords

Annual review, appointment attendance, clinical recommendations

Background

Multidisciplinary annual reviews are standard practice in patients with cystic fibrosis (CF). In the annual review progress from the previous year is observed and recommendations for treatment for the upcoming year are made.

Aim

To determine the attendance rate and number of recommendations completed at the time of annual review for patients with CF, comparing age, residential distance from hospital and socioeconomic class.


Patients’ (≤18 years old) with CF treated at the Royal Children’s Hospital (RCH) were included in this study. Age, residential distance from hospital, socioeconomic class, attendance at annual review appointment and the number of recommendations completed were measured. Descriptive analysis utilising standard univariate techniques was used.


127 (55.7%) participants attended their annual review. Participants living >300km away from RCH had the lowest rates of attendance. The average number of recommendations made per patient was 3.4 (SD ±1.93) and 54% of these recommendations were followed up from previous year. Participants living 50-100km away from RCH had the highest rates of partially completing their recommendations. While those living 200-300km away had the lowest rates of partially completing their recommendations. Thirteen to fourteen year olds had the lowest rates of attendance and recommendation completion.

Conclusion

Just over half of the patients attended their annual review and only half of the recommendations made during the annual review process were followed up. Use of telehealth, rural clinics and social media/app utilisation could improve both attendance and completion rates of recommendations.

38

Neonatal nurses’ utilisation of the Pain Assessment Tool (PAT) score

Poster Location: 12

Author(s)

Bianca Devsam and Sharon Kinney

Affiliation(s)


Keywords

Neonate, Pain Assessment, Pain Assessment Tool

Background

According to the literature, the PAT score is a reliable, valid and credible tool for assessing neonatal pain, despite its limited testing. No research has been conducted that analyses how nurses utilise the PAT score when assessing pain in ventilated, sedated and muscle-relaxed neonates.

Aim

To determine how nurses' utilise the PAT score when assessing pain in ventilated, sedated and/or muscle-relaxed neonates.


Online surveys (n=63) of neonatal nurses from the Royal Children’s Hospital, Neonatal Intensive Care Unit were utilised to assess the clinical utility of the PAT score. Focus groups were then completed to further explore themes that arose from the survey results.


The majority of nurses found that the PAT score was clinically useful, easy to use, clear to understand, and accurately reflected pain, in neonates that were ventilated and minimally sedated; but not in neonates that were ventilated and heavily sedated or muscle-relaxed. Further investigation revealed that there was confusion about ‘when and how to PAT score’ a neonate, as well as difficulties associated with assessing pain in a muscle-relaxed neonate. The ‘nurses perception of pain’ and the perception that the PAT score was ‘just a number only’ were also key findings. The ‘nurses logic and rationale’ and ‘clinical judgement or critical thinking processes’ were also emphasised when assessing pain in neonates.

Conclusion

More education and clearer guidelines are required to ensure greater consistency in how nurses utilise the PAT score to improve pain management in ventilated and muscle-relaxed neonates. Modification of the PAT score to allow for more reliable pain scoring in neonates that are ventilated, sedated and muscle-relaxed should be investigated.

39

Establishing consensus about the frequency of observations for the well newborn: “That shouldn’t be too hard!”

Poster Location: 13

Author(s)

Kinney, S. and Sloane, J.

Affiliation(s)


Keywords

newborn observations, standardising practice

Background

The Victorian Children’s Tool for Observation and Response (ViCTOR) project developed a standardised newborn observation chart suitable for use in birth suite/postnatal (BS/PN). In the absence of evidence as to the most appropriate frequency of observations, and the highly variable practice across the state, consensus was reached to trial hourly for the first four hours of life, then once a shift (eight hourly).

Aim

To examine the utility and appropriateness of the frequency of observations as outlined on the BS/PN pilot chart.


The ViCTOR BS/PN charts were piloted at 11 hospitals in Victoria from August to November, 2016. A multi method evaluation was conducted including chart audit and user surveys of midwives and nurses.


Chart audits (n=401) found the frequency requirements were adhered to well for both the initial four hours (88%) and ongoing eight hourly frequency (88%). Survey responders (n=105) agreed that the initial frequency was appropriate (77%), with the majority agreeing with the ongoing eight-hourly frequency (69%). Some midwives were concerned that the greater focus on observations was a move away from the wellness model of care. An undefined duration for observations, especially for the infant staying multiple days was also highlighted.

Conclusion

A standardised approach based on clinician consensus to frequency and duration of observations in the term well newborn has good clinician acceptability and can reduce variation in practice. The observation plan is considered realistic and feasible for a group of infants where the risk of clinical deterioration is low, but the consequences are potentially severe.

40

The Practice of Routine Post-Anaesthetic Observations at the Royal Children's Hospital

Poster Location: 14

Author(s)

Lachlan Hillman, Sakshi Kalani, Julian Kidon, Francis Rigor, Henry Tran, Professor Fiona Newall and Stacey Richards

Affiliation(s)


Keywords

Routine post anaesthetic observation, Postoperative care, Physiological monitoring

Background

Routine post-anaesthetic observations (RPAO) are important for detecting clinical deterioration in paediatric postoperative patients. There is a paucity of evidence regarding the practice of RPAO in paediatrics.

Aim

To describe the current practice of RPAO at The Royal Children's Hospital (RCH) and determine if documentation of RPAO adheres to the RCH clinical guidelines.


A cross-sectional observational study was conducted over a two-week period using a convenience sample of 94 paediatric patients (≤18 years). Data collection included: the time patients were ready for discharge from PACU, time of arrival to ward, time of baseline RPAO and use of continuous monitoring. Vital sign data was collected from the electronic medical record. Quantitative analysis was performed using Microsoft Excel.


Baseline observations were completed immediately on arrival to ward 55% of the time. 60.6% of the participants received continuous monitoring. Of the 684 sets of RPAO that should have been recorded as per the RPAO clinical guideline, 434 (63.9%) sets were actually documented. Of the documented vital signs, SpO2 (99%), HR (97%) and RR (91%) were the most frequently documented; with temperature (55%) and blood pressure (50%) as the least likely. Average time between RPAO sets was 30 minutes, irrespective of airway adjunct used intraoperatively.

Conclusion

Documentation for oxygen saturation, heart rate, respiratory rate, and time between RPAO sets closely mirror the recommended guidelines. This is the first Australian study to describe the practice of paediatric RPAO and it provides a blueprint for future research.

41

Implementation of an oxygen cessation algorithm for infants aged 0-24 months with Bronchiolitis

Poster Location: 15

Author(s)

Samantha Dowdney, Joanne Bastow, Nicole Rumanang, Tsz Lam Cheung, Keon-Ho Lee, Zhaoqi Yuan, Sharon Kinney, Helen Codman, John Kemp

Affiliation(s)


Keywords

Oxygen Weaning, Oxygen Cessation, Bronchiolitis

Background

The lack of clarity about the role of the nurse in weaning oxygen and a lack of clear guidance how to wean oxygen has contributed to prolonged unnecessary oxygen administration. Recently, clinical guidelines at RCH have been updated to provide better guidance about managing oxygen therapy in infants with bronchiolitis.

Aim

To determine the suitability of a new oxygen cessation algorithm designed and implemented by nurses at the RCH.


Nurses on the Sugar Glider and Dolphin Wards were briefly educated about the oxygen cessation algorithm. Patients less than 24 months of age with a primary diagnosis of bronchiolitis, receiving low flow oxygen therapy, were audited during April 2017. Data was collected about the duration of oxygen therapy, the person responsible for initiating the weaning of oxygen, actual oxygen saturation (SpO2) measurements and adherence with the frequency of observations described in the algorithm.


18 patients met the inclusion criteria and data was collected on 28 oxygen cessation attempts. Only 15% of cessation attempts had all the required observations recorded as specified by the observation regime outlined on the algorithm, with the poorest adherence at 30 minutes post cessation. In 29% of cases, patients did not meet the criteria indicating that they were ready to wean prior to the attempt taking place. Nurses initiated weaning 21% of the time, with an average SpO2 concentration of 98% prior to the attempt taking place.

Conclusion

Adherence to the algorithm was poor and determining the patient’s readiness to wean was inconsistent. The high SpO2 readings prior to discontinuing oxygen suggest that many patients received unnecessary oxygen. Revision of the algorithm and greater promotion of the clinical guidelines are required.

42

"It's still a big deal": Parent experiences following liver transplantation

Poster Location: 16

Author(s)

Alex Hodgson, Fiona Newall and Sally Lima

Affiliation(s)


Keywords

Parents lived experiences

Background

A key to improving the outcomes of paediatric liver transplantions is to understand the impact that transplantation has on the parent and family functioning. Qualitative research is important to provide an in-depth understanding of the parent experience, which can can improve the fovus and implementation of clinical interventions to improve patient outcomes.

Aim

To better understand the experience of parents following a child's liver transplant.


A phenomenological approach was used to achieve a rich and detailed description of parent experiences. 7 mothers and 1 father of children who had undergone liver transplant 18 months before the study were recruited from The Royal Children's Hospital, Melbourne. In-depth individual interviews were audiotaped and transcribed verbatim. Transcripts were anaylsed and conceptulised until thematic saturation was achieved.


The parents described their experiences as difficult and challenging. Key themes included (1) trauma and coping, (2) not being prepared, and (3) moving forward. Significant findings focused on the psychosocial challenges parents faced and the positive benefits parents gained from peer support. Moreover, parent descriptions of their experiences highlighted references to symptoms of posttraumatic stress, which previous research suggests is an outcome risk for parents caring for a child following a liver transplant.

Conclusion

The Liver and Transplant Clinical Nurse Consultants are ideally placed to improve support for parents, by conducting psychosocial assessments of parents pre-transplantation, and assisting in the introduction of a peer- support group for parents.

43

The Nurse’s role in the multidisciplinary management of patients on Enzyme Replacement Therapy

Poster Location: 17

Author(s)

Maria Normoyle

Affiliation(s)


Keywords

Nurse, ERT, management

Background

Enzyme replacement therapy (ERT) provides an artificial enzyme to replace the deficient enzyme in some Metabolic conditions. ERT is funded by the Australian Government under the Life Saving Drugs Program (LSDP). Access to treatment is strictly governed and requires annual reporting of outcomes.

Aim

This report highlights the role of the advanced practice nurse in supporting the management of children within the LSDP.


The Metabolic Clinical Nurse Consultant liaises between the family, the clinical teams, community health services and LSDP. They provide nursing leadership within the multidisciplinary team to ensure seamless appointments and treatments. Consultation with the family enables the identification and provision of support that fosters communication and adherence to the treatment regime.


In 2015, 11 patients were treated with ERT at the Royal Children’s Hospital (RCH), with this number growing to 16 patients in 2017. Complex care provision is required, as patients on ERT treatment attend RCH weekly or fortnightly for Intravenous (IV) treatment and have 10-48 sub-speciality appointments.

Conclusion

ERT is time consuming; it requires the patient and family to attend the hospital regularly for IV infusions and for specialists’ appointments to monitor treatment effectiveness.

Given the increase in the number of patients and predicted increase in the number of disorders for which ERT will be available, the nurse’s role has become pivotal to maintaining quality of care experience for this group of complex patients.

44

Australian Rules Football in Children

Poster Location: 18

Author(s)

Helen Jowett, Leopold Simma, Cameron Palmer, Warwick Teague

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, The University of Melbourne, Monash University, Melbourne

Keywords

Australian Rules Football, Injury, Concussion

Background

Australian Rules football (known eponymously as AFL) is a fast-paced contact sport using minimal protective equipment. In many states, AFL outranks all other sports in terms of ED presentations and hospital admissions; it has been suggested that injury rates are higher for AFL than any other code. However, no recent epidemiology has been published.

Aim

To evaluate patterns in hospital-treated AFL-related injuries at a large paediatric hospital, and to compare the hospital-related burden of injury to that of other team ball sports (TBS).


ED presentations data between January 2009 and October 2015 was obtained. Demographics, epidemiology and injury diagnoses for AFL and other TBS were reviewed. For admitted patients, data was supplemented by Trauma Registry data.


521,790 ED presentations were reviewed; 10,003 presentations were TBS-related, including 4,751 AFL-related presentations. 529 AFL patients were subsequently admitted, including 70 severely injured patients.

The incidence of AFL injury increased with age. AFL accounted for one in six ED injury presentations amongst 14-15 year olds, and nearly 10% of injury admissions in patients aged over 16.

The most frequently assigned injury diagnosis for AFL presentations was concussion (363 patients). AFL players were twice as likely to present with either head injury (OR 2.3) or abdominal injury (OR 2.2) compared to other TBS presentations.

Conclusion

AFL is a common cause of ED presentations and results in substantial morbidity. Previously suggested strategies for reducing injury risk such as helmets and rule modification for younger players should continue to be encouraged.

45

Long-Term Benefits of Intravenous Epoprostenol in Idiopathic Pulmonary Arterial Hypertension

Poster Location: 20

Author(s)

Tegan Dunmall

Affiliation(s)

The Royal Children’s Hospital, Lung Foundation Australia

Keywords

Pulmonary Arterial Hypertension

Background

Medical therapy for patients with idiopathic pulmonary arterial hypertension (IPAH) has improved outcomes, including functional status and quality of life. Despite these advances, patients with IPAH have considerable morbidity with many life altering challenges.

Aim

A case study to outline the longitudinal clinical outcomes of a patient with IPAH.


Observational study of a patient over the last 23 years.


TD was diagnosed with IPAH in 1995 at the age of 6, presenting with symptoms of syncope, dizziness and shortness of breath. With no effective therapies available in Australia, the median life expectancy for affected children was less than one year from diagnosis. She was commenced on Diltiazem with an initially good result, several years later developing symptoms of heart failure. She improved somewhat with the addition of Bosentan in early 2001, but remained highly symptomatic.

In late 2001 she was placed onto intravenous Epoprostenol via centrally inserted Hickman catheter and placed onto the wait list for lung transplantation. Within a few months the changes were profound; no further syncopal episodes, her exercise tolerance increased and she was able to return to school.

Although not symptom free, TD now faces the challenges of her disease and the side-effects of her medication in such a way that she exceeds the expectations of a patient with IPAH. With strict medication management, self-observation and attention to detail, TD is able to work as a Clinical Nurse Specialist in Oncology, has a passion for international travel.

Conclusion

The use of intravenous Epoprostenol combined with appropriate self-care has allowed TD to lead a busy and independent life over many years.

46

Reducing anaesthetic risk in children with idiopathic pulmonary arterial hypertension utilising a clinical practice guideline (CPG)

Poster Location: 21

Author(s)

Michelle Rose, Peta MA Alexander, Bronwyn Norman, Robert G Weintraub

Affiliation(s)

The Royal Children’s Hospital, Murdoch Childrens Research Institute, Boston Children's Hospital, Boston MA, USA.

Keywords

Pulmonary Arterial Hypertension, Clinical Practice Guideline, Anaesthesia

Background

Children with Idiopathic Pulmonary Arterial Hypertension (IPAH) are at increased risk when undergoing interventions requiring general anaesthesia (GA) & procedural sedation (PS). Complications, including death are more prevalent in this unpredictable population, prompting the development of a clinical practice guideline (CPG).

Aim

To undertake a review of clinical outcomes and the effectiveness following implementation of a service-specific CPG, for IPAH patients from a single tertiary centre (RCH Melbourne).


Data was retrospectively collected on patients diagnosed with IPAH across 3 distinct eras defined by the availability of PH targeted therapies and CPG implementation, from 1980 - 2016. Data included basic demographics at time of intervention with anaesthesia, severity of IPAH, symptoms, medication utilization, type of procedure, imaging and haemodynamic measurements, as well as CPG usage. Major complications were defined as death, unplanned intensive care, cardio-pulmonary resuscitation, ECMO, intubation and pulmonary hypertensive crisis.


41 patients underwent a total of 107 interventions with GA or PS. Mortality at 30 days post intervention in patients without access to PH therapies was 12%, reducing to 4.8% in those on PH therapies. Since CPG implementation in 2013, no deaths have occurred. Whilst there has been a reduction in mortality since implementation of a CPG, the incidence of major complications has remained consistent despite worsening disease severity in this high risk cohort.

Conclusion

Mortality and morbidity has reduced over time as children undergoing intervention with advanced disease has increased. Implementation of a specific CPG developed by the PH service APN's, has promoted institutional awareness, education and improved clinical outcomes.

47

The juxtapostion of end of life care and organ donation in the PICU

Poster Location: 22

Author(s)

Samantha Murphy

Affiliation(s)


Keywords

organ donations, experiences, nurses

Background

Sparse literature is available that explores the experiences of PICU nurses when caring for potential organ donors. The literature that is available focuses predominantly on the Donation after Brain Death (DBD) pathway, with some studies on the Donation after Circulatory Death (DCD) pathway . No studies were found that compared these two pathways.

Aim

The aim of this study was to explore the experiences of PICU nurses when caring for potential organ donors.


This study was completed using a qualitative, exploratory methodology. Three focus groups were conducted. The findings were then analysed using thematic analysis.


Three main themes were identified from this study - 1) nurses' perceptions of death and organ donation, 2) communication and 3) caring. Fundamentally what this study showed was how passionate PICU nurses are about providing the 'best death' and end of life care experience to their patients and their families. Though they had predominantly positive experiences, there was still a lot of anxiety surrounding raising organ donation with families and the difficulties in optimising a potentially unstable patient for the purposes of organ donation. The nurses highlighted how stressful it can be as the bedside nurse when discussions with families are delayed as they are unsure of what they should say if questions are asked. Overall, the nurses showed a deep sense of care and compass ion towards their patients and their families and a desire to do best by them.

Conclusion

This study demonstrated a deep seated need by nursing staff to provide patients and their families with the best possible experience during the end of life care process. Anxiety surrounding how staff communicate w ith each other and the families highlights a need to provide education and support to nursing and medical staff. Ultimately, the priority it caring for the patient and their family to the best of their ability and support them to make the best decision possible for them.

48

Auditing CVAD management in PICU - a fight against CLABSI's

Poster Location: 23

Author(s)

Hayley Farr, Sarah Duncanson, Grace Larson, Chloe Delianis

Affiliation(s)


Keywords

CVAD, Rosella, CLABSI

Background

CLABSI (Central Line Associated Blood Stream Infection) rates in Rosella are increasing. In order to reduce rates and guide education, CVAD (Central Venous Access Device) maintenance was audited.

Aim

To identify knowledge or skill deficits related to CVAD maintenance amongst Rosella nursing staff.


30 nurses working in Rosella, PICU, were audited on CVAD practice associated with access/management, medication preparation/administration, and infection control. An audit tool was developed and nurses were chosen at random. Audits were completed from December 2016 to February 2017 across all shifts on stable patients.


41% of nurses scrubbed the hub and allowed it to dry before accessing. 93% of nursing staff added a smart site to appropriate CVAD ports. 96.7% of CVAD’s had a dressing which was clean, dry and intact.

Use of critical micro aseptic fields occurred 27% of the time. 80% of nurses used a drawing up needle to decant medication from an ampoule and 44% of staff swabbed the vial top prior to access.

Hand hygiene moments in which staff were least compliant included moments 2, 3 and 5. Bare below the elbows was evident in 36% of nurses, with the least compliance on night duty. 87% of staff kept lanyards clear of medication preparation and 40% had clutter free desks, which are predominantly used for medication preparation.

Conclusion

In order to improve patient safety, further education of nursing staff needs to be undertaken in the following areas;

Scrubbing the hub, using micro critical aseptic fields for preparation of medications, practice for decanting medications from vials and ampoules, and hand hygiene related to CVAD access and management.

49

External Ventricular Drains: How to reduce infections, a systematic review

Poster Location: 24

Author(s)

Rachel Purdue

Affiliation(s)


Keywords

External Ventricular Drain, ventriculitis, catheter- related infection

Background

The research was to review the management of the External Ventricular Drains (EVD’s) to investigate ways of reducing the risk of infection in patients. During the amalgamation of two different hospital wards it became apparent that different management protocols for patients with EVDs was used with a variance of success.

Aim

The aim of the study was to review current literature with the intention of informing current nursing practice in the management of EVD's.


For this systematic review, initially 2 databases were searched to get relevant articles in relation to the management protocols of EVD and infections. The types of studies considered were quasi-experimental, before and after and cohort. From the 836 articles found, only 27 matched the inclusion criteria. From that group of 27 articles, the articles used in the systematic review were reduced to 13 using the JBI comparable cohort/case control appraisal tool and following the appraisal, 8 articles were found to be cohort studies.


Overall, the results of the review showed a decrease in the infection rate from the treatment groups but it was difficult to make clear comparisons because of the way the results were reported with only 3 papers used the same comparison infection rates per 1000 catheter days. The literature did suggest that poor hand hygiene, regular CSF sampling and the type of dressing used on the exit site could increase the risk of infection but there was no consensus of what would reduce infection rates when a patient has an EVD. Several articles reviewed that investigated a number of interventions, could not conclude which was the most effective way of reducing infection.

Conclusion

The purpose of this systematic review was to find primary research that could show an intervention that could reduce the risk of infection when a patient has an EVD. However due to a lack of high quality research this was difficult to get any kind of consensus. One positive result from the review was that the literature did show a reduced risk of infection when the CSF sampling was only done when a patient is showing signs of infection with a fever, neck pain and irritability.

50

Transmission Based Precautions: Knowledge and Practice

Poster Location: 25

Author(s)

Susanna Bills, Nilani Kathirkhanthan, Fritzie Marmita-Vina

Affiliation(s)


Keywords

Transmission based precautions, hospital acquired infections, adherence

Background

Best practice to reduce incidence of hospital acquired infections (HAIs) is through implementation of transmission based precautions (TBPs).

Aim

Observe healthcare workers' (HCWs) adherence to TBPs before, during and after patient interaction.


An observational study was utilised as this is a quality improvement project. 208 nurses currently employed at a major paediatric hospital in Melbourne completed the online survey and 79 HCWs were audited for adherence to TBP policy.


Of those surveyed, 93 were ward based nurses, 49 clinical nurses and 43 advanced practice nurses. The survey indicated that all nurses responded correctly to performing droplet precautions when vaccinated (n=134). However, only 15.8% correct removal of PPE for droplet precautions (n=23). Six out of eight questions had more than 50% correct responses indicating nurses had a high level of knowledge on TBPs.

Of the 79 HCW-patient interactions audited, adherence to TBP was very low at 17.7%. Out of this, nurses had the highest adherence at 25.5% while doctors were non-adherent (0%). The area of highest non-adherence for nurses was absence or incorrect removal of PPE at 60.8%; for doctors was absence or incorrect donning of PPE at 95.8%; and for allied health was equal for both absence or incorrect donning and removal of PPE at 75%.

Conclusion

The high level of knowledge yet low level of adherence to TBPs indicates a wide gap between HCWs' knowledge and practice of TBPs. Education sessions to all HCWs are recommended to promote correct practice of TBPs.

51

Paediatric cardiac surgery - who gets the wound infections?

Poster Location: 26

Author(s)

Clare Mason, Jane Tomlinson, Sue Scott, May Chan, Fiona Newall

Affiliation(s)


Keywords

Paediatric, cardiac, infection

Background

The number of paediatric patients developing wound infections following cardiac surgery seemed to be increasing, resulting in prolonged hospital admission, exposure to antibiotic treatment and often requiring further surgical intervention to debride the wound. These outcomes negatively impact timely access, excellent clinical outcomes, zero harm and positive experience.

Aim

This study aimed to determine the characteristics of these patients and identify common trends or predisposing factors among this patient group.


A 6-month retrospective audit was conducted, using the electronic medical record to review each patients’ admission. Monthly cardiac surgical lists were used to identify patients undergoing cardiac surgery then patients who developed a wound infection were analysed in more detail.


322 patients had cardiac surgery between May and October 2016, with 28 confirmed wound infections, an infection rate of 9%. Of patients with an identified infection, 54% had a cyanotic condition prior to surgical intervention; 32% remained cyanotic following surgery. 20% of patients were aged less than 30 days at time of surgery, however, this cohort represented 69% of identified infections. Infections were classified into three subgroups; superficial (75% of patients), deep (14%) and organ space (11%). 64% required a wound debridement and 93% were given antibiotics, yet only 25% had microbial growth on swabs.

Conclusion

The most prevalent age for a wound infection following cardiac surgery was less than 30 days of age and the highest percentage of infections were classified as superficial.

Recommendations: future studies employing a case control design will enable improved understanding of the unique patient characteristics associated with infection risk, for whom targeted interventions can be implemented.

52

From abstracts to nurse doctorates: the work of the Nursing Research Department

Poster Location: 27

Author(s)

Sacha Petersen, Naomi Brockenshire, Jenny O'Neill

Affiliation(s)


Keywords

nursing research, higher degrees, supervision

Background

Nurses of the Royal Children's Hospital (RCH) are uniquely supported by a small, yet valuable and highly skilled Nursing Research Department (NRD). This department initiates, facilitates and enables clinically embedded nursing research at RCH.

Aim

The aim of this work is to showcase the remarkable and innovative role of the NRD and its impact on the nursing workforce of RCH.


Historically, it is challenging for clinical nurses to undertake research, due to funding restrictions and lack of support. The structured support offered by the NRD combined with the support they have procured from RCH, as an employer, has enabled greater nurse engagement in research.


The expert clinical supervision of the NRD has resulted in clinical nurses at RCH undertaking and then completing research projects through the BEST Practice Program, Masters by course work and minor thesis, and PhDs. The department also provides, mentorship and career advice and supports nurses who seek funding for competitive scholarships.

The research completed by RCH nurses, supervised by the NRD, has improved the quality of clinical care of children at RCH and the nursing workforce. Three nurse PhD candidates will present their experience of being supervised by the NRD and a sample of the most impactful projects and clinical outcomes to date.

Conclusion

The expertise, passion, innovation and dedication of the NRD of RCH has resulted in significant increase in nurse engagement in research at RCH. The exact value of this department is difficult to quantify but to say it is immense would be an understatement.

53

Travel Tips

Poster Location: 28

Author(s)

Sacha Petersen

Affiliation(s)


Keywords

travel scholarships, site visits, nurse travel tours

Background

The nurses at the Royal Children's Hospital (RCH) are very fortunate to have access to funding for travel scholarships. Applications for travel scholarships can be challenging to compose and travel tours can be daunting to organise.

Aim

To provide practical, thoughtful and useful advice for travel scholarship applications and undertaking a productive and useful travel tour.


Australia is geographically isolated and has a relatively small population. These two factors often mean nurses working within niche clinical areas need to look beyond the borders of Australia for information, experience and resources relevant to their specialty. Travel tours and site visits provide a means to gain this knowledge.


Travel scholarships are offered annually at RCH and nurses are required to plan their travel tour, including making contact with sites they would like to visit as part of their travel application. Planning a worthwhile tour that also meets scholarship requirements can be difficult. How to identify worthwhile site visit objectives and how to translate those objectives into a valuable travel itinerary will be discussed. Specifics on how to write a successful travel scholarship application will be included.

The paper will also include reflections on not only what has been helpful but also a hindrance when travelling to international centres of excellence.

Conclusion

Site tours provide valuable experience and opportunities for networking. This paper will aim to share the experience of a successful travel scholarship recipient who has completed several productive travel tours.

54

An Advanced Practice Nurse roadmap to reduce clinic wait times

Poster Location: 29

Author(s)

Eade, Donna

Affiliation(s)


Keywords

Nurse, waitlist, triage

Background

Many Advance Practice Nurse (APN) roles sit within services with high referral numbers. Patients subsequently experience lengthy wait-times with no face-to-face information or support, and triage relies on the expertise of the referrer. APNs have developed clinical skills and knowledge relevant to their area of practice that could optimize this process.

Aim

To establish a Nurse-led model for assessment and triage that can reduce clinic waitlists and suggest how APNs might improve service provision through its adaptation.


The Royal Children’s Hospital Gender Service (RCHGS) has experienced a significant increase of referrals from 40 in 2013 to 220 in 2016. To reduce wait-time and identify triage candidates, a face-to-face Single Session Nurse-led clinic (SSNac) was established as the first point of contact with the patient.


In 2016, the initial consult into the RCHGS pathway was with a mental health provider and a paediatrician. The wait-time for this consult exceeded 12 months. A SSNac was introduced as the entry point into the clinical service pathway. While we anticipate referral numbers to rise in 2017, with the introduction of SSNac, patients will have their initial consult with an APN within 5 months. SSNac has also established of an efficient triage system with all urgent candidates, prioritorised into the medical pathway. This practice change is being evaluated to assess outcomes.

Conclusion

SSNac is an innovative approach to utilizing specialist APN skillsets to assess patient needs, triage and reduce wait-times. SSNac provides template that can be translated into the role of APNs to guide service improvement.

55

Building Capacity: Introduction of a Simulation Fellowship Program

Poster Location: 30

Author(s)

Amy Johansen, Melissa Heywood, Jo McKittrick, Marijke Mitchell, Laura Marco, Sile Smith, Suzanne Boyce, Angela Crooke, Jenni Sokel

Affiliation(s)


Keywords

Simulation, Inter-Professional, Education

Background

The RCH Foundation funded RCH Simulation Program in June 2015, for 5 years. Three years of funding included Nursing, Medical and Allied Health Simulation fellowships.

Aim

The aim of the fellowship program was to increasing capacity to deliver Simulation-based education (SBE) across the Royal Children’s Hospital (RCH), ultimately to improve patient outcomes, mitigate clinical and human error, and highlight potential latent threats.


The Fellowships, offered for 3 years, involves participating as faculty with the RCH Simulation Team, using a supportive apprenticeship model. Individuals learn how to develop and deliver SBE including technical and communication skills -based training, along with immersive simulation and debriefing. Each participating in a project –either clinical or research based, that will benefit their department and the organisation, with the aim of improving patient outcomes.


To date, the RCH Simulation Fellowship Program has supported 4 nursing, 4 medical, and 1 allied health fellows, representing several RCH departments (Paediatric Intensive Care, Anaesthetics, Emergency, General Paediatrics, Developmental Medicine, Social Work, and the Paediatric, Infant, Perinatal, Emergency Retrieval Service. The Simulation fellowships have resulted in increased departmental simulation activity over 12-18 months, including clinical and communication skills and human-factor training. Simulation Fellow feedback has highlighted an increased awareness of human factors, improvement in self-reflection and communication, and need for inter-professional education.

Conclusion

Simulation fellowships have increased the capacity for inter-professional simulation education across a number of key clinical areas within RCH. The program has also developed a greater connectiveness between departments involved, benefiting ongoing sustainability.

56

Regional outreach: expanding capacity for telehealth in paediatric oncology care

Poster Location: 31

Author(s)

Chris Williams, Nicole Sirianni, Jane Williamson

Affiliation(s)


Keywords

oncology, telehealth, outreach

Background

A RCH telehealth initiative was introduced in 2014 but the total number of encounters in paediatric oncology were small.

Aim

The objective was to promote awareness, build capacity and increase telehealth encounters for regional families, reducing the burden of travel and increasing scope of practice in regional health services.


The existing CNC outreach role was expanded in late 2015 to include dedicated telehealth coordination. A database of patients was developed, including place of residence and potential opportunities of care. Fifteen telehealth clinics were created in 2016, as well as building capacity for consultations outside these times.


For the year 20 17, the nursing role has been able to coordinate the delivery or planning of 178 telehealth encounters, including 62 for chemotherapy (a service unable to be offered prior), 85 surveillance and 31 survivorship reviews. Each encounter saved a n average of 450 kilometers of travel. This innovation has increased annual telehealth encounters by 286% since the start of the new role.

Conclusion

By providing a dedicated role to expand telehealth, the number of encounters has increased. This has supported the objective of providing families access to services closer to home, as well as expanding the scope of practice for regional healthcare providers by being able to deliver chemotherapy locally.

57

Developing a paediatric oncology care pathway for acute leukaemia

Poster Location: 32

Author(s)

Chris Williams, Emma Sayers, Jane Williamson

Affiliation(s)


Keywords

cancer, clinical pathways

Background

Childhood cancer is by definition rare, treatments are complex and surveillance/follow-up is a lifelong process. The need to define high quality care and document explicit cancer care pathways is recognised internationally, and has been set as a priority in healthcare in Victoria.

Aim

To document an evidence-based, best practice oncology care pathway (OCP), tailored to the paediatric context that will be used to minimise variability and improve patient outcomes.


An extensive literature review was undertaken. A wide range of key stakeholders were consulted. Specialised, multidisciplinary healthcare professionals participated directly in iterative draft revisions via a Victorian expert reference group. Where there was a lack of evidence, a consensus opinion was sought from the expert reference group. This process was repeated with interstate expert peer groups until a final draft was obtained.


The final document, the Victorian paediatric OCP for acute leukaemia, is the first to be developed in paediatrics in Australia. It is intended for cancer specialists, health professionals and service administrators. It describes principles of best practice at critical points in the continuum of care. It reflects evolving priorities in defining standards, including supportive care, communication and time-frames.

Conclusion

The Victorian paediatric OCP for acute leukaemia was developed for use by services and healthcare professionals, aimed at ensuring the provision of consistent, optimal treatment and supportive care at each stage of the patient’s experience. The pathway can be used as a tool to identify gaps in cancer services and inform quality improvement initiatives across all aspects of the care pathway.

58

Improving Neonatal CVAD management through targeted education intervention

Poster Location: 33

Author(s)

Sze Wu and Fiona Newall

Affiliation(s)


Keywords

Neonatal Central Venous Access Device, Targeted Education, CLABSI

Background

There were significant incidences of central line associated blood stream infection (CLABSI) and CVAD dislodgement in NICU at RCH between 2015-2016. A need was identified to evaluate nurses' CVAD knowledge and the effect of education in improving CVAD management in NICU.

Aim

This study evaluated nurses' CVAD management knowledge and barriers to best practice in CLABSI prevention and CVAD securement with the aim of developing an educational intervention targeting learning needs identified.


A neonatal CVAD management survey measured nurses' level of knowledge, self-reported competency and perceived barriers to practice in CVAD management. Responses to the survey informed an educational intervention targeting learning needs identified via nursing in-services, reading materials and posters. A follow up survey was administered to reassess nurses' knowledge, self-reported competency and confidence in CVAD management.


68 nurses completed the Neonatal CVAD Management Survey. Nurses perceived themselves as competent in CVAD management. However, 45% of nurses reported CVAD training in NICU had not increased their confidence in CVAD management. Targeted educational interventions were based on two of the key learning needs identified: PICC dressing change and aseptic technique. Barriers to practice emerged from nurses’ responses, including heavy work load, lacking regular training, variation of practice, lacking clear department procedures and difficulty to secure small CVAD. 30 nurses completed the follow-up survey. The education intervention increased nurses' confidence in PICC dressing change (mean= 2.6) (Mean > 2 = confident).

Conclusion

Regular education targeting learning needs could improve nurses' knowledge and confidence in neonatal CVAD management. However, other strategies are needed to overcome some of the barriers to best practice. There is a need to provide standardised departmental guidance to aid standardised practice.

59

The incidence, assessment and management of mental health issues in young people on anticoagulation therapy secondary to idiopathic venous thromboembolism

Poster Location: 34

Author(s)

Fiona Newall, Jodi Hislop, Leah Seneviratna

Affiliation(s)


Keywords

Idiopathic venous thromboembolism, anticoagulation, mental health

Background

Idiopathic venous thromboembolism (iVTE), a rare condition in young people, necessitates anticoagulation therapy (AT) and resultant lifestyle changes. The impact of commencing AT on the mental health of young people has not previously been reported.

Aim

To identify the prevalence of mental health issues in young people diagnosed with iVTE.


This retrospective study identified young people (10-19 years) with a diagnosis iVTE from 2003-2014. Demographic details, assessment data and treatment details were extracted from the medical record. A mental health assessment was defined as any documentation regarding the patient’s mood, specifically symptoms of depression or anxiety.


38 young people were diagnosed with iVTE (median age 15; range of 12-19) with primary diagnoses of deep vein thrombosis (23), pulmonary emboli (10), and combined DVT and PE (5). Six patients had a documented HEEADSS assessment; 3 were referred to the Adolescent Medicine department. A mental health assessment was documented for 23.7% of patients. Three patients had pre-existing depression prior to their iVTE. 11 patients were referred from Clinical Haematology to a mental health service, of which, 54.5% had a documented mental health diagnosis, including the 3 patients with pre-existing depression.

Conclusion

15.8% of young people diagnosed with an iVTE were diagnosed with a mental health disorder, suggesting a higher prevalence of mental health disorders in this sub-population of young people compared to population-based estimates. This study highlights the significant impact iVTE has upon the mental health of young people.

60

RCH BEST Practice Program: achieving outcomes for nurses

Poster Location: 35

Author(s)

Fiona Newall, Sally Lima, Sharon Kinney, Stacey Richards, Meaghan Hawley

Affiliation(s)


Keywords

Nursing, career development, research

Background

For the last 3 years, the Building Evidence with Support to Transform Practice (BEST Practice) program has enabled clinical nurses to have protected paid time (9 days across 6 months) to complete clinical research projects arising from practice. These nurses learn research skills in addition to advanced skills in stakeholder engagement, collaboration, presentation and writing skills and project management.

Aim

The objective of this analysis was to identify outcomes related to career progression experienced by participants of the BEST Practice program.


Across 3 years, 24 nurses completed this program. The career development opportunities experienced by these nurses during and post-participation in the BEST Practice program were reviewed in terms of: i). career promotions attained, ii). enrolment in further academic study, iii). presentations at national/international conferences or other professional development opportunities.


50% of BEST Practice graduates have gone on to be promoted to more senior roles, including roles in Education, Advanced Practice Nursing and Management. 21% of participants have commenced or completed Masters of Nursing qualifications, including Minor Thesis, Nurse Practitioner and Coursework programs. A further 27% of nurse participants have achieved successes such as international presentations of their work, publication in healthcare journals or invitations from professional nursing/healthcare bodies to continue their development.

Conclusion

Completion of the RCH BEST Practice program enables nurses working at the point of care to position themselves competitively for career development opportunities and further supports their development of confidence to embark upon academic studies and professional leadership.

Documents

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