Benchmarks for children’s orthopaedic nursing · PDF fileBenchmarks for children’s orthopaedic nursing care RCN guidance ... of a written care plan or evidence of the care being

Benchmarks for children’sorthopaedic nursing care

RCN guidance

RCN Legal Disclaimer

This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers areadvised that practices may vary in each country and outside the UK.

The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has beenmade to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which itmay be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be causeddirectly or indirectly by what is contained in or left out of this website information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2013 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or alicence permitting restricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publicationmay not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it ispublished, without the prior consent of the Publishers.

Acknowledgements

The RCN Children’s Orthopaedic and Trauma NursesCommunity (CYPOTC) would like to thank all theoriginal contributors for their input in developing thebenchmarks.

Julia Judd (Co-Chair POSIG), Advanced NursePractitioner, Paediatric Orthopaedics, SouthamptonUniversity Hospitals NHS Trust

Elizabeth Wright (Co-Chair POSIG), Advanced NursePractitioner, Paediatric Orthopaedics, SouthamptonUniversity Hospitals NHS Trust

Siobhan Lalor-McTague,Matron for Children’s Services,Royal National Orthopaedic Hospital NHS Trust

Jo Capron, Clinical Nurse Educator for Paediatrics, RoyalNational Orthopaedic Hospital NHS Trust

Nikki Critchley, Senior Ward Sister, SouthamptonUniversity Hospitals NHS Trust

Hannah Brown, Senior Staff Nurse, RN Child, GreatOrmond Street Hospital for Children NHS Trust

Angie Lee,Advanced Nurse Practitioner, PaediatricOrthopaedics and Trauma, Royal Berkshire NHSFoundation Trust

Pauline Heaton, Clinical Nurse Specialist, CentralManchester and Manchester Children’s UniversityHospitals NHS Trust

Carole Irwin, Practice Educator, Orthopaedic andTrauma Surgery, Head and Neck, Great Ormond StreetHospital for Children NHS Trust

Revised May 2013 by the RCN Children and YoungPeople’s Orthopaedic and Trauma Community CoreMembers:

Angie Lee (Co-chair) Paediatric Nurse Consultant,Paediatric Orthopaedics and Trauma, Royal BerkshireNHS Trust.

Jo Payne (Co-chair) Sister, Emergency Department,Watford General Hospital.

Elizabeth Wright, Advanced Nurse Practitioner,University Hospitals Southampton

Julia Judd, Advanced Nurse Practitioner, UniversityHospitals Southampton

Clare Kehoe, Lead Nurse/Named Nurse, Children’sService, RNOH Stanmore

Pauline Heaton, Clinical Nurse Specialist, LeadPractitioner, Spinal Unit, Royal Manchester Children’sHospital

Craig Walsh, Paediatric Orthopaedic Nurse Specialist,Oxford Children’s Hospital

This publication is due for review in December 2015. To provide feedback on its contents or on your experience ofusing the publication, please email [email protected]

R O Y A L C O L L E G E O F N U R S I N G

1

Benchmarks for children’s orthopaedic nursing careRCN guidance

Introduction 2

The benchmarks 3

1 Pre-operative assessment 3

Pre-operative assessment for a child/young person admitted for elective orthopaedic surgery

2 Cast and orthotics care 5

Care of a child/young person in a case

3 Neurovascular assessment 8

Neurovascular assessment (NVA) for a child/young person at risk of developing compartment syndrome

4 Traction 11

Traction application and maintenance for the clinicalmanagement of children with fractures or pre or post-orthopaedic surgery

5 Pin site care 14

Care of pinsites for a child/young person with an external fixator

6 Kirchner (K) wire removal 17

Removal of percutaneous K wires from a child/young person in an outpatient setting, following fixation of a fracture

7 Bone or joint infection 19

Care and treatment of a child/young person with bone or joint infection

8 Spinal cord injury 22

Care of a child/young person following a spinal cord injury

9 Spinal surgery 26

Care of a child/young person undergoing elective spinalsurgery

10 Children in outpatients settings 28

Care of a child/young person in an outpatient setting

Contents

This document provides a portfolio of evidenced-basedbenchmarks, which define best practice in key elementsof paediatric orthopaedic nursing care. They weredevised by a core team of expert, experienced nursesand more recently updated by members of the Childrenand Young People’s Orthopaedic and Traumacommunity to identify the optimal care managementfor children and young people with an orthopaediccondition. The benchmarks are based on the format ofThe Essence of Care (DH, 2001) to help practitioners ‘toidentify best practice and to develop action plans toimprove care’. The statements and indicators are aimedto stimulate discussion, help measure individualpractice and guide staff to review the various issuessurrounding each benchmark. The benchmarks are easyto use and auditable, and can be used to inform, updateand change practice.

This document provides a portfolio of evidenced-basedbenchmarks, which define best practice in key elementsof paediatric orthopaedic nursing care. They have beendevised by a core team of expert, experienced nursesfrom the children and young people’s orthopaedic andtrauma community (CYPOTC) to identify the optimalcare management for children and young people withan orthopaedic condition. The benchmarks are basedon the format of The essence of care (DH, 2010) to helppractitioners ‘to identify best practice and to developaction plans to improve care’. The statements andindicators are aimed to stimulate discussion, helpmeasure individual practice and guide staff to reviewthe various issues surrounding each benchmark. Thebenchmarks are easy to use and auditable, and can beused to inform, update and change practice.

General guidance for the use of thebenchmarks Each benchmark consists of factors which consist oftwo statements. One is the worst case scenario and theother, the ‘gold’ standard.

Indicators of best practice are provided to facilitateteam discussion and consideration to the grading to beallocated.

For example, if the team are able to answer ‘YES’ to eachindicator for best practice, an ‘A’ grade can justifiably begiven. If a ‘NO’ answer is applicable to one or moreindicators of best practice, the team need to decide onthe grade that is most applicable. The comments sectioncan be used to give supporting information to explainthe reason for the allocated grade.

2

C H I L D R E N ’ S O R T H O P A E D I C N U R S I N G C A R E

Introduction

Pre-operative assessment

RO Y A L C O L L E G E O F N U R S I N G

3

Benchmark 1

Scorer name Title Signed

Score

Justify score marked

Score


Factor 2:Practitioner competence

Indicators of best practice for factor 2To stimulate discussion about best practice in yourcomparison group, you may find it helpful to considerthe following:

� knowledge and expertise required for completingscreening and assessment and the process formaintaining and remaining up-to-date

� put in place mechanisms to assess the competenceof the screeners and assessors

� access specialist assessment if required

� document assessment for use by the caring team.

E D C B A

Child/young personis assessed bypractitioners who donot have therequired specificknowledge andexpertise.

Benchmark of bestpractice

Child/young person isassessed by apractitioner who has theknowledge andexpertise, and remainsup-to-date.

Factor 1:Screening and assessment


� assessment of children/young people to identifypotential risk and the initiation of a discharge plan

� adequacy and inclusion of the components of thescreening assessment and what tools are used

� documentation of the screening assessment

� screening assessment is carried out withinacceptable time frame

� inclusion of a manual handling assessment

� evidence base used for assessment is current.

E D C B A

Child/young personis not given theopportunity to comefor a pre-assessmentappointment.


Child/young person tobe admitted for electivesurgery is given theopportunity to come fora pre-assessmentappointment.

1

Pre-operative assessment for child/young person admitted forelective orthopaedic surgery

4


Score


Factor 3:Informing the child/youngperson and their carers


� range of information available and its format tomeet children/young people’s or carers’ individualneeds, such as language, tapes, videos and leaflets

� evidence base for the information

� children/young people’s understanding of theinformation is verified and choices are documented

� record sharing and understanding of information.

E D C B A

Child/young personand carers have noaccess toinformation.


Child/young person andcarers have access toinformation and havethe opportunity todiscuss this with aregistered practitionerat assessment.

Score


Factor 4:Implementation of anindividualised plan


� barriers to the implementation of planned care andhow variance is recorded

� document how the multidisciplinary team isinvolved

� how the parents and child/young person areinvolved

� the requirement to measure for a post-operativebrace or splint.

E D C B A

There is no evidenceof a written care planor evidence of thecare being givenaccording to a plan.

References

Great Ormond Street Children’s Hospital Trust (2002)Pre-admission clinic: family factsheets, London: GOSHTrust.

Lowry L and Lewis V (2004) Redesigning anorthopaedic pre-assessment clinic, Journal ofOrthopaedic Nursing, 8(2), pp.77-82.

Thomas D (1996) Assessing children it’s different, RN,April, pp.38-44.


The assessment leadsto an individualisedplan that is fullyimplemented inpartnership with themultidisciplinary team(MDT), child/youngperson and carers.


5

Cast and orthotics care

Benchmark 2


Factor 1:Education and training


� nurses have attended formal training by a qualifiedand competent practitioner

� nurses have completed practical competencies withannual updates and these are documented

� nurses are trained in neurovascular observations(refer to benchmark 3) and cast complication.

E D C B A

Nurses who have nocast care trainingcare for thechild/young person.


Child/young person iscared for by nurses whohave knowledge andexpertise in all aspectsof caring for a cast.

Score

Justify score markedScore


Factor 2:Patient care


� type of cast – plaster of Paris, synthetic – and itsspecific care

� handling and positioning of cast – upper/lowerlimb, hip spica, broomstick plasters etc

� cast is handled carefully when wet to avoid unduepressure and potential damage

� carry out regular assessment, for example,neurovascular observations, ooze, tightness, sharpedges, whether loose or cracked. Take appropriateaction

� documentation of above

� daily review by MDT, for example physiotherapist,occupational therapist, as needed.

E D C B A

Child/young persondoes not receive carefrom a competent andknowledgeablepractitioner and is notreferred to the MDTteam for additionalsupport.

Benchmark of bestpracticeChild/young personreceives care fromcompetent andknowledgeable nurses andhas access to MDT foradditional care and support.

2

Care of a child/young person in a cast

6


Score


Factor 3:Upper body cast


� type of cast, for example backslab/full, and specificadvice for care

� assist with hygiene and feeding needs. Address theissues of education needs (for example, writing,school attendance), limitations to sports activities

� appropriate aids for immobilising, for example, collarand cuff/sling, appropriate for the type for cast

� education/information needs regardingneurovascular observations and advice on elevatingupper limb(s) when at rest (see neurovascularassessment benchmark)

� documentation of care provided/information givenetc.

� offer coloured cast.

E D C B A

Child/young personreceives minimalcare, teaching anddischarge advice.

Benchmark of bestpracticeChild/young person iscared for by the MDTmeeting all aspects oftheir needs.

E D C B A


Benchmark of bestpracticeChild/young person iscared for by the MDTmeeting all aspects oftheir needs.

Score


Factor 4:Lower body cast


� type of cast and implications to care, for examplelong leg cast, backslab, hip spica

� personal hygiene is attended to by nursing team andtaught to the family

� care needs, particularly manual handling andmobility needs, are assessed, documented andtaught by appropriate practitioner, for examplenursing staff, occupational therapist/physiotherapist

� pressure area care and regular turning of child incast, as appropriate for type of cast, for example hipspica cast

� patient taught safe use of mobility aids byappropriate practitioner

� offer coloured cast and crutches.


7

Score


Factor 5:Orthotics


� the different types of orthotic available

� assessment for measurement and fitting

� type of orthotic, for example brace, splint etc, andimplications for care

� personal hygiene is attended to by nursing team andtaught to the family

� care needs and education, particularly manualhandling, application and mobility needs areassessed, documented and taught by appropriatepractitioner, for example, orthotist, nursing staff,occupational therapist, physiotherapist

� pressure area care and awareness of pressure pointsand turning of child, as appropriate for type oforthotic, for example hip abduction brace

� patient taught safe use of mobility aids byappropriate practitioner.

E D C B A

Benchmark of best practiceChild/young person is cared for by the MDT meetingall aspects of their needs.

Score


Factor 6:Discharge planning


� implement care plan at earliest opportunity, forexample at pre-admission/admission. Dischargeplan is documented

� document and perform the nursing assessmentappropriately, for example, neurovascular observations,ooze, tightness, sharp edges, looseness, cracked cast

� address and evaluate the family’s needs. Give advice(verbal and written) and education and informationabout neurovascular observations, mobility and castcare

� provide care for child by appropriately trained andexperienced MDT.

E D C B A


Benchmark of bestpracticeChild/young person iscared for by MDT anddischarge planning isevident.

ReferencesAltizer L (2004) Casting for immobilization,Orthopaedic Nursing, 23(2), pp.136-41.

Clarke S and McKay M (2006) An audit of spica castguidelines for parents and professionals caring forchildren with developmental dysplasia of the hip,Journal of Orthopaedic Nursing, 10(3), pp.128-37.

Hart ES, Albright MB, Rebello GN and Grottkau BE(2006) Developmental dysplasia of the hip: nursingimplications and anticipatory guidance for parents,Orthopaedic Nursing, 25(2), pp.100-11.

Newman DML (2005) Functional status, personalhealth, and self-esteem of caregivers of children in abody cast: a pilot study, Orthopaedic Nursing, 24(6),pp.416-25.

Prior M and Miles S (1999) Principles of casting,Journal of Orthopaedic Nursing, 3(3), pp.162-70.

Sparks L, Ortman MR and Aubuchon P (2004) Care ofthe child in a body cast, Journal of Orthopaedic Nursing,8(4), pp.231-5.

8


Neurovascular assessment

Neurovascular assessment (NVA) for a child/young person at riskof developing compartment syndrome

Benchmark 3


Factor 1:Education and competence

E D C B A

Health professionalsfail to assess thechild/young person’sclinical need for NVAand have not receivededucation relating tocompartmentsyndrome or training inthe correct use of theNVA tool.

Benchmark of bestpracticeThe health professionalhas received appropriateeducation and training inthe assessment of thechild/young person’sclinical need for NVA, thecompletion of the NVAtool and can demonstrateknowledge relating tocompartment syndrome.

Score



� clinical need for individual neurovascularassessment and the appropriate frequency ofobservations

� ‘best placed’ health care professional to make thedecision for frequency of NVA and the qualificationsor level of experience they possess

� any clinical protocols, guidelines or literature thatexists to guide this process

� training required to achieve knowledge andcompetence relating to this factor, the frequency oftraining updates and how this will be demonstrated.

3


9

Score


Factor 2:Recording and documentation


� educational needs of the health professionalcompleting the NVA tool

� importance of documenting why a part of the tool isnot completed, for example plaster in situ

� legal implications of documenting nursing practice

� who determines interval times for completion of theNVA tool.

E D C B A

The NVA tool isincorrectly or onlypartially completedand there is nodocumentation inthe child/youngperson’s nursingnotes relating to thecompletion of, orfindings from theNVA tool.

Score


Factor 3:Communication and information


� what information the child/young person andparents require and their communication needs

� appropriate format for the information.

E D C B A

The child/youngperson and parentsare not informedabout the necessityof NVA.

Benchmark of bestpracticeThe NVA tool iscompleted correctly andat the predeterminedinterval times, withevidence ofdocumentation in thechild/young person’snursing records ofcompletion and of theclinical findings.

Benchmark of bestpracticeThe child/young personrequiring NVAassessment and theirparents have beeninformed of thenecessity andunderstand therationale for NVA.

10


Score


Factor 4:Clinical action


� optimal clinical action for each indicator of potentialcompartment syndrome

� whether this differs according to experience andqualification of the health care professional

� appropriate health professional from whom thenurse should seek further advice, if neurovascularcompromise is a concern

� action taken if the referral is unsuccessful and theclinical cause of concern remains

� documentation of the event in the medical andnursing notes.

E D C B A

The nurse fails torespondappropriately anddoes not refer ortake clinical actionwhen aneurovascular causefor concern isidentified.

Score




� content of the information given and in what format

� to whom it should be given

� where this should be documented.

E D C B A

There is no evidenceof dischargeplanning relating tothe ongoingneurovascular careof the child.

Benchmark of bestpracticeWhen a neurovascularconcern is identified thenurse takes effective,speedy and appropriateclinical action.

Benchmark of bestpracticeThere is evidence ofdischarge planning anddocumentation relatingto the parents andchild/young personbeing given verbal andwritten informationregarding ongoingneurovascular care.


11

References

Altizer L (2002) Neurovascular assessment, OrthopaedicEssentials, 21(4), pp.48-50.

Dykes PC (1993) Minding the five Ps of neurovascularassessment, American Journal of Nursing, (6), pp.38-39.

Love C (1998) A discussion and analysis of nurse-ledpain assessment for the early detection of compartmentsyndrome, Journal of Orthopaedic Nursing, 2(3),pp.160-167.

McQueen M (2010) Acute compartment syndrome inBucholz R, Heckman J, Court-Brown C and Tornetta P(eds) Rockwood and Green’s Fractures in Adults (7thed). Lippincott Wiliams & Wilkins: Philadelphia.

Scott J and Mubarak MD (1995) Technique of diagnosisand treatment of the lower extremity compartmentsyndromes in children, Operative Techniques inOrthopaedics, 5(2), pp.178-189.

Swain R and Ross D (1999) Lower extremitycompartment syndrome: when to suspect acute orchronic pressure build up, Post Graduate Medicine,105(3), pp.159-168.

Wright E (2007) Evaluating a paediatric neurovascularassessment tool, Journal of Orthopaedic Nursing, 11(1),pp.20-29.

Traction

Traction application andmaintenance for the clinicalmanagement of children withfractures or pre or post-orthopaedic surgery

Benchmark 4


Factor 1:Education and the applicationof traction


� ‘best placed’ health care professional to teach andassess staff competency, depending on thequalifications or level of experience they possess

� clinical protocols, guidelines or literature that exist

E D C B A

Health careprofessionals havenot receivededucation relating tothe application oftraction.


The health careprofessional hasreceived appropriateeducation and trainingin the application oftraction and candemonstrate the skillcompetently.

4

12


Score


� training required to achieve the knowledge andcompetence relating to this factor, the frequency oftraining updates and how this will be demonstrated

� choice of different types of traction and their uses.

Score


Factor 2:Education, the management oftraction and nursing care


� principles of safe practice in the maintenance oftraction (for example safety checks, maintenance oftraction pull, neurovascular status of limb intraction) and the availability of clinical protocols,guidelines or literature

� recognition of deterioration of child/young person’scondition due to immobility

� tools that can assist with the assessment of potentialcomplications of immobility and traction (forexample neurovascular compromise and pressuresores) and the preventative measures that can beused to reduce the risk (for example see benchmarkfor neurovascular care)

� recognition of child/young person’s schooling andpsychological needs whilst in traction

� involvement of play specialist

� ‘best placed’ health care professional to care for thechild/young person in traction

� legal implications of documenting nursing practiceand the frequency of documentation for checkingtraction equipment and of patient clinical reviews.

Maintenance andcare of thechild/young personin traction issuboptimal.

Benchmark of best practiceTraction is safely maintainedand the equipment is regularlychecked. The child/youngperson receives optimal carewhile in traction, withevidence of documentation.

E D C B A


13

Score


Factor 3:Communication andinformation


� what information parents and the child/youngperson require

� appropriate format of the information.

E D C B A

The child/youngperson and carersare not informedabout the necessityfor traction.

Benchmark of bestpracticeInformation about thenecessity for tractionhas been given to thechild/young person andtheir carers verbally andis supported with awritten leaflet, so thatthey understand therationale for treatment.

References

Davis P and Barr L (1999) Principles of traction, Journal of Orthopaedic Nursing, 3 (4), pp.222-227.

Grippen Bryant G (1998) Modalities for immobilisation,cited in Maher AB, Salmond SW, and Pellino TAOrthopaedic Nursing (2nd edition), Philadelphia: WB Saunders.

Hakala BE and Blanco JS (2000) Pediatric femoral shaftfractures, Medscape Orthopaedics and Sports Medicinejournal, 4 (1). www.medscape.com/medscape/OrthoSportsMed/journal

Judd J (2007) Thomas splint traction cited in GlasperEA, McEwing G and Richardson J (2006) Oxfordhandbook of children’s and young people’s nursing, New York: Oxford University Press.

Judd J (2008) Application and care of traction. In: KelseyJ and McEwing G eds. Clinical skills in child healthpractice, Churchill Livingstone Elsevier: Edinburgh.

Nichol D (1995) Understanding the principles oftraction, Nursing Standard, 9 (46), pp.25-28.

14


Pin site care

Care of pin sites for child/young person with an external fixator

Benchmark 5


Factor 1:Screening and assessment


� signs of potential pin site infection through aconsensus of opinion and as described in theliterature

� training needs of the nurse in assessing the patient

� any clinical protocols, guidelines or literature thatexist to guide this process.

E D C B A

The healthprofessional fails toassess correctly forevidence of potentialpin site infection andhas not received therelevant educationand training.

Benchmark of bestpracticeThe health careprofessional hasreceived appropriateeducation and trainingin the assessment forsigns of potential pinsite infection and candemonstrate thisknowledge andcompetence.

Score


5


15

Score


Factor 2:Education


� the provision of information that parents andchildren require

� that information is given in an appropriate format.

E D C B A

The child/youngperson and parentsare not taught thesigns of pin siteinfection or informedas to what actionthey should take if apin infection issuspected.

Benchmark of bestpracticeThe child/young personand parents areknowledgeable indetermining the signs ofpotential pin infectionand understandrationale for promptintervention. They havebeen given an actionplan for treatment if pininfection is suspected.

Score


Factor 3:Evidence, knowledge andcompetence


� literature that supports best practice in pin site care

� availability of a guideline for practice

� frequency for reviewing the guideline.

E D C B A

An evidence basedguideline is notavailable for healthprofessionals toguide their practice.Pin site care isperformed based ontradition.

Benchmark of bestpracticeAn evidence basedguideline for bestpractice in pin site careis available and healthprofessionals candemonstrate knowledgeand competence inperforming pin site care.

16


Score


Factor 4:Clinical care


� rationale for quick and effective treatment of actualor potential pin site infection

� optimal clinical action and drug therapy for earlyand late signs of pin site infection

� documentation of clinical findings and actions taken

� potential for improving practice-based audit findings.

E D C B A

The nurse fails torespondappropriately anddoes not refer ortake clinical actionwhen a pin siteinfection is evident.

Benchmark of bestpracticeWhen a pin siteinfection is evident thenurse takes effectiveand appropriate clinicalaction.

Score




� information that should be given

� format of the information

� documenting that information has been given to theparents and child/young person.

E D C B A

There is no evidence ofdischarge planningrelating to theinformation given to thechild/young person andcarers to manage pinsites at home.

Benchmark of bestpracticeThere is evidence thatdocumentation was given tothe carers and child/youngperson with verbal andwritten informationregarding pin site care.

ReferencesDavies R, Holt N and Nayagam S (2005) The care of pin sites with external fixation, Journal of Bone Joint Surgery, 87-B,pp.716-719.

Judd J (2007) Pin site care cited in Glasper E.A, McEwing G and Richardson J, Oxford Handbook of children’s and youngpeople’s nursing, New York: Oxford University Press.

Lee-Smith J, Santy J, Davis P, Jester R and Kneale J (2001) Pin site management, Towards a consensus: part one, Journalof Orthopaedic Nursing, 5, pp.37-42.

Royal College of Nursing (2011) Guidance on pin care site – report and recommendations from the 2010 consensusproject on pin site care. November 2011. Available at: www.rcn.org.uk/__data/assets/pdf_file/0009/413982/004137.pdf(accessed 27 June 2013). RCN: London.

Santy J (2000) Nursing the patient with an external fixator,Nursing Standard, 14(31), pp.47-52.

Sims M and Saleh M (2000) External fixation – the incidence of pin site infection: a prospective audit, Journal ofOrthopaedic Nursing, 4 (2), pp.59-63.

Timms A, Pugh H Pin site care: guidance and key recommendations, Nursing Standard, September 2012, 5-11; 27(1):50-5.


17

Score


Kirchner (K) wire removal

Removal of percutaneous K wires from a child/young person in anoutpatient setting, following fixation of a fracture

Benchmark 6


Factor 1:Competency and knowledge


� level of experience, education and training needs fora practitioner to be competent

� assessment of the practitioner and by whom

� guidelines and evidence base for practitionerassessment.

E D C B A

The procedure isperformed by aninexperiencedpractitioner with nopaediatric ororthopaedicknowledge andskills.

Benchmark of bestpracticePractitioners removingK wires have paediatricand orthopaedicexperience, areknowledgeable, skilledand competent inperforming theprocedure.

Factor 2:Preparation of child/youngperson and carers


� putting in place evidenced-based guidelines forappropriate selection of children/young people forwire removal in outpatients

� what guidelines exist for appropriate pain relief forthe child/young person e.g. simple analgesia and/orEntonox (gas and air)

� advising parents/carers appropriately on pre-procedural pain relief

� the information needs of the child/young personand their family, the format of the information andthe timing of when to give the information.

E D C B A

The child/youngperson and theircarers do not receiveany informationrelating to theprocedure of K wireremoval.

Benchmark of bestpracticeThe child/young personand their carers referredfor wire removal in out-patients, receive fullverbal and writteninformation on theprocedure to enableinformed consent.

6

18


Score


Factor 3:Procedure


� what evidenced-based guidelines exist for theclinical procedure of removal of K wires in theoutpatient setting

� what evidenced-based guidelines are available forthe pain management and psychological care of thechild/young person

� whether the practitioner has appropriate medicalsupport available if required

� whether a play specialist is available for support anddistraction therapy and there is provision ofappropriate toys

� performing the procedure in a child-friendlyenvironment

� that the child/young person’s notes and X-rays aremade available to the practitioner

� the documentation of the procedure.

E D C B A

The wires are notsafely and effectivelyremoved,traumatising thechild.

Benchmark of bestpracticeA competentpractitioner safelyremoves K wires, thechild/young person’scare is individualised,evaluated anddocumented.

References

Moreton ML, Proctor I, Henderson A, Journal ofchildren’s and young people’s nursingVol 2, Iss 2, 6February 2008, pp.66-76.

Symons S, Persad R and Paterson M (2005) The removalof percutaneous Kirchner wires used in the stabilisationof fractures in children, Acta Orthopedica Belgica, 71,pp.88–90.

Wilson M and Hunter J (2006) Supracondylar fracturesof the humerus in children – wire removal in theoutpatient setting, Injury Extra, 37, pp.313-315.

� the involvement of a play specialist to facilitatechild/young person’s understanding of theprocedure and to engage in distraction therapy.

Score



19

Score


Bone or joint infection

Care and treatment of a child/young person with bone or jointinfection

Benchmark 7


Factor 1:Admission


� admission criteria for a child/young person withsuspected bone/joint infection

� advantages of being admitted to a specialistpaediatric orthopaedic ward with appropriatelytrained and competent nursing and medical staff

� availability of a paediatrician and microbiologist foradvice and support

� knowledge and skills of nursing staff to ensure thatinfection management is explained to thechild/young person and family.

E D C B A

The child/youngperson is admittedto a generalchildren’s surgicalward and cared forby staffinexperienced in themanagement ofbone and jointinfections.

Benchmark of bestpracticeThe child/young personis admitted to apaediatric orthopaedicward and cared for bystaff experienced inmanaging bone andjoint infections.

7

20


Factor 2:Assessment and screening


� format for assessment and screening

� role of the nurse in ensuring that appropriate bloodtests are performed at the appropriate time and theaffected area is X-rayed

� role of the nurse in explaining to the child/youngperson and family the need for furtherinvestigations e.g. bone or ultrasound scans, MRI

� role of the nurse in monitoring vital signs forevidence of infection, the frequency and accuracy ofscreening observations particularly temperatureand neurovascular observations.

E D C B A

Nursing and medicalstaff are notknowledgeable inthe assessment andscreening of thechild/young personwith suspectedbone/joint infection.

Benchmark of bestpracticeNursing and medicalstaff are knowledgeablein the assessment andscreening of thechild/young personwith suspectedbone/joint infection.

Score


Factor 3:Treatment


� the availability of a local evidence based protocol forintravenous antibiotic (IVAB) therapy.

Also, consider if nurses are:

� competent to administer IVAB

� aware of the rationale for resting and/orimmobilising the affected area

� competent in preparing the child/young person forsurgery and in recovery (where appropriate) andexplain the process to the family

� able to recognise deterioration in condition andreport to appropriate health professional.

E D C B A

Nursing staff cannotdemonstrateknowledge aboutthe management ofbone/joint infection.

Benchmark of bestpracticeNursing staff have theknowledge and skill tocare for the child/youngperson with bone/jointinfection and keep thechild/young person andfamily informed.

Score



21



� that the nurse regularly updates child/young personand family on clinical progress.

� that hospital and community multidisciplinaryteams involved in discharge planning should includecontribution of nursing and play staff whereappropriate, to ensure compliance by child/youngperson with antibiotic regime

� that there is evidence of documentation of dischargeplanning in notes, to include the written and verbaladvice given, and provision of contact numbers

� that local protocols for ongoing antibiotic therapyare followed, drugs to take home are ordered and theregime is explained to the child and family prior todischarge

� that a nurse has arranged and explained theoutpatients appointment and rationale for furtherblood tests to family.

E D C B A

Child/young personis dischargedwithout appropriateplanning orinformation.

Benchmark of bestpracticeChild/young person isdischarged witheffective planning andinformation.

Score


References

Burden J and Kneale J (2005) Orthopaedic infectionscited in Kneale J and Davis P, Orthopaedics and traumanursing, pp.217-219.

Faust SN, Clark J, Pallett A and Clarke NMP (2012)Managing bone and joint infection in children. Arch DisChild doi:10.1136/archdischild-2011-301089

Judd J (2007) Acute osteomyelitis cited in Glasper EA,McEwing G and Richardson J, Oxford handbook ofchildren’s and young people’s nursing, New York: OxfordUniversity Press.

Stott NS (2001) Pediatric bone and joint infection,Journal of Orthopaedic Surgery.

22


Score


Spinal cord injury

Care of a child/young person following a spinal cord injury

Benchmark 8


Factor 1:Assessment of injury

E D C B A

The child/youngperson sustaining aspinal cord injury isnot assessed orreferred forassessment.

Benchmark of bestpracticeAll children/young peoplesustaining a potentialspinal cord injury areassessed on the day ofinjury. The level and typeof injury is determined anda referral is made to aspecialist centre whereappropriate.


� a patient receives a full assessment of the initialinjury carried out by a competent practitioner usingappropriate tools to identify potential risks

� guidelines for assessment are available and evidencebased

� injury management is defined and recorded.

� knowledge and expertise for completing screeningand assessment is in place and mechanisms forassessing practitioner competence exists (considerthe ASIA score – the assessment of motor andsensory pathways determined by the AmericanSpinal Injury Association). Specialist knowledge isaccessed if required

� specialist assessment is accessed if required.

8


23

Factor 2:Stabilisation


� a child/young person is immobilised by a competentpractitioner prior to diagnosis in order to preventfurther injury

� appropriate imaging has been carried out and adiagnosis made

� appropriate referral is made

� transfer is in an appropriate ambulance and anystabilisation prior to the transfer is carried out by acompetent practitioner

� staff are appropriately trained to move patient in asafe way, for example, if unstable using a five-person turn.

E D C B A

Child/young personsustaining a spinalcord injury is notimmobilised orstabilised beforetransfer.

Benchmark of bestpracticeChild/young personsustaining a spinal cordinjury is appropriatelyimmobilised and/orstabilised before beingtransferred to aspecialist centre forongoing management.

Score


Factor 3:Acute care and rehabilitationprogramme


� acute care and rehabilitation programmes areindividualised and devised by appropriate MDTprofessionals

� rehabilitation programmes are reviewed andupdated on a regular basis

� a programme has an allocated amount of time forgoal planning meetings with the patient and theirfamily/carer and the MDT

� all members of the MDT communicate and ensurethat spinal cord injury care is a team approach

� patients and their families are able to accessappropriate spinal cord injury education toempower them to take control of their own care.

E D C B A

Children/youngpeople sustaining aspinal cord injury donot have a plannedrehabilitationprogramme.

Benchmark of bestpracticeChildren/young peoplesustaining a spinal cordinjury have anappropriate acute careand a rehabilitationprogramme that isplanned through amultidisciplinaryapproach.

Score


24


Factor 4:Psychological impact of aspinal cord injury

Indicators of best practice for factor 4To stimulate discussion about best practice in yourcomparison group, you may find it helpful to considerthat:

� regular MDT meetings are held to discuss anyconcerns between the family and/or team

� MDT, patients and their families have regular accessto child and adolescent psychiatric andpsychological services

� regular and ongoing assessment is carried out by theMDT

� members of the MDT have the knowledge andunderstanding of the psychological impact of aspinal cord injury

� specialist knowledge is accessed if required.

E D C B A

No consideration isgiven to thepsychological impactof a spinal cordinjury.

Benchmark of bestpracticeThe psychologicalimpact of a spinal cordinjury to the child oryoung person and theirfamily is adequatelyassessed andsupported by anappropriateprofessional.

Score




� discharge planning starts on admission withcontribution from the whole MDT

� assessment of the child and family’s livingarrangements is undertaken early in the admission

� appropriate outside services are accessed early inthe admission

� discharge planning takes into consideration theworst possible case scenario (no improvement ofcondition following rehabilitation)

� discharge planning takes into equal considerationthe psychological and physical aspects of a spinalcord injury, with a MDT approach to resolving bothprior to discharge or arranging follow-up support

� patients are not discharged until adequate servicesare in place and safety can be assured.

E D C B A

There is no evidenceof dischargeplanning.

Benchmark of bestpracticeDischarge planning forchildren and youngpeople with spinal cordinjuries starts onadmission, is thoroughand provides a safe andtimely discharge thatconsiders theirindividual needs.

Score



25

References

Kirk S, Glendinning C and Callery P (2005) Parent ornurse? The experience of being a parent of a technologydependent child, Journal of Advanced Nursing, 51(5),pp.456-464.

National Institute for Health and Clinical Excellence(2005) Post-traumatic stress disorder (PTSD): themanagement of post-traumatic stress disorder in adultsand children in primary and secondary care (clinicalguideline 26), London: NICE.

NHS Institute for Innovation and Improvement (2005)Improvement leaders’ guides, Warwick: NHS Institutefor Innovation and Improvement. www.institute.nhs.uk

Thomas D (1996) Assessing children it’s different, RN,April, pp.38-44.

26


Spinal surgery

Care of a child/young person undergoing elective spinal surgery

Benchmark 9


Factor 1:Pre-operative assessment

E D C B A

Environmentis unsafe.

Benchmark of best practiceEach child or young person has theopportunity to attend a pre-operative assessment appointmentfor elective spinal surgery.

Factor 2:Nursing care plan

E D C B A

There is no evidenceof a care plan or carehas not beenprovided accordingto the plan.

Benchmark of bestpracticeThe child/young person hasa plan of care appropriate toage and need, reflecting thespecific care following spinalsurgery.

Score

Justify score markedScore


9


� that the pre-operative assessment bench mark isreferred to

� that you ensure the patient and the family have fullunderstanding of the procedure, recovery pathwayand post-surgery management

� the involvement of MDT

� the reduction of anxiety by sharing of information

� the requirement to measure for a post-operativebrace or splint

� the start of individualised care pathway.


� the child/young person has undergone pre-operativescreening and assessment

� staff have appropriate knowledge to care of thepatient following spinal surgery, for example logrolling, pressure area care, positioning, bowelmanagement, nutrition requirements, painmanagement, mobilising

� that the neurovascular assessment and cast carebenchmarks are referred to

� involvement of the MDT

� involvement of patients and parents/carers.


27

Factor 4:Post-surgical mobility


� a physiotherapist should work with the patient onmobility practice for the first time following surgeryas per surgeon’s written instructions

� a patient should become mobile as soon as possiblepost-procedure

� if a brace is needed it should be cast and available assoon as possible

� sitting tolerance should be increased gradually

� the patient needs adequate rest between episodes ofmovement.

E D C B A

The child/youngperson is notmobilised in a safeor controlled mannerwith appropriateassistance.

Benchmark of bestpracticeThe child/young person ismobilised post-surgerywith guidance from thephysiotherapist and in asafe and controlledmanner.

Score


Factor 3:Pain management

Indicators of best practice for factor 3To stimulate discussion about best practice in yourcomparison group, you may find it helpful to consider:

� pain history

� whether assessment tools used are appropriate forage and competence of patients

� if pain management treatments are available andused

� the knowledge and expertise of staff and theirongoing development

� access to specialist pain service.

E D C B A

There is no evidenceof appropriate painmanagement.

Benchmark of bestpracticeThe child/young personhas their pain assessedregularly usingappropriate tools and hassufficient analgesiaprescribed.

Score


References

Harvey CV (2005) Spinal surgery patient care, Orthopaedic Nursing, 24(6), pp.426-442.

Kester K (1997) Epidural pain management for the pediatric spinal fusion patient, Orthopaedic Nursing, 16(6),pp.55–60.

Kotzer AM and Foster R (2000) Children’s use of PCA following spinal fusion, Orthopaedic Nursing, 19(5), pp.19–27.

Slote RJ (2002) Psychological aspects of caring for the adolescent undergoing spinal fusion for scoliosis, Orthopaedic Nursing, 21(6), pp.19-31.

28


Children in outpatient settings

Benchmark 10


Factor 1:Environment


� the overall environment, including access forwheelchairs and buggies, separate waiting area withno direct general public approaches and appropriatedécor

� the provision of adequate space for the attendance ofsiblings, play and general extras such as buggies,prams and wheelchairs

� facilities accessible for baby changing and feeding.

E D C B A

The outpatientsetting is notenvironmentallyfriendly to theneeds of the childand young person

Benchmark of best practiceThe outpatient setting hasbeen designed around theneeds of children and theyoung person, with suitabledécor, space, play andfacilities.

Factor 2:Play


� suitable toys/play/entertainment equipment

� provision of a designated play area

� the employment of a play specialist to facilitatechild/young person’s therapeutic play.

E D C B A

The outpatientdepartment doesnot haveappropriate toys orentertainmentsystems e.g. TV forthe child/youngperson and a playspecialist is notavailable to supportthem.

Benchmark of best practiceChild/young person hasaccess to an appropriatewaiting area with a playspecialist and the availabilityof toys and entertainmentsystems for the age rangeseen. Play is usedtherapeutically to support thechild and young person,throughout their visit to theoutpatient department.

10

Care of a child/young in an outpatient setting

Score


Score



29

Factor 3:Staff training


� a children’s trained nurse in each children’sorthopaedic clinic

� staff understanding on the rights of the child and onconsent.

� annual level 1 Child Protection training for all staff

� annual resuscitation training appropriate to the joblevel of the member of staff.

� staff communication with children on a level, and bymeans, best suited to their stage of development andtheir degree of understanding.

� the awareness of the needs of children and youngpeople from other cultures

� the knowledge of how to obtain an interpreter to aidcommunication when required.

E D C B A

The medical andnursing staff in theoutpatientdepartment havenot receivedtraining in the careof the child/youngperson

Benchmark of best practiceThe medical and nursing staffin the outpatients departmenthave received training in thecare of the child/young personand a children’s qualifiednurse is always in attendance.

Factor 4:Management of the clinic


� the level of orthopaedic knowledge required by thestaff running the clinic

� the benefits of staff training in simple informationtechnology to be able to retrieve patients results, forexample bloods, radiology reports

� the benefits of ‘prepping’ patients’ notes ready forconsultation by the medical practitioner.

� information giving to the parents/carers and thechild/young person to keep them informedthroughout their time in the outpatient department.

E D C B A

The staff are notcompetent toeffectively run theclinic and do nothave a clearunderstanding ofthe child/youngperson’s individualor orthopaedicneeds during theiroutpatient visit.

Benchmark of best practiceThe staff are competent in thesmooth management of theclinic and have a goodunderstanding of thechild/young person’sindividual and orthopaedicneeds during their outpatientappointment

Score


Score


30


Factor 5:Patient appointments


� the recommendations in the National ServiceFramework for Children

� barriers to the implementation of theserecommendations.

� benefits to the child/young person and family beingseen in an appropriate clinic setting.

� the privacy and dignity of the child and youngperson (Essence of Care).

E D C B A

The child/youngperson is seen along-side adult patients inthe same generalorthopaedic clinic.

Benchmark of bestpracticeThe child/young person isseen in designatedseparate children’sorthopaedic outpatientclinics.

Factor 6:Treatments


� the types of treatments that the nurse may be askedto perform, for example application of slings, splints,buddy strapping and wound care dressings

� the nurse’s competence in the performance oforthopaedic treatments and the level of nursetraining required

� nurses have good communication skills at theappropriate level for the child/ young personunderstanding to prepare and explain the rationalefor treatment

� the use of pain scoring tools to assess child/youngperson’s pain level

� provision of suitable pain relief for procedures, forexample Entonox

� training of qualified staff to administer pain relief,for example Entonox.

E D C B A

Nursing staff areunknowledgeableabout the carrying outof simple orthopaedictreatments performedin the outpatientsetting

Benchmark of bestpracticeNursing staff have theknowledge and skill toperform appropriateorthopaedic treatments inthe care of thechild/young person in theoutpatient setting

Score


Score



31

References

The Platt report (Report of the Central health servicesCouncil Committee. The Welfare of Children in Hospital(The Platt Report). Stationery Office. 1958

Department of Health (2003) Getting the right start:National Service Framework for Children, Young Peopleand Maternity Services: Standard for hospital services.Department of Health. Stationery Office.

The Health Care Commission (2007) Improving servicesfor children in hospital. Online:www.healthcarecommission.org.uk

Department of Health (2001) The Essence of Care:Patient-focused benc.0hmarking for health carepractitioners. Department of Health. Stationery Office

British Orthopaedic Association (2006) Children’sOrthopaedics and Fracture Care. Online:www.boa.ac.uk/site/showpublications.aspx?id=59

Notes

32


Notes


33

The RCN represents nurses and nursing,promotes excellence in practice andshapes health policies

December 2007Updated December 2013

RCN Onlinewww.rcn.org.uk

RCN Direct www.rcn.org.uk/direct0345 772 6100

Published by the Royal College of Nursing 20 Cavendish SquareLondon W1G 0RN

Publication code 003 209

ISBN 978-1-910066-04-01

www.rcn.org.uk/direct

www.rcn.org.uk

Documents

Benchmarks for children’s orthopaedic nursing · PDF fileBenchmarks for children’s orthopaedic nursing care RCN guidance ... of a written care plan or evidence of the care being