Enhancing a Rehabilitation Pathway for Pediatric Heart Transplant Recipients: An Improvement Project to Increase Adherence, Satisfaction, and Outcomes.

AIMS: To refine a cardiac rehabilitation pathway for pediatric heart transplant recipients; assess clinician knowledge and adherence to the program; and evaluate patient outcomes. METHODS: The center has utilized a rehabilitation pathway for pediatric heart transplant recipients. Challenges in practice include access to centers, lack of data tracing, and adherence to the pathway. The quality initiative focused on program refinements: implementation of text templates to improve data collection, collection of the Pediatric Cardiac Quality of Life Inventory (PCQLI), Functional Independence Measure (WeeFIM) and Child Occupational Self-Assessment (COSA), development of an outreach program, and creation of an educational program for therapists to increase content knowledge and improve clinician satisfaction. RESULTS: In the evaluation of rehabilitation follow-up post-transplant, there was no statistical significance between the pre- and post-implementation groups. After the implementation of the refined pathway, there was an increase in the completion of the six-minute walk test post-transplant (p = 0.048). Clinicians' responses post educational session noted familiarity with the pathway (88%), documentation (78.8%), and outcome measures (97%). Results of outcomes noted improvement in six-minute walk distances and a decrease in the rate of perceived exertion post-transplant. To ensure future pathway adherence, clinical support should be implemented, and key players identified to maintain sustainability.

An Evidence-based Protocol to Improve HPV Vaccine Initiation Rates at a County Immunization Clinic.

Human Papillomavirus (HPV) is responsible for 26,900 cancer cases yearly, including genital and oropharyngeal cancers. Despite providing nearly 100% protection against cancer-causing strains of HPV, only 68.9% of teenagers receive even one dose of the HPV9 vaccine. To increase HPV9 vaccine series initiation rates among 11-14 year-olds. Vaccine rates were examined before and after multi-modal protocol implementation at a nurse-run, walk-in immunization clinic. Initiation increased from 17.9% in 2017 to 35.5% in 2018. Use of same way/same day recommendation practices and inclusion of non-clinician staff could improve quality of care and decrease HPV-related disease.

Implementation of a School-Based Bullying Program.

A bully is defined as anyone who participates in any form of repetitive negative and hurtful behavior, with the intent of inflicting harm (Highmark & Center for Safe Schools, 2013). PURPOSE: The purpose of this project was to evaluate the feasibility of implementing a bullying awareness, prevention, and screening program for teachers and school nurses. METHODS: The sample included 174 fifth-graders from a public-school district in rural, southwestern Pennsylvania. Teachers received an educational program and students were screened for bullying using the PIPSQ. RESULTS: Although not a significant finding, there was an increase in teacher's knowledge post-education (p = 0.515). Although findings were not significant, the results of the PIPSQ revealed greater victimization in this school (M = 6.93), with bullying behaviors greater among boys (p = 0.000). CONCLUSIONS: The educational program and the PIPSQ tool appear to be a promising method to identify victimization and bullying within an elementary school setting; further research can determine significance of screening and faculty education.

Bullying: Effects on School-Aged Children, Screening Tools, and Referral Sources.

Bullying is not a new concept or behavior, and is now gaining national attention as a growing public health concern. Bullying leads to short- and long-term physical and psychological damage to both the victims and the bullies. The serious implications of bullying drive a clinical mandate for teachers and school nurses to be educated and adequately trained to identify and address bullying within schools. This review of the literature describes screening tools that can be utilized to identify both victims and bullies. In addition, referral services utilizing collaborative intervention measures are discussed. This literature review will help school nurses and teachers to identify and expand their role in school-wide bullying prevention and intervention measures.

Development, reliability and validation of a neurogenic bowel dysfunction score in pediatric patients with spina bifida.

OBJECTIVE: To develop a reliable and valid questionnaire to monitor neurogenic bowel symptoms in children. PATIENTS: Thirty-four children aged 6-18 with neurogenic bowel and their caregivers. Eighteen control patients. METHODS: An expert panel generated a domain of observables and formative/reflective content. Response options were scaled following Likert-type items. Key informant interviews revised the measures. A final questionnaire was given to patients twice to calculate intra-rater reliability using Cohen's Kappa Coefficient (k) and paired t-test. Blinded interviews were conducted after physical examination and health assessment and questionnaires completed by a nurse to determine construct validity and inter-rater reliability using k and Spearman's rank-order correlation. Control patients completed the questionnaire once, their results were used to determine discriminate validity and a receiver operating characteristic (ROC) curve. RESULTS: Intra-rater reliability showed 85% of the questionnaires having k >0.6. Paired t-test results of t(33) = 1.997, P = 0.054, d = 0.53, confirmed there was not a significant difference between the scores of the two completed questionnaires. Inter-rater reliability showed 97% of the questionnaires having k >0.6 between the nurse and the patient/caregiver responses. Scores had a strong positive correlation at rs (32) = 0.943, P < 0.0005. Mean score with neurogenic bowel was 15.18(STD ± 5.77) and control group 4.68(STD ± 2.98). ROC analysis showed an area under the curve of 0.9. A score of 8.5 correlated with presence of neurogenic bowel with sensitivity of 94% and specificity of 87%. CONCLUSION: The questionnaire shows positive reliability and validity when used for pediatric neurogenic bowel patients. The questionnaire differentiates between normal and neurogenic patients. Larger studies are necessary to conduct further validation.

Stakeholders Inform an LGBTQIA+ Health Best Practices Learning Module for Nursing Students.

INTRODUCTION: The American Association of Colleges of Nursing (AACN) summons nurse educators to address health care inequities by preparing leaders who advocate for vulnerable groups. A lack of academic guidelines promoting cultural competence in nursing with lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, and asexual and/or aromantic (LGBTQIA+) individuals exist. The purpose of this study was to develop a learning module for health care providers about best practices in LGBTQIA+ health informed by key stakeholders. METHODS: Exploratory qualitative design utilized focus group methodology obtaining stakeholder's views on LGBTQIA+ health, with a convenience sample recruited from a large public university. Focus group thematic analysis informed development of the learning module. RESULTS: Three overarching themes emerged from focus group discussions (n = 31): appropriate terminology, health disparities, and respectful communication. DISCUSSION: This project addresses an educational gap in nursing curriculum using an interactive online module, introducing key concepts about LGBTQIA+ health. Future research focused on the development of standards of care for LGBTQIA+ individuals can support inclusion and reduce discrimination in health care settings.

An evaluation of documentation and follow-up on the use of SBIRT in an outpatient behavioral health clinic through the use of the CRAFFT tool.

BACKGROUND: Substance use among adolescents continues to present as a public health concern. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an effective process that has been proven to identify, reduce, and prevent at-risk use of substances when appropriately applied. The CRAFFT tool is an evidence-based screen used to identify substance use in adolescents aged 12-21 years of age. PURPOSE: The purpose of this project is to assess the rates of substance use in the adolescent population at a behavioral health clinic through the CRAFFT tool while also assessing for provider documentation compliance and overall revenue benefits of SBIRT. METHODOLOGY: A retrospective chart review was used for this practice evaluation. Descriptive statistics were used through assessing frequencies and averages to gain insight not only on the rates of at-risk substance use and documentation compliance, but also on psychiatric diagnoses and medication regimens. RESULTS: Three hundred and forty-one patient encounters were reviewed over a 3-month period. Of these 341 encounters, 63.6% of the visits were in-person and 36.4% were conducted virtually. 72.4% of patient encounters had no documented CRAFFT screen, yet 31% of completed CRAFFT screens were positive for substance use or misuse. For those encounters with no completed CRAFFT screen documented, there was an estimated lost income for potential billings at a rate of $33.41 per encounter for a total of $8252.27. CONCLUSIONS: Substance use and misuse in adolescents continues to exist as a public health concern. The CRAFFT tool can be a feasible means of screening for substance use in adolescents when consistently and longitudinally incorporated.

Infant Immunizations in Pediatric Critical Care: A Quality Improvement Project.

INTRODUCTION: Infants with congenital heart disease can be critically ill; prolonged hospitalization is common. The purpose of this project was to create and then evaluate the efficacy of education programs for staff nurses and medical providers aimed at improving infant immunization administration during hospitalization for congenital heart disease. METHODS: This project used pre- and post-education program chart review to evaluate infant immunization rates at discharge. Pretests and posttests were administered to cardiac care staff to determine knowledge change. Paired t test, chi-square test, and descriptive statistics were used. RESULTS: The pretest and posttest surrounding the education programs indicated significant knowledge change for both groups. Immunization rates were improved before compared with after the education program (60% vs. 88%, respectively). There was significant improvement in immunization documentation on the discharge summary (p < .001). DISCUSSION: The findings suggest that customized education presentations to cardiac care staff can increase the administration of recommended immunizations to hospitalized infants and documentation on discharge summaries.

Policy support for expanding the adolescent vaccine school mandate in Pennsylvania to include the human papillomavirus (HPV) vaccine.

Approximately 27,000 men and women are affected by human papillomavirus (HPV)-related cancer every year. The Advisory Committee for Immunization Practices and the Centers for Disease Control and Prevention (CDC) routinely recommend that adolescents receive HPV, tetanus, diphtheria, and acellular pertussis (tetanus-diphtheria-acellular pertussis [Tdap]) and meningococcal (MCV) vaccines at age 11-12 years. Although the CDC and professional organizations such as the American Academy of Pediatrics make national vaccine recommendations, according to the National Vaccine Information Center, it is the responsibility of "state health departments to make and enforce vaccine mandates for school entry." The Pennsylvania Department of Health has only mandated two of the recommended three vaccinations: Tdap and MCV. As of 2016, 92% of adolescents aged 13-17 years in Pennsylvania received the Tdap vaccine and 92.7% received the MCV. However, only 58% of females and 44.4% of males aged 13-17 years received all three doses of the HPV vaccine. A comparison of HPV vaccine rates in states with school mandates was compared with Pennsylvania rates. Human papillomavirus vaccination rates were found to be significantly higher in the District of Columbia and Rhode Island, which have HPV vaccine school-entry requirements, supporting the need for a statewide HPV mandate in Pennsylvania.

Implementation of intimate partner violence education for adolescents with spina bifida.

OBJECTIVE: Intimate partner violence (IPV) prevention among adolescent patients with disability is needed, yet rarely discussed in the clinical setting. This study evaluated the feasibility of implementing a brief educational training based on an evidence-based IPV intervention in a pediatric spina bifida clinic. Frequency of IPV discussion was assessed through evaluation of patient feedback and provider surveys. METHODS: Adolescent patients with spina bifida aged 12-21 completed after visit surveys before (N= 13) and after the provider training (N= 21). Primary outcomes included frequency of provider discussion about IPV and receipt of patient safety cards. Chi-square tests compared patient feedback prior to and two months following the education session. Provider knowledge and attitude changes were assessed with pre-post surveys. RESULTS: More patients discussed IPV with providers following the education session compared to baseline (p= 0.03). Provider feedback, both immediately and at two months after the education session showed increased awareness of IPV, comfort with assessment, disclosure, and referral to resources. CONCLUSIONS: The educational intervention increased provider comfort with addressing IPV within a specialty clinical setting. The frequency of IPV communication significantly increased as compared to baseline, patients reported the discussions were beneficial, and providers reported greater comfort discussing IPV and referring patients to resources.

Evaluating Emergency Department Opioid Prescribing Behaviors After Education About Mandated Use of the Pennsylvania Prescription Drug Monitoring Program.

INTRODUCTION: Prescription drug monitoring programs (PDMPs) are among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk for prescription drug misuse, overdose, and death. In 2016, Pennsylvania launched an initiative mandating all prescribers to search the PDMP for each patient when the patient is prescribed controlled substances. OBJECTIVES: The primary aim of this project was to support the Pennsylvania PDMP mandate by educating emergency department (ED) providers regarding the opioid epidemic and use of the PDMP and measure opioid prescriptions posteducation. Secondary aims were to evaluate provider knowledge and identify barriers to PDMP use. METHODS: This quality improvement project was conducted through a retrospective chart review of patients 18-85 years old discharged from the ED with a chief complaint of pain. A pretest and a posttest measured provider knowledge change after an education program and assessed barriers to PDMP use. Numbers of opioid prescriptions written at discharge were examined. RESULTS: Provider knowledge scores increased significantly (p = .000). Barriers to PDMP use focused on access and process issues. A statistically significant decrease was observed in opioid prescriptions written (p = .002) during the project. CONCLUSION: An education program increased ED providers' knowledge of the opioid epidemic and the Pennsylvania PDMP mandate and identified barriers to use. A decrease in opioid prescriptions written may have been associated with improved knowledge and suggests that providers can change prescribing behaviors. More research is needed in this area, and future projects may want to focus on prescriber attitudes toward PDMP usefulness.

Evaluation of a Self-Instructional CPR Program for Parents With Children Enrolled in Community Swim Lessons.

INTRODUCTION: This project evaluated an evidence-based self-instructional program aimed at improving cardiopulmonary resuscitation (CPR) knowledge and confidence in parents with children in swim lessons. METHOD: A prospective, repeated-measures design evaluated the CPR Anytime Child program. Twenty-nine parents completed questionnaires before, immediately after, and 1 month after the program. RESULTS: Knowledge and confidence scores improved significantly over time. Compared with a baseline knowledge mean score of 47.3%, mean score immediately after the program was 93.5% (t = -12.176, p < .01) and at 1 month was 80.9% (t = -8.459, p < .01). Confidence in determining CPR need increased from a baseline of 2.52 to 3.18 points immediately after the program (t = -2.88, p = .013) and 3.20 at 1 month (t = 4.759, p < .01). Confidence in performing CPR increased from a baseline of 2.14 to 3.18 immediately after the program (t = 4.759, p < .01) and 2.73 at 1 month (t = -2.88, p = .013). DISCUSSION: The CPR Anytime Child program had a significant sustained effect on improving knowledge and confidence in parents of children in swim lessons. The simplicity of this program makes it replicable and sustainable in this setting.

A quality improvement initiative to increase HPV vaccine rates using an educational and reminder strategy with parents of preteen girls.

INTRODUCTION: A quality improvement project was undertaken to determine if an evidence-based educational brochure and reminder system can increase human papillomavirus (HPV) vaccine uptake and dose completion rates. METHOD: Development of a brochure to promote HPV vaccine uptake was based on predictors of parental acceptance and Health Belief Model concepts. Electronic alerts prompted telephone reminders for dose completion. This quality improvement project utilized a quasi-experimental design with 24 parents of preteen girls from a private pediatric practice and a historical control group of 29 parents. HPV vaccine rates were compared between the groups. RESULTS: A significant difference in HPV vaccine uptake (χ(2) = 11.668, P = .001; odds ratio [OR] = 9.429, 95% confidence interval [CI] = 2.686-33.101) and dose completion (χ(2) = 16.171, P < .001; OR = 22.500, 95% CI = 4.291-117.990) rates were found between the historical control and intervention groups. Parents who received the clinical protocol were 9.4 times and 22.5 times more likely to have HPV vaccine uptake and dose completion, respectively. DISCUSSION: Low national HPV vaccine rates demonstrate the need for theory-based vaccine delivery programs. These results show that an evidence-based educational brochure and reminder system appeared to improve HPV vaccine uptake and dose completion rates at this private pediatric practice.

Uptake of the human papillomavirus vaccine: a review of the literature and report of a quality assurance project.

PURPOSE: The aims of this study were to review predictors of knowledge about human papillomavirus (HPV), HPV vaccine, and factors related to HPV vaccine uptake and report a quality assurance project that evaluated HPV vaccine uptake and three-dose completion rates. METHODS: The setting was a small private urban pediatric practice. Chart review was used to describe HPV vaccine uptake and dose completion rates in 2007. The convenience sample included 189 girls aged 12 to 21 years with HPV vaccine uptake. RESULTS: During 2007, 153 girls aged 12 to 17 years and 42 girls aged 18 to 21 years were seen at well-child care visits. HPV vaccine uptake was 72% (n = 110) for the younger group and 79% (n = 33) for the older group. There was no significant difference in HPV vaccine uptake by group. One quarter (24%, n = 46) received the HPV vaccine dose at an episodic visit. The dose completion rate was 64% (n = 120). DISCUSSION: HPV vaccine uptake and dose completion rates were higher than rates reported by the Centers for Disease Control and Prevention. Effective strategies are needed to promote HPV vaccine uptake and dose completion.