Proof of concept of the Universal Baby video innovation for early child development in Lima, Peru.

OBJECTIVE: Community-based video interventions offer an effective and potentially scalable early interaction coaching tool for caregivers living in low resource settings. We tested the Universal Baby (UB) video innovation; an early interaction coaching tool using video sourced and produced locally with early child development (ECD) expert supervision. METHODS: This proof-of-concept study enrolled 40 caregivers of children ages 10-18 months assigned to intervention and control groups by health establishments in Carabayllo, Lima, Peru. Mother/child dyads received 12 weekly group health education sessions with social support. Of those, 16 caregivers also received 6 UB videos featuring brain science education and local clips of responsive, reciprocal interaction, also known as "serve and return" interaction. Survey data assessed feasibility and acceptability of the intervention. We assessed improved quality of mother/child interaction using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO). RESULTS: We found the program feasible. We successfully trained the local team to produce UB videos using locally-sourced footage and delivered the videos as part of a community-based intervention. We also found it to be acceptable in that participants enthusiastically received the UB videos, reporting they enjoyed being videotaped, and learned how to recognize and appropriately respond to their child's nuanced sounds and gestures. The median change in total PICCOLO scores favored the intervention group compared to the control group. CONCLUSIONS: UB offers great potential as a sustainable, potentially scalable, and culturally appropriate tool to promote equity for child development among young children living in low resource homes globally.

Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU.

OBJECTIVES: To assess the impact of a nurse-implemented goal-directed sedation strategy on patient care and nursing practice in a pediatric cardiac ICU. DESIGN: Quality improvement project with a pre-post interval measurement plan. SETTING: Thirty-one bed pediatric cardiac ICU in a freestanding tertiary care children's hospital. PATIENTS: Postoperative pediatric cardiac surgery patients. INTERVENTIONS: The implementation of cardiac-Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a nurse-implemented goal directed strategy to improve pain and sedation management in a pediatric cardiac ICU which included daily team discussion of the patient's trajectory of illness (acute, titration, or weaning phase), prescription of a sedation target score based on the patient's trajectory of illness, arousal assessments, and opioid and/or sedative titration. Withdrawal Assessment Scores were used to assess and manage iatrogenic withdrawal symptoms. MEASUREMENTS AND MAIN RESULTS: Data related to opioid and sedation use, pain and sedation scores, and the occurrence and management of iatrogenic withdrawal symptoms were reviewed on 1,243 patients during four separate time periods: one pre-implementation and three discontinuous post-implementation time intervals. Patient age and complexity were consistent across the data collection periods. Post-implementation opioids and benzodiazepines use was reduced about 50% without a concomitant increase in the use of other sedative classes. Few post-intervention patients were discharged from the pediatric cardiac ICU or to home on methadone (pediatric cardiac ICU: pre 19% to post 3%; hospital: pre 12% to post 1.3%). Documentation of pain, sedation, and withdrawal scores became more consistent and nurses reported satisfaction with their patient's comfort management. CONCLUSIONS: The implementation of a nurse-driven goal-directed plan such as cardiac-RESTORE to manage pediatric cardiac ICU patient pain and sedation is possible, sustainable, and associated with reduced sedative and methadone use.

Experience participating in the American College of Cardiology Quality NetworkTM: paediatric and adult congenital cardiology collaborative quality improvement.

BACKGROUND: The American College of Cardiology Quality Network enables national benchmarking and collaborative quality improvement through vetted metrics. We describe here our initial experience with the Quality Network. METHODS: Quarterly data for metrics pertaining to chest pain, Kawasaki disease, tetralogy of Fallot, elevated body mass index, and others were shared with the collaboratives for benchmarking. National improvement efforts focussed on counselling for elevated body mass index and 22q11.2 testing in tetralogy of Fallot. Improvement strategies included developing multi-disciplinary workgroups, educational materials, and electronic health record advances. RESULTS: Chest pain metric performance was high compared with national means: obtaining family history (90-100% versus 51-77%), electrocardiogram (100% versus 89-99%), and echocardiogram for exertional complaints (95-100% versus 74-96%). Kawasaki metric performance was high, including obtaining coronary measurements (100% versus 85-97%), prescribing aspirin (100% versus 86-99%), follow-up with imaging (100% versus 85-98%), and documenting no activity restriction without coronary aneurysms (83-100% versus 64-93%). Counselling for elevated body mass index was variable (25-75% versus 31-50%) throughout quality improvement efforts. Testing for 22q11.2 deletion in tetralogy of Fallot patients was consistently above the national mean (60-85% versus 54-68%) with improved genetics data capture. CONCLUSION: The Quality Network promotes meaningful benchmarking and collaborative quality improvement. Our high performance for chest pain and Kawasaki metrics is likely related to previous improvement efforts in chest pain management and a dedicated Kawasaki team. Uptake of counselling for elevated body mass index is variable; stronger engagement among numerous providers is needed. Recommendations for 22q11.2 testing in tetralogy of Fallot were widely recognised and implemented.

Supine counterstrain technique for rhomboid tender point.

Because poor posture is a common instigating factor in back, shoulder, and neck pain, the rhomboid muscles should be considered in a complete physical evaluation. Previous techniques for treating a rhomboid tender point have addressed only one of the two main actions of the muscle, specifically retraction of the scapula utilizing shoulder abduction. This modified supine counterstrain technique for the rhomboid tender point incorporates both scapular retraction as well as superior, medial rotation of the inferior border of the scapula without abduction, providing a comprehensive treatment to accommodate patients with shoulder movement restrictions. This article discusses indications, contraindications, treatment, and a list of problem-solving strategies for the rhomboid tender point.

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment.

Introduction: Pediatric cardiac surgery is complex and has significant risk, requiring interprofessional teamwork for optimal outcomes. Unhealthy work environments have been linked to poor patient outcomes, staff dissatisfaction, and intention to leave. We describe the interprofessional health of pediatric cardiovascular operating room (CVOR) work environments in the United States and the establishment of a healthy work environment (HWE) benchmark score. Methods: Utilizing the American Association of Critical Care Nurses Healthy Work Environments Assessment Tool (HWEAT), interprofessional staff from 11 pediatric CVORs were surveyed. Responses were aggregated, summarized, and stratified by role to examine differences. The following phase used an e-Delphi approach to obtain expert consensus on a benchmark target. Results: Across 11 centers, 179 (60%) completed surveys were reviewed. The interprofessional mean HWEAT score was 3.55 (2.65-4.34). Mean scores for each standard were within the "good" range. Participants reported the highest scores for effective decision-making, with a mean of 3.69 (3.00-4.20). Meaningful recognition scored lowest, mean 3.26 (2.33-4.07). When stratified, surgeons reported higher overall HWE scores (M = 3.79, SD = 0.13) than nurses (M = 3.41, SD = 0.19; P = 0.02, two-tailed). The proposed benchmark was 3.50. Conclusions: This is the first time the American Association of Critical Care Nurses HWEAT has been used to describe the interprofessional health of work environments in pediatric CVORs in the United States. The targeted benchmark can support pediatric CVOR improvement strategies. Creating and sustaining an HWE is an interprofessional opportunity to support high-quality patient outcomes and clinical excellence.

Counterstrain technique for anterior and middle scalene tender point.

When a patient presents with head, neck, or respiratory concerns, the scalene muscles are not commonly considered. However, somatic dysfunctions of the anterior/middle scalenes (AMS) can be contributing to or causing these medical concerns. Although tender points within the scalene muscles have been documented within the muscle belly, they have not been documented at the insertion site. This article details how to diagnose and treat an AMS tender point with an efficient technique that requires minimal exertion and maximal comfort for both the physician and patient at a new tender point location. This article also discusses the importance of this tender point and provides a list of additional somatic dysfunctions that may be used to problem-solve a scalene tender point that fails to correct.

Steroid Use for Management of Vasoactive Resistant Shock in Pediatric Cardiac Intensive Care Patients: Experience of the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice.

BACKGROUND: Although a variety of doses and duration of hydrocortisone have been reported as a treatment modality for congenital heart surgery patients with refractory hypotension, there remains a lack of understanding of the clinical use in pediatric cardiac programs. OBJECTIVES: The aim of this study was to describe the current practice of steroid use for refractory hypotension in postoperative congenital heart surgery patients. METHOD: Survey participants were recruited from the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice. The survey focused on 4 areas: diagnosis, intervention, duration of therapy, and clinical decision making. Data were summarized using descriptive statistics. RESULTS: Among the programs, 24 of 31 (77%) responded, with 21 (95%) using hydrocortisone as a treatment modality. Most, 20 (83%), reported no written clinical guideline for the use of hydrocortisone. Variation in dosing existed as 3 centers (14%) use 50 mg/m2/d, 6 (29%) use 100 mg/m2/d, and 8 (38%) indicated that dosing varies by provider. DISCUSSION: Nearly all centers reported using hydrocortisone for the treatment of hypotension refractory to fluid resuscitation and vasoactive medications. Substantial variation in practice exists in areas of diagnosis, dosing, and duration of hydrocortisone. More research is needed to develop a clinical practice guideline to standardize practice.

Nurse-Sensitive Quality Metrics to Benchmark in Pediatric Cardiovascular Care.

BACKGROUND: Associations between the quality of nursing care and patient outcomes have been demonstrated globally. However, translation and application of this evidence to robust measurement in pediatric specialty nursing care has been limited. OBJECTIVES: To test the feasibility and performance of nurse-sensitive measures in pediatric cardiovascular programs. METHODS: Ten nurse-sensitive measures targeting nursing workforce, care process, and patient outcomes were implemented, and measurement data were collected for 6 months across 9 children's hospitals in the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice (C4-MNP). Participating sites evaluated the feasibility of collecting data and the usability of the data. RESULTS: Variations in nursing workforce characteristics were reported across sites, including proportion of registered nurses with 0 to 2 years of experience, nursing education, and nursing certification. Clinical measurement data on weight gain in infants who have undergone cardiac surgery, unplanned transfer to the cardiac intensive care unit, and pain management highlighted opportunities for improvement in care processes. Overall, each measure received a score of 75% or greater in feasibility and usability. CONCLUSIONS: Collaborative evaluation of measurement performance, feasibility, and usability provided important information for continued refinement of the measures, development of systems to support data collection, and selection of benchmarks across C4-MNP. Results supported the development of target benchmarks for C4-MNP sites to compare performance, share best practices for improving the quality of pediatric cardiovascular nursing care, and inform nurse staffing models.

Management of Opioid and Sedative Weaning in Pediatric Congenital Heart Disease Patients: Assessing the State of Practice.

BACKGROUND: Opioid and sedative medications are commonly used to treat pediatric patients with congenital heart disease; however, their use is not without adverse effects. Symptoms of withdrawal can occur if the medications are discontinued abruptly or weaned too quickly. OBJECTIVE: The aim of this study was to understand and describe the current management of opioid and sedative weaning in pediatric congenital heart disease patients in freestanding children's hospitals across the United States. METHODS: A Web-based survey of pediatric congenital heart centers was conducted. Survey participants were recruited from the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice. Quantitative data were summarized using frequency and proportions. Qualitative data were summarized using content analysis. RESULTS: Twelve sites participated in the survey (44% response rate). Methadone was used as a weaning medication at 100% of participating sites, lorazepam at 83% of sites, and clonidine at 75% of sites. Seventy-five percent of sites reported using a clinical assessment tool to monitor withdrawal symptoms. Twenty-five percent of sites used a standardized clinical pathway when weaning opioid and sedative medications. Eighty-three percent of sites will consider discharging a patient to complete the medication wean at home. DISCUSSION: Weaning practices varied across sites. While some similarities were observed among sites, substantial practice variation exists. The majority of sites used a clinical assessment tool to assess for withdrawal symptoms. Few sites reported using a standardized approach to weaning patients. Discharging patients to complete an opioid or sedative wean at home was common practice. Opportunities exist for the development of weaning practice guidelines.

Development of an outcome measure to monitor the effectiveness of pain management.

Attention to the pain that occurs during treatments and procedures for pediatric patients with cancer continues to be a priority. This article describes the development of a pain effectiveness outcome measure at an academic pediatric medical center in order to inform about the implementation of quality improvement strategies and evaluate the effect of these pain interventions within the hospital setting.