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preventing unplanned extubations


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preventing unplanned extubations

  1. 1. Staffing the Pediatric Intensive Care Unit<br />Marti George, RN<br />University of Wisconsin<br />Green Bay<br />
  2. 2. Caring for intubated pediatric patients<br />For pediatric patients in an intensive care setting, is there a difference in unplanned extubations with nurse to patient ratio of 1:1 as compared to a nurse to patient ratio of 1:2?<br />
  3. 3. Summary of Evidence<br />Source #1 <br />daSilva, P., & de Carvalho, W. (2010). Unplanned extubation in pediatric critically ill patients: A systemic review and best practice recommendations, Pediatric Critical Care Medicine, 11(2).<br />Purpose<br />A systemic literature review to update the state of knowledge of unplanned extubations in the pediatric population<br />
  4. 4. Summary of Evidence<br />Source #1 cont.<br />Sample<br />11 total articles based on pediatric studies involving unplanned extubations<br />9 prospective cohort studies <br />1 retrospective and prospective cohort study <br />1 case-control study<br />Design<br />Systemic review<br />
  5. 5. Summary of Evidence<br />Source #2<br />Ream, R., Mackey, K., Leet, T., Green, C., Andreone, T., Loftis, L., & Lynch, R. (2007). Association of nursing workload and unplanned extubations in a pediatric intensive care unit, Pediatric Critical Care Medicine, 8(4), 366-371.<br />Purpose<br />To estimate nursing workload from the patient acuity level assigned to patients in a pediatric intensive care unit and to determine its influence on unplanned extubations.<br />
  6. 6. Summary of Evidence<br />Source #2 cont.<br />Sample<br />Purposive sampling of 2139 nursing shifts with 1,919 admissions to the PICU over a 2 year period<br />739 PICU patients (39%) received mechanical ventilatory support<br />40 unplanned extubations of 40 individual patients (n=40)<br />Shifts with unplanned extubations (n=40)<br />Shifts without unplanned extubations (n=2153)<br />
  7. 7. Summary of Evidence<br />Source #2 cont.<br />Design<br />Prospective cohort study<br />Independent Variables: <br /> Patient acuity level (using a hospital acuity scoring system)<br /> Patient / nurse ratio <br />Dependent Variable: <br /> Unplanned extubations<br />
  8. 8. Summary of Evidence<br />Source #2 cont.<br />Measurement<br />Data collected from the PICU database, respiratory therapy department database (therapist hours and intubated patients per shift), and nursing department records. (staffing, patient census, and patient acuity level).<br />Monthly reports from risk management and shift reports were reviewed for unplanned extubations<br />
  9. 9. Summary of Evidence<br />Other Sources of Evidence<br />American Academy of Pediatrics. (2004). Clinical report: Guidelines and levels of care for pediatric intensive care units. Pediatrics, 114(4), 1114-1125. <br />This clinical report provides guidelines for care of patients in the pediatric intensive care unit. It covers personnel, hospital services, hospital facilities, training, medications and monitoring.<br />
  10. 10. Summary of Evidence<br />Other Sources of Evidence<br />Society of Pediatric Nurses (2007). Position statement: Safe staffing for pediatric patients. Pensacola, FL.: Author<br />This position statement provides guidelines and addresses nurse staffing and education based on patient needs for pediatric patients in an inpatient setting.<br />
  11. 11. Summary of Evidence<br />Conclusions<br />Incidence of unplanned extubation is higher in the pediatric population.<br />Nursing staff shortage was associated with unplanned extubation.<br />Nurse-to-patient ratio of 1:1 is recommended.<br />Continuous quality improvement team<br />Development of appropriate data tracking tools and data collection <br />
  12. 12. Summary of Evidence<br />Conclusions<br />Future studies are recommended to further explore the work environment in the PICU and adverse events.<br />Staffing ratios should take into account not only patient acuity mix but also nursing skill mix.<br />
  13. 13. Innovation<br />Change staffing in the pediatric intensive care unit to acuity based and make intubated patients a 1:1 staffing ratio.<br />
  14. 14. Stakeholders identified<br />Patients<br />Staff nurses<br />Support staff <br />Physicians <br />Hospital<br />Parents<br />Family<br />
  15. 15. Policy and procedures identified as needed or updated<br />Staffing policy - include an acuity based model<br />Staffing policy - how to achieve 1:1 ratio in case of short staffing. <br />Education policy - address the care of intubated pediatric patients.<br />
  16. 16. Kotter’s Phases of Change Model<br />Project Name<br />Pilot- Trial staffing in the pediatric intensive care unit by acuity, making intubated pediatric patients 1:1<br />Establish Urgency<br />Develop a presentation for staff meeting to show the relationship between staffing and unplanned extubations, including statistics and outcomes. <br />
  17. 17. Kotter’s Phases of Change Model<br />Create Coalition<br />Assemble a team- a staff nurse from each shift on pilot unit, unit director, nurse manager, charge nurse, respiratory therapist and unit medical director.<br />Develop Vision<br />How does this affect nurses, support staff, physicians, families, budget. <br />Vision statement: Decrease unplanned extubation rates, improve patient outcomes improving staff, physician and family satisfaction.<br />
  18. 18. Kotter’s Phases of Change Model<br />Communicate Vision<br />Poster presentation for break room detailing how staffing will be handled to accommodate new staffing ratio and acuity. <br />Email presentation to all involved.<br />Empower Action<br />Weekly team meetings for first month and then monthly to review staff responses and suggestions. <br />Suggestion box placed in unit where staff can voice concerns or recommendations and may do so anonymously if needed. <br />
  19. 19. Kotter’s Phases of Change Model<br />Generate Short-term Wins<br />Present unplanned extubation data monthly compared to previous months, along with staff, physician, and family satisfaction. <br />Post information in break room, department newsletter, and hospital newsletter<br />Consolidate Gains/Produce More<br />Expand pilot to one additional unit after six months, using staff from original unit as change champions and support for new unit. <br />
  20. 20. Kotter’s Phases of Change Model<br />Anchor Approaches<br />Discuss ongoing results and concerns at quarterly staff meetings for two years. <br />Team will continue to keep track of extubation rates and circumstances.<br />