And the first of our abstract presentations this afternoon is by Alicia Peregrino, who is a nurse practitioner at Penn State Health Hershey Children's Hospital. And she's going to talk about pediatric neurosurgery, pediatric nursing communication tool, a multidisciplinary approach to improve communication and patient safety. Welcome. Hi. My name is Alicia Peregrino. I'm a pediatric neurosurgery nurse practitioner at Penn State Hershey Children's. And thank you to the scientific committee for allowing me to talk today on a multidisciplinary tool to increase patient care and quality of care, as well as safety, while trying to help with the neurosurgery nursing communication. I do not have any disclosures. A little bit of background. I think we all can agree that communication is vital in what we do for our patients and their families, communication within our own team, and then also multidisciplinary with other teams, including bedside nursing. There is limited research on bedside rounding tools with pediatrics in general, neurosurgery, and then also doing the doctor to nursing communication in general. Their workflow with surgical services, as I think we also can agree, is very different for a surgical service versus an actual medical team. So in a medical service, sometimes they're enclosed within four walls, and that allows for them to have readily accessed questions and answers with their medical team on the floor. So we did a pre-survey trying to see that there was a need for some sort of communication intervention. We surveyed the nurses on the pediatric hematology oncology floor, which is where the majority of our pediatric neurosurgery patient population goes postoperatively, or during their inpatient communication, or inpatient care while they're here with us with neurosurgery. So in that survey, it did show that nursing felt that their concerns were not being addressed in a timely fashion. It also expressed the need for improved communication in how we communicate. So this tool was thought that would be beneficial. So we ended up naming it the Neurosurgery Nursing Communication Tool, so the NNCT. The goal was to hopefully improve communication amongst the neurosurgery team with bedside nursing, specifically in morning bedside rounds. We were also hoping that we would be able to easy, we would be able to easy, sorry, that we would be able to identify the bedside nurse. That way, we could actually grab them for bedside rounds. In turn, we were hoping to increase team rapport, decrease more injury and team stress. This is a copy of the NNCT on the left. It's a yellow, it's very bright. We did it on purpose, and that way it wouldn't actually coincide with any of the other colored papers or forms on the units. And it pretty much goes through everything you would need to successfully discharge a patient. So we looked at patient's diagnosis, and then we actually looked for the accuracy of whether or not that was a communication deficit on the unit, which would contribute to some of the confusion with patient care. We were looking at neuro exams, because that was something on the pre-assessment survey that said that nursing felt that there was a need for improvement with addressing those concerns in a timely fashion. So we wanted nursing to be able to have an avenue to go ahead and depict that for us, so that way we could pull the tool on rounds, and then have that addressed immediately. We were looking at pain, whether or not it was well controlled, if they were tolerating an oral diet, or whether or not they were G-tube or tube fed. And then whether or not they were avoiding stooling at their baseline. We were also looking at disposition in terms of whether or not they need some sort of therapy service. So speech, occupational, or physical therapy. On the hematology-oncology floor at Hershey Children's, they do have a high incidence of falls, and so that was something that was an ask of the nursing unit to put on there, whether or not patients were being assessed for their risk of falls. A lot of our post-operative population, they do receive medications that could ultimately inhibit their ability to walk, or have good balance. The pediatric population is naturally at a high risk of falls. We looked at whether or not they were having drain issues with their EBDs, or if they had a drain that was placed somewhere else. Something that we found was that nursing sometimes didn't know exactly where that drain was draining, and how that could possibly harm their patients. So we were trying to increase patient safety, whether or not knowing that it was functioning, if we were doing cultures, whether or not the patient had a fever, and that way it was something readily assessable during rounds. And then all the other things in terms of patient guardian, or parental guardian concerns, as well as nursing, and then discharge questions. The hope of this tool was that bedside nursing at night, it would be night shifts, so those are the slower shifts of the day, and that way the nurse would fill it out overnight for their shift, and then also any concerns that were in the evening for the night shift prior, so that they would be addressed in the morning between 5 and 7 a.m. with the residents, and then daytime rounds. This is, these are two pictorial graphs. So the first one's just showing hospital days for our neurosurgery population. In blue, it's the total number of hospital days that we had with our pediatric neurosurgery, and then the green is the number that was actually on the unit of pediatric hematology oncology. This proved, and kind of gave us a little bit more insight that we assumed that the majority of our patients were going to this floor, and we upheld competency on the floor for a lot of our neurosurgical postoperative care. This showed us about 36% of the patients during these four months were actually cared on this unit, so it opened our eyes to improve education on the other units. Months one through four, we had a 46% overall completion rate. There is a little bit of green on month two and three. In the morning, how it would work is that we would go look for the form and get bedside nursing to come join us. Sometimes the nurses, they would complete the tool after we rounded during day shift that way the unit would get credit for having the tools completed even though it wasn't completed for the evening before, which would elicit all those concerns that they may have had overnight that weren't addressed. This is another graph that just shows that we did have a little steep decline in month three in terms of whether or not they were completed, and then month four, we did have an increase. We're currently at month nine, which unfortunately, we have had less participation by bedside nursing with the tool, so it will be a little bit more difficult but it will become mandatory come May that the tools are filled out for patient safety and quality of care. In terms of the diagnosis, this was something that we found very shocking because in order to adequately express and educate to our families the plan of care and what was going on while they're inpatient, having the accurate diagnosis is important. So that way we know what nurses are educating the families on as well as where we need to improve our deficits and teaching the nurses. The first month, only 55.6% of that 90% of tools had an accurate diagnosis. We found that within the patients that were filled out, there was a varying wordage or description of what these diagnoses were, which allowed us to notice that we needed to do more education with our nurses. The big numbers in the middle of the graphs are depicting the number of tools actually filled out for each month, and so you can see that those numbers are very limited for the 46% overall for the four months. We did have an improvement after that first month. We aren't really sure from the neurosurgical side if there was some sort of nursing education or where they were changing that. We did ask on our one-month post-implementation survey whether or not they were getting the diagnoses from patient charts from each other or from some sort of report outside of bedside nurse to bedside nurse, and we found that in that first month for the majority was doing nurse to nurse. And so I believe that they started looking at the charts, but it was unofficial on the surveys. We were looking at on these tools whether or not they were giving us the information. That way we could find the bedside nurse, a contact phone number. All of our nurses carry ASCOMs. And then whether or not the surgeon name was there. Something that the unit also expressed to us was that they didn't know how to escalate care if they weren't getting the proper response from the APP or from the resident in order to escalate care in critical situations. And so we found that amongst all of these tools from three to 20 that the nurses still weren't able to fully participate with giving us that information. So we did do an implementation around month three. And that will be on the next slide for you. So the timing of bedside rounds is something, again, that nursing doesn't readily understand in terms of workflow of a surgical service. And so this chart shows you the range of each month of when we did bedside rounds, mostly between 0700 and around 1300. And then the dots are the means for each month that the majority of rounds took place. So for the most part we're rounding at times during high nursing sign-out periods when they do their nursing bedside reports. And so we found that to potentially be one of the reasons why nursing was unable to join us for bedside rounds. So at month three we started on the hospital, the Children's Hospital actually started having the nurses' photos with a name and an ASCOM number readily posted right outside of the door. And that way we could contact them. And so we started tracking whether or not the signs were being posted if we were able to call them or if we were able to physically find them on the unit at the nurse's station in the hallway and have them join us in rounds. And so the first month was our lowest month, and that's in the teal, the teal blue. It was 79% of bedside nursing was able to join us. And then we've gotten it all the way up to 97%. And so for the most part overall we've had 86% of bedside nurses at rounds, which helped with the qualitative report from nursing saying that neurosurgery was still unable to have them be involved in active part of rounds. So we did a one and four-month post-implementation nursing survey. And it actually showed us that the blue line is communication, that there was an increase of communication at the one-month mark. That four-month mark is where the communication tools kind of dropped off. So we feel that that number did come down because not a lot of people were utilizing the tool. And then our patient population also only dropped down to 17 hospital days. The green is whether or not they felt that their concerns were addressed. And we had a difference of 35% despite not having the tools filled out. So that may be because of having mandatory bedside presence during morning rounds. We also looked at their perceptions. And so the one thing that we found that it increased nursing confidence in bedside rounds just by having these tools. And again, there wasn't a big participation in the tools. But by having the tool and having them at bedside rounds, they felt more confident in being a team member at the bedside. In purple is improved communication. Again, those tools, the numbers dwindled down with the hospital days. We did have a positive correlation with more active part of rounds. And then the decreased quality of care. Going back through the surveys, we did notice that the senior nurses were the ones that typically were filling out the surveys for that last cohort of surveys. And so it was a yes or no answer. So if they said no, it actually had a negative correlation despite because they had an expertise. So some of the limitations is that this is a single center, single unit, single surgical service line study. And so something that nurses did say on the surveys was 73% thought that it would be beneficial to other patient populations. And actually their general pediatric hematology, oncology population. And so the tool is actually being disseminated to the pediatric hematology unit and then also other service lines. And so the one thing that we did not capture was the pediatric neurosurgery perception of how they felt that the tools have positively impacted their care and also their communication with nursing. For the most part, as the pediatric nurse practitioner, I typically am the ones that are grabbing the nurses and then the residents typically stay with the surgeons during morning rounds if they aren't in the OR. And so for the most part, the perception would be our surgeons who felt that the tools have increased their communication but it was not quantified with a survey or anything that would be in order to catch statistical analysis. So the other thing is that it is, since it is a single unit, single service line, it's a, we have a very small capture of tools. And so it's a small sample size. So in conclusion, a communication tool such as the NNCT, it can improve nursing confidence, improve communication and quality of care. It helps the nurses actually truly understand what the patient care plan was for each day and it can aid in increasing bedside presence. And then we just need more data, which we're currently at month nine of our current pilot. I wanted to thank my primary surgeons, Dr. Diaz, Dr. Iantosca and Dr. Rizek, and then our Department of Neurosurgery as well as the Children's Surgery Center. Thank you. Any questions? Yes? As far as nursing staff, what are they available to people that are contacting them right now if they have a question or concern? Is it paging, do you have an app? So we have, we actually have a couple ways of communication. We've created an escalation plan of care for the neurosurgery service specifically. And that allows for paging of myself or the residents, the primary resident that has the pager for the entire hospital for neurosurgery. And then it escalates up to the attending on call and then all the way up to the attending that would be on record. So there is an ASCOM. I have an ASCOM, the residents have an ASCOM and then we also have pagers. And they do, the interdisciplinary narrative, they do write things in there as well for us to look at and read.

Alicia Peregrino

nurse practitioner

Penn State Health Hershey Children's Hospital

Neurosurgery Nursing Communication Tool

pediatric neurosurgery