Table of Contents

HK J Paediatr (New Series)
Vol 18. No. 4, 2013

HK J Paediatr (New Series) 2013;18:230-265

Proceedings of Congress

Joint Annual Scientific Meeting 2013 - Poster Presentation (Nurse's Session)

The Hong Kong Paediatric Society and Hong Kong Paediatric Nurses Association

The Effectiveness of Fall Prevention Program in Paediatric Wards

MW Young

Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong

Background: Fall in hospitals are currently considered a nursing quality indicator. Prevention of hospital falls is a important aspect of the management of patients in acute care settings. Failure to provide a safe environment can lead to fall that may result in injury. Such injuries may prolong hospitalization. The fall incident rate increased from 0.2 to 0.44 (1Q2010) and 0.54 (2Q2010) in paediatric department on 2010, so that the fall prevention team formed for quality improvement. The fall prevention team evaluated the fall risk assessment tool, fall prevention signage and posters, and parents' education. CHAMPS Pediatric Fall Risk Assessment Tool was used to replace the Morse Fall Scale for fall risk assessment. To educate nurses and healthcare workers about fall risk assessment tool and preventive measures in department. In retrospective review the 14 fall incidents, 71.4% fall cases had accompanied by parents or carers. Therefore, the fall prevention program should involve parents' education. Nurse should introduce the ward environment and fall prevention on admission. Moreover, fall prevention video was played once daily in paediatric wards for parents/carers' fall prevention education.

Aim: Nurse and parents could understand the important of fall prevention, and the fall incident rate decreased after the application of fall prevention program.

Methods: The fall incidents rate and the satisfaction survey of parents/carers were used to explore the effectiveness of the fall prevention in ward. Nurses were interviewed to evaluate the effectiveness of the fall prevention video.

Results: The fall incident rate was decreased from 0.54 (2Q2010) to 0.1(4Q2012). The fall incident rate in paediatric department was lower than the hospital (0.79) and HA (0.47) in 4Q2012. 32 copies of questionnaires about the fall prevention received, 94% of respondents showed that the video could enhance their awareness on fall prevention in hospital. Only 6% respondents reported that no effective for improving their concern for fall prevention. 100% respondents showed that nurses explained to them about using bed rails and ward environment for fall prevention. Moreover, all nurses working in paediatric fever and triage ward were interviewed, they felt the fall prevention videos could enhance parents and carers' awareness on fall prevention.

Conclusion: The effective fall prevention program involves preventive measures, and the education to healthcare workers and parents/carers. Although, fall incident rate was decreased, the fall prevention team should review fall incident continuously to create effective preventive measures for fall prevention in paediatric ward.

Treatment of Children with Drugresistant Graft-Versus-Host-Disease by Extra-corporeal Photopheresis

SY Chiu, HY Chan, SK Shum, DKL Cheuk, P Lee, ASK Chiang, SY Ha, GCF Chan

Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong

Purpose and Method: We retrospectively reviewed the clinical experience of performing extracorporeal photopheresis (ECP) for the treatment of children with drug-resistant graft-versus-host disease (GVHD) after allogeneic haematopoietic stem cell transplantation at Queen Mary Hospital in Hong Kong since 2011.

Results: We performed ECP 89 times (discontinuous flow 16 times and continuous flow 73 times) in 3 children (body weight 26 to 35 kg) who suffered from severe extensive sclerodermatous chronic GVHD with pulmonary fibrosis (patient 1, beta-thalassaemia major girl received matched unrelated stem cell transplant), steroid refractory grade 4 acute gut and liver GVHD (patient 2, AML boy received 5/6 HLA-matched unrelated cord blood transplant), and progressive bronchiolitis obliterans (patient 3, AML boy received matched sibling bone marrow transplant) respectively.

Nurse is a key stakeholder in managing the technical and logistic parts of ECP program. The nurse's roles are discussed on developing the ECP program, setting operating standard, case management, problem encountered and staff training.

The ECP procedures in small children are technically challenging and require special planning with attention to extracorporeal volume, inlet blood flow rate and trouble shooting. Blood priming and prior hypertransfusions were required to minimize fluid shifts in these underweight patients. ECP was performed 1-3 times per week. The anticoagulant: blood ratio (heparin saline 20 units/ml) was adjusted according to the patients' hemostatic status between 8:1 to 12:1. Problems including machine failure possibly caused by poor inlet blood flow, blood clots or air in the circuits were encountered. Transient hypertension and cold sensation had been reported during discontinuous flow but not in continuous flow ECP. There were no adverse hemodynamic events noted. Patient 2 and 3 had significant improvement in their GVHD resulting in the reduction of immunosuppressive drugs. Patient 1 started ECP at a relatively late stage and she died of pulmonary aspergillosis and atypical mycobacterial infection, unrelated to the procedure. The nurse-led ECP program gained high satisfaction from staff and patients.

Conclusion: ECP was well tolerated in these underweight patients by using the continuous flow photopheresis system. It seems to be an efficacious and safe alternative therapy for drugresistant severe acute or chronic GVHD. A nurse-led ECP program facilitates the success of technical and logistic parts of this new treatment modality.

A Continuous Quality Improvement Programme to Enhance Medication Safety

WF Ko, KM Chan, PYA Ho, YML Leung, CYA Chong, YF Chan, PK Ma, HB Chan

Department of Paediatric and Adolescent Medicine, United Christian Hospital, Hong Kong

Introduction: Enhancing medication safety is the top priority of neonatal nursing. Though all medications are counter checked by 2 nurses upon administration, errors still occur. As neonates are vulnerable to medication errors, a continuous quality improvement (CQI) programme on safe intravenous medication administration was developed using multidisciplinary approach in 2011.

Objective: To enhance patient safety in medication administration.

Methodology: Unit doses of intravenous (IV) medication were prepared in the pharmacy. An electronic

verification system, Paediatric IV "Verify to Administer" System (PIVAS) was developed to verify "5 Rights" after counter checking by 2 nurses.

Results: From 24/1/2011 to 23/1/2013, after PIVAS verification, nurses administered 18090 doses of IV medications prepared in the pharmacy. There were 2 medication administration errors occurred out of the 18090 doses.

Conclusion: The outcome of the programme is promising. A multidisciplinary team approach to strengthen medication safety assured safe intravenous medication administration.

A Pilot Study of Paediatric Early Warning Scores Application

TH Chan, YK Hui, YM Yeung

Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong

Objectives: We evaluated the Paediatric Early Warning Score (PEWS) sensitivity as an early indicator of patient deterioration leading to improve patient outcome. Besides, it aims to support and empower nurses especially the newcomers in nursing assessment, observation and caring for patients at risk of deterioration.

Methods: A task working group for PEWS was formed in January 2012 to formulate and endorse an integrated observation chart with PEWS and algorithm for the Paediatric Department of Queen Elizabeth Hospital. PEWS are assigned in 3 domains: behaviour, respiratory and cardiovascular. Scores in each domain range from 0 to 3 points. In addition, 2 points are added to nebulization that are continuous or every 15 minutes and 2 points for persistent postoperative vomiting. The total score can range from 0 to 13. Four identical PEWS workshops were conducted in March, 2012 to enhance nurses' knowledge, skill of application, concept of PEWS. A pilot study of PEWS was implemented since May 2012 in all general paediatric wards. Questionnaires from nurse on trial use of nursing observation chart with PEWS were conducted in August 2012. Moreover, a local audit was conducted in December 2012 in four general paediatric wards of Queen Elizabeth Hospital.

Results: Total thirty-one samples and two hundred and sixty-three chartings were identified in December 2012. The sensitivity of PEWS was 57.14% and the specificity of PEWS was 94.11%. The PEWS algorithm, guiding staffs for actions including frequent assessment time, senior nurse consultation or referral to an experienced physician based on the resulting paediatric early warning score. Total eight out of thirty-one samples scored PEWS equal or >3 and received interventions. Treatment may involve elective transfer of the child to Paediatric Intensive Care Unit or ward-based interventions to prevent further deterioration. Furthermore, a total of forty-one questionnaires from nurses on trial use of nursing observation chart with PEWS received with 59% agreed that PEWS is helpful to alert on patient deterioration.

Conclusion: PEWS is a tool which is easy, convenient and helpful to assist nurse early identification of deteriorating sick children who subsequently have an immediate need for medical intervention. When this tool is used consistently as part of a routine nursing assessment, it allows the bedside nurse to quantify a score and promote concise communication among physicians to alter plans of care in response to changing patient status.

Effective Training to Help Staffs Deal with Paediatric Emergencies

SK Ng, KM Chim, ML Ngai, MC Lui, PK Ma, HB Chan

Department of Paediatric and Adolescent Medicine, United Christian Hospital, Hong Kong

Background: The outcome for Paediatric cardiopulmonary resuscitation (CPR) is poor especially without high quality of resuscitation. The Paediatric cardiopulmonary arrest is rare occurrence in general paediatric ward. Even experienced paediatric nurses have limited exposure in care critically ill paediatric patient. Many studies stated that the team training resuscitation drill can improved the skills in dealing with cardiopulmonary arrest patient; increase practitioners' confidence and decrease anxiety during actual resuscitations. However, there was an impact on emergency drills which took away the time of care for patients.

Objective: We conducted this study to determine whether resuscitation training program would effective training staffs deal with CPR.

Methods: The researchers used several methods for their study which was organized in two phases. The first phase was intervened some resuscitation training during in 2011 at UCH a general paediatric ward. The second phase was an exploratory the impression on team training resuscitation drills and resuscitation training program of nursing staff. It sought by some questions.

Results: Twenty-eight nursing staffs participated (96% of total number of staff in a ward). Ninety percent of participants can be accomplished the all items of resuscitation training twice in one year. The remaining participants can be accomplished the all items of resuscitation training at least once. On the other hand, there was only about 50% of participation to take part in a team training resuscitation drills. Moreover, there was 100% of participants agree these two training programs both can be improved clinical skills in paediatric emergencies and knowledge in paediatric emergencies. The amounts of participant preferred these two training program were nearly same. 100% of junior RN (<5 clinical experience) and 75% of APN preferred the resuscitation training program because it can be enhanced the procedural knowledge. Large amount of experienced RN (≥ clinical experience) preferred the team training resuscitation drills because it can be enhanced their team management knowledge.

Conclusion: The resuscitation training program was an effective training especially for junior nurses. These two training programs were necessary to help staff deal with paediatric emergencies. Further research was necessary to measure the improvement of clinical outcomes after resuscitation training program.

Prospective Evaluation of the Pews Tool

LW Chow, E Poon, HB Chan, YM Leung, KL Ng, PK Ma, SH Wu, WK Yick, WK Chiu

Department of Paediatric and Adolescent Medicine, United Christian Hospital, Hong Kong

Background: As healthcare providers, we believe that delayed recognition of critically-ill patients is a significant contributor to mortality and morbidity. In order to improve the recognition of patients at risk of deterioration, a structural approach to evaluation of bedside patient observation is essential. This leads to the development of the Paediatric Early Warning Score (PEWS). Abnormal warning score triggers the call out of medical emergency teams for early assessment and prompt treatment. Early intervention is expected to improve outcomes of unexpected cardiac arrest and unplanned intensive care admissions.

Objectives: To test the reliability of a newly developed PEWS assessment tool in detecting clinical deterioration among hospitalized children requiring transfer to paediatric intensive care unit.

Design: Prospective descriptive study.

Participants: All paediatric patients (aged from 1month old to 18 years) admitted into an acute-general paediatric medical ward in United Christian Hospital were scored using the PEWS over a 4-month period.

Methods: The newly developed PEWS tool was used to score patient status in all admissions by nursing staff. In addition, patients' age, gender and responses upon patient deterioration (i.e. a PICU transfer) were recorded. Data were analysed using SPSS. Receiver operating characteristic (ROC) analysis was performed to examine the sensitivity and specificity of the PEWS tool to differentiated between children who needed PICU transfer and those who did not.

Results: 1042 patients were admitted in the 4-month period. The PEWS tool was able to differentiate between those who needed transfer to PICU from those who did not (area under the curve=0.83, 95% CI=0.76-1.02, p<0.001).According to the ROC curve, the sensitivity=1, specificity=0.71, PPV=0.02, NPV=1.

Implications: The newly developed PEWS tool is a reliable tool in detecting clinical deterioration among hospitalized children who require transfer to PICU.

Evidence-Based Nursing Practice on Changing Intravenous Infusion Set of Central Line in Paediatric Department in UCH

YL Chan, ML Yeung, KM Chan, YF Chan, PK Ma

Department of Paediatric and Adolescent Medicine, United Christian Hospital, Hong Kong

Introduction: Changing intravenous infusion (IVF) set of central line is a common nursing procedure in our department. However, there are different ways of practice among our units. By limiting the variability of this procedure, an evidenced-based practice initiation is implemented.

Objectives: (1) To standardiae the nursing practice on changing IVF set of central line including antiseptic solution, time of rubbing and needleless devices. (2) To provide the best evidence on nursing procedure.

Literature search: Antiseptic solution: Over the literature review, 18 articles including CDC guidelines are recommended using alcoholic chlorhexidine gluconate solution (2%) for disinfection of skin and devices to reducing colonization (Level 1). However, there is not mentioned the safety or efficacy of using this solution in patients less than 2 months old.

Time of rubbing: Only 5 articles are mentioned the rubbing (vigorous)/scrubbing time of hub/accessing port which is ranged from 10 to 15 seconds (Level 2). One study found that 3-5 seconds which did not adequate to disinfect the surface. The time spent rubbing/scrubbing with disinfectant may be important. In CDC guidelines, the antiseptics should be allowed to dry according to the manufacturer's recommendation prior to placing the catheter (Level 1).

Needleless devices: One of 3 studies recommended using of needleless connectors or mechanical valves appear to be effective in reducing connector colonization. In one study, the incidence of central line associated blood stream infection (CLABSI) was reduced when the needleless connector was compared with standard stopcocks.

Bundle of care: multifaceted strategies are "bundled" together to improve compliance with evidence-based recommended practices (Level 1).

Recommendation: After reviewed the literatures, there has been strong evidence of using alcoholic chlorhexidine gluconate solution (2%) as an antiseptic solution to reduce CLABSI. Additionally, allowing the rubbed/scrubbed accessing port/hub to dry after rubbing/scrubbing at least 10-15 seconds is recommended. The element of using needleless devices is also documented. The departmental guideline on bundle-care of central line is revised and implemented to promote patient safety.

Conclusion: This evidence-based nursing practice is being promoted for implementation across our department. Further study is required to review the compliance of this evidenced-based practice but foresee remarkable outcome.


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