• Buzzy® for Pain Management During Routine Immunizations in Pediatric Patients

      Kang, Lacey; Connolly, Mary Ellen (2022-05)
      Problem: Children receive multiple vaccines throughout their childhood. Immunization associated pain can change the way the body responds to stress. Despite the development of multiple pain management techniques, many primary care offices have no forms of pain management during routine immunizations. Purpose: The purpose of this quality improvement project was to implement and evaluate a protocol for Buzzy® use during routine immunizations in a pediatric primary care office. Methods: During a 15-week implementation period, all children greater than 18 months of age were offered a Buzzy® when receiving a vaccine. Key stakeholders were identified, and staff were educated on Buzzy® indications, administration, and contraindications prior to implementation. Written materials about Buzzy® were placed in the waiting room and exam rooms for parents to review. Staff were provided with educational sessions that included a presentation and a hands-on demonstration. All eligible children were offered a Buzzy® by the provider. If parent and child agreed the Buzzy® was incorporated into routine immunization administration by the nursing staff. Data logs were developed, and nurses completed the log after each eligible patient. Data related to the number of patients who were offered a Buzzy® by the provider and how many patients received their immunizations with a Buzzy® were collected. Data analysis was conducted through run charts. Results: 100% of staff members completed the education by week 6. An average of 15% of patients were offered a Buzzy® by a physician, while 44% of the patients who were offered and agreed were administered vaccines with a Buzzy® by a nurse. Conclusion: Educating and implementing a protocol on Buzzy® use increased the rate of providers offering a Buzzy® to eligible patients and nursing staff administering routine immunizations with a Buzzy®.
    • Development of a Pediatric Post-Chemotherapy Vaccination Protocol

      Burley, Samantha R.; Simone, Shari (2022-05)
      Problem: Pediatric oncology patients are at a high risk for acquiring vaccine-preventable diseases due to their previous immunocompromised status and loss of protective titers following chemotherapy treatment. According to a nationwide study in 2019, only 48% of providers assess immune status prior to revaccination and re-vaccination time frame ranges from 6-18 months. This inconsistency is mirrored within an urban pediatric oncology clinic, leading to children with unnecessary and prolonged vulnerability to vaccine-preventable diseases. Purpose: The purpose of this quality improvement project was to implement an evidence-based standard of practice for re-immunization of pediatric oncology patients following completion of chemotherapy treatment. Methods: The project was implemented over a 16-week period in a pediatric oncology clinic. Eligible patients included those diagnosed with cancer since 2013 and off chemotherapy treatment for at least 6 months. The new standard of practice included a formal guideline detailing the vaccine titers to be obtained based on current evidence. A template was created and inputted into the patient’s problem list. A standardized letter was sent to each patient’s primary care provider detailing the patient’s individualized vaccination plan. Weekly chart audits were conducted and run charts created to track data. Results: Results of the intervention demonstrated 83% of eligible patients had required titer orders and had the need for immunization added into their problem list. 50% of patients had fully resulted titers. Of the 50%, 100% demonstrated loss of immunity to one or more vaccine preventable diseases. Several confounding factors delayed results of titers and communication with primary care providers such as insufficient blood quantity and hemolyzed samples leading to partially resulted titers. Pediatric oncology providers sought to send one letter to the patient’s primary care provider detailing comprehensive immunization recommendations following fully resulted titers. Conclusions: This quality improvement project demonstrated the need for immunization assessment and intervention following treatment with chemotherapy. Creation of a standard post-chemotherapy vaccination guideline improved the identification and re-immunization of this population.
    • Implementation and Evaluation of a Nonpharmacological Device to Improve Satisfaction During Immunization

      Kim, Tamara K.; Satyshur, Rosemarie D. (2021-05)
      Problem & Purpose: Immunization pain is the most common pain experienced by children when visiting their primary healthcare office. In a pediatric primary care office on Maryland’s Eastern Shore, there are inadequate pain relief options used during immunization. Untreated pain can lead to sensitization to future painful experiences leading to greater fear and anxiety, intense distress with future immunizations, needle phobia, and avoidance of healthcare as the individual ages. The purpose of the project was to implement and evaluate the use of the Buzzy device to improve satisfaction during immunization for children aged four to 18 years. The Buzzy device combines vibration and external cold analgesia to control pain at the injection site. Methods: All families with children aged four through 18 years receiving an immunization were educated on and offered use of the Buzzy device. The LPNs assessed the child’s pain score after all administrations and distributed a satisfaction survey to each family when Buzzy was utilized. Data were collected using an implementation log. Data were analyzed using run charts and were presented to the Clinical Site Representative and staff on a monthly basis to elicit feedback. Results: Results indicate that after receiving education on the Buzzy and project goals, 100% of the children and families were willing to try using the Buzzy device to minimize immunization pain and improve satisfaction. Overall satisfaction was scored at 86.3% and among satisfied families, the average pain rating was two out of 10. Conclusions: Data collected indicate that use of the Buzzy device is effective in improving satisfaction during immunization in children and should continue being offered for distraction during immunization. Buzzy sustainability will continue to be driven by family satisfaction with the device during immunization and the device remaining in the practice. Project results will be disseminated through poster presentations.
    • Implementation and Evaluation of the Ottawa Ankle Rules in Pediatric Orthopedic Triage

      Kim, Benjamin S.; Satyshur, Rosemarie D.
      Problem & Purpose: Overcrowding of emergency departments (EDs) is a national healthcare crisis, which include pediatric EDs (PEDs). During overcrowding, the length of stay (LOS) for patients with low acuity distal orthopedic complaints is longer than all other complaints combined at this site. This PED has no interventions to expedite care during high patient volume scenarios. This project implemented and evaluated the Ottawa Ankle Rules (OARs) in a PED. The OARs is a clinical decision tool to aid clinicians in determining if a patient requires radiography for ankle or foot injuries. Nurses implemented this tool in triage on patients to expedite diagnostic imaging prior to physician assessment to decrease LOS and door to diagnostic evaluation times. Methods: Nurses implemented the OARs on all pediatric patients 5 years and older presenting to the PED with ankle or foot complaints. Data on median times for both total emergency department LOS and ankle or foot complaint patients as well as door to diagnostic evaluation were collected. The percentage of nurses compliant to the OARs and nurses’ education completion percentage was also collected. Results: There was 100% adherence of the nurses in implementing the intervention and 100% education completion by the sixth week of implementation. Median door to diagnostic evaluation time decreased to 29 minutes from 31 minutes pre- versus post-intervention. The total EDLOS did not change during the implementation of the intervention; however, when compared to the same months in the previous year, there was a 26.15-minute decrease in median total EDLOS. There was a 2-minute increase in EDLOS for ankle/foot patients. Conclusions: Findings suggest implementing the OARs in PED triage can decrease EDLOS, and nurses are able to comply with the OARs in triage. Incorporation of the OARs into written PED protocol was conducted for sustainability. Implications of these data suggested using the OARs in similar settings is feasible and may decrease EDLOS.
    • Implementation of a Safety Checklist and Guidance Tool During Well-Child Visits

      Choe, Jennie H.; Miller, Marilyn, Ph.D., C.R.N.P., C.S.P (2022-05)
      Problem: Unintentional injuries are the leading cause of morbidity and mortality in pediatrics. Providers have difficulty with injury screening and prevention counseling during well visits due to a lack of time and nonstandard screening methods. Purpose: To implement the pre-visit electronic Safety Checklist and Safety Guidance Tool developed by CHADIS (Comprehensive Health and Decision Information Systems), at a pediatric clinic as an efficient and comprehensive approach to injury screening and the delivery of focused anticipatory guidance to caretakers. Methods: A pediatric practice elected to participate in a quality improvement initiative and implement the safety tool over a 15-week period. Age-specific safety checklists were auto-assigned by CHADIS to eligible patients two weeks prior to their well visit. Following checklist completion by caretakers, evidence-based safety guidance was electronically provided, focusing on topics of perceived risk based on results. Providers reviewed results in preparation for well visits to provide focused guidance to families. Data was collected weekly during the implementation period to determine the percentage of assigned safety checklists and the number of checklists completed. Results: Of the 418 eligible patients, 23% (n=95) were registered with CHADIS and auto-assigned the safety tool. Of those assigned the tool, 84% (n=80) of these caretakers accessed the checklist through their patient portal and 17% (n=14) of these caretakers submitted completed safety checklists. Providers reviewed 100% of the submitted checklists prior to the patient’s visit. Conclusions: Adoption of the Safety Checklist and Guidance Tool into the clinic’s workflow processes was achieved within a 15-week period and was well received by providers and participating caregivers given their familiarity with utilizing CHADIS’s screening tools routinely in their clinic. Providers felt that the safety tool’s content facilitated visits and offered thorough injury risk assessment and focused guidance to families without interrupting workflow processes during well visits. Barriers included getting patients registered with CHADIS and having caretakers complete and submit the safety checklists during implementation. Future quality improvement initiatives will have better success if patients are auto-registered and the implementation trial period is longer to make it possible to identify and mitigate the barriers to caretakers completing the CHADIS registration process.
    • Implementation of the revised-FLACC Observational Pain Scale on a Pediatric Unit

      Hansen, Amanda M.; Simone, Shari (2022)
      Problem: Children with developmental delays, cognitive impairments, and intellectual disabilities are more likely to receive pediatric specialty care leading to frequent hospitalizations and surgeries. This population has atypical pain behaviors and cannot self-report pain; therefore, they are at risk for the under recognition and treatment of pain. In a large academic hospital, a pediatric inpatient unit has a high population of children meeting this criterion. The current standard pain assessment for patients unable to self-report is the FLACC scale; however, the revised-FLACC (r-FLACC) is tailored to assess pain in this population and offers the opportunity for parent or caregiver input. Purpose: The purpose of this quality improvement project was to implement and evaluate the r-FLACC pain scale for assessing pain in pediatric patients with developmental delays, intellectual disabilities, and cognitive impairments. Methods: The practice change took place over 15 weeks on a pediatric medical-surgical unit. Nursing utilized the r-FLACC pain scale to quantify eligible patients’ pain every four hours with parental involvement. Data collection included nursing compliance with the r-FLACC, parent or caregiver opportunity to individualize the pain scale on admission, r-FLACC scores, and pain interventions. Parent and caregiver perception of the child’s pain assessment using the r-FLACC was assessed upon discharge anonymously. FLACC scores concurrently recorded in the electronic medical record by nurses were extracted and compared to r-FLACC scores. Results: During implementation approximately three (15%) patients a day qualified for use of the r-FLACC pain scale. There were 465 observations for which both the FLACC and r-FLACC were collected across 15 patients. The r-FLACC pain scores were similar and often higher than concurrent FLACC scores. Discharge surveys revealed parents and caregivers were satisfied with the r-FLACC pain scale and their child’s pain management and treatment. Conclusions: The r-FLACC scale adequately captured this pediatric population’s pain and caregivers were satisfied with their child’s pain management. The r-FLACC pain scale provided an opportunity to better recognize and treat pain in this population. Next steps include integration of the r-FLACC pain scale in the electronic medical record to be used in all pediatric areas.
    • Implementing Mobile Text-messaging to Improve Attendance at Well Visits in Primary Care Pediatrics

      Osuagwu, Ngozi E.; Connolly, Mary Ellen (2019-05)
      Background: Missed appointments are a long-standing problem encountered both in the United States and abroad with rates ranging anywhere from 5% to 55%. It is a major cause of inefficiency in the medical system and consequences include poor health outcomes, wasted health care dollars, waste of provider time and adverse effect on patient -provider relationship. Local Problem: No-shows are a significant problem in primary care especially in underserved populations. The implementation site for this quality improvement project provides care to an underserved population with a no-show rate of 35%. The purpose of the DNP quality improvement project was to implement and evaluate the use of mobile text messaging to reduce the non-attendance rate to routine well visits in a primary care pediatric clinic in inner city Baltimore. There is evidence to support the use of text message reminders to improve both medication adherence and attendance rates when compared to other available appointment reminder systems. Intervention: The project was implemented in a sample of patients by nurses, front office staff and providers. The intervention involved sending text message appointment reminders to patients. The attendance rate was later analyzed and compared to the attendance rate prior to the implementation period. Inclusion criteria for the patient population was patients aged 18 years and older or the legal parent or guardian of a patient who was under the age of 18 years. Staff attended a 4-hour training session, which was led by the project leader and I.T. personnel. A preimplementation survey was conducted to determine patients’ and parents’ perception of the planned mobile text-messaging system. The questionnaire was quantified, averaged and the result was favorable. During the implementation period, data was collected that reflected the rate of attendance during the project. This information was aggregated and stored by the EHR system. Data was retrieved from the EHR and Run charts were used for data analysis. Results: The attendance data from the intervention showed that there was no significant increase in attendance to well visits for October, November and December compared to the preceding months of July, August, and September 2019. Conclusions: Though the result of the intervention did not reflect the expected impact, several lessons were learned. There were some positive unexpected findings, including an increase in portal registration, improvement in the update of patient phone numbers in the EHR database, and greater rapport among staff due to teamwork.
    • Improving Influenza Vaccination Rates in Inpatient Pediatrics

      Hoffer, Amy; McComiskey, Carmel A. (2021-05)
      Problem: This quality improvement project was implemented on an inpatient pediatric unit at an urban academic medical center whose rate of influenza vaccination prior to discharge was only 39% of eligible patients. This gap in vaccination is not unique to this unit and morbidity and mortality of influenza is high despite widespread availability of a vaccine and the recommendation that all children over six months of age receive the vaccine. Purpose: The purpose of this project was to increase vaccination rates by providing education and rescreening prior to discharge. Methods. The electronic health record (EHR) was modified to populate a prompt to the nursing task list for every patient who initially refuse the flu vaccine. Bedside nurses then provided education to all patients and parents who refused. They documented this education and asked the parents if they would reconsider vaccinating prior to discharge. The outcome measures of this project included improving EHR nursing documentation of education and rescreening and increasing vaccination rates prior to discharge. Results: Of patients whose caregiver refused the flu vaccine on admission, 61% received the intervention and 27% of these caregivers reconsidered and decided to vaccinate. The vaccination rate of eligible patients prior to discharge for this unit increased from 39% to 60%. Conclusion: Optimizing the use of the EHR to automatically remind nurses to provide education and additional vaccination opportunity can increase vaccination rates. This unit’s improvement in vaccination rates and the number of caregivers who received the intervention and subsequently agreed to vaccinate demonstrates that this is a valuable tool if there is otherwise no process in place to prioritize vaccination. This intervention can be easily modified to be used in other patient populations and for other vaccinations.
    • Reducing Pediatric Vaccine-Associated Pain Using The Buzzy

      Hoke, Brittany M.; Connolly, Mary Ellen (2019-05)
      Background: Vaccinations are recognized as a major cause of iatrogenic pain in childhood. Currently no pain management protocol exists at a large suburban pediatric primary care clinic in the mid-Atlantic, for children undergoing vaccination. Local Problem: The purpose of this DNP project was to implement and evaluate the usage of the Buzzy device during vaccination of children ages 4-17 years, at this pediatric primary care clinic. Buzzy is an effective combination of vibration and external cold analgesia, which significantly reduces injection pain in children. The project was designed to improve patient care at this clinic, by addressing the pain management needs of children undergoing vaccination. Interventions: The project took place over the course of 16 weeks. During the first two weeks, the project leader posted Buzzy advertisements throughout the clinic and distributed brochures to families. Nurses (n = 11) and medical assistants (n = 1) were individually trained during this time, regarding proper technique and usage of the device. During weeks 3-16, the nurses and medical assistant utilized Buzzy when vaccinating children ages 4 to 17 years. The project leader collected data using two audit tools: (1) a running log documented by the nurses/MA that tracked the number of patients receiving the Buzzy intervention, and (2) a running log documented by the project leader that randomly tracked those who utilized Buzzy. Staff provided a satisfaction survey to each patient who received Buzzy during vaccination that was submitted anonymously prior to patients leaving the clinic. During weeks 3-16, the project leader reviewed and entered data into an Excel spreadsheet and conducted an analysis of data utilizing descriptive statistics. Data was also analyzed via a run chart to track Buzzy usage and to identify trends over the course of the 14-week period. Results: Staff offered Buzzy to a total of 761 patients. Six hundred and eighteen patients used the device during vaccination, while 143 patients declined. The mean number of patients using Buzzy per week was 43. A total of 523 surveys were completed, yielding an 84.6% survey response rate. Ninety-seven percent of parents and patients surveyed reported satisfaction with their vaccination experience using Buzzy, which well surpassed the project’s goal of 50%. One hundred percent of nurses (5 out of 5) offered Buzzy to patients during audit weeks 3, 5-9, 11 and 14. The satisfaction rate among nurses who utilized Buzzy ranged from 67% during week 4, to 100% during weeks 6-16. Conclusion: The positive response from patients, parents, and staff demonstrates the device’s efficacy and the success of this project, and will aid in its sustainability at this clinic. With continued provider and nursing support, Buzzy has potential to become standard of care during vaccination at this clinic. Implications for future research include use of the device on a younger population of patients, application during additional needle stick procedures, as well as incorporating Buzzy usage into the clinic’s EHR. This project can be utilized as a model for pediatric clinics seeking methods to decrease vaccine-associated pain for their patients.
    • Screening for Adverse Childhood Experiences in Pediatric Primary Care

      Gross, Sarah M.; Franquiz, Renee (2020-05)
      Problem & Purpose: Pediatric mental illness is a growing epidemic in the United States, yet the average time from onset of symptoms to treatment is eight to ten years. Screening children for Adverse Childhood Experiences (ACEs) is associated with early identification of mental illness risk and improved outcomes. The purpose of this quality improvement project was to implement an ACEs Screening Program for adolescents in a pediatric primary care practice and evaluate the program’s effectiveness in early risk-identification and referral to mental health services. Methods: Patients ages 8-18 years were screened for ACEs using the Center for Youth Wellness Adverse Childhood Experiences Questionnaires (CYW ACE-Q) during routine pediatric well visits and consults. Patients and/or caregivers self-completed the pen/paper CYW ACE-Q screening tools and pediatricians then analyzed and discussed the results with the patients and/or caregivers. Patients with positive screens were referred to mental health services if not already under care, and appointments were confirmed by the office practice nurses. Statistical Process Control procedures were utilized to demonstrate change over time with screening and referral. Results: Over 70% of all eligible patients and caregivers during the 13-week implementation period were screened for ACEs (n=232). Of those, 14% (n=32) screened positive, and four were referred for mental health services. Phone-call follow-up to referred patients found one patient obtained an appointment with a mental health professional. Eighty-eight percent of stakeholders strongly agreed that the screening program was feasible for well visits and consults. Conclusions: An ACEs Screening Program using the CYW ACE-Q tools is an effective and feasible strategy for primary care practices to identify children at higher risk for mental illness and facilitate earlier referral to mental health services. This increase in early identification and referral of higher-risk children can play a key role in decreasing the burden of pediatric mental illness and its associated complications in the United States.