November 21, 2016

Working with the Children’s Hospital Association (CHA) and some 100 children’s hospitals on ways to reduce the incidence of central line infections in children, Johns Hopkins pediatric nurse researcher Carol Rosenberg was gratified to see declining infection rates for patients in the hospital. “However,” she says, “we found infection rates two to three times higher in the ambulatory setting.”

Rosenberg, senior research program manager in the Division of Quality and Safety at the Johns Hopkins Children’s Center, was not surprised. She knew that the literature showed parents leave the hospital very stressed and worried sick about what’s going to happen to their child, yet they’re expected to flush central lines and perform dressing changes at home? Readiness to learn while processing a serious diagnosis, she adds, is difficult.

“We needed to do a better job of teaching parents,” Rosenberg says.

With that goal in mind Rosenberg developed a quality improvement project incorporating the pediatric-specific CHA central line-associated bloodstream infections (CLABSI) prevention bundle. This bundle was based upon elements of the Johns Hopkins-led Keystone ICU Project, which reduced bloodstream infections to nearly zero at Johns Hopkins and two other hospitals. She included CHA’s safety checklist for doctors and nurses to follow when placing a central-line catheter, and then added a simulation twist—breathing and crying mannequins with which the parents could practice and demonstrate what they learned in the hospital prior to their child’s discharge.

“They actually performed central line care like flushing a line with saline, which one study determined is actually over 40 separate actions,” says Rosenberg. “Most hospitals don’t use simulators to teach patients and families, but we found it to be a highly effective learning tool. For the parents, it’s a bit like becoming a nurse.”

Rosenberg also assessed parents’ knowledge of central line care, their psycho motor skills, and their hands-on ability to scrub central lines correctly, connect syringes and flush a line. Among the questions for parents, says Rosenberg: “Do I understand why I have to wash my hands? Do I understand and know what signs and symptoms to look for in my child that indicate a possible central infection? Do I know when to call the doctor?”

Parents were also asked to watch a video created to illustrate common missteps by physicians and nurses to see if they could recognize when best practices were not being followed.

“We deconstructed many ways these lines can be infected, since these children are treated in so many different settings,” says Rosenberg.

While limited in size to 17 parents of children newly diagnosed with cancer, the study yielded positive results. First off, practicing on the mannequins helped the parents feel more confident about providing central line care. Among parents’ responses: “The simulator felt more real than the plastic chest—like when it was breathing and talking,” and “Being able to feel it when I flushed the line was very helpful.”

Also, post-survey data showed an increase in knowledge, skill and recognition of best practices by the parents. In some clinical areas, learning was dramatic. For instance, in the pretest group, only two of the parents checked the syringe for the correct solution as instructed by nurses, compared with 15 parents in the post-test group.

“They need to know what they’re putting into their child,” says Rosenberg.

The survey data also showed increased recognition of non-adherence to evidence-based infection prevention practices by health care providers and a sense of empowerment by parents to approach those providers.

Rosenberg concludes: “A lot of the burden of care now on parents and families in the home used to be done only in the hospital. We know that simulation has been demonstrated to be a highly effective way to teach novice nurses and new physicians knowledge and skills, so why not use it with the parents?”

Next steps, says Rosenberg, include a similar study for a larger cohort to determine the impact on infection rates.