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- 1. Staffing the Pediatric Intensive Care UnitMarti George, RNUniversity of WisconsinGreen Bay
- 2. Caring for intubated pediatric patientsFor 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?
- 3. Summary of EvidenceSource #1 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).PurposeA systemic literature review to update the state of knowledge of unplanned extubations in the pediatric population
- 4. Summary of EvidenceSource #1 cont.Sample11 total articles based on pediatric studies involving unplanned extubations9 prospective cohort studies 1 retrospective and prospective cohort study 1 case-control studyDesignSystemic review
- 5. Summary of EvidenceSource #2Ream, 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.PurposeTo 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.
- 6. Summary of EvidenceSource #2 cont.SamplePurposive sampling of 2139 nursing shifts with 1,919 admissions to the PICU over a 2 year period739 PICU patients (39%) received mechanical ventilatory support40 unplanned extubations of 40 individual patients (n=40)Shifts with unplanned extubations (n=40)Shifts without unplanned extubations (n=2153)
- 7. Summary of EvidenceSource #2 cont.DesignProspective cohort studyIndependent Variables: Patient acuity level (using a hospital acuity scoring system) Patient / nurse ratio Dependent Variable: Unplanned extubations
- 8. Summary of EvidenceSource #2 cont.MeasurementData 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).Monthly reports from risk management and shift reports were reviewed for unplanned extubations
- 9. Summary of EvidenceOther Sources of EvidenceAmerican Academy of Pediatrics. (2004). Clinical report: Guidelines and levels of care for pediatric intensive care units. Pediatrics, 114(4), 1114-1125. 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.
- 10. Summary of EvidenceOther Sources of EvidenceSociety of Pediatric Nurses (2007). Position statement: Safe staffing for pediatric patients. Pensacola, FL.: AuthorThis position statement provides guidelines and addresses nurse staffing and education based on patient needs for pediatric patients in an inpatient setting.
- 11. Summary of EvidenceConclusionsIncidence of unplanned extubation is higher in the pediatric population.Nursing staff shortage was associated with unplanned extubation.Nurse-to-patient ratio of 1:1 is recommended.Continuous quality improvement teamDevelopment of appropriate data tracking tools and data collection
- 12. Summary of EvidenceConclusionsFuture studies are recommended to further explore the work environment in the PICU and adverse events.Staffing ratios should take into account not only patient acuity mix but also nursing skill mix.
- 13. InnovationChange staffing in the pediatric intensive care unit to acuity based and make intubated patients a 1:1 staffing ratio.
- 14. Stakeholders identifiedPatientsStaff nursesSupport staff Physicians HospitalParentsFamily
- 15. Policy and procedures identified as needed or updatedStaffing policy - include an acuity based modelStaffing policy - how to achieve 1:1 ratio in case of short staffing. Education policy - address the care of intubated pediatric patients.
- 16. Kotter’s Phases of Change ModelProject NamePilot- Trial staffing in the pediatric intensive care unit by acuity, making intubated pediatric patients 1:1Establish UrgencyDevelop a presentation for staff meeting to show the relationship between staffing and unplanned extubations, including statistics and outcomes.
- 17. Kotter’s Phases of Change ModelCreate CoalitionAssemble a team- a staff nurse from each shift on pilot unit, unit director, nurse manager, charge nurse, respiratory therapist and unit medical director.Develop VisionHow does this affect nurses, support staff, physicians, families, budget. Vision statement: Decrease unplanned extubation rates, improve patient outcomes improving staff, physician and family satisfaction.
- 18. Kotter’s Phases of Change ModelCommunicate VisionPoster presentation for break room detailing how staffing will be handled to accommodate new staffing ratio and acuity. Email presentation to all involved.Empower ActionWeekly team meetings for first month and then monthly to review staff responses and suggestions. Suggestion box placed in unit where staff can voice concerns or recommendations and may do so anonymously if needed.
- 19. Kotter’s Phases of Change ModelGenerate Short-term WinsPresent unplanned extubation data monthly compared to previous months, along with staff, physician, and family satisfaction. Post information in break room, department newsletter, and hospital newsletterConsolidate Gains/Produce MoreExpand pilot to one additional unit after six months, using staff from original unit as change champions and support for new unit.
- 20. Kotter’s Phases of Change ModelAnchor ApproachesDiscuss ongoing results and concerns at quarterly staff meetings for two years. Team will continue to keep track of extubation rates and circumstances.