CLINICAL PRACTICE DEPARTMENTEditor: Mary D. Gordon PhD, RN, CNS-BC

rdon PhD, RN, CNS-BC

Journal of Pediatric Nursing (2014) 29, 272–278

Standardizing Family Education in a Pediatric Respiratory Care UnitMary V. Szondy BSN, RN⁎, Danielle E. Morton MSN, RN-BC, CNL,

Mary D. Go

Heather M. Parrott BSN, RN, Alia Bazzy-Asaad M

D,Concettina (Tina) Tolomeo DNP, APRN, FNP-BC, AE-CYale-New Haven Children’s Hospital

Received 26 November 2013; accepted 12 December 2013

Skills checklists werecreated to standar-dize teaching and de-termine proficiency.

THE PEDIATRIC RESPIRATORY care unit (PRCU) is a6-bed unit for infants and children with a tracheostomy tubewhomay ormay not also be ventilator dependent. The primarygoal of the PRCU is to support these patients and theircaregivers through education by utilizing evidence basedmulti-disciplinary care. In planning for these patients'discharge to home themost critical piece is caregiver educationand skills training for tracheostomy and ventilator care.Discharge requirements for home include two caregiverswho have completed our training program in tracheostomy andventilator care, so they can safely manage the child duringtimes when there is no nursing support in the home. Theprogram has been in place for more than 20 years however wefound that over time, caregiver education and skills trainingbecame unstructured among the nursing staff resulting inprolonged training time, length of stays, and varying levels ofcompetency of caregivers.

Purpose

The model of care (MOC) committee was established in2009 following a survey of caregivers, nurses, and physiciansthat identified several areas that needed improvement. Some ofthe responses described nursing care and skills education asinconsistent. The MOC committee was composed of a leadpediatric respiratory physician and nurse practitioner as well asrepresentatives from nutrition, care coordination, staff nurses,child life, respiratory therapy, physical and occupationaltherapy, religious ministries, and several parents of previouspatients who had “graduated” from the PRCU. Four sub-

⁎ Corresponding author: Mary V. Szondy, BSN, RN.E-mail address: ginny.szondy@ynhh.org.

0882-5963/$ – see front matter © 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.pedn.2013.12.010

committees were established based on the identified needs inthe surveys: education, communication, transition, and

developmental care. The educationsub-committee included staff nurses,pediatric respiratory nurse practition-er, nurse educator, and nurse carecoordinator. The education subcom-mittee had six main goals: evaluatethe current practice of the PRCU,standardize caregiver education, de-velop a timeline to decrease the length of training time, establish consistency in teaching anddetermining competence with each skill learned, establishdischarge expectations and requirements, and develop writtenscenarios to help assess and improve the critical thinking skillsof the caregivers.

Getting Started

The education sub-committee started with a query of otherinstitutions that discharge similar patient populations todetermine what protocols and guidelines they used for trainingand discharge planning. We found widespread variation amonginstitutions; some had no formal training program in place, somehad an otolaryngology nurse perform all the caregiver educationwithin a fewdays to a fewweeks, and others had no expectationsfor caregiver return demonstration. Using this information, ouroriginal tools for educating and documenting caregivercompetency were evaluated and revised. Resources andprocesses were then developed based on the American ThoracicSociety's consensus statement “Care of theChildwith aChronicTracheostomy” (Sherman et al., 2000). The resources andprocesses developed emphasized a multi-disciplinary approach.

273Clinical Pratice Department

Timeline

The education sub-committee established a timeline forcaregiver education based on past experience with this patientpopulation, as well as the number and complexity of skills thatwere required for a safe discharge. It was determined that thecomplete training process should be completed in 12 weeks.Caregivers were expected to be at their child's bedside for aminimum of 4 hours a day, 3 days a week, complete a 12 hourday and 12 hour night stay, and participate in comprehensivecare days to maintain their skills if the child was not medicallyready for discharge after the training was complete. A step bystep guide, called Stepping Stones to Home, was developedto help families manage the 12-week program (Figure 1). Thesteps helped reinforce weekly goals by breaking down thetraining program into 1 week intervals.

Establishing a Sequence

A sequence was established for caregivers to learn theskills they needed for a safe discharge home. This includedbasic infant care, safe handling of the infant or child with atracheostomy tube and ventilator, and respiratory assessment.Once these skills were mastered, the caregiver could advanceto suctioning, changing tracheostomy ties, changing thetracheostomy tube, and home ventilator training. A caregivercould not become proficient in a new skill until they masteredthe previous one. The Stepping Stones to Home helped thenursing staff adhere to the sequence of skills training.

Calendar

In rooms, calendars were posted to encourage communi-cation between caregivers and nursing staff during the training

Provide basic(i.e. bathe, diahold child inde

Week 1: Identify second caregiver & begin to read PRCU binder

Locate patient care items (diapers,

suction catheters, etc)

Establish daily routine

for child

Identify signs/symptoms of respiratory distress

Observe RN suction technique & begin to

suction w/RN support

Week 2: Verbalize daily routine, follow it, continue basic child care & appropriately notify RN

for monitor/ventilator alarms

Perform respiratorassessment & recogniz

of respiratory distre

Identify trach type/size & need for spares at the bedside

Verbalize medication schedule

& administer

Verbalize steps otasks with RN inc

task, proper set up

Figure 1 Selections from St

process. Caregivers were expected to write their trainingappointments on the calendar ahead of time and identify whatskills they were preparing to work on, such as tracheostomytie change. Utilizing the calendar allowed the nursing staff toplan ahead and know when they could expect to spend blocksof time in the patient's room for teaching. Caregivers alsoused the room calendar to schedule their 12-hour stays andcomprehensive care days.

Determining Competency

Skills checklists were created to standardize teachingand determine proficiency. Checklists with pictures weremade available in both English and Spanish and weregiven to caregivers as part of their welcome binders(Figures 2 and 3). The committee developed skillschecklists for respiratory assessment, tracheostomy tiechange, suctioning, saline lavage (note: according to theAmerican Thoracic Society Consensus Statement, salinelavage should not be performed routinely but parentsshould be taught the indications for when it is appropriateto use lavage), tracheostomy tube change, feeding (bymouth, nasogastric, or gastrostomy tube), and nasogastrictube placement based on established hospital policies. Eachskill had an itemized checklist so that every nurse couldfollow the same sequence of directions and steps. An addedbenefit of the checklist was the fact that theymade the processfor determining proficiency less subjective. When determin-ing whether a caregiver “passed or failed” a task, the nursecould refer to the checklist and use it as an educational toolwith the family to remind them of the steps they missed. Thechecklist also gave the family something concrete to reviewbefore they would have to repeat the skill and master itwithout missing a step. A caregiver was deemed proficient in

child care per, dress & pendently)

Observe feeding routine & identify type of formula/additives, feeding

schedule & route

Verbalize purpose of

tracheostomy

Observe trach care & tie change

y e signs ss

Identify suction catheter size/depth for suctioning & verbalize need for

sterile technique

Verbalize when child needs suctioning & demonstrates

task with support of RN

f trach care/tie change & begin to demonstrate luding site assessment, need for suction during for tie change, appropriate tightness of ties, etc

epping Stones to Home.

Figure 2 Suctioning Competency Check List.

274 Clinical Practice Department

a skill once they could perform the skill without any cues orreminders from the nurse. It was determined there should beno prescribed number of demonstrations to be successful, assome caregivers needed more practice than others before theywere deemed proficient.

Scenarios

Scenarios were created to help promote and improvecritical thinking skills of the caregivers. The scenariosincluded topics on assessment, suctioning, tracheostomychange, monitoring alarms, medication administration, andgeneral emergencies (Figure 4).

Documentation

A new caregiver tool was developed and added to theelectronic medical record in lieu of the original paper version.This tool was a checklist of all the skills the caregivers wererequired to learn prior to discharge home. The tool wascreated to accommodate up to three caregivers.

Extended Stays

Once the caregiver was deemed to be proficient in all skillsand had received ventilator training as needed, they wererequired to complete a 12-hour day shift and a 12-hour night

Figure 3 Trach change competency check list.

275Clinical Pratice Department

Figure 3 (continued)

276 Clinical Practice Department

Figure 3 (continued)

277Clinical Pratice Department

Figure 4 Selected examples from scenarios for education.

278 Clinical Practice Department

shift independently. During these stays the caregiver wasexpected to provide all the needed care to their child withoutany cues or help from staff. The purpose of these twoextended stays was to simulate a home environment, givingthe family an opportunity to safely experience what being athome with their child for long periods of time would be like,without the constant support of the hospital staff.

Comprehensive care days were also created to helpcaregivers maintain their newly acquired skills once theycompleted the training but were still waiting for their child tobe medically ready or waiting for adequate staffing for home.The two caregivers, combined, were required to complete aminimum of four comprehensive care days each month. Eachday was at least a 4-hour block of time. During this time theyhad to perform all care, and each caregiver had to change thechild's tracheostomy tube at least once a month to maintaintheir skills.

Outcomes

We implemented the revised caregiver education programin January 2011. The length of stay in the PRCU wasmonitored, as well as the caregiver training time. There wereeight admissions 12 months prior to implementing our neweducation program (January 2010–December 2010), and tenadmissions afterwards (January 2011–December 2011).

After 1 year we did a follow up survey of parents/caregivers, nurses, and physicians. Responses reported nursingcare and education as confident, experienced, and consistent.Prior to our revised training program 38% of caregiverscompleted the training program in 12 weeks. Once weimplemented the program 80% of our caregivers completedthe training program in 12 weeks or less. Utilizing thecaregiver education log in the electronic medical record,

instead of the previous paper format, assisted the interdisci-plinary team with closely tracking and evaluating the progressof caregiver education.

Conclusion

After we implemented our revised education program wedemonstrated a decrease in the length of time it tookcaregivers to complete their training. Training by the nurseand determining competency of the caregiver was reported asmore consistent. The biggest challenge was educating all thenurses, including the float staff, to follow the skills teachingsequence, as well as determining proficiency utilizing theskills checklists as guidelines. The multi-disciplinary teamalso struggled with getting the nurses to hold the familiesaccountable for making the appointments (4 hours, 3 days aweek) for their education sessions. Further monitoring andevaluation of the 12-week education program is needed toensure safe and competent caregivers. This requires ongoingre-education of nursing staff and continued involvement ofthe interdisciplinary team.

Our future plan for the program is to add simulation to theeducation process utilizing a SimBaby with a tracheostomytube. The MOC committee has worked with past caregiversto develop a variety of emergency scenarios so thatcaregivers can experience urgent situations in a safeenvironment prior to going home.

Reference

Sherman, J. M., et al. (2000). Care of the child with a chronic tracheostomy.American Journal of Respiratory and Critical Care Medicine, 161,297–308.