INFORMATION, NEWS AND SUPPORT

The PICUStetho-ScoopN E W S L E T T E R

July, 2015Issue #4

Join us for the 5th Annual MCHF5K Run/Walk!

Continues on page 5

As our largest annual community

event, the MCHF5K is designed to

increase awareness of Nicklaus

Children’s Hospital and its pediatric

sub-specialties, showcase our

cutting-edge research, work, talent

and the dedication of our

physicians and staff.

See Alana Assing for details.

Join the PICU Team (Lifesavers).

2 The PICU Stetho-Scoop

education CornerBy Ginel Capdevila, MSN Ed, RN, CPN

Chest tube reminders

■ Assess and record hourly:

- Condition of dressing

- Amount and character of drainage

■ Drainage output:

- Note color and amount

- Place marks on drainage system to

help keep track of level

■ Respiratory status:

- Presence of chest pain or shortness

of breath

■ Assess for the following and

communicate to the physician:

- Fluctuation in water seal column

(non-fluctuating may be due to

obstruction of chest tube or re-

expansion of lung; large fluctuations

may indicate pneumothorax)

- Bubbling (indicates air leak;

vigorous bubbling usually indicates

dislodgement)

- Subcutaneous emphysema (leakage

of air into subcutaneous tissues)

■ A written physician's order shall be

required to disconnect the chest tube

from suction to place to water seal.

■ Must disconnect completely off the

suction system and vent to air.

Leaving it connected to the suction

with the actual suction being off, acts

like a clamp

■ Nursing interventions:

- Elevate head of the bed

- Keep drainage system below the

level of the chest

- Not routinely milked or stripped.

Only light tapping or moving the

position of the drainage tube to

facilitate gravity

- Encourage coughing and deep

breathing, including the use of the

incentive spirometer

- Always keep a sterile petrolatum

gauze dressing and dry sterile gauze

at the bedside to use in the case of

an accidental removal

■ Chest tubes are ONLY flushed by MD,

NP, or PA when ordered. RNs do NOT

flush egardless of physician order.

■ Transporting patients off the unit for

testing: Do not clamp chest tube (it

should be kept as ordered, either to

suction or water-seal)

■ Chest tubes are never to be clamped,

as this can result in a tension

pneumothorax; only if ordered

by the MD. ■

A big thank you to nicole Defauwfor completing our PICU brochure

Announcements

WeLCoMe To oUR neW STAFF:

Zuleny Rodriguez, Belen Baluja, Arthur

Quintero, Emily Mallon, Carolyn Ramirez,

and Sandra Amoretti

WeLCoMe To oUR HIP RnS:

Krystina Machin, Monique Nortelus,

Yesica Peraza, and Ricardo Ortega

WeLCoMe To oUR neW FeLLoWS:

Kaitlin Kobaitri, and Prithvi Raj Sendi

Keshavamurthy

CongRATULATIonS!

Soeurette Joseph for finishing her MSN!

UnIT CoUnSeL STRUCTURe

Chairs:Denise Collins and Rachel De PonsCo-chairs:Clinical Practice: Nicole Sardinas-LagoEvidence Based Practice: Yamile VieraExemplary Professional Practice: Lidia RosadoFinance: Mercedes CosioQuality: Mara Ceruto

From the eeP Comittee

Hey guys! Just wanted to give an update

on the status of raising money for the

gala. We have raised $130!!!! Keep up

the great work!!! Bags of candy are still

avaliable for sell for $5, they contain a

different array of candy and chocolates.

We will as well be raffling a bottle of wine

for $3. Thank you guys!!! We got this!!!

Drainage Chamber

Suction Control

Water Seal Chamber

5K Team Shirt!Dri-Fit Style made comfortable for the race. Let’s all represent PICU

with our team shirts on or outside the race! Deadline to order August 3rd.

Must pay in full to place order. Please see Lidia, Francesca, or Adriana ■

$20

February, 2015. Issue #3

The PICU Stetho-Scoop 3

An unplanned extubation (Ue) is an accidental or unscheduled dislodgementor removal of an artificial airway (i.e. endotracheal tube [eTT]). The eTT canbe inserted through the nose or mouth into the trachea. Ue can be medicalpersonnel related (accidental) or patient related (accidental or deliberate)

Reducing Unplannedextubations in thePediatric IntensiveCare Unit (PICU)

Risk Factors

■ Age related

■ Gender

■ Inadequate sedation

■ Patient agitation

■ Copious secretion

■ Loose and in-secure tape

■ Procedure related

■ Nurse-patient ratio

Complications

■ Re-intubation

■ Increase length of hospitalization

■ Bronchospasms

■ Arrhythmias

■ Airway traumas

■ Ventilator-associated pneumonia (VAP)

■ Increase in morbidity and mortality

Strategies to Prevent Ue

■ 1:1 nurse patient ratio while weaning

off sedation

■ Continuous quality improvement (CQI)

■ Standardization for procedures and

transportation

■ Standardization of tube

■ Securement and sedation protocol

■ Patient and family education

Proper positioning of

intubated patients

The proper positioning of intubated

pediatric patients is very important in

preventing UE, and also ventilated

associated pneumonia (VAP). These

positions varies from supine, left and right

lateral, with head of bed up at 30 degrees

to prevent (VAP), and provide adequate air

exchange. The sniffing and prone positions

are also used.

Capnography

Capnography measures exhaled carbon

dioxide (CO2). This is measured by placing

a CO2 detector at the opening at the top

of the ETT. If the ETT is in place/patient is

intubated the color on the detector turns

yellow after five seconds. If the tube is

displaced/patient is not intubated the color

will be purple.

Method of securing eTT

The fixation of an ETT is important as

tapes can become loose from oral

secretions and tongue movements. The

nurses would be taught standardized

method of taping the ETT as per Niklaus

Children's Hospital policy. The tape of

choice is water proof which is placed on

By Pat Thorpe, BSRN, MSN Ed.

4 The PICU Stetho-Scoop

the cheeks, upper lips and around the tube.

Prior to application of the tape Cavilon a

protective skin barrier and duoderm is

applied to the taping area on the cheeks.

This procedure should be carried out by two

trained personnel; respiratory therapist,

registered nurse, or doctor (Miami

Children’s Hospital, 2014). According to

Durham and Alden (2008), human-patients

simulators can be used in continuing

education to enhance self-confidence, in the

delivery of safe effective care to patients.

Supplies needed

for Intubation

■ Laryngoscope with blade

■ Endotracheal tube

■ Co2 detector

■ Stylette, oral airway

■ Detachol, Mastisol

■ Tape, cavilon, duoderm

■ Abu-bag, oxygen, suction

Conclusions

■ UE is an accidental dislodgement or

removal of an ETT

■ National benchmark of UE is 1.0 UE

per 100 ventilated days

■ UE is a potential life threatening event

that poses risks to patient safety and

quality of care

■ Early detection of risks factors can

decrease UE

■ Implementation of a CQI program is

effective in reducing UE

■ Increase nursing staff knowledge and

awareness of UE can reduce this

adverse event ■

We are deeply honored that our

name will be associated with a

healthcare organization that so

many know and trust throughout the

world,” said Jack and Barbara Nicklaus in a

joint statement. “Children are our region’s

most precious and vulnerable resource. We

have heeded a call to make a difference for

all children in need and have found a

worthy partner in Miami Children’s Health

System.

The organization shares our passion and

commitment to care excellence. We are

delighted that we are further united in our

common purpose.”

The name change is in recognition of a $60

million pledge from the Nicklaus Children’s

Health Care Foundation to the Miami

Children’s Health System. The Miami

Children’s Health Foundation, which raises

funds for the health system, is currently in

the midst of its Together for the Children

Campaign, aimed at raising $150 million by

2017.

Dr. Narendra Kini, President and CEO of

Miami Children’s Health System, said, “The

65th anniversary celebration presents a

perfect opportunity to treasure our past

and embrace a new name and future for

our hospital and outpatient centers. We are

the same great nonprofit network of

healthcare facilities for children made

stronger by the generous philanthropic

support of the Nicklaus Children’s Health

Care Foundation and Jack and Barbara

Nicklaus.

In addition to the pledge, the Nicklauses

are now the chairs of the Together for the

Children Campaign and will spearhead

fundraising efforts to support major

enhancements for the hospital, including

supporting construction of the planned

212,000-square-foot Advanced Pediatric

Care Pavilion, now in progress. This new

facility will include provisions for three new

family-centered intensive care units. Funds

will also support emergency and trauma

preparedness, and enhance globally

recognized centers for excellence at the

hospital.

“We are truly grateful for Jack and

Barbara’s long-term commitment and

generosity to our mission of providing

health and happiness to children

everywhere,” said Lucy Morillo, President

and CEO of Miami Children’s Health

Foundation. “As chairs of the Together for

The Children campaign, they will help us

Miami Children’s Hospital Becomes

nicklaus Children’s Hospital

RUnneR, WALKeR & 5K STRoLLeRBeneFITS:

■ Awards for top finishers in each

runner age group category

■ Official Race day medal for all

finishers

■ Official Race day tech t-shirt

■ Race or walk with a team or

individually

■ Access to celebration with music,

awards, food and beverages

■ Access to Vendor Village

■ Opportunity to make a difference in

the life of a child

FUn RUn BeneFITS:

■ Custom event t-shirt

■ Medals for all finishers

■ Access to Kids Fun Zone

■ Access to celebration with music,

awards, food and beverages

■ Opportunity to make a difference in

the life of a fellow child

MAKe A DIFFeRenCe:

■ $25 - Buys 50 preemie-sized diapers

for babies as small as your phone

■ $50 - Helps buy baby blankets for 10

patients in the NICU

■ $100 - Provides games and entertainment

for the Michael Fux Family Center

■ $500 - Helps provide 100 meals for

families with limited resources

■ $1000 - Sends a child to a week at

one of the many camps available at

Nicklaus Children’s Hospital ■

February, 2015. Issue #3

The PICU Stetho-Scoop 5

LIKINS, SARAH.................................1-JulPATINO, CRISTHIAN D.....................1-JulFORCINE, CHRISTINA.....................5-JulESPINAL, STEPHANIE.....................9-JulGONZALEZ, MIRTHA......................14-JulHUNTER, DANIELLE ......................21-JulBERMUDEZ, ENRIQUE..................23-JulDOBBINS, VIVETTE........................5-AugLOPEZ-CALLEJA, SARAH..............8-AugSTEPHEN, SYLVIA........................14-AugSMITH, JULIE................................15-AugSCHEFLOW, ALISON....................22-AugESCOBAR, VANESSA...................25-Aug

CABALLERO, KIRIAN ...................29-AugGRIFFITHS, SARAH .......................8-SepMURILLO, RUTH.............................9-SepDAZA-GALLEGO, EILEEN ............11-SepSERRANO, MARCIA.....................13-SepARRAZOLA, LAURA......................17-SepBARLEY, ROSALYN ......................19-SepDIAZ, BOBBI..................................19-SepDIMAANO, GINA ...........................26-SepVALDES, JENNIFER .....................27-SepRODRIGUEZ, MICHELLE .............28-SepWALKER, PAULETTE ...................28-Sep

Happy BirthdayPICU Nurses ! !

Join us for the 5th Annual MCHF 5K Run/Walk!

ensure that we not only reach our $150

million goal, but hopefully exceed it.”

Miami Children’s Health System, the parent

organization for the hospital, outpatient

centers, foundation and other entities, will

retain its name, as will Miami Children’s

Health Foundation. The hospital and its

network of facilities now embrace new

names as follows:

■ Nicklaus Children’s Hospital

(main campus near Coral Gables)

■ Nicklaus Children’s Dan Marino

Outpatient Center (Weston)

■ Nicklaus Children’s Doral

Outpatient Center

■ Nicklaus Children’s Miami Lakes

Outpatient Center

■ Nicklaus Children’s Midtown

Outpatient Center

■ Nicklaus Children’s Miramar

Outpatient Center

■ Nicklaus Children’s Palm Beach

Gardens Outpatient Center

■ Nicklaus Children’s Palmetto Bay

Outpatient Center

■ Nicklaus Children’s West Kendall

Outpatient Center ■

See Alana Assing for details. Join the PICU Team (Lifesavers).

6 The PICU Stetho-Scoop

State Behavioral Scale (SBS)ICU Sedation Workgroup:

PICU Intensivists: Dr. Totapally, Dr. Raszynski, Dr. Beltramo. Dr. Luis Lee, PICUFellow. Carolina Soto, PICU Pharmacist. PICU Nurses: Yamile Viera, MichelleRodriguez, Viviana Castillo, and Ming Li

What is SBS: SBS is a 6-point nursing scale that describes level of sedation (state behavior).

Why: A pediatric sedation scale & protocol can significantly decrease days of

benzodiazepine & opiate administration, which may improve pediatric intensive care unit

resource utilization. Prolonged sedation has been associated with increased procedures,

acquired neuromuscular disorders, delirium and post traumatic stress disorder. Who:Every supported mechanically ventilated (MV) patient. Where: PICU. Other critical

care areas could benefit in near future. When: Started Monday June 1, 2015. Phases:Phase 1 (June 1- Aug 1). Hand collection of data from sedation nursing flow sheets.

Return to ICU committee with summarized collected data for review. Phase 2

(August). SBS will go live in Cerner under ICU Quick view. Nurses will chart SBS

score in PEDS. Phase 3 (January 2016). Implement nursing driven sedation

intervention as per hospital approved protocol. In pediatric patients supported onMV, state behavior is described as a summative characteristic of the followingdimensions: 1. Respiratory Drive/Response to Ventilation 2. Coughing 3. Best

Response to Stimulation 4. Attentiveness to Care Provider 5. Tolerance to Care 6.

Consolability 7. Movement After Consoled. Scale of -3 to +2. More negative scores

reflect a sedated state. More positive scores reflect a more agitated state. ■

Coordination, graphic design and editing: William Padron. Contributions: Ginel

Capdevila, Christianne Caceres, Karla Filosa, Mercy Cosio, Mirtha Gonzalez, Harry

Reyes, Christian Patino, Pat Thorpe, Lidia Rosado, and Mara Ceruto.

By Karla Filosa, M.A. Ed. CCLS II

How Can We Help our

Patients Cope with

Painful Procedures?:

■ Utilize Child Life to provide teaching,

medical play, support, and distraction.

■ Embrace the concepts of family

centered care

■ Encouraging parent’s presence and

participation is key

■ Advocate for typical analgesia

and appropriate pharmacologic

interventions when need is identified

■ Utilize comfort positioning

■ Let patient know what they can do,

not what they can’t!

■ Make expectations clear!

■ Offer appropriate choices!

■ Offer character band-aids

■ Utilize stickers when appropriate ■

THE VOICEOF PICUGet your Voice

Heard! Fill the forms out and deposit on

drop box or contact your representatives

from day and night shift. ■

Child LifeSCORE DESCRIPTION DEFINITION

+2 Agitated

■ May have difficulty breathing with ventilator■ Coughing spontaneously■ No external stimulus required to elicit response■ Spontaneously pays attention to care provider■ Unsafe (biting ETT, pulling at lines, cannot be left alone)■ Unable to console■ Increased movement (restless, squirming or thrashing side-to-side, kicking legs)

+1 Restless and difficult to calm

■ Spontaneous effective breathing/Having difficulty breathing with ventilator ■ Occasional spontaneous cough ■ Responds to voice/No external stimulus is required to elicit response ■ Drifts off/Spontaneously pays attention to care provider ■ Intermittently unsafe ■ Does not consistently calm despite 5 minute attempt/unable to console ■ Increased movement (restless, squirming)

0 Awake and able to calm

■ Spontaneous and effective breathing ■ Coughs when repositioned/Occasional spontaneous cough ■ Responds to voice/No external stimulus is required to elicit response ■ Spontaneously pays attention to care provider ■ Distresses with procedures ■ Able to calm with comforting touch or voice when stimulus removed ■ Occasional movement of extremities or shifting of position/increased movement

(restless, squirming)

-1 Responsive to gentle touchor voice

■ Spontaneous but ineffective nonsupported breaths ■ Coughs with suctioning/repositioning ■ Responds to touch/voice ■ Able to pay attention but drifts off after stimulation ■ Distresses with procedures ■ Able to calm with comforting touch or voice when stimulus removed ■ Occasional movement of extremities or shifting of position

-2 Responsive to noxious stimuli

■ Spontaneous yet supported breathing ■ Coughs with suctioning/repositioning ■ Responds to noxious stimuli ■ Unable to pay attention to care provider ■ Will distress with a noxious procedure ■ Does not move/occasional movement of extremities or shifting of position

-3 Unresponsive

■ No spontaneous respiratory effort ■ No cough or coughs only with suctioning ■ No response to noxious stimuli ■ Unable to pay attention to care provider ■ Does not distress with any procedure (including noxious) ■ Does not move