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TRANSCRIPT
CAPSTONE Quinn Crosta, MN, RN
University of Washington March 11, 2014
NMETH 801 COURSE OBJECTIVES
1. Appreciate and successfully engage in collaborative partnership building with clinicians, consumers, faculty and/or fellow students. 2. Demonstrates a scientific curiosity and critique stance towards specialized practice. 3. Value and adhere to ethical and human subject guidelines. 4. Design and implement a scholarly project that entails addressing a question about some element of translating evidence to practice. 5. Analyze results and its implications for future clinical research and practice at agency and at the local, regional and/or national level. 6. Disseminate results to appropriate audiences within the agency and whenever possible outside the agency at the local, regional and national level.
OVERVIEW
• Background
• Purpose
• Methods & Outcomes • Parent interview • Interface • Introductory education • Super-user training
• Lessons learned
• Implications for future practice
BACKGROUND
Adverse Safety Event
Complex pain
assessments
Lack of Specialized
Measure
r-‐FLACC
• Revised- Face, Legs, Activity, Cries & Consolability Scale (r-FLACC) • Additional pain behaviors (i.e. spacticity,
head-banging) • Parent report
• Valid and reliable pain measure for
hospitalized children with cognitive impairment (Malvia et al., 2006)
• Evidence suggests that the r-FLACC has
greater clinical utility compared to other pain measures (Voepel-Lewis et al., 2008; Chen-Lim et al., 2012)
PURPOSE
• Implement the r-FLACC at SCH improve pain intensity assessments in children with CI who are unable to self-report
• Specific goals • Electronic interface for bedside use and charting • Introductory education • Training for super-users
PARENT INTERVIEW
• Parent was an active member of Family Advisory Council and the mother of a child with severe cognitive impairment
• Feedback was incorporated into r-FLACC interface design and nurse education
THE IN
TERFACE -‐ iV
iew
POW
ER FORM
TEACHING METHODS
Me
Teaching RN
RN RN RN
Teaching RN
RN RN RN
POWERPOINT DEVELOPMENT
Introductory PowerPoint Parent
Teaching RNs
DNP Student
Committee Members
(Lisa Peters)
Best Evidence (Chen-Lim et
al., 2012)
CHALLENGES
• Learner fatigue • End of a 4-hour training
session • Efforts made to re-focus
attention
• 20-minute time limit • Limited content • Preserved essential
teaching elements (flowchart)
• Slide design
“Like an optical illusion, pain behaviors in children with DD might not be easy to recognize.”
Should this child’s pain intensity be assessed with the r-FLACC?
• 4 year-old with severe autism, non-verbal. Family speaks Spanish only.
• Yes. They key is that this child with DD cannot self-report pain intensity. Note: an interpreter is needed to individualize.
Pain intensity assessment indicated.
Is the child able to self-report pain intensity?
r-FLACC
Assess pain intensity with developmental age
appropriate standard pain tool.
Ø > 7 yrs: 0-10 scale Ø 4-6 yrs: Faces Ø 1-3 yrs: FLACC Ø 0-12 mos: NPASS Ø ICU pt., sedated: ICU
Comfort Scale
No Yes
No Yes
Is the child typically
developing?
SUPER-‐USER TRAINING
• Goal to sustain appropriate use of the r-FLACC long-term
• Medical Unit Practice Council nurses • These nurses often cared for patients with CI • Council committed to improving patient care
• Two teaching sessions at Practice Council meetings
SESSION #1
• Needs Assessment Questionnaire • Low response rate (n=3)
• In-depth teaching session • Case-study & role playing • Q&A; discussion encouraged
• Nurse-identification of barriers and solutions
• Teaching evaluation • “Outstanding performance” • Positive comments
SESSION #2
• One month after the r-FLACC went “live”
• Objectives • Observe the super-user nurses using the r-FLACC at the
bedside • Observe super-user nurses teaching (peer coaching)
bedside nurses
• Created a peer coaching exercise outline and handout
PEER COACHIN
G
• A colleague-to-colleague discussion, observation and reflection of practice
• Direct peer feedback most effective (Chen-
Lim et al., 2012)
OBSERVATIONS
• Observations • r-FLACC assessments in 2 children • Individualization of the r-FLACC with a parent • Super users teaching 2 bedside nurses
• Strengths • Super users appropriately identified patients for r-FLACC
assessment • Individualized the r-FLACC when possible
• Areas for Improvement
LESSONS LEARNED
• Flexibility is essential • Change in project timeline • Cooperative effort of many people with additional
responsibilities • Time constraints – “make the most of what you have”
• New practice requires critical thinking & creative solutions • Selecting terminology “developmental disability” • Minimum age for the r-FLACC
IMPLICATIONS FOR PRACTICE
• Implementing the r-FLACC improved patient care • Provided method for improved pain
intensity assessments • Increased nurse knowledge • Encouraged partnership with parents
• Potential for improving patient outcomes… • Better pain management • Safer care • Increased family satisfaction
• Possible ripple effect to other children’s hospitals
ACKNOWLDEGMENTS
• Dr. Teresa Ward, PhD, RN
• Lisa Peters, MN, RN
• Dr. Amy Walker, PhD, RN
• My husband Nic
• My family
REFERENCES
Chen-Lim, M. L., Zarnowsky, C., Green, R., Schaffer, S., Holtzer, B. & Ely, Elizabeth. (2012). Optimizing the assessment of pain in children who are cognitively impaired through the quality improvement process. J Pediatric Nursing. Advanced online publication. doi:10.1016/j.pedn.2012.03.023
Malvia, S., Voepel-Lewis, T., Burke, C., Merkel, S. & Tait, A. R. (2006). The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, 16, 258-265. doi:10.1111/j.1460- 9592.2005.01773.x
Voepel-Lewis, T., Malviya, S., Tait, A. R., Merkel, S., Foster, R. & Krane, E. (2008). A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesth Analg, 106(1), 72-78. doi: 10.1213/01.ane.0000287680.21212.d0