Trends in Pediatric Critical Care Nursing

By Debra Donahue

In the interest of providing cost-effective and high-quality care, a growing number of health care
organizations are enhancing their pediatric critical care nursing staff, by hiring nurses with an even higher
professional scope of practice. Two such examples include; the pediatric clinical nurse specialists (CNS)
who tends to work within the hospital setting and the pediatric nurse practitioner (NP), who often works
in outpatient clinics.

The need for more specialized pediatric critical care nursing stems from changes in health care delivery
systems and the fact that patients are having more dynamic and complex health care needs. In an effort to
create a more seamless, synchronized and effective method of care delivery, some health care
professionals are advocating that these two roles, the CNS and NP, be merged into one advanced nursing
role.

Pediatric critical care nursing is specialized, in that it focuses on the pediatric patient. However an
advanced practice nurse, such as the NP, has further training and the knowledge required for taking
histories, performing physical exams, making a diagnoses, and prescribing medications. The CNS focuses
more on patient and staff education; they are valued for their unique contributions to case management,
care coordination, and patient teaching.

he exact scope of the CNS and NP roles can be governed by the policies and procedures of their
employer, as well as their state licensing board. Advocates for merging these roles, suggest that an
advanced pediatric critical care nurse should be able to perform both of these roles, of CNS and NP.

Health care organizations are concerned about containing costs, ensuring patient and family satisfaction
and improving quality of care. Pediatric critical care nursing benefits by having access to these higher
level specializations. Some specialty physicians, such as pediatric cardiologists, recognize that employing
a pediatric NP may support the expansion of his/her current practice. However, not all professions will
necessarily be supportive of a merger between the CNS and the NP roles; some Physician Assistance may
perceive the new Advanced Practitioner role as a threat to their current positions.

Moving forward with this proposed merger will require restructuring at the academic and institutional
levels. Educational administrators will be required to find innovative ways of facilitating the enrollment
process for nurses who wish to progress from pediatric critical care nursing, toward advance practice
nursing. Offering these courses via distance education or through evening courses, may facilitate the
nurse's ability to pursue professional development and career advancement, while at the same time
balancing work, family and school.

Beyond physiology, pathophysiology, pharmacology and diagnostics, the APN is expected to be

knowledgeable in the areas of health promotion, counseling, and management of common pediatric
conditions from birth through adolescences. The APN is also expected to support the administration team.

Therefore, the course curriculum is expected to cover management principles such as budgeting, creating
and developing corporate policies and procedures and managing human resources; each of these issues
affects the APN's role.

Pediatric critical care nursing has become increasingly complex. The merging of the CNS and NP roles
into one advance practice nursing role is expected to produce a more efficient and effective form of care
delivery. However, the benefits of such a merger continue to be hotly debated amongst academic circles.
Time will tell whether the CNS and NP roles merge or remain distinct and separate positions; in either
case, these advanced level roles play a critical role in providing cost-effective and efficient quality of
care.
Patient- & Family-Centered Care Improves Florida ICUs

Susan Meyers
Monday February 25, 2008

In the wee hours of the morning one spring day in 2005, Matt Mashburn awoke to find his 11-year-old

son Nick having uncontrollable seizures. Paramedics determined the situation was dire, so with the

closest hospital more than 20 minutes away, Nick was flown by helicopter to Joe DiMaggio Children’s

Hospital in Hollywood, Fla.

When Matt and his wife Melissa arrived by car some 30 minutes later, they were frazzled and worried

sick. But to Matt’s surprise, a staff member waiting for them in the ED immediately whisked them to the

pediatric ICU where Nick was being treated. While doctors and nurses tended to Nick, Matt and Melissa

helped restrain him when seizures struck, they held his hand, they watched, and they prayed. The staff

kept the Mashburns informed the entire time. By the end of the day, they had a diagnosis. Their physician

explained that Nick had pancreatitis. His blood sugar levels had dropped to dangerous levels, causing him

to seize. Nick would have to be in the hospital for the next four to five weeks to recover.

“This was a critical point for us,” says Matt. “He could have told us he was going to be in the hospital for

a week and kept us hanging on from week to week. Instead he was honest and upfront, which allowed us

to deal with it right away and make long-term plans.”

For 51 days, the pediatric ICU on the fourth floor would be a second home for the Mashburn family. “We

almost lived there,” recalls Matt. “We brought our computers and many of our personal belongings and

made ourselves at home. We were never asked to leave. It was like we were part of the care team. They

invited our input, answered our questions, never withheld information or sugar-coated it, and even

followed through with some of our suggestions.”

A new care model

Joe DiMaggio Children’s, which is a part of Memorial Health System, consisting of seven healthcare

facilities serving South Broward County, is part of an emerging trend in health care in which hospitals

integrate patients and family into the care experience. Instead of being restricted to limited visiting times

and overcrowded waiting areas with no privacy, families are invited to stay with their loved ones and be a

part of the care team. They stay in private rooms equipped with sofa sleepers. Many facilities provide

access to shower facilities, family lounges, meal services, Internet, and educational resources.

“We’ve always had a reputation for being family-friendly,” says Paula Solomone, RN, BSN, CPN,

pediatric nurse at Joe DiMaggio. “But we decided to take it one step further. Patient- and family-centered

care has involved both a change in the philosophy of care we provide as well as physical changes to our

organization. In the past, we had signs around the hospital that said, ‘cared for.’ Now we’ve changed those

to say, ‘cared for and cared about.’”

A growing body of research shows numerous benefits to patient- and family-centered care, including

fewer medication errors, shorter lengths of stay, fewer return visits to emergency rooms, and less stress on

the part of the patient and family, says Joanna Kaufman, RN, MS, resource and information specialist for

the Institute for Patient and Family Centered Care, a nonprofit organization founded in 1992. Hospitals

also tend to see improved retention rates and rising employee and patient satisfaction after patient- and

family-centered care has been in practice, she says.

At Joe DiMaggio, nurse turnover dropped from 10.84% in fiscal year 2002/2003 to 7.10% in fiscal year

2006/2007. Patient satisfaction scores have ranked in the top 1% to 2% in the nation, according to Press

Ganey surveys. The new care philosophy has been so successful at Joe DiMaggio that in 2003, Memorial

Health System decided to implement patient- and family-centered care systemwide.

A popular philosophy

The Joint Commission and the Society for Critical Care Medicine both endorse the model. In addition, the

American Hospital Association has partnered with the Institute for Healthcare Improvement to develop

tools to help healthcare providers accelerate their efforts to provide more patient- and family-centered

care.

According to the Institute for Patient and Family-Centered Care, the model is

grounded in several key principals: respecting the choices, values, and beliefs of the patient and his or her

family; sharing unbiased information on a timely basis; supporting patients and families in their decision

making; and collaborating with patients and families at all levels and in all areas of the hospital to

improve delivery of care.

“It’s about treating the patient and family as one unit,” says Julissa Jimenez, ARNP, nurse

practitioner/clinical coordinator at Joe DiMaggio. “We want to convey the message that their input is

valuable. Parents can often provide some very helpful information to clinicians. We encourage them to

trust their sixth instinct and voice their concerns.”

Developing a relationship with the patient and family is key to the patient- and family-centered care

philosophy. Initially, this may take some extra time on the part of the nurse, but it pays off in better

communication, trust, and improved safety and quality of care, says Sarah Thirlwell, RN, OCN, CHPN

MS, MS(A), a clinical specialist in nursing at Moffitt Cancer Center in Tampa, Fla. Thirwell provides

hands-on learning through direct interaction and role-modeling with clinicians at Moffitt. “One of the first

things nurses should do when they walk into a room is acknowledge the patient, family, and other people

in the room,” she says. “The nurse needs to take time to learn about a patient’s uniqueness as a person so

these things can be incorporated into the care plan.”

To help create an environment of trust and collaboration, Thirlwell suggests that nurses ask patients and

families about their goals for the day and their concerns, encouraging them to ask questions and to be

involved in the decision making. She also says nurses should: be sensitive to patients’ and their families’

verbal and nonverbal behavior; acknowledge their past experiences in regards to coping, challenges and

concerns; acknowledge their expertise by discussing what has been working for them in terms of

managing their own health, etc.; be an advocate for them during rounds; provide individualized

education; reach out with compassion and support; and know when to refer to social workers, chaplains or

other disciplines.

“A critical component of patient- and family-centered care is the creation of patient and family advisory

councils that can provide input into any number of areas, including safety and quality measures, hospital

design, and care processes,” says Thirlwell.

Families care about care

Mashburn, who has been a member of the family advisory council at Joe DiMaggio since his son’s illness,

says that empowering parents is key to improving the patient experience. “We realize the work of others

before us helped make our experience so much better that we now feel indebted to make it even better for

those after us,” says Mashburn.

Since joining the advisory council, he says the hospital has implemented many changes, such as including

parents in multi-disciplinary rounds, introducing patient- and family-centered care during orientation,

including presentations by former patients and families in orientation, developing new signage,

eliminating the use of medical acronyms in patient care, and pairing former patients and families with

new patients with similar medical conditions to provide support and education.

At Memorial Hospital Miramar (Fla.), a part of Memorial Health System, patient- and family-centered

care was incorporated into the care philosophy before the hospital opened in March 2005. One of the

biggest obstacles was the concern that it would take nurses more time, but it has done just the opposite,
says Betty Delvalle, RN, BSN, MSHSA, director of nursing for med/surg services at Miramar. “It helps

staff members because families serve as another set of eyes and ears and they often help with the care of

the patient,” she says. Patient satisfaction scores have hovered in the 98%-to-99% range and physician

satisfaction at 95% and above.

“Patient- and family-centered care has become the foundation for guiding our practices,” says Delvalle.

“While it is still relatively new in the adult world, I see this as the future of health care. Patients and

families will grow to expect it.”

Current trends in the development of sedation/analgesia scales
for the pediatric critical care patient
Pediatric Nursing, Sept-Oct, 2006 by Ivy Razmus, David Wilson

In the Pediatric Intensive Care Unit (PICU), sedation and analgesia are administered to provide comfort
and pain relief, decrease anxiety, and prevent accidental removal of lifesaving devices. Many patients are
managed without the use of neuromuscular blockade. When a patient is pharmacologically paralyzed with
a neuromuscular blockade agent, physical assessment of comfort often becomes impossible and the nurse
must rely on physiologic variables (Berkenbosch, Fichter, & Tobias, 2002). Through the use of medical
and nursing assessments, patient observation, parental input, and physiologic parameters, a valid and
reliable tool can be developed to assess comfort and pain in the sedated neuromuscular blocked pediatric
patient.

Most Recent
Research Problem

Pain and agitation assessments often have been inadequate in children because of the child's
developmental level or inability to communicate because of sedation or intubation. The major limitations
of observational scales are that they cannot be used in children with neurologic deficits or for patients
receiving neuromuscular blocking agents (Brinker, 2004). The advantage to having an appropriate
sedation scale is that it promotes synchrony with the ventilator and helps relieve anxiety and discomfort
associated with the intensive care environment (Brinker, 2004). Neuromuscular blocking agents (NBAs)
are used to improve oxygenation and facilitate mechanical ventilation. These agents do not have sedative
or analgesic properties and are not intended to be used without concomitant use of opioids and sedation
(Martin, Bratton, & O'Rourke, 1999). Previous studies confirm that protocols using valid and reliable
scoring systems can enhance the use of sedation and analgesia, thereby improving patient outcomes and
cost effectiveness (Brook et al., 1999; Kress, Pohman, O'Connor, & Hall, 2000; Mascia, Koch, &
Medicis, 2000).

Adult BIS studies. The Bispectral Index (BIS) has been studied as an objective tool that can monitor
critically ill patients with decreased levels of consciousness. Nasraway and colleagues (2002) found no
correlation between the Sedation-Agitation-Scale (SAS) and the BIS scores. However, Simmons, Riker,
Prato, and Fraser (1999) found a significant correlation between the two scales (see Table 2).

The BIS may be a more reliable method of assessing sedation and analgesia because it measures the state
of the brain and does not require stimulation for assessment (Shapiro, 1999). Other methods of assessing
sedation include the electroencephalogram (EEG), which is more labor intensive and equipment
dependent (Hamill-Ruth & Marohn, 1999). The EEG allows for interpretation of level of consciousness
based on wave forms. There is a general problem with electrophysiologic monitoring in the ICU because
of the noisy environment and the difficulty of obtaining a good quality wave form (Avramov & White,
1995). Because of the variety of tools and methods currently used to evaluate analgesia and sedation,
there is a lack of congruence among intensive care units. In general, the clinical evaluation is the most
widely used method of determining sedation with ICU patients (Detriche, Berre, Massault, & Vincent,
1999).

The COMFORT scale was modified to use in pharmacologically paralyzed pediatric mechanically
ventilated patients and compared to an Adequacy of Sedation Scale, previously known as the Physician
Adequacy of Sedation Scale (Marx et. al., 1994). The Physician Adequacy of Sedation Scale's name was
changed to the Adequacy of Sedation Scale to include nurses in the evaluation process (Razmus, Clarke,
& Naufel, 2003). The COMFORT scale was modified to exclude parameters that may not have been
applicable to the neuromuscular blocked pediatric patient. The indicators evaluated heart rate, blood
pressure changes, skin perfusion, pupil size, and response to auditory and tactile stimulation. The
Adequacy of Sedation Scale and the Modified COMFORT Scale were not correlated significantly
(Razmus et al., 2003) (see Table 4).

The COMFORT scale also was studied in the preterm infant population and found to be a valid and
reliable measurement tool for assessing stress of ventilated prematurely born babies (Wielenga, De Vos,
de Leeuw, & De Haan, 2004). De Carvalho and colleagues (1999) compared the COMFORT and the
Hartwig sedation scales in pediatric patients undergoing mechanical ventilation and found no significant
statistical difference between the two scales. No single validated assessment tool has been recommended
over another (Jacobi et al., 2002) (see Table 4). The University of Michigan Sedation Scale was found to
have good overall reliability in the assessment of pediatric sedation; however, the Neurobehavioral
Assessment Scale and the Vancouver Sedation Recovery Scale were more discriminating in their depth of
sedation (Malviya, et al., 2002). The issue of under sedation and over sedation of critical care patients can
have negative effects on the patient. Under sedation may result in ventilator asynchrony, increased oxygen
needs, unwanted removal of devices, increased use of resources, and post traumatic stress. Over sedation
could result in excessive mechanical ventilation, ventilator associated pneumonia, ventilator associated
lung injury, and neuromuscular irregularities (Watson & Kane-Gill, 2004). The methodology of adjusting
sedation is not well defined and patients may suffer from being under sedated or over sedated (Olson,
Cheek, & Morgenlander, 2004). A true gold standard has yet to be established, and the Society of Critical
Care Medicine and the Association of Health-System Pharmacists recommend using a validated
assessment scale to achieve a goal or end point in treatment.

Discussion

Evaluation of pain in the PICU patient population is challenging. Many scales measure sedation and
analgesia in critical care patients, but they are not useful for the neuromuscular blocked patient. Valid and
reliable sedation scales are important for consistent assessment of pain and comfort, yet
pharmacologically paralyzed patients have been excluded from previous studies of pain rating
instruments. Limitations to studying children who are critically ill includes the variability of ages and
neurologic responses to pain, and the paucity of firm data to support the physiologic responses to pain in
the pharmacologically paralyzed patient. Although there is increasing research in evaluating
sedation/analgesia scales, only one known study involving mechanically ventilated neuromuscular
blocked children or adults has been published. No single tool has emerged that can adequately address
pain management for this population. Continued evaluation of sedation/ analgesia is recommended to
develop simple, accurate, and reliable tools.
Most Recent
Nursing Implications

Nurses can and must be involved in defining appropriate sedation and comfort management for children.
It would be beneficial to study critically ill pharmacologically paralyzed pediatric patients with a larger
sample size in hopes of finding parameters that relate to adequate sedation and analgesia. A tool that
attempts to measure adequacy of sedation may be better than no tool at all, especially if the patient's care
is compromised by under sedation or over sedation. Education of health care staff and application of
research can improve the sedation and analgesia for children who are mechanically ventilated and muscle
relaxed.
Autism Spectrum Disorders: Earlier Screening for Early

Intervention
Beth Kantz, RN, MS
Monday February 11, 2008

At 2 years old, Meghan Wallace often spent 20 to 30 minutes sifting rocks or toys through her fingers and

watching them fall. Her mother’s friends thought she was a remarkably good baby, but her parents,

Vanessa and Leland Wallace, saw things differently.

“Our two older boys were diagnosed with Asperger syndrome after they reached school age,” says

Vanessa, who lives with her husband and five children in San Jose, Calif., “We knew that Meghan’s

behavior might be a sign of something more serious.”

After discussing their concerns with Meghan’s pediatrician, Meghan was referred for a comprehensive

evaluation that confirmed she had autism.

If the Wallaces already hadn’t had two children with Asperger syndrome, they might not have identified

Meghan’s behavior as falling outside the range of normal childhood development. Vanessa Wallace also

has a background in teaching that made her more sensitive to developmental differences.

Experts believe the sooner children are identified as having autism, the better their chances of reaching

their full potential through early intervention. That is why at the end of 2007 the American Academy of

Pediatrics (AAP) called on all pediatric providers to begin routinely monitoring and screening children 2
years old or younger for autism spectrum disorders (ASDs), which include autistic disorder, Asperger

syndrome, and pervasive developmental disorder-not otherwise specified (PDD-NOS).

A new policy and algorithm released by the AAP expands on the group’s guidelines for general

developmental surveillance that were published two years ago. The new guidelines recommend that

providers incorporate an assessment of ASD risk factors into the general developmental surveillance that

should be performed at every well-child visit and that they administer an autism-specific screening tool at

the 18- and 24-month visits. (ASD-specific screening tools for children less than 18 months of age are not

yet available for routine clinical use.) Screening with a standardized tool is also recommended whenever

the provider or parent has an ASD-related concern.

“In the past, children with ASDs were typically diagnosed between 3 and 4 years of age,” says Chris

Plauché Johnson, MD, a clinical professor of pediatrics at the University of Texas Health Science Center

in San Antonio, who has a background in special education and helped develop the AAP’s policy and

algorithm. “The goal of the revised policy is to detect children who are at risk for ASD by age 2.”

Naida Grant, an early childhood autism specialist who works with the early education program in the

Brookline, Mass., public school system, applauds the AAP’s stance, saying, “The brain is more malleable

when children are younger. So, in general, you can achieve better outcomes if you intervene and start

intensive therapy before the child is 3.” Grant works with preschool teachers on curriculum and behavior

support plans for children with autism. She also teaches a 10-week course for parents on behavior

management.

Signs of ASDs

Children with ASDs can have severe social-skill and language-skill deficits. Also, they may parrot words

(echolalia) and use spontaneous “pop-up” words without communicative intent. Children with Asperger

syndrome may not demonstrate significant language delays, but they may show difficulty in sustaining

conversations.
In children under age 2, notes Plauché Johnson, signs of ASD tend to be in the areas of receptive and

gestural language and socio-emotional development and are expressed more subtly. For this reason,

ongoing surveillance and routine screening are essential for early recognition.

One of the most distinguishing characteristics of toddler with ASDs is their inability to engage another

person’s attention to share enjoyment, which is called joint attention, says Plauché Johnson. Joint

attention develops in stages, beginning with the joyous smile a young infant produces when he or she

recognizes and responds to a parent or caregiver. Later, the child is able to follow a parent’s gaze and then

to follow a parent’s point and look back to the parent and share enjoyment. The final step in the

development of joint attention is when an infant initiates the point himself or herself and looks back at the

parent or caregiver to make sure he or she is looking at the interesting object/event and is sharing the

experience.

This ability to engage another person and share enjoyment is almost always present in typical children by

16 to 18 months of age, says Plauché Johnson, who authored a paper in an October 2007 issue of
Pediatrics presents the revised screening guidelines and discusses their rationale

(http://www.aap.org/pressroom/AutismID.pdf).

Although children with ASDs might make rudimentary pointing motions by opening and closing their

hands or might try to lead parents to objects, they are less likely to share enjoyment by looking back and

forth between the objects and the caregivers.

Other early skills that might be missing in a child with ASD include turning when his or her name is

called (although deficits in this area also can be due to a hearing impairment) and social referencing,

which involves noticing the emotional displays of others and mimicking their response. Understanding

developmental milestones is critical for ASD effective surveillance efforts.

Screening and referral

Children should be screened for ASDs using a standardized tool, including a parent questionnaire, at

regular intervals and whenever parents or clinicians raise a concern. According to the AAP’s algorithm,

children who screen positive or who have two or more risk factors for ASDs — such as a sibling with an

ASD or parental and provider concerns — should be referred to early intervention services and to

specialists who can conduct a comprehensive evaluation. Children who have language delays also should

be referred for an audiologic evaluation.

Providers should share information about ASDs with parents (so they can accurately report symptoms)

and help parents access the early intervention system. Parents also should be referred for genetic

counseling regarding recurrence risk in siblings. Information about developmental milestones, copies of

sample screening tools, and other resources for clinicians are included in an AAP toolkit.

In Illinois, several groups are partnering on a project called Enhancing Developmentally Oriented

Primary Care (EDOPC) that helps pediatric providers incorporate developmental assessments and ASD

surveillance and screening into routine practice.

“Social and emotional changes in their children are things parents want to discuss,” says project director

Anita Berry, RN, MSN, CNP/APN. “By focusing on these issues using a parent-report screening tool,

providers bring parents into the discussion, making them part of the team.”

“It’s reassuring to know your child is doing what they are suppose to be doing developmentally as well as

emotionally,” says Neferteria A. Price-Demus, a Hope Children’s Hospital employee who has a 2-year-old

son with autism. “When your healthcare provider screens your child for delays and concerns and

discusses your child’s development with you, you’re confident that, at this point, they are right on target.”

Early intervention

Intervention for ASDs in children under age 3 ideally involves a minimum of 25 hours of intensive

therapy, says Grant. The treatment plan varies for each child and addresses the child’s cognitive, motor,
and language deficits/delays. Therapy is highly structured and typically focuses on developing and

reinforcing communication and social skills and reducing disruptive and maladaptive behaviors. Once

children reach preschool age, the responsibility for planning and implementing treatment is transferred to

the schools. At every stage, notes Grant, parents play a critical role in advocating for their children.

Although the success of treatment varies depending on a number of factors, including the severity of

autistic symptoms and the child’s level of intelligence, Grant says, “Early intervention is beneficial for all

children with ASDs, regardless of severity, since it optimizes the outcomes an individual child can

achieve.”

Vanessa Wallace says her daughter’s social skills improved markedly once intensive intervention was

introduced. When asked about her goals for her children, Wallace says, “I know they can achieve things.

They have dreams, and they are people like anyone else. I want them to become all they can be. Isn’t that

what all parents want for their children?”