Patricia Branowicki

Chemotherapy error reduction: a multidisciplinary approach to create templated order sets.

More than 48,000 newly diagnosed cancer patients can expect to have some adverse events related to their care each year. Historically, 20% of these adverse events have been medication related, and two thirds have been thought to be preventable. Since the majority of these errors occurred during the order writing process, the prioritized changes made at the joint pediatric program for Children’s Hospital, Boston, and Dana-Farber Cancer Institute have been the initiation of templated orders and the development of a computerized order entry system. The goal of this initiative was to decrease errors related to chemotherapy administration by creating legible, complete, clearly defined order sets, and at the same time, to make order writing and reviewing more efficient. Chemotherapy templates were created using a consistent format and a rigorous multidisciplinary review process. Each order set includes the following: identification of the patient and cycle of chemotherapy to be given, criteria necessary to receive chemotherapy, chemotherapy orders with modifications if appropriate, and supportive care orders. Templated order sets have reduced the duplication of work efforts by significantly reducing the number of changes made during the order verification process; orders are more complete, and standardization has occurred.

Clinical practice guideline improves the treatment of sickle cell disease vasoocclusive pain

Pain is the most common complication of sickle cell disease requiring emergency department (ED) visits and hospitalization. A Clinical Practice Guideline (CPG) to manage acute sickle cell pain offers clinicians a standardized approach for the provision of evidence‐based, cost‐effective care. After CPG implementation, monitoring of pre‐established indicators is a strategy to evaluate progress toward meeting the goal of providing rapid, effective pain relief for patients with acute sickle cell pain.

Can End of Life Care for the Pediatric Patient Suffering With Escalating and Intractable Symptoms Be Improved

Over twelve thousand children are diagnosed each year with cancer, and approximately 2200 children die each year from the disease. A percentage of these patients experiences escalating and intractable distress with symptoms that include pain, dyspnea, and agitation. These symptoms may continue for hours to days. Intractable symptoms of pain, agitation, and dyspnea can be very distressing to the patient, family, and staff and often a challenge for the physicians and nursing staff to treat. To meet this challenge, The Dana-Farber Cancer Institute/Childrens Hospital Cancer Care Program has made it a priority to create a process of care that includes identifying barriers to care and the development of an end-of-life (EOL) rapid response model that includes guidelines and physiciantemplated orders for rapid escalation of opioids. The goal of this quality-improvement initiative was to develop a model of care that would enable the caregivers to provide effective comfort care to any patient experiencing symptoms of rapid escalation of pain, dyspnea, and agitation. A model of care was created to overcome barriers to care. The model includes role clarification, “Guidelines for the Management of Escalating Pain/Dyspnea/Agitation at the End of Life,” and “Rapid Titration-Templated Physician Orders.” Staff feedback was solicited relative to the content, format, and usability of the guidelines and templated orders. The physician and nursing staff reported that they found the templated orders and guidelines very helpful and effective and suggested only a few edits. A retrospective chart review is currently under way. The purpose of this chart review is to systematically document and compare the record of management of rapidly escalating symptoms of pain and/or dyspnea and/or agitation prior to and after instituting the EOL Rapid Response Model of Care. Care of the EOL patient experiencing symptoms of pain, dyspnea, and agitation is challenging. The EOL Rapid Response Model of Care outlines a process of care and provides recommendations and templated physician orders for rapid titration of opioids.

Nursing Leadership Orientation: A Competency and Preceptor Model to Facilitate New Leader Success

Many nurse manager orientation programs are loosely structured and fail to provide new managers with the experiences and support that will assure them a smooth transition. The authors describe an orientation program for new nurse managers that combines 3 components-nurse manager competencies, precepting by the nurse managers supervisor, and written and classroom resources that, together, assure that new managers are ready to face the challenges that await them.

Exemplary Professional Practice Through Nurse Peer Review

The development and execution of a nurse peer review program to evaluate nursing practice associated with significant adverse events has resulted in systemic changes. Descriptive analyses were conducted for 23 peer-reviewed cases involving 41 RNs and 2 advanced practice nurses from 14 specialties over a 4-year period. Thematic analysis revealed four common event categories: assessment and monitoring, team communication, skin integrity, and vascular access. This approach demonstrates the impact of professional nurse accountability for improving the quality of care and may serve as an exemplar for professional practice.

Observational Cohort Study of Pediatric Inpatients With Central Venous Catheters at “Intermediate Risk” of Thrombosis and Eligible for Anticoagulant Prophylaxis

The risk of deep vein thrombosis (DVT) among hospitalized children is rising.The optimal approach to DVT prophylaxis in children is unclear. This study set out to ascertain the prevalence of DVT among pediatric inpatients who neither have contraindications to nor absolute indications for prophylactic therapy. A prospective surveillance of at-risk children plus a retrospective chart review were conducted. Patients were considered to be at risk after the first 2 days of their admission. Of 1,637patients reviewed, 198 patients met criteria; among these, 84% did not receive prophylaxis. Of 2,354 observed days at risk for nonprophylaxed patients (including days at risk prior to initiating prophylaxis among prophlyaxed patients), there were 9 DVT events, for a rate 3.82/1,000 days observed. A total of 31 patients received prophylaxis. Three of these patients experienced a DVT. One patient had a bleeding event, hematuria. These results describe patients who may be eligible for prophylaxis and should be screened for further risk factors.

Collaboration among nurse executives in complex environments: fostering administrative best practice.

In the past decade, many healthcare institutions have formed new partnerships, alliances, and networks. Collaboration among chief nursing officers and other leaders from affiliating institutions is essential to the success of these new organizational structures. The authors explore the nature of the collaboration among chief nursing officers and senior nurse leaders at 5 Harvard-affiliated teaching hospitals that provide cancer care. In particular, this article examines how collaborative relationships have been fostered and highlights the challenges, benefits, and outcomes of successful cross-institutional collaboration.

Building Bridges From Hospital to Home Understanding the Transition Experience for the Newly Diagnosed Pediatric Oncology Patient

Caregivers of pediatric oncology patients are expected to understand and adhere to a complex medical plan of care while at home; yet little is known about how to assess and evaluate the caregivers’ abilities to adequately meet these demands. The purpose of this study was to describe the issues and daily challenges faced by caregivers as they transition from hospital to home after their child’s cancer diagnosis. Patients and caregivers received a home visit by an expert pediatric oncology nurse within 72 hours postdischarge after initial diagnosis. The nursing narrative notes from these visits were analyzed using content analysis. Four explanatory themes emerged: (1) “We’re doing okay,” (2) “This isn’t going so well,” (3) “I could use a little help with this,” and (4) “An RN in the house makes you feel safe and know what is correct.” These analyses revealed many caregivers achieved mastery of caring for the child at home; however, an overwhelming majority of caregivers expressed questions or concerns to the nurse during the home visit, even those achieving mastery of care. A home visit by an expert pediatric oncology nurse assisted the caregiver in transitioning to caring for the child at home. Such programs should be considered when planning transition programs from hospital to home.