Partner with patients and families to prevent infections in the ambulatory setting.
By Amanda Bertholf
Children's hospitals are focusing on how to partner with parents, families and caregivers to prevent infections in the home—an important way to keep patients healthy and out of the hospital. But the challenge for clinicians is they're not there—they don't really know what's happening in the patient's home. To create successful partnerships, medical teams are leveraging technology as well as traditional educational materials like handouts and notebooks.
Some hospitals are achieving improved outcomes among patients with cancer or renal disease by training parents and patients in infection prevention for home care of central lines and dialysis catheters. Here are the strategies some children's hospitals are implementing to educate these patients.
Clinic nurses, home health nurses and patients or family members perform line care maintenance in the ambulatory setting, so standardization of care and extensive training and follow-up with families are important strategies. Hospitals are exploring ways to improve the process of care and empower parents and families to be a part of the solution.
Provide a visual
Boston Children's Hospital created a series of educational videos available on YouTube that show proper technique set-up in a patient's home. "These are nice tools when a family goes home, and they're feeling overwhelmed and dealing with the stress of just being discharged," says Margaret Brill Conway, R.N., oncology infection liaison nurse at Boston Children's. "They get home and think, ‘Oh, no, how am I supposed to do that?'" The video, along with step-by-step illustrated care sheets help the family care for the central line at home.
The care team also presents an informational binder to the oncology parents at discharge. "When their kids are diagnosed, the parents are in shell shock, and they don't remember much of what we tell them, so the information is there and they can refer to it throughout the course of treatment," Conway says.
The team also gives the family members business cards with QR codes leading to the instructional videos, and tries to make teaching ongoing from when the patient is first admitted to the hospital so it's not a rush to get it done a few days before the family is discharged. The videos cover topics like proper handwashing, making a clean workspace, how to flush a line change dressing, how to change a cap, and how to put on sterile gloves. They are translated into Spanish and Arabic.
These educational efforts have led to increased confidence levels in parents and help them feel comfortable speaking up in other clinical settings. "Parents are the gatekeepers and taking a big responsibility in being the ones to protect their child and that child's line," Conway ways. "They are speaking up if they see less than optimal care about to happen in other settings."
Educate home health nurses
The team at Children's Health Children's Medical Center Dallas realized there was a need to further educate home health nurses after patients would come in repeatedly with line infections. Team members were also hearing from parents that what they were seeing at home was not what the hospital was teaching them. "There was a big gap between what we were showing patients and families here and what they were seeing from the home health provider," says Melissa Langford, R.N. "The skill levels of home health nurses, who might not always be up-to-date on the latest practice for central line care, varied."
The hospital developed a monthly class to educate home health agencies, and this strategy has been effective in spreading the hospital's best practices to community nurses. The class also gives home health nurses the opportunity to earn CNE. "Any time one of our patients comes in with central line infection, even before the class started, we would get in touch with the home health company," Langford says.
"We continue to do this with a reminder that we offer this class in case there are any nurses who want to come." The program has now extended to school nurses in the area. "It's a culture change," says Cindi Winkle, R.N., patient and family educator. "But these are our patients whether they're in the hospital or the home, so we should work together and bring that unity to what's best for the patient."
The class averages 15 to 20 participants a month and lasts about two hours. The first hour consists of a lecture and presents the hospital's best practice for central line care. The last half of the class features demonstrations on addressing change on a central line, cap change, accessing central line or PICC line, and wraps up with a skills check-off station where the nurses perform skills on a mannequin.
"We cover a lot of anatomy because these nurses don't always understand insertion sites," says Karie Falder-Saeed, R.N. A pre- and post-test tracks progress in class as well as assess progress over the years. This educational offering has helped the hospital strengthen relationships with the home health groups.
In addition to working with home health providers, Children's Medical Center team members do everything they can to empower parents, encouraging them to speak up on behalf of their child. "When they get in the home, a nurse is viewed as an authority, and some parents might not be comfortable questioning what the nurse is doing," Winkle says. "Some are very comfortable, but others don't know if what they saw was right or wrong."
Train the family
Peritoneal dialysis is a home-based therapy for patients with end-stage kidney disease, utilizing a dialysis cycler to perform dialysis while patients sleep. It is important for the dialysis team to work in a partnership with patients and families to improve catheter care and prevent serious, even deadly, infections.
To get a better idea of what patients and caregivers are doing in the home, the team at Johns Hopkins Children's Center in Baltimore uses iPads to record in-home care and share an interactive training video on touch contamination. "When patients and caregivers are in the clinic, we test them to see if they're following proper protocols, but when they're in clinic, they're on their best behavior," says Barbara Case, R.N., head dialysis nurse.
To get a better sense of what's going on in the home, the team loaned iPads to each of the patients and had someone video record the caregiver in the home setting up the cycler and disconnecting it. "Even knowing they were going to bring the video back into the clinic and share it with us, small mistakes were made, like putting on their mask incorrectly," she says. "So it was useful for us to review the video with the parents and point out the incorrect steps in a positive way and share with them how to perform the correct step."
A video for patients and families shows Case demonstrating the cycler set up and disconnections with multiple mistakes. The patient and family watches the video and points out the mistakes to the clinical team. Also, to help patients and families learn more about touch contamination, the team created a game with videos of 10 different touch contaminations. The video asks what corrective action should be taken, with one correct and one wrong choice. When the patient clicks on the right answer, it lets him or her know and it shows the correct action.
While the team doesn't have measurable outcomes because patients don't always report a touch contamination, Case says she sees a difference when she does the training. "It's more fun for the patient, parent and for me, too, than just lecturing them or demonstrating it myself." Families are also providing positive feedback on the education.
The clinic has one patient who has been on dialysis for almost four years, so monthly visits can be mundane and the same every time. But this technique allows the team to pick and choose different games to keep the appointments interactive and fun. "We all remember what it was like when we sat in high school with a boring teacher—you drift off and you don't pay attention," Case says. "We know in teaching if it's interactive and fun, we can engage the kids and younger parents.
Go low tech
Low-tech strategies that don't rely on technology can be just as effective at educating patients and families as the latest gadget. Children's National Health System in Washington, D.C., developed a simple notebook with photos of corrective actions to educate parents and caregivers on touch contamination. The notebook features photos of a clinical team member doing the wrong thing. Then, on the back of the photo, is an image or instructions on how to do it correctly. For example, in an image illustrating incorrect handwashing, a provider is touching the faucet handles.
The information on the back outlines the correct World Health Organization handwashing guidelines. "Every picture brings up discussion about how things are supposed to be done," says Jennifer Wilcox, R.N., a peritoneal dialysis nurse at Children's National. To reiterate the message, providers will then watch patients wash their hands at every clinic visit. The low-tech approach is showing promising results. Over the last few months, Children's National has seen improvement—and went almost nine months without a peritonitis case. "Seeing the pictures is better than me just talking about things," Wilcox says. "If you show pictures, play games or have the patient demonstrate, it's easier for them and it builds their confidence."