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Danielle Sebbens CRNP

The effect of an education program, delivered by digital video disk, on decreasing catheter-related bloodstream infections in children with short bowel syndrome. Danielle Sebbens CRNP. Problem Statement. Short Bowel Syndrome (SBS) can be a congenital or acquired condition (Buchman, 2006).

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Danielle Sebbens CRNP

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  1. The effect of an education program, delivered by digital video disk, on decreasing catheter-related bloodstream infections in children with short bowel syndrome. Danielle Sebbens CRNP

  2. Problem Statement • Short Bowel Syndrome (SBS) can be a congenital or acquired condition (Buchman, 2006). • Children with SBS need nutritional support to maximize growth and development and to provide fluid and electrolyte support (Goulet et al, 2006). • Total parenteral nutrition (TPN) is the gold standard of nutritional support (Messing et al, 2006).

  3. Problem Statement • Central venous catheters (CVCs) are required for the use of TPN. • CVCs are associated with complications such as catheter related blood stream infection (CRBSI). • CRBSI can be a major cause of morbidity, mortality, and increased health care costs.

  4. Specific Aims • The primary purpose of this project is to reduce the incidence of CRBSI in children with SBS. • Preliminary data and information will be obtained regarding the effectiveness of DVD delivered education on care of a CVC in reducing frequency of CRBSI.

  5. Background and Significance • A large population of patients with SBS require long term central line access. • These children can have multiple central lines inserted and subsequently removed secondary to CRSBI. • In some patients the CRBSI cannot be successfully treated despite antimicrobial therapy.

  6. Surgical management

  7. Background and Significance • Failed medical management may lead to surgical removal of the CVC. • In several patients, options for vascular access are significantly reduced. • This can be a life-threatening scenario for children that require TPN to maintain their nutritional status. • The absence of central venous access is a contraindication to intestinal transplantation.

  8. Preliminary studies • Generally, more than 200,000 nosocomial blood stream infections occur each year. • The risk factors for these infections vary with: • type of catheter • location of the site of insertion • duration the line is in place • care used when accessing the catheter (Jarvis et al, 1991)

  9. Preliminary studies • The rate of CRBSI is higher in children and infants in pediatric intensive care units (ICUs) than in adults in ICUs (NNIS, 2000). • CRBSIs accounts for up to 70% of re-hospitalizations in children and adults receiving home parenteral nutrition (O’Keefe et al, 1994).

  10. Preliminary studies • CRBSI is used to measure the quality of line care (Richards et al, 1997). • Low rates of infection are not related to the device used but the use of strict aseptic techniques both at the site of catheter entry and at the connectors (Howard et al, 1989). • Educational programs on the use of aseptic technique have shown effectiveness in decreasing CRBSI (Smith et al, 2003).

  11. Preliminary studies • Interactive and videotaped educational intervention has been used with adults in the past and has shown a reduction in CRBSI (Smith et al, 2003). • DVD delivered education has contributed to adult patient knowledge, behavior and satisfaction in preoperative education (Lewis et al, 2002).

  12. Preliminary Studies • Smith et al, 2003, conducted a clinical trial to evaluate an Interactive Educational Videotaped Intervention (IEVI) designed to prevent home TPN complications of CRBSI. • A randomized placebo-controlled clinical trial was used to test IEVI that engaged patients in infection prevention problem-solving activities. • It was concluded that IEVI reduced CRBSI which resulted in fewer hospitalizations and improved quality of life (Smith et al, 2003).

  13. Preliminary studies • Coopersmith et al, 2002 performed a pre and post intervention observational study where the intervention targeted at RNs and was developed by a multidisciplinary task force to correct practice with CVC insertion and maintenance. • There was a 66% decrease in CRBSI after the intervention (Coopersmith et al, 2002). • Educational programs can have a substantial impact on morbidity, mortality, and health care costs associated with CRBSI.

  14. Project design and Methods • The proposed pilot project will use a randomized quasi-experimental and mixed design. • There will be a comparison of the number of CRBSIs between two groups. • The first group of patients will include those participants that receive the educational DVD. • The second group will receive usual care.

  15. Project design and Methods • The patients will be randomized using alternate assignment. • A semi-structured questionnaire will also be used to obtain parent input on the usefulness/effectiveness of the tool. • All participants will receive the DVD upon completion of the project.

  16. Project design and methodsSetting • Children’s Hospital of Pittsburgh of UPMC (CHP). • The educational DVD will be shown to the patients and families during their hospitalization.

  17. Project design and methodsSubjects • Children with short bowel syndrome who have been admitted to the hospital during a one month enrollment period. • Inclusion criteria: Patients with SBS and central venous access admitted to CHP with anticipation that the patient will receive medical care at CHP for the majority of the CRBSIs over the next 3 months. • Exclusion criteria: • Participation in an ethanol lock protocol. • Patients/parents/caregivers with the inability to speak or understand English will be excluded.

  18. Project design and methodsProcedures • The investigator will develop an educational DVD with the assistance of the Medical Media Division of UPMC. • The DVD will provide both visual demonstration and verbal explanation of the care of a central venous catheter. • This care will include dressing changes and accessing the catheter for medication and TPN administration. • Also information will be presented about infection and aseptic technique. The process will follow the current Children’s Hospital of Pittsburgh of UPMC policy and procedure for the care of a CVC.

  19. Project design and methodsProcedures • Parents/caregivers of the children will be approached within 24 hours of admission to determine interest in participation in the project. • Parental consent and assent from the child will be obtained. • Based on alternate assignment the participant will receive usual care or DVD education. • The PI will watch the DVD with the patient and family and collect qualitative data for future research consideration. • The participant will be given a copy of the DVD and encouraged to review it in the future and/or use it to educate other caregivers that may provide care to the patient.

  20. Project design and methodsProcedures • The investigator will then complete retrospective chart reviews for all participants, regardless of their randomization, to determine the number of CRBSIs that they have had in the past 3 months. • A 3 month prospective chart review will also be conducted to determine the frequency of CRSBIs after the participants receive usual care or DVD education.

  21. Project design and methodsProcedures • At study completion, the parent/caregivers will be asked to complete a brief, semi-structured questionairre. • The questionairre will describe their experience with this educational tool. • It will also determine if the DVD was reviewed by the caregiver after the initial viewing or used to educate others who provide care to the child.

  22. Project design and methodsOutcome Measures • The primary outcome measure is the comparison of CRBSI prior to receiving the DVD education and after the education is completed. • Compare the CRBSI between the two groups. • The secondary outcome measure is to determine, from the questionairres, if participants find this type of education delivery effective and if they used the DVD after the intial viewing.

  23. Project design and methodsData collection • Methods of data collection include: • A computer generated data collection table that will be specially designed and maintained by the primary investigator. • Narrative log collected by the primary investigator while watching the DVD with the participants. • Semi-structured questionairre.

  24. Project design and methodsData analysis • Descriptive statistics will be used to summarize the demographic data. • Qualitative outcomes obtained from the questionnaire will report on any themes observed in the effectiveness of the delivery method and the educational materials; as well as the number of times the DVD was viewed after the initial education session. 

  25. Project design and methodsData analysis • Chi Squared test will be used due to the expectation of a small sample size. The null hypothesis being that the mean number of CRBSI's between groups during the 3 months after education shows no difference than the 3 months prior to randomization to treatment group. • Odds Ratio's (OR) will be obtained to assess the odds of reoccurrence of CRBSI occurring in the SBS group receiving DVD education compared to the SBS group receiving usual care.  • The odds ratio's will then be used in logistic regression models for the prediction of the probability of occurrence of CRBSI in a 3 month period of time, given certain risk factors are included in the model to control for confounding. 

  26. Implementation: Barriers • The subjects for this project are children, therefore one of the barriers is dealing with a vulnerable population.

  27. Implementation: Facilitators • Because CRBSIs have been identified as a major issue in our facility and there is a call for action this project has received strong support.

  28. Potential funding source • NAPNAP Foundation- National Association of Pediatric Nurse Practitioners • Gardner Foundation/Infusion Nurses Society • Society of Pediatric Nurses

  29. Successful Results? You’re Fired

  30. References • Buchman, A. (2006). Etiology and initial management of short bowel syndrome. Gastroenterology, 130 (2), S5-S15. • Coopersmith, C.M., Rebmann, T.L., Zack, J.E., Ward, M.R., Corcoran, R.M., Sona, C.S., Buchman, T.G., Boyle, W.A., Polish, L.B., Fraser, V.J. (2002). Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical Care Medicine, 30(1), 59-64. • Georgeson, K.E. & Breaux, C.W. (1992). Outcome and intestinal adaptation in neonatal short-bowel syndrome. Journal of Pediatric Surgery, 27, 344-350.

  31. References • Goulet, O. & Ruemmele, F. (2006). Causes and management of intestinal failure in children. Gastroenterology,130(2), S16-S28. • Howard, L., Claunch, C., McDowell, R., Timchalk, M. (1989). Five years of experience in patients receiving home nutrition support with the implanted reservoir: a comparison with the external catheter. Journal of Parenteral and Enteral Nutrition, 13, 478-483. • Jarvis, W.R., Edwards, J.R., Culver, D.H., Hughes, J.M., Horan, T., Emori, T.G., Banerjee, S., Tolson, J., Henderson, T., Gaynes, R.P. (1991). Nosocomial infection rates in adult and pediatric intensive care units in the United States. The American Journal of Medicine, 91(3, supplement 2), S185-S191.

  32. References • Lewis, C., Gunta, K., Wong, D. (2002). Patient knowledge, behavior, and satisfaction with the use of a preoperative DVD. National Association of Orthopaedic Nurses, 21(6), 41-43, 45-49. • Messing, B. & Joly, F. (2006). Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology, 130(2), S43-S51. • National Nosocomial Infections Surveillance (NNIS) System Report, Data Summary from January 1992-April 2000, Issued June 2000. American Journal of Infection Control, 28(6), 429-448. • O’Keefe, S.J., Burnes, J.U., Thompson, R.L. (1994). Recurrent sepsis in home parenteral nutrition patients: an analysis of risk factors. Journal of Parenteral and Enteral Nutrition, 18(3), 256-263.

  33. References • Richards, D.M., Deeks, J.J., Sheldon, T.A., Shaffer, JL. (1997). Home enteral and parenteral nutrition: a systematic review. Health Technology Assessment, 1:i-iii, 1-59. • Smith, C.E., Curtas, S., Kleinbeck, S.V.M., Werkowitch, M., Seidner, D.L., Steiger, E. (2003). Clinical trial of interactive and videotaped educational interventions reduce infection, reactive depression, and rehospitalizations for sepsis in patients on home parenteral nutrition. Journal of Parenteral and Enteral Nutrition, 27(2), 137-145.

  34. Thanks • Thank you to the members of my RMU group • Sheree Shafer • Susan Van Cleve

  35. Gratitude • Finally, this project would not be possible without my team at CHP and the faculty at RMU.

  36. Questions??? Lets Go Pens!!!!

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