Exemplary Professional Practice

Nurse-Sensitive Indicators

As professionals, nurses have a responsibility to measure, evaluate and improve their practice as they have since the mid-1800s when Florence Nightingale began using statistics to find correlations between patient outcomes and the physical environment. Current nurse-sensitive indicators measure the structure, processes and outcomes of nursing care in a variety of related domains.

Nurse-sensitive indicators are quality outcomes that improve when a greater quality of nursing care is provided. In 2021, we saw strong performances in many of these metrics, including a decrease in serious safety events and our lowest central line-associated bloodstream infection (CLABSI) rate ever. Three quality improvement initiatives described below further highlight our continuous focus on nursing excellence, specifically related to CLABSIs and patient falls.

• Reducing CLABSIs in the Pediatric Intensive Care Unit (PICU)
  With a focus on reducing central line-associated bloodstream infections (CLABSI), Dallas PICU nurses convened a quality improvement team they named the CLABSI Crew. The team of over a dozen clinical nurses developed a charter and established an aim statement to reduce CLABSIs from a rate of 2.2/1,000 patient line days in 2020 to 1.3/1,000 patient line days in 2021.
  
  The CLABSI Crew served as expert nurses and champions in CLABSI prevention for their patients, rounding on patients with central lines three times each week to ensure the CLABSI prevention bundle was followed. Findings from the rounds were tracked and trended by an infection prevention specialist to identify nursing practice gaps.
  
  The CLABSI Crew met monthly to review the data and discuss their rounding experiences to identify opportunities for improvement. In addition to implementing those improvements, crew members provided the unit’s nurses with evidence-based practice tips and reminders at staff meetings, and they posted flyers. With their focused engagement in reducing CLABSIs, the CLABSI Crew was able to reduce the CLABSI rate to 0.7/1,000 patient line days, well below their goal.
• Preventing Pediatric Falls at Our Children’s House
  The inpatient blended acuity unit at Our Children’s House provides comprehensive services to children from infancy through age 18 who have developmental or birth disorders, traumatic injuries, feeding difficulties and other conditions. The interdisciplinary Our Children’s House Falls Committee meets monthly to analyze all patient fall events on this unit and to discuss any potential interventions or changes that could be made to prevent a similar event in the future. Recognizing a trend in patients falling from in-room sofas, the committee members brainstormed ways to best partner with patients’ caregivers to keep children injury-free in their hospital rooms. Understanding that children often climb on furniture at home and that families receive comprehensive fall safety information upon admission, committee members determined that a simple visual reminder was the key. They collaborated with the creative marketing team to design a washable vinyl sticker and piloted the placement of the visual reminder on the wall above the sofa in each patient room.
  
  The subsequent decline in the rate of inpatient falls from sofas is depicted in the graphic below.
  
  
  
  Furniture (sleeper sofa) fall rate calculations for pilot and prior year comparison period:
  
  
  
  Based on the results of this falls prevention pilot, placement of the vinyl sticker resulted in a 66% reduction in patient furniture falls compared to the prior year.
• Ambulatory Fall Risk Assessment
  Just as healthy children under a certain age may fall from time to time, patients may fall during outpatient visits – and some patients’ illnesses or injuries may increase their fall risk. Ambulatory nurses organized a workgroup to determine the best approach for assessing the general fall risk for specific patient populations so they could tailor interventions based on individual patients’ condition and/or the treatment they received during their visit.
  
  The nurse-led workgroup developed an annual comprehensive assessment using a modified tool from the Center for Improvement in Healthcare Quality for all outpatient areas at Children’s Medical Center Dallas and Children’s Medical Center Plano. This annual assessment involves reviewing the current patient population, routine treatment/therapy provided and patient falls data from the prior year. The results of this assessment determined the requirements for patient-specific fall risk assessments and interventions. The workgroup also recommended the implementation of basic fall prevention education for patient families, depicted on posters now displayed in the clinic exam rooms.
  
  
  
  In November 2021, the fall risk assessment was completed by leaders in 46 clinics. The assessment showed that 29 clinics (63%) care for patients who are at a higher risk of falling than the general pediatric outpatient population. Based on these findings, the workgroup decided to revise the annual assessment plan and instead build out an Ambulatory Fall Screening Tool in the electronic health record for every clinic. This tool will ultimately provide consistency in screening patients for falls across all outpatient areas. In 2021, Ambulatory Services outperformed the National Database of Nursing Quality Indicators (NDNQI) benchmark for reducing patient falls with injury.

Ongoing Growth and Development

Clinical Nurse Achievement Program: The Professional Development Council (PDC) collaborated with colleagues from Human Resources, Compensation and the Executive Leadership team to launch the Clinical Nurse Achievement Program (CNAP) in 2017. Program participation has grown exponentially. CNAP participants consistently demonstrate their commitment to advancing nursing excellence, professional accountability and autonomous practice in a program designed to encourage ongoing development and reward professional growth.

In 2020-2021, CNAP introduced a multitude of program updates and improvements to further enhance participation, including:

• The addition of the detailed CNAP Instruction Manual and participation checklist
• An easier and more streamlined way to report preceptor and charge nurse hours
• Clarification to the expert nurse, research study and educational activity sections

Professional Development Council members analyze RN certification rates each year to evaluate the correlation of CNAP participation with the increase in RN certification. Each year since 2019, we have surpassed the RN certification goal, which has largely been attributed to nurse participation in CNAP.

Healthy, Resilient Workforce

Healthy, Resilient Workforce RISE Programs: RISE (Resilience, Integrated Ethics, Staff Support, Engagement) programs support our mission and values by promoting resilience, integrated ethics and staff support through efforts that enhance the ethical climate, create moral spaces, address secondary traumatization and mitigate burnout. In 2021, Clinical Resilience Specialists participated in 88 RISE sessions supporting team members across the organization, and they facilitated 68 resilience events.

Resilience: Raising individual awareness and partnering with stakeholders to mitigate system barriers.

• Education: General resilience and burnout principles, as well as skill-building education to identify coping and resilience factors.
• Group Staff Support: Mindfulness exercises and group discussion that foster selfcompassion and focus on strengths
• Refresh Sessions: Brief mindfulness sessions, conducted individually or in groups, for stress relief and reconnection to meaning and purpose

Our job is to recognize that we must nurture who we are in order to do the job we have chosen – the job that connects us to our internal values.

Integrated Ethics: Support for team members navigating moral distress, clinical conflict and caregiver grief.

• Integrated Ethics and Moral Distress: Virtual or in-person discussions that are offered individually or in a group setting to address the moral distress brought on by the COVID-19 pandemic.
• Reflection Sessions: Facilitated discussions that explore challenges arising during clinical care.

Staff Support: Support for team members following adverse events, unexpected outcomes and/or traumatic experiences.

• Peer Support and Psychological First Aid: 1:1 intervention that provides active listening following an adverse patient event, unanticipated outcome or death.

Engagement: Promoting ongoing connection to the mission and values of our organization.

• Supportive Rounding: Brief check-ins that offer support to both clinical and non-clinical team members.

The RISE programs have helped us hone our self-awareness and individual resiliency, so that we can keep our team members and patients safe in situations that are frequently chaotic

Additionally, the Resilience Committee interdisciplinary team delved deeply into the elements that foster individual and organizational resilience in 2021, implementing resources to serve the entire organization, including:

• Team Member Support intranet site: One convenient webpage housing the many avenues of assistance for all Children’s Health team members who encounter resilience-related issues. Since its launch in April 2021, the site has logged more than 3,500 page views.
• Creating and expanding quiet rooms for team member respite and relaxation.