Highlights from Cardiology 2011: The 15th Annual Update on Pediatric and Congenital Cardiovascular Disease

Cardiology 2011, the 15th Annual Update on Pediatric and Congenital Cardiovascular Disease, took place February 2–6, 2011 in Scottsdale, Arizona. The conference was sponsored by The Children’s Hospital of Philadelphia. In this article we feature interviews with some of the presenters.

Key Steps to Recruit and Sustain Workforce Talent

by Marcella Bryant, RN, MSN, NE-BC, Director of Cardiac/Critical Care Services, Children’s Healthcare of Atlanta In what ways can staffing for pediatric cardiology programs be challenging? Pediatric programs, unlike most others, generally experience smaller candidate pools to fill RN positions. Cardiology is a very specialized and highly technical service that challenges even the top-level graduate nurse. There is competition to screen for the best experienced nurse as well as the top-ranked new RN graduate. Adult as well as pediatric cardiology programs are often a step in the career path toward advanced practice Nurse Practitioner, Certified Registered Nurse Anesthetist, Physician Assistant, and Master’s level, which creates turnover of the highly motivated RN professional. Prestigious nationally-ranked pediatric academic centers can boast an array of specialty disciplines, yet are in constant demand to replace their talent. When key RN talent is siphoned to other programs or more attractive internal positions, a vicious cycle of staff turnover can easily become the critical norm. Subtle or sudden vacancies can mount a perfect storm of stress that brews among staff and erupts at all levels of administration, creating a paralysis that can become financially challenging with respect to the costly impact of RN talent replacement. In what areas was improvement needed? Cardiac Services was poised for the next phase of growth having completed a Master Facility Plan expansion. However, forecasted vacancy and turnover in the cardiac nursing staff had contributed to higher costs and limited growth due to an inability to adequately staff to capacity. Improvements in recruitment, on-boarding, orientation, and retention of cardiac nurses were seen as critical. Solving the revolving RN turnover became the pivotal strategic initiative. We felt inadequate RN staffing was leading to persistent challenges for quality of services, financial health, and growth. For the sake of our patients, physicians, nurses, and patient referral sources, we had to address the looming staffing crisis. Solving this factor would allow Children's to capitalize on referral and outreach efforts, reduce turnover costs, fix staffing inefficiencies, eliminate contract labor, and maximize our investment in facilities and equipment. Tell us about the four cross-functional teams that were developed: Workforce Plan, Recruitment Strategy, Enhanced Training, and Retention Strategy. We were confident that one of the keys to success was to have our staff involved in and help lead every step. Four work teams were co-facilitated by a physician and staff member to focus on specific strategies, identified as: 1) the Workforce Plan, 2) Recruitment, 3) Enhanced Training, and 4) Retention. Each of the teams incorporated experts from within our organization who worked with the members on their strategy development. Each team developed and followed a road map that incorporated specific, staged analysis that began to tell a story of how our work environment impacted patient care. The introspective self-analysis resurrected and exposed some not-so-surprising cultural phenomena. Quantitative data and trends were gathered from operational, corporate, marketing, and benchmarking sources. Staff focus groups were all held by trained facilitators. Financial implications were also evaluated. A case for change was developed that demonstrated opportunities for improved quality of care, capacity expansion, increased nursing satisfaction and reputation as a referral choice:

• Workforce Plan: Comprehensive workforce plan that projects human capital needs to address staffing needs proactively.
• Recruitment Strategy: Ensuring we have nurses in the pipeline at all times.
• Strong Student Programs: Expanded programs to better prepare for the inevitable planning of hiring more graduates (externs, practicum students, etc.).
• Training and Orientation Program: Training and educational resources for increased new graduate hiring, as well as to aid in increasing retention.
• Retention Strategy: Retention strategies for new graduates and tenured nurses help us better understand why they leave, and more intelligently address morale and incentive needs.

What were some of the most surprising lessons learned from this? After experiencing several years of chronic talent loss in spite of trying the latest in recruitment incentives, the cardiac service line of Children's Healthcare of Atlanta determined to approach RN turnover from an introspective view. In other words, the answer was internal. Focused attention on the work environment is key. A professionally satisfying and challenging work environment is also one that maintains professional respect and close teamwork connections. Retention is the first part of recruitment. Additionally, the cardiac medical and clinical leadership joined Human Resources in total ownership for the resolution of the RN talent turnover.

Key Learning Points:

• There is a strong advantage having a cross-functional team with different vantage points and perspectives.
• Using new tools and processes have stretched the team’s thinking and allowed for more focus.
• Inclusiveness of everyone’s thoughts and perspectives has allowed for a more holistic approach.
• Scope creep can be the biggest obstacle — you must stay very focused and commit to what’s in and what’s out.
• Be careful to avoid the tendency to fix everything at once.
• Peeling the onion on the situation reveals surprises.
• Validation of assumptions is critical.

Describe your results. What suggestions can you offer in how to best recruit and maintain workforce talent in cardiac nursing?  Key learning items developed included cross-functional teams, utilization of new tools, and process “stretch thinking.” Inclusiveness allowed for a more holistic approach. We also noted that “scope creep” can be the biggest obstacle. We had to avoid the tendency to fix everything at once. In addition, we discovered that “doing” the plan doesn’t ensure change, and that measurement and collaboration were critical keys to the project’s success — the validation of our original assumptions. ————————————————————

Establishing Institutional Practice Guidelines to Reduce Cardiac Implantable Device Infections: An Endeavor in Quality Improvement

by Jamie Ganley, RN, The Children's Hospital of Philadelphia What methods are currently being used to treat cardiac implantable device-related infections? Cardiac implantable device-related infections (CDI) are treated depending on the severity of the infection. Superficial infections are treated with antibiotics (usually intravenous antibiotics for several days, followed by a 7–10 day course of antibiotics taken by mouth only). Deep infections and erosions of the device through the skin are treated with long-term intravenous antibiotics (usually a 4–6 week course of IV antibiotics) and removal of the device and leads (preferred method) or removal of the device only (with leads left in place). Tell us about the practice guidelines for reducing CDI used in pediatric and congenital heart disease patients who received pacemakers or ICDs at your hospital. The practice guidelines that we instituted are: 1) Preoperative antibiotics are given within 1 hour of the skin incision (antibiotic timing is verified during the procedure time out); 2) 2% chlorhexidine gluconate surgical skin wipes are applied to implant site on the morning of device implantation; 3) 2% chlorhexidine gluconate with 70% isopropyl alcohol skin agent is used at the time of operative site preparation. What did the guidelines specify? How did use of the guidelines reduce device-related infections? In the fiscal year prior to implementation of these guidelines, the cardiac device-related infection rate had risen to 15.5%. In the fiscal year since implementation of the guidelines, the cardiac device related infection rate has fallen to 4.7%. ————————————————————

Don't Miss a Beat in Planning Your Heart Center

by Mary Beth Martin, RN, BSN, Senior Director, Heart Center, Children's Medical Center Dallas, CV Administration Tell us about your role as the Senior Director of the Heart Center at Children's Medical Center Dallas. I provide administrative leadership and support within the Heart Center to facilitate innovative program development and operational systems in support of the Heart Center’s Strategic Plan and annual goals. I work in concert with the Heart Center’s executive directors, medical directors, and nursing leadership to articulate a shared vision, develop a comprehensive strategic plan and establish priorities for the programs within the Heart Center. As the service line leader, I serve as a liaison and work collaboratively with hospital administration, physician leadership, nursing and other program administrators within the cardiac service line to create a cohesive, quality-oriented Heart Center. I have a matrixed reporting relationship to the hospital’s Sr. Vice President of Operations and the Vice President & Chief Nursing Officer to define growth opportunities specifically for the Heart Center that expand the referral network and increase cardiac procedures. How are heart centers changing and/or improving in the area of pediatric care? Our center is currently in a collaborative relationship with another standalone children’s hospital in Texas providing cardiac surgery. This is a joint surgical program with the University of Texas Southwestern Medical Center of Dallas and Children’s Medical Center. The program allows the other center to grow and develop a robust cardiac surgical program, and allows the children to benefit from our program in Dallas, where only the most critical cases are performed for this population. Tell us about your research presented at Cardiology 2011. Our department had several posters presented at the conference, including: 1) Heart Center Facility Design; 2) Decreasing CPR Events in the CVICU; 3) Heart Center — The Ideal Patient Experience; 4) On Time Starts in the Cath Lab; 5) Tool to Measure the Experience of Adolescents with ICD Device; and 6) Improving Staff confidence in Resuscitation to ECMO. I also had a formal presentation on Professional and Leadership Development. ————————————————————

Patients, Families and Staff in the Driver Seat: The Road to Creating an Ideal Experience in the Heart Center

by Felicia McLaren, MBA, Project Manager, Patient & Family Experience, Children's Medical Center, Dallas, Texas Tell us about your work with Children's Medical Center Dallas. What is a typical day like for you? I work as a project manager for the Office of the Patient and Family Experience (OPFE). One of my main responsibilities for the OPFE is managing our departmental partnership projects. A typical partnership project engagement includes a team of 12–15 individuals consisting of unit leadership, front line staff and family advisors. The core group meets once every two weeks to first understand the voice of the customer, uncover opportunities for improvement, and subsequently identify and implement improvement solutions in that department. My role is to guide and facilitate the team in an effort to achieve the greatest results. Why is it important to include patients and their families when finding ways to improve the heart center experience? At Children’s we strive to place patients and families at the center of all our work. Continuously seeking feedback from our patients and families helps us understand more about our processes from the patients’ and families viewpoint. We value family input not only because families can provide insight about our heart center processes from the patient’s perspective, but also because we recognize their expertise when it comes to their child’s care. Partnering with families in our heart center process improvement project allows us the opportunity to create the ideal healthcare experience for patients. What are some of the things cardiac patients and their families can do to have a better experience while in a heart center? How can their needs and/or concerns be better addressed? Communication and teamwork between patient families, hospital staff, and the clinical care team are key components for an enhanced experience in any heart center. As a patient or family member, it is important that you get to know the heart center staff and consider yourself as a part of that care team. Being familiar with the team may allow you to feel more comfortable providing input and asking questions about your child’s care. It is also important to become familiar with the hospital’s process for concern resolution. If you ever need to express concern in the future, you will know who to contact, providing a more timely resolution. What components make up the “ideal experience” for patients and staff? Based on principles developed by the Institute for Patient- and Family-Centered Care, Children’s Medical Center has defined five guiding principles of patient- and family-centered care. These principles allow us to provide the ideal healthcare experience that promote the best interest of the child across the continuum of care. The principles include:

• Best Medical Science: Patients are provided with medical and surgical care that is in keeping with modern practices and based on most current scientific evidence.
• Dignity + Respect: Health care practitioners and families listen to and honor each other’s perspectives and choices.
• Information Sharing: Patients and families receive and share timely, complete, and accurate information in order to effectively participate in care and decision making.
• Participation: Patients and families are encouraged and supported in participating in care decision making at the level they choose.
• Collaboration: Patients and families are also included on an institution-wide basis. Heath care leaders collaborate with patients and families in policy and program development, implementation, and evaluation, and in health care facility design, professional education, and delivery of care.

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Creating Opportunities for Parent Empowerment at The Cardiac Center of The Children’s Hospital of Philadelphia: Successes and Challenges

by Mary Stuart, BNS, RN Tell us about your work with patients at The Cardiac Center of The Children’s Hospital of Philadelphia. Creating Opportunities for Parent Empowerment (COPE) is an evidence-based way for parents to learn about and bond with their infant while their infant is hospitalized. It is also proven to help parents deal with the stresses that accompany the hospitalization. In 2009, Dr. Sharon Barton applied for a grant from Big Hearts to Little Hearts to trial Dr. Bernadette Melnyk’s NICU COPE program for the pediatric cardiac population for the first time. Prior to our trial, COPE had only been implemented in the NICU and PICU population. After being awarded the grant, a group of two advanced practice nurses and four bedside nurses were trained to implement COPE. In September 2010, we began our feasibility trial, in which our goal was to enroll 20 parents. As of January 2011, we’ve enrolled eight parents with limited success. We’re finding that the hospitalization course is much less predictable for a cardiac patient than the NICU patient. Also, having bedside nurses find time that matches with parents when they are ready for an intervention is a challenge. What challenges do parents of pediatric heart patients often encounter? Parents of hospitalized infants with cardiac disease have the challenge of bonding with their newborn who might act and look differently from other children. Also, they are in a foreign environment and have very little autonomy in the physical care of their baby. With this in mind, they might have difficulty noticing their baby’s developmental milestones and not gain much confidence in their parenting abilities. What strategies do you recommend to help parents? Our tailored COPE cardiac plan meets with families for three interventions throughout the hospitalization with a follow up after they’ve been discharged. With each intervention, we ask families how they’re doing and go over typical characteristics their infants might have and how the parents can soothe and care for the babies in a developmentally appropriate fashion. After reviewing the information, we ask the parent to fill out an activity to make note of the progress their baby has made and what the parent has learned about their child. ————————————————————

Hypertrophic Cardiomyopathy in the Pediatric Population: A Single Center's Experience with a HCM Program

by Margaret Strieper, DO, Director, Pacing and Electrophysiology, Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta Tell us about the formation of the Hypertrophic Cardiomyopathy (HCM) program at Sibley Heart Center. What do you consider the most important components of the program? The formation of the HCM clinic was driven by the desire to provide the most comprehensive, multilevel care for patients with HCM. There are multiple components that make this clinic work well. The HCM clinic is staffed by a group of physicians that are dedicated to improving the quality of life of the patients and families with HCM. This includes a genetic counselor that meets with the family to ensure all family members that have the potential for HCM are screened appropriately, and helps to arrange for genetic testing if appropriate. We have a dedicated exercise lab that performs stress echocardiograms, as well as MRI physicians that are able to evaluate the patients thoroughly. Working together and communicating well ensures that families are evaluated in a comprehensive manner. Describe the screening tools available for diagnosing HCM in pediatric patients. In what percentage of pediatric HCM patients is genetic testing performed? Screening tools include an examination, ECG and echocardiogram; 24-hour Holter, stress test and MRI as indicated. Genetic testing has been performed in approximately 30% of our patients. The limitations of obtaining genetic testing primarily involve who is going to pay for the testing. Many families have difficulties with paying all or some of the cost associated with genetic testing. Some families have chosen not to have genetic testing performed because they are concerned about the ramifications of being genetic positive and phenotypic negative. What are some of the most common challenges encountered in the HCM program? Compliance and having the families follow through with the recommended screening test for extended family members is by far the most difficult challenge we face. The other significant issue is the risk stratification of the pediatric patients. To date there are no guidelines for pediatric patients, so we adapt the adult guidelines to recommend when an ICD should be implanted. We are developing, based on our experience, a pediatric scoring system for the identification of high-risk pediatric patients with HCM. What special considerations are taken when treating pediatric patients with HCM? When given the diagnosis of HCM, many children (as well as their parents) feel that they can do no activities. Our job as a pediatric cardiologist is to help these children to be as normal as possible and to reach their full potential. Therefore, we encourage them in the activities that they can participate in, give them options of things they can do, and not just list the things they can’t do. Have you seen an increase in the number of children being diagnosed with HCM? I feel we are doing a better job of diagnosing children with HCM, in part because of the pre-participation form that children fill out prior to sports physicals, and by the referrals from the pediatricians that have listened to the warning signs of possible HCM.