Dawn Polkabla: No.
Meredith Rodriguez: I don't know why.
Susan: There we go okay so.
Lisa Gray: hi everyone in the nurse breakout room, we are going to get started here shortly.
Lisa Gray: technical difficulty getting in starting.
Mónica Regalado: So we're.
Lisa Gray: going to turn it over to Michelle Maggie.
Michelle Moegling: We have olivia on.
Susan: yeah hi.
Michelle Moegling: hi, so I am going to introduce olivia fanta Fontana, hopefully i'm not chewing that up too much.
Michelle Moegling: Her she is an emergency.
Michelle Moegling: Emergency department nurse in port at portland adventist for the last five years, and in that time she is has a lot of accomplishments she has her BC an auntie and CC as well as their pediatric champion the hospital and in her free time she's co authoring.
Michelle Moegling: A global manuscript.
Michelle Moegling: For abnormal vital signs with two other Co authors from the NP rp in remains both on her semi committee and pediatric committee at the hospital so welcome olivia we're excited to have you.
Susan: Thank you so much i'm excited to be here, I have a little PowerPoint here that I wonder if I can let me see if I can share my screen here.
Susan: It looks like I may need.
Susan: Are you able to send over.
Susan: The.
Susan: screener.
Lisa Gray: Your tab olivia this is Lisa to share screen because it looks like it looks like you should be able to.
Susan: See hey let's try to do this again real quick.
Okay.
Lisa Gray: I think we lost her.
Michelle Moegling: I know that he ended.
Lisa Gray: Okay, hang tight everyone sorry.
Michelle Moegling: This is our last session, and so on, we have technical difficulties.
Susan: let's see if it'll let me know okay.
Susan: Oh sorry, are you guys able to see.
Susan: Yes.
Michelle Moegling: There you go perfect.
Susan: awesome Okay, so this is just kind of a little bit about where we are at at our hospital as well.
Susan: So she already kind of introduced me that my name is on the vehicle indiana I have been the pediatric champion for adventist health I have our Chair over the last five years, I initially started out as a critical care float new Grad and I love the er so much that I decided to stay.
Susan: With the pediatric Committee I first started in 2017 or so.
Susan: And I kind of got brought on the npr.
Susan: National pediatric readiness project with one of our partner managers who was kind of.
Susan: Meeting, not on her own, and so we kind of were tag teaming that for the first year or so and we are located in portland Oregon we are a adventist health portland it's an only chest you partner hospital and if those of you who aren't familiar, maybe with the area, or we just you is our.
Susan: Level one trauma Center our main research facility kind of our like stem head hospital here.
Susan: partnering partnering with them has been super helpful with pediatrics as well as other things, but we are 302 medical bed martyrs medical Center and 34 bed er.
Susan: We are not a pediatric hospital, but it is really interesting that on some of the surveys.
Susan: Looking at our numbers of pediatric patients, especially stemming back from 2018 we actually saw more PDF trick patients that were walking then during Becker, which is our.
Susan: pediatric hospital of the city, so our numbers, even though we don't get ambulances come to walk in Member of pediatrics pediatric patients.
Susan: And since we do not have since we're not a pediatric hospital, we do not have a pediatric unit or a pediatric physician on call, but we do have access to the osu dorm bad dorm Becker pediatric physician for console which has been incredible essentially.
Susan: If we have any sick patients patients that were unsure of even patients that they're like I don't know if we're going to admit them but.
Susan: Even with questions of doing an LP or not things like that are physicians are able to contact them almost kind of do a Tele health thing.
Susan: and get pretty prompt responses and talk with them so that's been great our pediatric committee has been going on for several years, but it's been a little bit difficult.
Susan: To upkeep the group due to turnover that i'm sure we all have seen amidst even the last two years, so it's just different managers turning over I think we have like five managers five three or four directors over the last three to four years.
Susan: And, as well as not having initially a physician presence in our pediatric Committee, which is something that we can now say we have, but just a couple of little.
Susan: hiccups that were tough.
Susan: and trying to keep the pediatric committee going but initially we were enrolled with the national pediatric prod.
Susan: Project, starting with our site survey about five years ago, and then we continue to carry out the project with Nice that one manager and myself, so we were one of the 160 to 240 affiliate sites for the project.
Susan: We go.
Susan: Looking at kind of our project overview and hat how we spearheaded it initially looking at the four topics for bundles we decided that the one that would be most applicable and helpful is to do the recognition and notification of abnormal vital signs and pediatric patients.
Susan: In terms of the other bundles for inter facility transfers we didn't necessarily have we don't have a, I feel, maybe enough of them that it would be helpful, since if they're sick we transcribe but the majority of ones that come in.
Susan: Maybe quickly assessed and then discharged so for us, this one made the most sense we also pretty much adhere to weighing in kilograms but this one was pretty widespread in terms of.
Susan: Our ability to carry out a full set of vital signs and what's abnormal.
Susan: Which i'll go through here so just start out I audited at random 30 charts spanning over January 2018 to 2018 and from that information created smarting statements are short term and long term for our hospital.
Susan: And after incorporating education and teaching based on those baseline findings, I did three pdsa cycles.
Susan: Each one spanning seven weeks and covering at least 30 or so charts with the goal to finish our third pdsa cycle by January 2020 and then be able to look at the findings and see how changes work throughout that time.
Susan: Unfortunately I don't have access to a lot of the charts on that website as it's no longer up, but this was one of the ones that I had screenshot it to take in showing our pediatric committee in terms of education.
Susan: So our findings here, show that our pediatric patient assessment was completed 40% of the time and triage, meaning a quantifiable number and location.
Susan: And that a full set of vital signs, including mental status and blood pressure was collected during triage and 43% of pediatric patients.
Susan: Unfortunately, since we do not have pediatric vital sign protocols, I chose to omit the.
Susan: abnormal vital signs because we don't necessarily have a standard that our staff could adhere to, or be gauged against it didn't feel very fair so that one is unfortunately we couldn't quantify but those were the two ones that we saw so clearly.
Susan: area for improvement.
Susan: And there.
Susan: Are here.
Susan: For our smart aim statements essentially working with the PDF for pediatric providers within the end prp and who are wonderful we created the site specific goals or the smart end statements for our er to work towards which essentially were a short term and long term goal.
Susan: Obviously, the general goal is for a full set of vital signs on all pediatric patients that come into the er but for us it seemed to be most feasible and.
Susan: easier for staff to follow through and adhere to to at least start with our goal of by April 2020 to have 100% of pediatric patients with an asi triage level of one, two and three.
Susan: To get a full set of vital signs, including the pain assessment so heart rate temperature respiratory rate blood pressure to stop mental status and pain collected during triage.
Susan: And then, our slightly shorter goal, which was the site specific or pdsa cycle goal was for 100% of pediatric patients to have a pain assessment collected during triage so essentially That was our first one, and then, with the goal of moving towards a full set of vitals.
Susan: Are operationalize area was to focus on a pain assessment and overtime progress to capturing the full set of vital signs.
Susan: Okay, so this was one of the biggest things that was incredibly helpful over the last.
Susan: year or so and after completing the project, this was one of our education components, so we created these bad or I created these badge buddies.
Susan: Based off of towels and prior badge buddies that we had for the department, as well as ones that you can find online pretty easily they sell them off of.
Susan: Like some of the pals affiliate websites and they were super super helpful essentially I went in and I made one side of the bad.
Susan: buddy to do a standard vital signs, including waiting towns in kilograms just to have as a brief record there.
Susan: And then on the backside of the badge buddy I actually was able to find this small a little bit of a loose policy that we had for our er and.
Susan: it's one that we have stationed up and triage and I was looking for it online, because in our own.
Susan: policy system we have this it's it was very brief but it's something so I wanted to add X, as our own site specific policy for now and then allows us to see where we've grown from.
Susan: So this policy, I put on the back, which essentially has to check temperature pulse and respiratory rate of all patients under three years.
Susan: blood pressure on all patients under three years with a normal respiratory rate or pulse and rectal time preferred for children under to.
Susan: repeat all temperatures greater than 102 and then I just added on the bottom, because we are trying to push for that full set of vital signs that best practice was to obtain full set of idols on all pediatric patients.
Susan: To be honest, I think the biggest thing from this one was just remember to take rectal tampon patients under to just to make sure staff would remember that component was huge and then the next.
Susan: One here.
Susan: and
Susan: While it loads it was pretty easy to print those out after reformatted them I essentially cut them out laminated and hole punch them so that way, we had enough for the whole department primarily for nurses, so we created.
Susan: enough for the whole er nursing staff, but if anyone else wanted them, they could have them as well and me.
Susan: A little bit of a flickering light there, and the next thing we did was create a poster to illustrate the goals the smart aims.
Susan: and make it a visual aid for the different pain assessment skills for pediatrics and we use this poster to do staff teachings and then afterward put it in our bedroom so that way people could use it as a reference point.
Susan: Our staff teachings essentially were.
Susan: carried out during huddle so over the course of a week to two weeks, I went into the hospital and came in.
Susan: Essentially, met with all the nursing staff at shift change so day shift title night shift title and I held individual hud huddles for each of our mid shifters they don't normally have one.
Susan: So 10 1112 to we might have had a three or 5pm in there as well, but essentially touching base with all of them as they came in for work.
Susan: I brought the poster in i'd have the badge bodies ready if they needed them or had not received them yet, and then I had them read through what our goals for.
Susan: For the hospital and then had them sign off on a sheet, to make sure that they had signed off they completed the education.
Susan: And then afterward place that poster board in the bedroom just to have for us as a visual aid because there wasn't a great spot in the whole department, besides and triage which.
Susan: The next component kind of ties into it, that we eliminated all of our pediatric pain scales and place them up front in our triage since we aren't the pediatrics preferred hospital they don't pediatric patients don't really come in by ambulance unless it's like.
Susan: Family request them to come in, or something something bizarre I seen maybe to come in by ambulance over the past five years.
Susan: But having it up and triage we had it laminated and place pretty large up on the wall and actually made it so that it's removable.
Susan: So that way if there were ever second triage nurse or someone that was coming up to help out let's say triage multiple people, you can actually take the pain scale off the wall.
Susan: and bring it over to the kid and they can use it to like they can actually see it up close so it's hung up a little bit.
Susan: Mid level height, but if they were smaller are being treated in a different area, you could bring it over so they could look at the faces skill slack or the regular numerical rating skill.
Susan: And the additional thing we did was create a station for Kanga bands to play some pediatric patients with that asi triage level of one, two or three.
Susan: This was obviously not part of our smart and statement, but it was just something to kind of.
Susan: If we can get that click of we want to make sure that we're taking care of pediatric patients that we're aware of asi ones twos and threes.
Susan: kind of just to keep pediatrics on the radar since we do see a fair amount of them and.
Susan: One of the nurses and the pediatric committee actually set this up and it looks awesome so Essentially, we have our infant scale and above it we placed these Kanga bands which are wait based color based based on the brazos pediatric resuscitation system.
Susan: And essentially have the bands listed in different bags across the wall, so that way after you weigh the patient, you could take a band pop it on them put their weight on it, or even just grabbed the band, so they had the color there a sick kids so that you can bring it back to the room.
Susan: And if anyone has not had the King of bands or heard of them before I just added this little.
Susan: tidbit in that essentially they help to quickly and accurately identify size and weight categories of pediatric patients, it provides a quick reference for accurate medication administration and proper equipment usage.
Susan: For us, if a sick patient comes in, or sick baby comes in, if they even stop and triage which a lot of times they just get brought back to the room, which is fine.
Susan: If there's that sick you obviously skip that area, but we try to push for people to at least get a quick weight on them.
Susan: And then, if they're still like if they're sick bring them back to the room, but it can just be so helpful to even just have that one numerical weight in kilograms so that way when you bring them back to a room, they can start the medication path.
Susan: sooner and instead of trying to lay them flat and measure them with the browser tape it can just be a nice quick reference tool, so that worked awesome as well.
Susan: Those were our Big Three education points the poster.
Susan: With staff trainings essentially during huddles the badge buddies placing the paint skills assessment up in triage so that way they had accurate and quick.
Susan: ability to see that they need to assess pain and then having the King of bands just to keep a like pediatric presence in mind, because.
Susan: If it's on the wall right in front of triage it's just a lot easier to oh okay yeah I need a way them I need to really assess if this is a sick kid and get all the information that I need to So those are kind of our big things.
Susan: Some of the barriers in terms of our education and throughout the process.
Susan: We did not have an abnormal vital sign notification process or standard set of vital signs for the ED like I mentioned before, and we did try to actually push for it in cerner because.
Susan: For our adult patients, we are able to if there is an abnormal vital sign it'll pop up and flag it on the screen, but unfortunately with cerner we weren't able to put the pediatric one into it in the future we're moving into epic knock on wood, maybe in the next year to two years.
Susan: Hopefully fingers crossed, and so that will be something that we're pushing forward to have just a general set of normal vital signs and a notification process.
Susan: But for now we just unfortunately couldn't you just kind of had to make a clinical note, if there was an urgency or.
Susan: We always encourage staff to notify a provider and clinical know documented, but that wasn't something we could quantify so it wasn't our big push at the moment and.
Susan: Also, the the turnover, which I had mentioned as well, we had.
Susan: A couple different managers and directors, that all would have a brief presence on the pediatric committee and then, when they left, obviously we would have to turn it over to the next one.
Susan: And kind of re update them, but one of the most awesome and helpful components we've had over the last year is actually bringing a physician on board.
Susan: We initially had one two years ago, and he left the hospital as well, then we briefly had our medical director, as our physician presence and then he stepped out and we now have a simplified position.
Susan: On our committee, and it has been so helpful to just keep that presence to add things even in terms of knowing what the where the nursing staff are at and talking with him about problems that.
Susan: They see as providers and nurses and it's been incredibly helpful we've also recently added on one of our mid level providers are one of our PhDs who.
Susan: In our emergency department, we have a essentially small area of fast track like the quick turnover runny nose rash etc and.
Susan: Ours is called our little fast track area and that's where most of the mid level see the majority of our pediatric patients.
Susan: Because if they're very sick and they need to get transferred a minute, they would go back to a regular pod bed and a physician would see them, but the majority of patients are seen by our mid level providers, so it was really important for us to bring a mid level provider on to our.
Susan: pediatric committee because they can say a lot of the patients that we see the issues that they have.
Susan: Sometimes, more than us nurses individually, who are just occasionally in that area or not.
Susan: And the last barrier is obviously just influx of you know, new agency staff even over the last year and a mass exodus of course stuff trying to keep that information up and current.
Susan: and continue to educate we're trying to hope for quarterly to get just a little reminder like hey make sure you're taking vital signs hey make sure you're getting a weight and kilos.
Susan: etc so that's kind of where we're at now.
Susan: In terms of outcomes, unfortunately I wasn't able to access the exact chart of outcomes following the project.
Susan: And as the site had gone down before I was able to get the chart, but this is what I had from my notes from.
Susan: After the pdsa cycles that our baseline as we've mentioned before, was the 43% of the time standard vitals 40% of the time a pain assessment and post pdsa cycles.
Susan: 63% of the time we did get a standard set of vital signs and 80% of the time got a pain assessment which for us was huge obviously pdsa cycles weren't they're not massive so there's.
Susan: Obviously lots of room for error and there were only 30 baseline charts compared to a total of 90 ish charts in terms of post pdsa cycles and total charts but still like a nice, we were pleasantly surprised to have that.
Susan: Change and now.
Susan: If we were to reassess that information again i'm not sure we would be up as high, to be honest with you just with all the new agency staff coming in, but that's why we want to.
Susan: Really head honcho for this and make sure that we're introducing each quarter and because the course staff has.
Maryanne Higbee: done so well.
Susan: With us essentially.
Susan: So overall the presence of pediatric resources throughout the ED has just exponentially grown and our department familiarity it's a lot more common to see little pediatric resources, even in our code room, we have a big poster up from that Panda gave us the.
Susan: sign in triage the King of bands It just shows a lot more of a presence that we do even allow staff to feel like they we can take care of pediatric patients, things are here so that's been very helpful and currently like I said, have a physician on our pediatric committee and one ATP.
Susan: Work we're in the process of actually submitting a standard protocol for az licensed for pediatrics that one's more on the head like on the forefront, because it's a nurse driven protocol so it's it's not the same process of getting it into cerner or a standardized protocol.
Susan: Like the vital signs are that we would have to incorporate into cerner but just awesome to start getting that nz laces on board, because it just allows us to feel like we're moving forward, even if we can't instill new.
Susan: Protocols into cerner I guess you could say, since we have to wait till epic for a lot of things that's been an awesome thing that we're excited about.
Susan: We have pediatric meetings monthly and we're currently planning a sims regarding pediatric emergencies and they're present to the ED I know they've done one already.
Susan: At another hospital and essentially we had one scheduled but.
Susan: Due to code that was cancelled, so we should have that in the next couple of months, and then, lastly, just that really reiteration of education, over the last.
Susan: year or two, since that project kind of ended for that moment and that's kind of everything.
Michelle Moegling: So we have a question is Michelle we have a question in the chat who are your stakeholders from your pizza committee in the ED.
Susan: yeah so we have our.
Susan: One of our charge nurses Brittany Wang she's our pediatric committee lead and she's wonderful and we have three other nurses, two of which are one of which has worked at randalls.
Susan: Providence pediatrics and so she brings a lot of great information to the group, we also have Dr trailer and essentially.
Susan: Dr Hansen, who works up on the hill we just you pediatrics as well, even though he's not in our hospital all the time he picks up shifts and he's a wonderful resource.
Susan: And then, a couple other of our staff nurses as well we just brought two new people on and our mid level provider is our PA.
Susan: gail shears who has been wonderful as well.
Susan: And i'm reading through here, I saw it says that cerner does have it, the ability, I.
Susan: We thought we talked with them as well and Brittany, who really head honchos all of it in terms of.
Susan: trying to get things instilled into the cerner system, I think the issue was the fact that they said because we're moving over to epic.
Susan: The steps that it would take would take months and to get it reincorporated into cerner when they wanted to do away with cerner they said would essentially be pointless so.
Susan: Even though it was possible.
Susan: That it wasn't going to be a quick thing it would take months, and then the approval process will be forever and that they were hoping to just go to epic so they essentially said let's just skip it for now.
Betsy O: Well that's good, I just wanted to share with you that they do have it, because.
Betsy O: Totally we did put it in, and that was just but getting changes made is often difficult thing if you're moving it won't be but.
Susan: Any Mr.
Betsy O: should be able to.
Betsy O: background I like color code whatever.
Betsy O: Whatever yeah.
Betsy O: i've no more vital signs you set as it now your project only was thinking of the the size of one two threes at this point.
Betsy O: Correct.
Betsy O: For current project that's okay it's a it's a topic that's well known across the country for the same reasons, so.
Betsy O: Totally looks like you did a really great job.
Susan: Well, well, thank you yeah We obviously want to obtain full set of vital signs on everyone, but just as a group, the biggest vital sign that with miss was blood pressure and due to the high rates as i'm sure.
Susan: yeah essentially with the amount of low acuity pediatric patients coming into the department that's still our goal, we want a full set of vital signs on everyone, but just trying to get staff to get like confident and consistent and competent in their.
Susan: triage assessment skills and getting all of those vital signs to do it on the ones twos and threes we want it to really hit home for like this is.
Susan: We want you to focus on this because the end of the day we really want to make sure you obtain the vital signs on any one you are even like maybe they could be sick i'm not sure.
Susan: And then that's why we have the add on like hey The goal is going to be eventually like we want to get.
Susan: In general, the goal is well now, but to really push to assess, like all pediatric patient vital signs assessment and even though that was our goal to do that, yes, I levels ones twos and threes I was still auditing charts based on the fact of full set of vitals for everyone, I didn't like.
Susan: discriminate for asi.
Susan: But yes, it is unfortunate that for cerner like obviously since it hasn't for adults and you can do it for paid their.
Susan: The hiccup which it's a it's a bummer because I think it might be a little bit until we get, I think, maybe not maybe not maybe i'll be real quick, but I think it could be a wee bit of time that.
Susan: It would be awesome to have it, and still, but I think the issue is, we first have to get the vital signs established as the policy.
Susan: First of normals established as a policy then get it approved to go into cerner and then have it incorporated into cerner and they were like we're not even going to keep cerner so let's just push for like trying to get a.
Susan: general standard vital signs, like the bag buddies under the department and then, when epic comes around will have it so.
Susan: i'm guessing that was kind of the the main spiel but Brittany weighing who's been heading all of that is super on the ball with it so i'm sure i'm sure if it took a while to get to epic or anything like that that she would probably spearhead that one.
Michelle Moegling: Did you find any problems when you are looking at your data on respiratory rates in kids.
Susan: In terms of.
Michelle Moegling: actually getting them I think some bar chart out it's because I work in a large system hospital.
Michelle Moegling: yeah i'm the pizza coordinator for the system.
Michelle Moegling: And I find a lot of times everybody's respiratory rate is 20, no matter what your age.
Susan: Totally.
Susan: No um yeah.
Susan: You come in and 20 we talked about to in the huddle teachings obviously.
Susan: Like providing questions, because one of the big ones was how do you get accurate.
Susan: blood pressure and such with respiratory rate that because we weren't able to measure in our data abnormal vital signs i'm not sure, to be honest with you how skewed that one was.
Susan: However, on some of the charts if someone was really sick they get a respiratory rate of like 45 and the pool socks, and that patient was clearly then brought back to a room, because that would be the only component there.
Susan: But I think you're 100% right, we always encourage people to at least check it for 30 seconds and double that if you can.
Susan: But if they're sticking up totally definitely can be either like 20 or 30 to 40 there's pretty pretty the standard.
Susan: But that if you really need if the respiratory rate if they're sick that's like obviously one of our our big key points that we want, especially over this coven respiratory season.
Michelle Moegling: Thank you Kristen you have your hand raised.
Kristen Colsden: yeah so I have a question I came a little late to the show here but.
Kristen Colsden: You said you are working currently on a pediatric.
Kristen Colsden: Vital sign policy for your emergency department.
Susan: We are, yes, but essentially waiting for epic to like.
Susan: come out and then be able to establish it so we're actually working with our agency dorm Becker and getting access to their policies.
Susan: and hopefully be able to apply them to our er as well if there's general enough and I think that will kind of be the component that leads are.
Susan: Vital sign policy for our hospital, since it it's got to be decently decently broad but we wanted to have a good standing to back it from a waitress you dorn Becker which will come after epic i'm assuming.
Kristen Colsden: Because i'm in the quality department and one of my projects and i'm going to work on is the vital signs on pediatrics in the emergency department, I guess, looking for something to do one day and was just started reviewing charts.
Kristen Colsden: And yeah not every single pediatric that came through how vital signs.
Kristen Colsden: Is I came from a trauma Center in Kansas, where there was a really bad case where a like five year old girl came through vital signs are abnormal they never got rechecked a discharge she went home she had strep she stroked and it was like a $5 million lawsuit against the.
Kristen Colsden: Facility.
Kristen Colsden: So our providers became super passionate about vital signs the moment they come in a discharge and what i'm noticing is we do a decent job of getting them on admission but rarely ever is there, another repeat at discharge.
Kristen Colsden: The other issue that i'm noticing is our monitors are integrated into our epic and we're just going over there and hit hitting except on all the vitals so you.
Kristen Colsden: know we gold, who came comes in, with vitals.
Kristen Colsden: With the respiratory rate of 12 and rang leader, a respiratory rate of 60 and you're like Okay, where we back in the.
Kristen Colsden: right direction, no rang rang with something so yeah i'd be interested to be caught up today or just kept up to date on everything that you guys are doing.
Susan: yeah totally um you can always shoot me an email to I can add mine after the meeting, but essentially.
Susan: yeah I can definitely let you know to as we get information from HQ door and Becker for their vital same policy because I completely agree, I think that can often be a.
Susan: recheck vital sign issue or consistency of vital signs throughout the visit our mid level providers are pretty cognizant about.
Susan: Especially because they're the ones, seeing our lower acuity patients or starting lower acuity because, obviously, that can escalate that if something is up normal.
Susan: Though they're pretty on the ball about making sure it's rechecked but for the nursing staff.
Susan: The big thing is if they get a full set of vital signs on arrival, it seems to be the trend that before they discharge at least to have a respiratory.
Susan: heart rate and pulse ox that's kind of been our our big mainstay and if they had a fever to recheck that it's at least going down doesn't have to be 100.4 and lower type of things, but that, if it was 103 it better be 101 before they go type of thing.
Susan: Because our general protocol for our hospital is that within discharge, they need to have vital signs within 30 to 30 minutes to an hour, depending on the case before they leave.
Susan: So that unless the patients will be there for an hour and a half, they should have some sort of vital signs recheck before they go it's kind of our general like protocol teachings.
Susan: And if they're sick and on a monitor you're right, it can definitely as soon as you pull through the vitals you're like wow the respiratory rate was 22 and triage and it is 57 but.
Susan: Obviously, very different so that part I, I completely agree, I think that one will definitely at times get missed or even just the random erroneous number that will pull through if you are like pulling numbers directly from the monitor because ours is set up, that we have as well.
Susan: And unfortunately, since ours don't register exactly for pediatrics like a it will flag red like it would, for an adult if the vital sign is off, essentially, I think, because once they're sick we become super super highly cognizant because we don't see as many sick sick kids.
Susan: That you'll see the vital signs.
Susan: pulled through pretty pretty consistently and, if not it's because Panda team is sitting there, and like scoop them away.
Susan: or they were trying to work so hard on IV access and doing an LP or any of the things, but because we don't see as many.
Susan: When we do have big kids it's kind of like an all hands on board like everyone's like to the point of sometimes there's so many cooks in the kitchen type of thing but usually.
Susan: that's why so it's more of the.
Susan: Patients who are in the middle that's the part we struggle with it seems to be as our hospital like really easy quick level fours and fives like in and out came in with like a cough runny nose we swap them check for strep.
Susan: send them home, people who are very sick hypoxic the kids that come in status epilepticus anything like that bring it back to your room it's either a novice or an admin.
Susan: But it's those middle ground kids like dehydrated vomiting maybe cut down fluids, maybe not is failing keeping down fluids or.
Susan: we're running blood work and had a little bit of a lactic or something the middle realms that's the part where I feel like our fallout is and deciding.
Susan: Where to move forward, which, in terms of providers who are seeing them can be based on their comfortability with discharging are escalating it to a physician and moving them out of our fast track area or.
Susan: being concerned about any vital sign, because sometimes it, you know they just have fevers and they just are sick or they're still tacky and deciding when they kind of pull that trigger I think that's where our fallout tends to be.
Michelle Moegling: When we did our vital sign policy we actually require half hour to before discharge or admission to the floor and then we did it based on asi.
Michelle Moegling: And we added across our pizza and adult world.
Michelle Moegling: So it's a system policy, whether you see whether you're in a pgd or you're seeing kids and adults it's all based off asi and we did it with a range like I think ones were like every 15 minutes until an order for that to change, and I think tues we're at a minimum of every one hour.
Michelle Moegling: And then I think we almost went to every four hours, I think, for three years force.
Susan: yeah, I think, ours is.
Michelle Moegling: Because for five simulator that.
Susan: three plus four is it's.
Susan: Like I feel two hours three hours every hour to the every 30 minutes and ones.
Susan: 15 minutes or continuous or however that love.
Susan: yeah continuous.
Michelle Moegling: Mixed hospital, making sure that it fits for both that way it's easier yeah just singling out the pediatric patients if it's the same policy for both.
Susan: Know totally.
Betsy O: yeah this hi i'm Betsy I was born and i'm the pediatric liaison nurse from hospital in La here torrance in that's part of the E dot program that Los Angeles, has had for 30 years.
Betsy O: In this topic has always been a well discuss topic and we currently as a group are collecting and looking at all the policies involved and having best practice so it's it's it's definitely a.
Betsy O: great project that you've taken on, you know, in a smaller area for vital signs and the standard out here is definitely 30 minutes.
Betsy O: Prior to admissions and transfers for everybody, regardless of what their yes, I level was if they're admitted or transfer for.
Betsy O: Best practice.
Betsy O: And, and before dish charges with some carve outs in certain hospitals, for the lower yes, is there, real quick.
Betsy O: In and outs very simple ones, but that anything three and above always is getting.
Betsy O: getting more and it is the whole setup vital signs, including blood pressure and including I love that respiratory comment because it is I look at charts all the time, right now, currently, because we are trying to collect data.
Betsy O: system wife, the hot various hospitals in our PDL and group, which is the equivalent of a Pec, but this has been a great collaborative to talk to you and listen to the things that.
Betsy O: across the board, but we have 38 hospitals, that you know we collectively meet and discuss these issues, so this is a really valid topic in any.
Betsy O: department eventually you'll have a policy which is best practice to what your staff can refer to and badge buddies with the abnormal or one of the key things we shared with everybody just because.
Betsy O: A lot of hospitals don't see a lot of kids all the time, and you forget it's not like the adult that you're always doing.
Betsy O: Right, so I like your batch, but it was very nice.
Susan: Thank you and yeah.
Betsy O: I.
Susan: guess, I did not mention on that too for any admin or transfer all of our packets.
Susan: Adult versus pete's exact same in terms of you check vital signs within 30 minutes on the part so essentially any of the patients are as high level ones and twos.
Susan: odds are they'll get transferred, at least for an odds sometimes not but that's it'll be a long lengthy discussion after.
Susan: door and baker says, you know what go ahead and autism there for a couple hours and then they'll go home if usually if they're ones or twos they'll get transferred, so the vital signs policy.
Susan: For the on the part within 30 minutes of them, leaving applies, but if they're not sick they're usually pretty continuous with vitals, it is the lower acuity ones that for us, we say if someone's getting discharged regardless of pediatric adult.
Susan: You want vital signs, depending on their asi acuity but best with best practice within an hour as like a general, but if it's a higher acuity it's kind of an understood ones twos or threes within 30 minutes.
Susan: Prior to discharge, and if it's level four or five it's the whole one hour to hour to if they're discharged before two hour mark.
Susan: And their lower acuity would not probably get any retracted vitals once it hits that to our mark, is where we kind of teach people that okay that's when you should look at it, we need to reassess vitals.
Betsy O: yeah well the things you can it depends on how you want your policies written is in some places there's the carve out of if there were ever any abnormal vital signs.
Susan: that's a mandate regardless.
Betsy O: are also that sort of covers because that they were totally normal coming in and out that one to to our windows nothing.
Betsy O: And right now we don't repeat them or waste of time on it.
Right.
Betsy O: Those are good things when you create policies is to make sure you give yourself not such a tight window that you can't meet what you want to be.
Susan: Doing completely, especially with the wait times in the lobby it's you're completely right yeah I love that the recheck abnormal.
Susan: In general, I think we just kind of do that by like best practice, whether it be the provider or the nurse who sees it.
Susan: But, and I could be wrong, I don't think we have a generic policy for adults through periods as if it's a normal recheck it that's just like if it's a normal recheck it to make sure it's trending down.
Susan: But ya know completely, especially if they've been waiting in the lobby for five hours because there were no beds, to take them and you bring them back in.
Susan: And it's still a normal because their fever has come back so you like to recheck it and see where we're at definitely to have that incorporated into our policy, and hopefully soon ish.
Susan: Does anyone else have any other questions at all.
Michelle Moegling: anybody else with any questions for olivia or from our presentation prior to this.
Susan: Yes, I can I will put it in the chat group right here for my email.
Susan: Okay, I think I should have added my email to the chat.
Susan: Let me know if you didn't get it.
Michelle Moegling: I don't see it there.
Michelle Moegling: There we go.
Susan: There we are oh yeah I think the first one was just a direct message back to her, but there's that one.
Susan: In case anyone has any other questions to.
Susan: A charter for our committee, and you know I actually don't know if we have a written in turtle procedure policy for our committee, I think it's.
Susan: Now that we have a physician presence in a mid level provider presence and we're progressing forward i'm not sure if that's something that.
Susan: We will have but, in general I think we've just had a pediatric committee kind of it's just that our basis for our pediatric resource as an er I don't think there was like a written procedure for it but it's definitely good idea to look at.
Susan: If we don't have it, I could be wrong, maybe we have it somewhere in the depth.
Michelle Moegling: Thank you.
Michelle Moegling: If anybody doesn't have any other questions or thoughts.
Michelle Moegling: um you're free to go.
Michelle Moegling: Thank you again, this was great presentation.
Susan: Thank you guys so much for listening and thank you for the questions if anyone has anything, please feel free to email me.
Michelle Moegling: it's always good to learn from each other.
Susan: Definitely Thank you guys so much really appreciate it.
Michelle Moegling: Thank you.
Michelle Moegling: bye bye.