Publications by authors named "Patricia A Hickey"

35 Publications

Nursing science fellowship at Boston Children's Hospital.

Appl Nurs Res 2020 10 16;55:151292. Epub 2020 May 16.

Harvard Medical School, Boston, MA, United States of America; Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA, United States of America.

Introduction: Clinical inquiry is vital to safeguard nursing practice and ensure optimal outcomes for our patients and families. The innovative Nursing Science Fellowship (NSF) was developed to provide structured mentorship for pediatric nurses by nurse scientists to design and conduct clinical inquiry generated from their practice.

Methods: Each fellow is paired with a nurse scientist mentor to receive support for timely project completion. Dedicated mentors guide the immersion of fellows in nursing science by providing them with didactic content detailing the process of clinical inquiry and bi-monthly one-on-one mentorship sessions. Throughout their journey, fellows learn the appropriate method by which to address their clinical inquiry question and complete a scholarly project that contributes to the science of nursing. On a quarterly basis, fellows share their progress and achievements with peers, mentors, and senior leadership.

Results: Since 2011, 84 fellows have enrolled in this two-year program. Sixty-two nurses have graduated from the NSF and 22 fellows are currently active. Collectively, the fellows have received 46 grants to support their projects. Twenty-one fellows have received promotions and 22 fellows have furthered their education in a masters, clinical or research doctorate program. There have been 78 external disseminations highlighting their clinical inquiry work, including poster and podium presentations and peer-reviewed published manuscripts. Lastly, there have been 26 new or updated clinical practices implemented across the enterprise as a result of completed projects.

Conclusions: Combined these efforts have ensured a sustained commitment to advancing the science and practice of pediatric nursing.
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http://dx.doi.org/10.1016/j.apnr.2020.151292DOI Listing
October 2020

Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU.

Pediatr Crit Care Med 2020 12;21(12):1064-1070

Department of Cardiovascular and Critical Care Nursing Services, Boston Children's Hospital, Boston, MA.

Objectives: To assess the impact of a nurse-implemented goal-directed sedation strategy on patient care and nursing practice in a pediatric cardiac ICU.

Design: Quality improvement project with a pre-post interval measurement plan.

Setting: Thirty-one bed pediatric cardiac ICU in a freestanding tertiary care children's hospital.

Patients: Postoperative pediatric cardiac surgery patients.

Interventions: The implementation of cardiac-Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a nurse-implemented goal directed strategy to improve pain and sedation management in a pediatric cardiac ICU which included daily team discussion of the patient's trajectory of illness (acute, titration, or weaning phase), prescription of a sedation target score based on the patient's trajectory of illness, arousal assessments, and opioid and/or sedative titration. Withdrawal Assessment Scores were used to assess and manage iatrogenic withdrawal symptoms.

Measurements And Main Results: Data related to opioid and sedation use, pain and sedation scores, and the occurrence and management of iatrogenic withdrawal symptoms were reviewed on 1,243 patients during four separate time periods: one pre-implementation and three discontinuous post-implementation time intervals. Patient age and complexity were consistent across the data collection periods. Post-implementation opioids and benzodiazepines use was reduced about 50% without a concomitant increase in the use of other sedative classes. Few post-intervention patients were discharged from the pediatric cardiac ICU or to home on methadone (pediatric cardiac ICU: pre 19% to post 3%; hospital: pre 12% to post 1.3%). Documentation of pain, sedation, and withdrawal scores became more consistent and nurses reported satisfaction with their patient's comfort management.

Conclusions: The implementation of a nurse-driven goal-directed plan such as cardiac-RESTORE to manage pediatric cardiac ICU patient pain and sedation is possible, sustainable, and associated with reduced sedative and methadone use.
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http://dx.doi.org/10.1097/PCC.0000000000002505DOI Listing
December 2020

Pediatric nurses' perceptions of preparedness for global health fieldwork.

J Spec Pediatr Nurs 2020 10 21;25(4):e12304. Epub 2020 Jul 21.

Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, Massachusetts, USA.

Objectives: The purpose of this qualitative descriptive research study was to understand the current state, perceived content, and experiential needs of pediatric nurses preparing for global health (GH) fieldwork experience. This study aimed to inform stakeholders about the standard and unique preparation needs of pediatric GH nurses.

Study Design And Methods: One group and five individual interviews were held with nurses from a large pediatric quaternary care facility in the Northeast United States. Data from the interviews were transcribed verbatim, eliminating personal data. Only deidentified transcripts were used for data analysis. Members of the study team used content analysis to systematically code and analyze the data.

Results: Qualitative content analysis revealed five categories: (1) identifying clear objectives, (2) understanding the practice environment, (3) self-assessment of clinical skills, cultural competencies, and adaptability, (4) safety and logistics planning, and (5) psychological self-care and reentry anticipatory guidance.

Conclusions: Findings can provide a basis for program planning to prepare pediatric nurses for GH fieldwork. Program planning must account for the unique features of the site and situation. Organizational and personal preparation can influence the perceived success of the GH experience.
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http://dx.doi.org/10.1111/jspn.12304DOI Listing
October 2020

The Measurement of Pediatric Inpatient Nursing Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) Tool.

J Pediatr Nurs 2020 Mar - Apr;51:42-48. Epub 2019 Dec 28.

Cardiovascular and Critical Care Patient Services, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America. Electronic address:

Purpose: Physiologic measurement of patient acuity has been used to predict patient outcomes, length of stay, and resource utilization. To date, these tools are not sufficiently comprehensive to inform nurse staffing assignments and have limited practical application. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) acuity tool was initially developed and validated to quantify patient acuity in terms of complexity of nursing cognitive workload in pediatric intensive care units (ICU). This article describes development and implementation of the Inpatient CAMEO© in the pediatric inpatient setting.

Design And Methods: Utilizing a modified Delphi technique, an expert panel convened to scale and implement the Inpatient CAMEO© in the pediatric inpatient units through four Delphi rounds.

Results: The expert panel identified care items unique to the pediatric inpatient setting and assigned a cognitive workload scale of 1-5. To consolidate the tool, the panel identified items to be classified as "Standard of Care" and developed a new baseline score for the Inpatient CAMEO©. Expert panel members served as unit-based ambassadors to foster the expansion and implementation of the new Inpatient CAMEO©.

Conclusions: The Inpatient CAMEO© describes and quantifies acuity beyond the intensive care setting. The implementation and use of the Inpatient CAMEO© was accomplished through unit-based ambassadors and the support of leadership.

Practice Implications: Quantifying nursing cognitive workload in both direct and indirect care is important to determining nursing assignments and comprehensive staffing models in the pediatric inpatient setting.
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http://dx.doi.org/10.1016/j.pedn.2019.12.005DOI Listing
February 2021

A Vision for Excellence by Design.

Am J Crit Care 2019 07;28(4):247-254

Patricia A. Hickey is vice president and associate chief nurse, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, Massachusetts and assistant professor, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.

Generating evidence for care improvement has characterized my program of research spanning 20 years. Six domains are highlighted to advance the science and practice of critical care nursing in today's complex health care systems. Employee well-being and taking care of team members are key priorities for successful leaders. Understanding that patient and staff outcomes are inextricably linked strengthens the need for care environments to be healing and holistic for staff and patients. The American Association of Critical-Care Nurses' Healthy Work Environment framework empowers staff and optimizes the experience for patients, their families, and care teams. Appropriate staffing, guided by contemporary acuity measurement, takes into account the cognitive workload and complexity of nursing. Committing to a culture of certification and ensuring staffing models with appropriately educated and experienced nursing staff will remain important. In the past decade, we have established the impact of these specific nursing characteristics on improved patient outcomes. Understanding the attributes of empathic and empowered teams is requisite for authentic leadership. Interventions to mitigate moral distress are necessary to foster moral resilience among critical care nurses. The challenge for the future will be to support organizational health through the coexistence of highly reliable processes and clinical innovation. Excellence is achieved when systems are designed to support professional practice and clinical teams and environments.
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http://dx.doi.org/10.4037/ajcc2019651DOI Listing
July 2019

Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: retrospective analysis of quality improvement data.

BMJ Open 2019 06 22;9(6):e028307. Epub 2019 Jun 22.

Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA.

Objective: Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies.

Design: Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated.

Setting And Participants: The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included.

Outcome Measures: In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission.

Results: The IQIC registry includes 24 917 congenital heart surgeries performed in children<18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=-0.34, p=0.18), and health expenditure per capita (r=-0.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality.

Conclusions: Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings.
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http://dx.doi.org/10.1136/bmjopen-2018-028307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6596958PMC
June 2019

A Vision for Excellence by Design.

Am J Crit Care 2019 05;28(3):172

Patricia A. Hickey is vice president and associate chief nurse, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, Massachusetts and an assistant professor, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.4037/ajcc2019682DOI Listing
May 2019

Validation of the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) Acuity Tool for Pediatric Critical Care Nursing.

Dimens Crit Care Nurs 2019 May/Jun;38(3):153-159

Jean A. Connor, PhD, RN, CPNP, FAAN, is director of Nursing Research, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, and clinical instructor of pediatrics, Harvard Medical School, Boston, Massachusetts. Christine LaGrasta, DNP, RN, CPNP-PC/AC, is nurse practitioner II, Cardiac Acute Care Unit, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Massachusetts. Kimberlee Gauvreau, ScD, is senior biostatistician, Department of Cardiology, Boston Children's Hospital, and associate professor, Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts. Courtney Porter, MPH, CPHQ, is program administrative manager II, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Massachusetts. Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, is vice president and associate chief nurse, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, and assistant professor of pediatrics, Harvard Medical School, Boston, Massachusetts.

Background: The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) acuity tool was developed to quantify patient acuity in terms of nursing cognitive workload complexity in a large, freestanding children's hospital in the United States.

Objectives: To describe the acuity and complexity of pediatric critical care nursing at a large children's hospital and correlate the CAMEO II with pediatric physiologic measures.

Methods: Construct validation was conducted correlating the CAMEO II to a pediatric classification system and 2 physiologic acuity tools. Descriptive statistics summarized patient characteristics. Construct validity across tools was evaluated using the Spearman correlation coefficient.

Results: CAMEO II was described both continuously and as ordinal complexity levels (I-V). Among 235 patients who completed CAMEO II across 4 intensive care units (ICUs), the mean total score was 99.06 (median, 97; range, 59-204). The CAMEO II complexity classification for 235 patients was as follows: I: 22 (9.4%), II: 53 (22.6%), III: 56 (23.8%), IV: 66 (28.1%), and V: 38 (16.2%). Findings from the 235 patients across the 4 ICUs revealed a significant correlation between the CAMEO II and the Therapeutic Intervention Scoring System-Children (ρ = 0.567, P < .001), CAMEO II and Pediatric Risk of Mortality III (ρ = 0.446, P < .001), and the CAMEO II and Score for Neonatal Acute Physiology Perinatal Extension II (ρ = 0.359, P = .013).

Discussion: Utilization of CAMEO II across ICUs provides an opportunity to validate the current complexity of pediatric critical care nursing in a large children's hospital.
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http://dx.doi.org/10.1097/DCC.0000000000000355DOI Listing
December 2019

Scaling the Measurement of Pediatric Acuity Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) Tool.

Dimens Crit Care Nurs 2019 May/Jun;38(3):146-152

Jean A. Connor, PhD, RN, CPNP, FAAN, is director of nursing research, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, and clinical instructor of pediatrics, Harvard Medical School, Boston, Massachusetts. Christine LaGrasta, DNP, RN, CPNP-PC/AC, is nurse practitioner II, Cardiac Acute Care Unit, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Massachusetts. Kimberlee Gauvreau, ScD, is senior biostatistician, Department of Cardiology, Boston Children's Hospital, and associate professor, Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts. Courtney Porter, MPH, CPHQ, is program administrative manager II, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Massachusetts. Kendra O'Brien, BA, is nursing student, University of Massachusetts-Boston. Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, is vice president and associate chief nurse, Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, and associate professor of pediatrics, Harvard Medical School, Boston, Massachusetts.

Background: The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) acuity tool was developed to quantify patient acuity in terms of nursing cognitive workload complexity. An expert panel including representatives from 4 intensive care units (ICUs) convened to scale and implement the CAMEO II across the ICUs in a large, freestanding children's hospital in the United States.

Objectives: The aims of this study were to scale and implement a standardized acuity measure of pediatric critical care nursing.

Method: This study used a modified Delphi technique.

Results: Through a series of 3 Delphi rounds, the expert panel identified care items not characterized in the original CAMEO and assigned each of these items a cognitive workload scale of 1 to 5. The expert panel identified 4 additional Domains of Care while confirming the original 14 Domains of Care in the first CAMEO version. The panel agreed that a number of care items could be classified as "Standard of Care," reducing items in the CAMEO and generating a baseline score. The panel, serving as ambassadors and unit-based experts, then implemented the refined CAMEO II in each of the 4 ICUs.

Discussion: Utilization of the CAMEO II across ICUs provides a standardized measure to describe and quantify the acuity of pediatric critical care nursing. Use of this acuity measure informs projection of staffing models and benchmarking across pediatric ICUs. Further research is needed to validate the CAMEO II for multisite use.
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http://dx.doi.org/10.1097/DCC.0000000000000356DOI Listing
December 2019

Building and Sustaining a Culture of Clinical Inquiry in a Pediatric Quaternary Hospital.

J Nurs Adm 2019 Jan;49(1):28-34

Author Affiliations: Director of Nursing Research, Neonatal Intensive Care Unit (Dr DeGrazia), Nurse Scientist, Orthopedic Center (Dr Difazio), Director of Nursing Research, Cardiovascular and Critical Care Patient Services (Dr Connor), Vice President, Cardiovascular and Critical Care Patient Services, and Associate Chief Nursing Officer (Dr Hickey), Boston Children's Hospital, Massachusetts; Assistant Professor (Drs DeGrazia and Hickey), Clinical Instructor (Drs Difazio and Connor), Pediatrics, Harvard Medical School, Boston, Massachusetts; Instructor (Dr Difazio), Fitchburg State University, Massachusetts.

The Nurse Executive Committee for Research and Inquiry (NECRI) was established to align clinical inquiry with nursing clinical operations to advance nursing science and improve patient care and outcomes for patients and their families. The authors describe the development, structure, and function of NECRI, outcomes to date, and infrastructure necessary to support a sustainable model.
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http://dx.doi.org/10.1097/NNA.0000000000000704DOI Listing
January 2019

Interprofessional Use and Validation of the AACN Healthy Work Environment Assessment Tool.

Am J Crit Care 2018 09;27(5):363-371

Jean Anne Connor is director of nursing research, cardiovascular and critical care patient services, Boston Children's Hospital, and a clinical instructor of pediatrics, Harvard Medical School, Boston, Massachusetts. Sonja I. Ziniel is an assistant research professor, Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, and senior survey methodologist, quality and patient safety, Children's Hospital Colorado, Aurora. Courtney Porter is a program administration manager, cardiovascular and critical care patient services, Dennis Doherty is a professional development specialist, clinical education and informatics, Marilyn Moonan is a professional development specialist, nursing patient services, Patricia Dwyer is a nurse scientist, satellite services, and Laura Wood is senior vice president, patient care operations, and chief nursing officer, Boston Children's Hospital. Patricia A. Hickey is vice president and associate chief nursing officer, cardiovascular and critical care patient services, Boston Children's Hospital, and an assistant professor of pediatrics, Harvard Medical School.

Background: Health care work environments affect patient outcomes, staff satisfaction and retention, and organizational financial viability. The American Association of Critical-Care Nurses (AACN) Healthy Work Environment Assessment Tool (HWEAT) is a resource for patient care units and organizations to assess the work environment and track progress on their journey to excellence.

Objective: To validate interprofessional use of the AACN HWEAT across a large free-standing children's hospital.

Methods: The AACN HWEAT was administered to staff members across professional categories. Responses were averaged to achieve an overall score and a score for each standard included in the instrument. Nurses' and physicians' scores were further stratified. Test-retest reliability and internal consistency were assessed. Construct validity was measured by correlating the AACN HWEAT and the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (H-SOPS).

Results: Of 2621 AACN HWEAT surveys, 1030 (39.3%) were returned for review. The organization-wide HWEAT mean overall score was 3.58 (3.87 for physicians vs 3.54 for nurses, = .02). Test-retest reliability was indicated by Spearman correlation coefficients of 0.50 to 0.68. Internal consistency was shown by a Cronbach α of 0.77 overall (range for standards, 0.77-0.81). Convergent validity between AACN HWEAT standards and AHRQ H-SOPS items was shown by correlation coefficients of 0.30 to 0.52.

Conclusion: The AACN HWEAT was both reliable and valid, supporting its interprofessional use as an organizational measure. Active evaluation of health care environments is critical to achieving optimal patient outcomes.
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http://dx.doi.org/10.4037/ajcc2018179DOI Listing
September 2018

Pressure injury prevention for paediatric cardiac surgical patients using a nurse-driven standardized clinical assessment and management plan.

Cardiol Young 2018 Sep 6;28(9):1151-1162. Epub 2018 Jul 6.

2Cardiovascular & Critical Care Services,Boston Children's Hospital.

Background: The description of pressure injury development is limited in children with CHD. Children who develop pressure injuries experience pain and suffering and are at risk for additional morbidity.

Objectives: The objective of this study was to develop a standardized clinical assessment and management plan to describe the development of pressure injury in paediatric cardiac surgical patients and evaluate prevention strategies.

Methods: Using a novel quality improvement initiative, postoperative paediatric cardiac surgical patients were started on a nurse-driven pressure injury prevention standardized clinical assessment and management plan on admission. Data were recorded relevant to nursing assessments and management based on pre-defined targeted data statements and algorithm. Nursing feedback regarding diversions was recorded and analysed.

Results: Data on 674 congenital paediatric cardiac surgical patients who met criteria were collected between May, 2011 and June, 2012. In 5918 patient days, a total of 4603 skin assessments were completed by nurses from the cardiac ICU and the cardiac inpatient unit, representing 77% of the expected assessments. The majority (70%, 21/30) of the 30 pressure injuries were medical-device-related and 30% (9/30) were immobility-related. The overall incidence of pressure injury was 4.4%: device-related was 3.1% and immobility-related was 1.3%. Most pressure injuries were Stage 1 (40%), followed by Stage 2 (26.7%), mucosal membrane injury (26.7%), and suspected deep tissue injuries (6.7%).

Conclusion: A nurse-driven pressure injury prevention standardized clinical assessment and management plan supported a programme-based evaluation of nursing practice and patient outcomes. Review of practices highlighted opportunities to standardise and focus prevention practices and ensure communication of patient vulnerabilities.
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http://dx.doi.org/10.1017/S1047951118000975DOI Listing
September 2018

The Impact of Critical Care Nursing Certification on Pediatric Patient Outcomes.

Pediatr Crit Care Med 2018 08;19(8):718-724

Cardiovascular and Critical Care Patient Services, Boston Children's Hospital, Boston, MA.

Objectives: To examine the relationship of nursing and unit characteristics including Critical Care Registered Nurse certification on patient complications for children undergoing congenital heart surgery in free-standing children's hospitals in the United States.

Design: A cross-sectional descriptive survey of nursing and organizational characteristics was sent electronically.

Setting: Free-standing children's hospitals in the United States.

Patients: Children undergoing congenital heart surgery (congenital cardiac cases).

Intervention: Nursing and unit characteristics from children's hospitals were obtained via electronic survey during years 2010 and 2014. Survey data from 2014 were linked with patient-level data age less than 18 years old using the Pediatric Health Information System for years 2013-2014. The Complication Screening Method of Congenital Heart Surgery was used to adjust for baseline patient differences.

Measurements And Main Results: Among 23 of 43 free-standing children's hospitals (53%) in 2014, the median proportion of nurses with Bachelor of Science in Nursing preparation or higher at each site was 77% and with Critical Care Registered Nurse certification was 24%. Among 12,324 eligible congenital cardiac cases, the rate of complication was 34.4%. The odds of complications significantly decreased as the institutional percentage of nurses with a Bachelor of Science in Nursing increased (odds ratio, 0.83; p = 0.04). The odds of complications also significantly decreased as the institutional percentage of nurses with Critical Care Registered Nurse certification increased (odds ratio, 0.86; p = 0.02).

Conclusions: Bachelor of Science in Nursing education and Critical Care Registered Nurse certification significantly impact pediatric patient outcomes. Recognition of nursing and organizational characteristics that are associated with improved pediatric patient outcomes is important to patients, their families, and society. Clinical leaders must commit to facilitating pathways for hiring candidates with Bachelor of Science in Nursing as a minimum to practice in PICUs and supporting a culture of professional certification.
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http://dx.doi.org/10.1097/PCC.0000000000001609DOI Listing
August 2018

Informing Leadership Models: Nursing and Organizational Characteristics of Neonatal Intensive Care Units in Freestanding Children's Hospitals.

Dimens Crit Care Nurs 2018 May/Jun;37(3):156-166

Cheryl A. Toole, MS, RN, CCRN, NEA-BC, is director of nursing patient services, Neonatal Intensive Care Unit, Cardiovascular and Critical Care Nursing and Patient Services, Boston Children's Hospital, Massachusetts. Michele DeGrazia, PhD, RN, NNP-BC, FAAN, is director of nursing research, Neonatal Intensive Care Unit, Cardiovascular and Critical Care Nursing and Patient Services, Boston Children's Hospital; and assistant professor, Pediatrics Harvard Medical School, Boston, Massachusetts. Jean Anne Connor, PhD, RN, CPNP, FAAN, is director of nursing research, Cardiovascular and Critical Care Nursing and clinical instructor, Pediatrics Patient Services, Boston Children's Hospital, Massachusetts. Kimberlee Gauvreau, ScD, is senior biostatistician, Department of Cardiology, Boston Children's Hospital; and Harvard Medical School, Boston, Massachusetts. Hillary Bishop Kuzdeba, MPH, is program coordinator, Cardiovascular and Critical Care Nursing and Patient Services, Boston Children's Hospital, Massachusetts. Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, is vice president and associate chief nursing officer, Cardiovascular and Critical Care Nursing and Patient Services, Boston Children's Hospital; and assistant professor, Pediatrics Harvard Medical School, Boston, Massachusetts.

Background: Neonatal intensive care units (NICUs) located in freestanding children's hospitals may exhibit significant variation in nursing and organizational characteristics, which can serve as opportunities for collaboration to understand optimal staffing models and linkages to patient outcomes.

Objectives: Adopting methods used by Hickey et al in pediatric cardiovascular critical care, the purpose of this study was to provide a foundational description of the nursing and organizational characteristics for NICUs located in freestanding children's hospitals in the United States.

Methods: Clinical nurse leaders in NICUs located in freestanding children's hospitals were invited to participate in an electronic cross-sectional survey. Descriptive analyses were used to summarize nursing and organizational characteristics.

Results: The response rate was 30% (13/43), with 69.2% of NICUs classified as level III/IV and 30.8% classified as level II/III. Licensed bed capacity varied significantly (range, 24-167), as did the proportion of full-time equivalent nurses (range, 71.78-252.3). Approximately three-quarters of staff nurses held baccalaureate degrees or higher. A quarter of nurses had 16 or more years (26.3%) of experience, and 36.9% of nurses had 11 or more years of nursing experience. Nearly one-third (29.2%) had 5 or less years of total nursing experience. Few nurses (10.6%) held neonatal specialty certification. All units had nurse educators, national and unit-based quality metrics, and procedural checklists.

Conclusion: This study identified (1) variation in staffing models signaling an opportunity for collaboration, (2) the need to establish ongoing processes for sites to participate in future collaborative efforts, and (3) survey modifications necessary to ensure a more comprehensive understanding of nursing and organizational characteristics in freestanding children's hospital NICUs.
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http://dx.doi.org/10.1097/DCC.0000000000000296DOI Listing
November 2018

Measuring Care Coordination in the Pediatric Cardiology Ambulatory Setting.

J Nurs Adm 2018 Feb;48(2):107-113

Author Affiliations: Director of Nursing Research (Dr Connor), Program Administration Manager II (Ms Porter), and Vice President (Dr Hickey), Cardiovascular and Critical Care Nursing Patient Services; Project Coordinator, Cardiology (Ms Kuzdeba); Associate Chief Nursing Officer (Dr Hickey); and Medical Director of Integrated Care (Dr Antonelli), Boston Children's Hospital; and Clinical Instructor (Dr Connor), Assistant Professor of Pediatrics (Drs Hickey and Antonelli), Harvard Medical School, Massachusetts; Director of CSU/CVSL (Ms O'Connell), Marin General Hospital, Greenbrae, California.

The role of ambulatory nursing is diverse, and the impact on patient outcomes is difficult to measure. The concept of care coordination is an important focus for the ambulatory nurse. We describe the efforts to implement the Cardiac Care Coordination Measurement Tool to document and quantify care coordination activities in a pediatric cardiac ambulatory setting.
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http://dx.doi.org/10.1097/NNA.0000000000000581DOI Listing
February 2018

Parental perceptions of disease-severity and health-related quality of life in school-age children with congenital heart disease.

J Spec Pediatr Nurs 2018 Jan 20;23(1). Epub 2017 Dec 20.

Professor, Department of of Nursing, University of Massachusetts Boston, Boston, MA, USA.

Purpose: Understanding parents' perceptions of their child's health status is important as parents are drivers of healthcare utilization in the pediatric setting. Understanding parent-perceived disease-severity and its effects on a child's health-related quality of life (HRQOL) in children with congenital heart disease (CHD) is necessary to evaluate outcomes of care, improve care coordination, and inform policies focused on advancing family-centered care for pediatric cardiac patients. The impact of CHDs and disease-severity on the child's HRQOL has been investigated with inconsistent results. The overall aim of this study was to examine parents' perceptions of HRQOL in their school-age child with CHD, and to compare HRQOL among patients with CHD across severity categories.

Design: This was a descriptive correlational study design.

Methods: A total of 71 parents of school-age children aged 5-12 years completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) (including total, physical health, and psychosocial health summary scores) and cardiac-specific HRQOL Scale (PedsQL 3.0). PedsQL scores among CHD severity categories were compared by analysis of variance.

Results: School-age children with CHDs had an overall good HRQOL with significant differences among disease severity categories for all scores. Parents reported lower scores on their HRQOL of older children compared to younger children across severity groups (p < .01) and for those children with more severe disease (p < .01).

Practice Implications: Based on the results of this study, interventions should focus on targeting psychosocial health in older children with CHD and physical health in younger children with CHD. This information is useful in providing practical recommendations in caring for children with CHDs while informing relevant policies.
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http://dx.doi.org/10.1111/jspn.12204DOI Listing
January 2018

International quality improvement initiatives.

Cardiol Young 2017 Dec;27(S6):S61-S68

21Department of Anesthesiology, Perioperative and Pain Medicine,Texas Children's Hospital,Houston,Texas,USA.

Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.
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http://dx.doi.org/10.1017/S1047951117002633DOI Listing
December 2017

Excellence by Design: The Patricia A. Hickey Award for Excellence in Cardiovascular Nursing.

World J Pediatr Congenit Heart Surg 2017 11;8(6):721-725

1 Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, MA, USA.

This award reflects the high-impact contributions of pediatric critical care nurses that have helped to shape the field. Lessons from an ongoing career in nursing leadership are shared by Dr Patricia Hickey. Four themes are highlighted which include (1) our role models/mentors, (2) our profession and its impact, (3) our teams and environments of excellence, and (4) our bright future. Program and practice excellence does not just happen. It requires strategic thinking, deliberative processes, risk-taking and guts to create and sustain. A bright future is forecasted with stellar contributions of professional nurses and interprofessional cardiac critical care teams.
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http://dx.doi.org/10.1177/2150135117708707DOI Listing
November 2017

Characteristics of Nurse Directors That Contribute to Registered Nurse Satisfaction.

J Nurs Adm 2017 Apr;47(4):219-225

Author Affiliations: Associate Chief Nurse, Women and Children, Mental Health, Cancer Center and Community Health Nursing Practice (Dr Burke); Nurse Scientist, Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital and, Associate Professor, Boston College Connell School of Nursing (Dr Flanagan); Executive Director, Patient Care Services Operations and Magnet Recognition (Dr Ditomassi), Massachusetts General Hospital; and Vice President and Associate Chief Nurse (Dr Hickey), Cardiovascular and Critical Care Services, Boston Children's Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts.

Objective: The aim of this study was to explore RNs and nurse directors' (NDs') perceptions of leadership on units with high RN satisfaction scores.

Background: Identifying the characteristics of NDs that contribute to RN satisfaction is important in the recruitment and retention of RNs and in the selection and role development of NDs.

Methods: This study used a qualitative design using appreciative inquiry-guided data collection.

Results: Nine RNs and 9 NDs met the inclusion criteria. Each group identified 4 themes.

Conclusions: Registered nurse and ND participants identified similar themes representative of leadership attributes and behaviors that contribute to RN satisfaction.
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http://dx.doi.org/10.1097/NNA.0000000000000468DOI Listing
April 2017

Use of a Pediatric Cardiovascular Nursing Consortium for Development and Evaluation of Quality Measures: The C4-MNP Experience.

J Pediatr Nurs 2016 Sep-Oct;31(5):471-7. Epub 2016 Jun 28.

Cardiovascular and Critical Care Nursing/Patient Services, Boston Children's Hospital, Boston, MA.

Unlabelled: The evidence linking nursing care and patient outcomes has been globally demonstrated. Thus, it is time for translation and application of this evidence to robust measurement that uniquely demonstrates the value of nursing care and the characteristics of the nursing workforce that contribute to optimal patient outcomes.

Objective: The aim of this study was to identify and develop standardized measures representative of pediatric nursing care of the cardiovascular patient for benchmarking within freestanding children's hospitals.

Methods: Using a consensus-based approach, the Consortium of Congenital Cardiac Care- Measurement of Nursing Practice (C4-MNP) members developed quality measures within working groups and then individually critiqued all drafted measures. Final draft measures were then independently reviewed and critiqued by an external nursing quality measurement committee. The final quality measures were also made available to a national parent support group for feedback.

Outcomes: The development process used by C4-MNP resulted in 10 measures eligible for testing across freestanding children's hospitals. Employing a collaborative consensus-based method plus implementing the criteria of the National Quality Forum and external vetting period provided a strong framework for the development and evaluation of standardized measures.

Next Steps: The Consortium will continue with implementation and testing of each measure in 9 of our 28 collaborating centers. This activity will support initial development of benchmarks and evaluation of the association of the measures with patient outcomes.
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http://dx.doi.org/10.1016/j.pedn.2016.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026894PMC
September 2017

Critical Care Nursing's Impact on Pediatric Patient Outcomes.

Ann Thorac Surg 2016 Oct 10;102(4):1375-80. Epub 2016 May 10.

Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

Background: Previous studies have demonstrated the effect of adult nursing skill mix, staffing ratios, and level of education on patient deaths, complication rates, and failure to rescue (FTR). To date, only one known study had examined the effect of nursing experience and education on postoperative pediatric cardiac operations.

Methods: Nursing survey data were linked to The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database for patients undergoing cardiac operations (2010 to 2011). Logistic regression models were used to estimate associations of nursing education and years of clinical experience with in-hospital mortality rates, complication rates, and FTR. Generalized estimating equations and robust standard error estimates were used to account for within-center correlation of outcomes.

Results: Among 15,463 patients (29 hospitals), the in-hospital mortality rate was 2.8%, postoperative complications occurred in 42.4%, and the FTR rate was 6.4%. After covariate adjustment, pediatric critical care units with a higher proportion of nurses with a Bachelor of Science degree or higher had lower odds of complication (odds ratio for 10% increase, 0.85; 95% confidence interval, 0.76 to 0.96; p = 0.009). Units with a higher proportion of nurses with more than 2 years of experience had lower mortality rates (odds ratio for 10% increase, 0.92; 95% confidence interval, 0.85 to 0.99; p = 0.025).

Conclusions: This is the first study to demonstrate that higher levels of nursing education and experience are significantly associated with fewer complications after pediatric cardiac operations and aligns with our previous findings on their association with reduced deaths. These results provide data for pediatric hospital leaders and reinforce the importance of organization-wide mentoring strategies for new nurses and retention strategies for experienced nurses.
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http://dx.doi.org/10.1016/j.athoracsur.2016.03.019DOI Listing
October 2016

Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative.

Dimens Crit Care Nurs 2016 May-Jun;35(3):116-24

Jean Anne Connor, PhD, RN, CPNP, FAAN, is director of nursing research for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and clinical instructor of pediatrics at Harvard Medical School. Jeanne P. Ahern, MHA, BSN, RN, CCRN, is staff nurse III, Cardiovascular Operating Room at Boston Children's Hospital, Massachusetts. Barbara Cuccovia, MSN, RN, CPON, is nurse manager for the Hematopoietic Stem Cell Transplant Unit of Boston Children's Hospital. Courtney L. Porter, MPH, is Program Administration Manager II for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital. Alana Arnold, PharmD, is director of the Department of Pharmacy, Boston Children's Hospital. Roger E. Dionne, PharmD, is formulary and medication safety manager for the Department of Pharmacy, Boston Children's Hospital. Patricia A. Hickey, PhD, MBA, RN, FAAN, is vice president and associate chief nurse for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and Assistant Professor of Pediatrics at Harvard Medical School.

Background: The incidence of medication errors remains a continued concern across the spectrum of health care. Approaches to averting medication errors and implementing a culture of safety are key areas of focus for most institutions. We describe our experience of implementing a distraction-free medication safety practice across a large free-standing children's hospital.

Methods: A nurse-led interprofessional group was convened to develop a program-wide quality improvement process for the practice of medication safety. A key driver diagram was developed to guide the Red Zone Medication Safety initiative. Change acceleration process was used to evaluate the implementation and impact of the initiative.

Results: Since implementation in 2010, there has been a significant reduction in medication events of 79.2% (P = .00184) and 65.3% (P = .035) (in the cardiac intensive care unit and acute care cardiac unit, respectively), including months with unprecedented zero reportable medication events. There also has been a sustained decrease in the number of events reaching the patient (33.3% in the cardiac intensive care unit and 57.1% in the acute care cardiac unit).

Conclusions: The implementation of a distraction-free practice was found to be feasible and effective, demonstrating a sustained decrease in the overall number of medication events, event rate, and number of events reaching patients. This interprofessional approach was successful in a large inpatient cardiovascular program and then effectively transferred across all hospital inpatient units. Additional sites of implementation include other high-risk patient care areas such as procedure/operative units.
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http://dx.doi.org/10.1097/DCC.0000000000000179DOI Listing
March 2017

Monitoring the health of the work environment with a daily assessment tool: the REAL - Relative Environment Assessment Lens - indicator.

Cardiol Young 2016 Aug 1;26(6):1082-9. Epub 2015 Oct 1.

1Cardiovascular and Critical Care Services,Department of Nursing Patient Services,Boston Children's Hospital,Boston,Massachusetts,United States America.

Background: Evidence shows that the health of the work environment impacts staff satisfaction, interdisciplinary communication, and patient outcomes. Utilising the American Association of Critical-Care Nurses' Healthy Work Environment standards, we developed a daily assessment tool.

Methods: The Relative Environment Assessment Lens (REAL) Indicator was developed using a consensus-based method to evaluate the health of the work environment and to identify opportunities for improvement from the front-line staff. A visual scale using images that resemble emoticons was linked with a written description of feelings about their work environment that day, with the highest number corresponding to the most positive experience. Face validity was established by seeking staff feedback and goals were set.

Results: Over 10 months, results from the REAL Indicator in the cardiac catheterisation laboratory indicated an overall good work environment. The goal of 80% of the respondents reporting their work environment to be "Great", "Good", or "Satisfactory" was met each month. During the same time frame, this goal was met four times in the cardiovascular operating room. On average, 72.7% of cardiovascular operating room respondents reported their work environment to be "Satisfactory" or better.

Conclusion: The REAL Indicator has become a valuable tool in assessing the specific issues of the clinical area and identifying opportunities for improvement. Given the feasibility of and positive response to this tool in the cardiac catheterisation laboratory, it has been adopted in other patient-care areas where staff and leaders believe that they need to understand the health of the environment in a more specific and frequent time frame.
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http://dx.doi.org/10.1017/S1047951115001808DOI Listing
August 2016

Complexity Assessment and Monitoring to Ensure Optimal Outcomes Tool for Measuring Pediatric Critical Care Nursing.

Am J Crit Care 2015 Jul;24(4):297-308

Jean Anne Connor is director of nursing research in the Cardiovascular and Critical Care Programs, Department of Nursing Patient Services, Boston Children's Hospital and a clinical instructor of pediatrics at Harvard Medical School, Boston, Massachusetts. Christine LaGrasta is a nurse practitioner in the Cardiovascular Program, Boston Children's Hospital. Patricia A. Hickey is vice-president and associate chief nursing officer, Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and an assistant professor of pediatrics at Harvard Medical School.

Background: Historically, nursing productivity has been measured in adult settings and based on time, intensity, and resource allocation.

Objective: To develop a comprehensive measure of pediatric critical care nursing workload.

Methods: An expert panel of pediatric critical care nurses used a modified Delphi method to identify 14 domains of nursing care with a number of corresponding care items in each domain. By consensus, they assigned each care item a cognitive complexity rating from 1 to 5. The panel next developed a classification system (classes I-V) to support interpretation of the patient's total score. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) tool was initiated with a cohort of 75 pediatric cardiac critical care patients to verify comprehensive capture of nursing care. Results of completed CAMEO tools were summarized by using descriptive statistics.

Results: The cognitive workload across 14 domains of care was described, and each care item in the domain was scored. The range of CAMEO total scores was 25 to 230 (median, 124). For the initial cohort of patients, the cognitive complexity of care classifications were 13% as class I or II, 80% as class III or IV, and 7% as class V.

Conclusions: The CAMEO tool was comprehensive in describing and quantifying the cognitive workload of pediatric critical care nurses. The CAMEO classification process informs staffing needs that support synergy between the needs of patients and their families and nurses' knowledge and skill. Articulation of nursing care focused on informed clinical decision making is needed to justify the value of skilled nurses.
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http://dx.doi.org/10.4037/ajcc2015230DOI Listing
July 2015

Pediatric Critical Care Nursing Research Priorities-Initiating International Dialogue.

Pediatr Crit Care Med 2015 Jul;16(6):e174-82

1PICU and Children's Nursing Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom. 2School of Health, University of Central Lancashire, Preston, United Kingdom. 3Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. 4PICU, Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada. 5Department of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada. 6Department of Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA. 7Harvard Medical School, Boston, MA. 8Department of Nursing Research, The Royal Children's Hospital, Melbourne, Australia. 9School of Health Sciences and the Department of Paediatrics, The University of Melbourne, Melbourne, Australia. 10School of Nursing and Midwifery, Faculty of Health and Human Sciences, Plymouth University, Plymouth, United Kingdom. 11School of Nursing and Midwifery, Faculty of Health Sciences, Curtin University, Perth, WA, Australia. 12Department of Pediatric Nursing, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil. 13Division of Pediatric Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL. 14School of Nursing and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Objective: To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice.

Design: One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process.

Setting: Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey.

Participants: Pediatric critical care nurses and nurse scientists attending the open consensus meeting.

Interventions: Systematic review, gap analysis, and interactive multivoting.

Measurements And Main Results: The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children.

Conclusions: The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.
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http://dx.doi.org/10.1097/PCC.0000000000000446DOI Listing
July 2015

Reducing mortality and infections after congenital heart surgery in the developing world.

Pediatrics 2014 Nov 13;134(5):e1422-30. Epub 2014 Oct 13.

University Hospital Geneva, Geneva, Switzerland.

Background: There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact.

Methods: Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated.

Results: Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced.

Conclusions: Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities.
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http://dx.doi.org/10.1542/peds.2014-0356DOI Listing
November 2014

The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States.

J Nurs Adm 2014 Oct;44(10 Suppl):S19-26

Objective: This study explored pediatric critical care nursing and organizational factors that impact in-hospital mortality for cardiac surgery patients across children's hospitals in the United States.

Background: Congenital heart disease is the most common birth defect and the no. 1 cause of death for infants with a congenital defect. Little is known about the impact of pediatric critical care nursing and organizational factors on pediatric mortality.

Methods: Nursing leaders from 38 children's hospitals that contribute data to the Pediatric Health Information System data set completed an organizational assessment for years 2009 and 2010. These data were linked with patient-level data. The Risk Adjustment for Congenital Heart Surgery method was used to adjust for baseline patient differences in patients younger than 18 years.

Results: The odds of death increased as the institutional percentage of pediatric critical care unit nurses with 2 years' clinical experience or less increased. The odds of mortality were highest when the percentage of RNs with 2 years' clinical experience or less was 20% or greater. The odds of death decreased as the institutional percentage of critical care nurses with 11 years' clinical experience or more increased and for hospitals participating in national quality metric benchmarking. Clinical experience was independently associated with in-hospital mortality.

Conclusions: These data are the 1st to link clinical nursing experience with pediatric patient outcomes. A cut point of 20% RNs or greater with 2 years' clinical experience or less was determined to significantly affect inpatient mortality. Participation in national quality metric benchmarking programs was significantly associated with improved mortality.
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http://dx.doi.org/10.1097/NNA.0000000000000120DOI Listing
October 2014

The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States.

J Nurs Adm 2013 Dec;43(12):637-44

Author Affiliations: Vice President, Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts (Dr Hickey); Research Associate in Cardiology, Boston Children's Hospital, and Associate Professor in Pediatrics, Harvard Medical School, Boston, Massachusetts (Dr Gauvreau); Ellen and Robert Kapito Professor in Nursing Science, School of Nursing, University of Pennsylvania, Philadelphia, and Nurse Scientist, Cardiovascular and Critical Care Services, Boston Children's Hospital, Massachusetts (Dr Curley); Director of Nursing Research, Cardiovascular Program Department of Nursing Patient Services, Boston Children's Hospital, Massachusetts (Dr Connor).

Objective: This study explored pediatric critical care nursing and organizational factors that impact in-hospital mortality for cardiac surgery patients across children's hospitals in the United States.

Background: Congenital heart disease is the most common birth defect and the no. 1 cause of death for infants with a congenital defect. Little is known about the impact of pediatric critical care nursing and organizational factors on pediatric mortality.

Methods: Nursing leaders from 38 children's hospitals that contribute data to the Pediatric Health Information System data set completed an organizational assessment for years 2009 and 2010. These data were linked with patient-level data. The Risk Adjustment for Congenital Heart Surgery method was used to adjust for baseline patient differences in patients younger than 18 years.

Results: The odds of death increased as the institutional percentage of pediatric critical care unit nurses with 2 years' clinical experience or less increased. The odds of mortality were highest when the percentage of RNs with 2 years' clinical experience or less was 20% or greater. The odds of death decreased as the institutional percentage of critical care nurses with 11 years' clinical experience or more increased and for hospitals participating in national quality metric benchmarking. Clinical experience was independently associated with in-hospital mortality.

Conclusions: These data are the 1st to link clinical nursing experience with pediatric patient outcomes. A cut point of 20% RNs or greater with 2 years' clinical experience or less was determined to significantly affect inpatient mortality. Participation in national quality metric benchmarking programs was significantly associated with improved mortality.
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http://dx.doi.org/10.1097/NNA.0000000000000005DOI Listing
December 2013

Building a nursing productivity measure based on the synergy model: first steps.

Am J Crit Care 2012 Nov;21(6):420-30; quiz 431

School of Nursing, University of Pennsylvania, Philadelphia, USA.

Background: The Synergy Model describes nurses' work on the basis of the individual needs of patients and their families.

Objective: To generate data necessary to develop a nursing productivity system by using the Synergy Model as a conceptual framework.

Methods: Nurses from 3 different intensive care units participated. In phase 1, charge nurses in focus groups described patient and family indicators considered when making nurse-patient assignments. In phase 2, charge nurse data were used to construct a survey for experienced staff nurses, asking them to link the indicators to 3 levels of nursing workload.

Results: Thirty charge nurses considered all 8 patient dimensions of the Synergy Model when making nurse-patient assignments. Thirty-two experienced staff nurses completed 79 surveys ranking patients' stability as the most important dimension in patient care followed by complexity and predictability. Respondents linked a common set of unique indicators to each of the patient dimensions of the Synergy Model: fluctuation in vital signs was linked to stability; number and severity of diagnoses, to complexity; trajectory of illness, to predictability; lack of reserve, to resiliency; invasiveness of procedures, to vulnerability; family educational level and participation style, to family participation in decision making/care; and home environment, to resources. Sets of indicators were common across units and clustered around level of workload.

Conclusion: The Synergy Model shows promise as a conceptual framework for a nursing productivity system. Using a model that centers nursing work on patients' needs may better capture what nurses do and enhance our capacity to quantify nursing resource allocation.
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http://dx.doi.org/10.4037/ajcc2012859DOI Listing
November 2012

Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change.

Am J Respir Crit Care Med 2012 Dec 20;186(11):1133-9. Epub 2012 Sep 20.

Cardiovascular and Critical Care Programs, Boston Children’s Hospital, Boston, Massachusetts, USA.

Rationale: Parent presence during invasive procedures and/or resuscitation is a relatively underdeveloped and controversial practice. Much of the concern stems from the apprehension of the medical community.

Objectives: To evaluate whether implementation of formal practice guidelines and corresponding interprofessional education would improve clinicians' sense of preparation and comfort in providing parents with options during their children's procedures.

Methods: Multiphase pre-post survey of (1) clinician perceptions and (2) practice from the perspective of clinicians and parents experiencing the same procedure. Data were collected over 4 years from a cardiovascular and critical care program in one U.S. children's hospital.

Measurements And Main Results: More than 70% of clinicians participated in the perception surveys (n = 782) and 538 clinicians and 274 parents participated in the practice surveys. After the intervention, clinicians reported that parents were present during more invasive procedures and reported higher levels of comfort with the practice of providing options to parents during resuscitative events. Levels of comfort were higher in clinicians who had practiced skills in a simulated learning environment. During both phases, few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%). During the post phase, clinicians reported more active parent behaviors during procedures. Parents who reported receiving information to help them prepare for their children's procedures reported higher levels of procedural understanding and emotional support.

Conclusions: Implementation of practice guidelines and interprofessional education had a positive impact on clinicians' perceptions and practice when providing parents with options and support during their children's invasive procedures and/or resuscitation.
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http://dx.doi.org/10.1164/rccm.201205-0915OCDOI Listing
December 2012