Stories | 2020-21 Nursing Annual Report | Nicklaus Children's Health System

nurse in PPE administering vaccine to girl.

Expansion of the COVID-19 Vaccination Clinic to Children

As COVID-19 vaccines became available to adults in December 2020, Nicklaus Children’s Hospital was at the forefront, quickly opening a vaccination clinic and offering vaccines to employees and other South Florida community members who were eligible to receive it. However, as the eligible population for the vaccine expanded to those 16 and older and then ultimately to younger children, it soon became apparent what Nicklaus Children’s Hospital needed to do.

In February 2021, the interprofessional workgroup reconvened to discuss the process for screening and eligibility criteria as the vaccine became available to younger populations. Their focus was on getting as many eligible children as possible vaccinated against COVID-19. Very quickly afterward, the vaccination clinic was administering the COVID-19 vaccine to eligible children.

By March 2021, 90 percent of hospital employees were vaccinated, so the vaccination clinic pivoted their focus to solely vaccinating eligible children. Employee vaccinations were now given in the Employee Health Office. As the vaccination availability restrictions expanded to include children as young as 6 months old, Nicklaus Children’s Hospital continued to adapt to meet the growing demand for vaccines.

The result of this effort was a success both for the hospital and the community. By July 31, 2022, the vaccination clinic had administered approximately 18,000 doses of the COVID-19 vaccine to children in the community.

Making Patients More Comfortable by Letting Them Display Their Preferred Names

Some patients, particularly those who are transgender, may have a preferred name that they choose to use over their legal name. There are various reasons for this, but often, their legal name can be a trigger and remind them of their gender dysmorphia. Referring to a patient by their preferred name creates an affirming, supportive and safe space for patients. It also allows Nicklaus Children’s Hospital to provide culturally and socially sensitive care to all its patients.

Previously at Nicklaus Children’s Hospital, patients were allowed to give their preferred name upon check-in. However, their legal name was printed on their armband, and nurses typically use that name, since it’s all that is visible for them to use. Beginning in 2019, nurses at Nicklaus Children’s sought out a more standardized method for documenting this preferred name and displaying it for use among the hospital staff.

A meeting of key stakeholders discussed the best way to address the situation and began implementing their solution in early 2020. Moving forward, ID bands were printed in a manner that allowed the patient’s preferred name to be added alongside their legal name. This made it easier for nurses and other staff to identify and use that name with their patients. In addition, the patient access department was provided a script that provided instructions for asking a patient for their preferred name. An educational flyer was also printed and distributed to raise awareness on the importance of this issue for patients.

The result at Nicklaus Children’s Hospital is a more inclusive, affirming and supportive space for all patients. This decreases potential triggers for patients and improves their overall experience.

Nurses’ Efforts to Reduce Hospital Readmissions

Philicity Tinnie-Wilson, MAS, BSN, RN, ACM-RN, Case Management Manager, is actively engaged in the national effort to reduce readmissions across children’s hospitals in her role as the Solutions for Patient Safety (SPS) Readmissions work group lead and the President of the Florida Chapter of the American Case Management Association. Over the past few years, she has been examining the best practices for reducing readmission rates and coming up with practical solutions for use at Nicklaus Children’s Hospital.

In the course of her research, Tinnie-Wilson discovered that two of the key factors that led to readmissions were the lack of a pediatric-specific readmission risk assessment tool, as well as a lack of standards when it came to planning patient discharges. Nurses Jenna Klareich and Ana Bandin soon began utilizing a morning interprofessional care coordination huddle as a tool for discussing and coordinating a discharge plan for patients.

In 2020, the Readmission Task Force began implementing their new strategy, and the results have been dramatic. In a little over a year, readmissions had dropped from 9.8 percent to 7.2 percent in one area of the hospital, and from 12.2 percent to 8.4 percent in another area. Overall, readmission rates in different areas of the hospital decreased anywhere from 20 percent to 42 percent.

The Readmissions Task Force continues to review standards and practices on a monthly basis for further refinement and enhancement, but thus far, the efforts to have a coordinated discharge plan in order to reduce hospital readmissions has been a success.

Improving Outcomes for Infants with Hyperbilirubinemia

When red blood cells break down in the body, a substance called bilirubin is formed. While most people can safely and easily remove this substance from the body, babies often have not developed this ability yet. The result is that a condition known as hyperbilirubinemia, or excess bilirubin in the blood, is common among infants. This can cause yellowing of the skin (jaundice), poor feeding or lethargy or more severe complications for the baby.

In early 2020, clinical specialist Diana Gomez noted some concerns with the treatment of hyperbilirubinemia. Most notably, the length of the stay in the hospital for these babies was increasing, as was the time from admission until their treatment for hyperbilirubinemia. Finally, equipment often wasn’t ready to go when the patients needed it.

To improve the patient experience and outcomes in regard to hyperbilirubinemia, Gomez helped establish an interprofessional taskforce in order to examine best practice and develop a Clinical Effectiveness Pathway (CEP) model in regard to hyperbilirubinemia. The taskforce began looking into practices to make the treatment of babies with hyperbilirubinemia more effective and more efficient.

By December 2020, new educational content had been developed and was being disseminated to relevant professionals throughout the hospital. Then the Hyperbilirubinemia Clinical Pathway officially went live in January 2021. Since then, the results have been quite successful: The implementation of these new practices has resulted in a 12.7 percent decrease in the patient’s length of stay in the hospital, as well as a 28.6 percent decrease in the time from the patient’s arrival to the treatment beginning.

Stepping Up Against Sepsis

Sepsis is a life-threatening condition that should be treated as a medical emergency. It occurs when the body reacts extremely to an infection, causing a chain reaction within the body that causes the body’s immune system to begin attacking itself. Every year, around 80,000 children are hospitalized for sepsis, and 65 percent of those are treated in children’s hospitals.

In 2015, Nicklaus Children’s Hospital participated in the CHA Improving Sepsis Outcomes collaborative and began implementing best practice protocols. However, their effort to improve sepsis recognition, management and prevention didn’t stop there. In 2018, they incorporated the innovative St. John Sepsis (SJS) Surveillance algorithm into the electronic medical record (EMR) data. What this algorithm strives to do is recognize patients with a high risk of developing sepsis during the earliest stages.

With the integration of this data, Nicklaus Children’s Hospital seeks to continually review and improve the outcomes related to sepsis at the hospital. This review is overseen by a Performance Improvement Council, which monitors the sepsis alert data and the team’s response to it. Through the first quarter of 2020, team responses to the sepsis alert data were still in need of improvement.

Through the early months of 2020, PICU Clinical Nurse Specialist Lian Santiago worked with key stakeholders in order to establish and implement best practices related to sepsis intervention. By June 2020, they had developed a Sepsis Shock Power Plan to be reviewed and implemented by the medical staff tasked with treating sepsis. Though it is still early, it appears that the implementation of this plan has been effective, and mortality rates for sepsis at Nicklaus Children’s Hospital have already decreased dramatically.

toddler girl safely buckled in car seat.

Nurses Collaborate with Safe Kids to Promote Car Seat Safety

Injuries from motor vehicle crashes are the leading cause of injuries and death among children in the United States. This fact alone is devastating, but when you realize that 71 percent of these deaths could be prevented by proper car seat use, it becomes even more heartbreaking.

For years, Nicklaus Children’s Hospital has been at the forefront of this safety effort through their partnership with Safe Kids, a worldwide organization with a mission of prevention of unintentional injury. The hospital is the lead agency for the Safe Kids Miami Dade County Coalition. As part of this program, they pay for registered nurses to become trained as Child Passenger Safety Technicians (CPST). Nurses were invited to attend the course free of charge to become certified as CPST. Clinical nurses Kavita Amache and Jaqueline Martinez, attended the course and received their certifications, thus strengthening the number of nurses at the hospital who can help with this community outreach effort.

The hospital also hosts and attends various community outreach events throughout the year in order to educate the community on the appropriate use of car seats, as well as install and inspect car seats to ensure that they are safely installed.

Nurses Improve Care for Neonatal Abstinence Syndrome (NAS)

The opioid crisis has had a major negative impact on our culture and health care in recent years, but unfortunately, it’s not a crisis that just impacts adults. A growing number of infants are being born with neonatal abstinence syndrome, or NAS. This condition can cause a number of symptoms and complications for the baby, most acutely the withdrawal symptoms that occur as the drugs leave the baby’s body.

NICU clinical nurse Amanda Morales shared her findings with the Florida Perinatal Quality Collaborative (FPQC) as they sought higher quality treatment processes for babies affected by NAS in partnership with Nicklaus Children’s Hospital. While Morales said that the hospital did have processes in place for treating babies with NAS, there was a lack of standardization. There was variation among the medical staff in terms of medications used, weaning preferences and non-pharmacological interventions.

By January 2021, standards and protocols for treating NAS were developed and presented, and nurses were educated on these new standards later in the year. Now, the Clinical Pathway for the management of NAS is available to all nurses. Education for adhering to these standards is now mandatory for all nursing staff during their first year of hire as part of their NICU Lactation Counseling training.

Reducing IV Infusion Errors in the NICU

When a mistake is made with intravenous fluid or medication, it can have a major impact on any patient. If that patient is a tiny baby in the NICU, however, the consequences of that error can be even more significant.

Considering that, NICU clinical nurse Jacklyn Del Rio set her sights on reducing IV fluid infusion errors in the NICU, beginning in early 2020. Jacklyn and her colleagues began a number of interventions at that time to reduce the number of IV infusion errors, including developing a documented library of large infusion pump settings, creating recommended parameters based on baby weight, providing educational videos and other resources for programming the pumps correctly, and programming hard stops for the pumps in the NICU. All of these interventions were completed by June 2020.

In the months that followed, IV infusion errors have decreased dramatically, indicating that these interventions were successful. Of course, careful monitoring of these protocols and continuous reviews and improvements will continue to occur in the future.

Nurses Participate in the Miami-Dade Big Latch On to Promote Breastfeeding

There’s no question that breastfeeding remains the best way to feed a baby through the first year of life. Not only does it promote good nutrition and protect babies from both short-term and long-term illnesses, but it also provides protection to the mother, as well. According to the CDC, breastfeeding can reduce a mother’s risk of developing breast cancer, ovarian cancer, type 2 diabetes and high blood pressure.

Despite all this evidence supporting breastfeeding, rates appear to be declining across the country. This is one of the reasons why Nicklaus Children’s Hospital supports the Healthy People Goals 2030. One of this initiative’s objectives is to increase the proportion of infants who are breastfed exclusively through 6 months of age and continue to be breastfed through one year of age.

The Miami-Dade community promoted this idea through a Big Latch On event, which took place on August 7, 2021. Not only did Nicklaus Children’s Hospital sponsor the event, but many nurses participated at the event as educators and volunteers. The nurses helped provide breastfeeding education and support throughout the event.

Participants at the Big Latch On event described it as a success. They expressed increased knowledge of the importance of breastfeeding, as well as a desire to continue to breastfeed their child past one year of age. The nurses at Nicklaus Children’s Hospital also expressed their interest in continuing to support this great event in the years to come.

Keeping Nurses Safe with the Code Bear Response Team

Workplace violence is an unfortunate but all-too-real situation for many in the nursing profession. In a 2019 survey of over 5,000 nurses, the American Nurses Association (ANA) found that 59 percent of nurses have been verbally assaulted by a patient, and 25 percent have been physically assaulted by a patient.

Nicklaus Children’s Hospital takes this issue very seriously and has a Workplace Violence Committee that meets quarterly to review safety and security event, assess gaps and develop action plans accordingly. Amy Jones, Director of Nursing Operations and Nursing Excellence, joined the taskforce and presented data on Code Strong activations and employee injuries. (A Code Strong is the term used when security personnel are alerted to a violent or threatening individual.)

As a result of Jones’ finding and subsequent surveys, Nicklaus Children’s Hospital established a change in addressing these issues, particularly for autistic patients. The hospital began phasing out the Code Strong approach for patients. The security personnel addressing the situation were in favor of a “Code Bear” approach, which taught them strategies to de-escalate with words and behaviors. This approach has been shown to be particularly effective with autistic patients who may have specific triggers or de-escalation strategies that can be helpful.

The Code Bear Response Team also includes more than just security: A psych RN, social worker, security, shift administrator and department clinical coordinator are included as part of this response team. In addition, a Code Bear Response Checklist was created to clearly communicate expectations and possible interventions that may be effective. The result is a evidence-based approach to dealing with potential incidences of workplace violence at Nicklaus Children’s Hospital.

Introduction of the ADT (Admission Discharge & Transfer) Nurse to Improve Efficiency

Nurses are often tasked with taking on the same workload for a varying number of patients. When that patient number increases a lot, things can get challenging. If the hospital gets very busy, the result can be bottlenecks and discharge delays.

To alleviate this situation at Nicklaus Children’s Hospital, Amy Jones, DNP, MPH, RN, CCRN, NE-BC, Director of Nursing Operations, tried a couple of novel approaches in early 2019. First, they used a house-wide nurse in a “PRN” role for a trial period of 4 weeks. Next, they trialed a nurse in an “ADT” role (admission, discharge and transfer) for an additional 4-week period.

At the end of the trials, the ADT nurse position proved to be most effective at alleviating demands on the other nurses, improving the overall work environment and increasing nurse and patient satisfaction. As a result of the trial, two part-time ADT nurses were added to the Nicklaus Children’s Hospital workforce.

Thus far, the program has been highly successful. The ADT nurses have provided numerous benefits to the organization, including identifying barriers to discharge, recognizing near-misses in discharge medications and assisting in improving current workflows. Administrators at Nicklaus Children’s Hospital are currently evaluating the ADT position and determining if even more ADT nurses may be needed.

Reducing Self-Injury Events in the Psychiatry Unit

Patients in Nicklaus Children’s Hospital’s Psychiatry Unit, a 20-bed adolescent crisis stabilization program, face a number of challenges. Prior to the pandemic, nurses and other professionals in the unit were able to meet these challenges head on with innovative programs such as music therapy, pet therapy and even a theater group. Unfortunately, the restrictions of the COVID-19 pandemic put a stop to many of these programs.

Whether there was a correlation or not, after these activities ceased, clinical nurse Shirley Kendzora, MSN, APRN, PMH-BC, noticed an increase in self-injury incidents among patients in the Psychiatry Unit. Concerned, she approached Psychiatry Nurse Manager Leyden Diaz, BSN, RN, PMH-BC, CPN, about what possible steps could be taken to reduce these incidents.

The idea that Kendzora and her team arrived at was to revive some of the activities that took place before the pandemic but do so in a safe way that adhered to COVID-19 safety measures. Some of the new activities they brought in for the patients included “Healthy Humor” with the Red Nose Docs (Clowns), virtual recreation activities, and activities at the Michael Fux Family Center. The nurses met with various staff members to ensure the safety of their new activity schedule, and then they began the new schedule in early 2021.

To date, the program has been very successful. Incidents of self-injury are down substantially since implementing the new activities. The nurses continue to evaluate the activities and make updates during quarterly check-ins to review progress and seek new activity opportunities when they become available.

The Baby Steps Program: Going the Extra Mile for New Parents

With its Level III D, gold-level Beacon Award-winning NICU, Nicklaus Children’s Hospital already offers some of the best medical care available for newborn babies and their families. But with the introduction of the Baby Steps program in 2020, the best became even better.

The goal of Baby Steps is to provide families discharged from the NICU with access to trained NICU nurses as they are navigating the transition from hospital to home. Through this nurse-led intervention supported by our nursing research department and telehealth teams, telehealth visits are provided to caregivers through the Nicklaus Pediatric Virtual Care application. This application allows caregivers to talk to a NICU trained nurse five days a week, free of charge, during the first two weeks after discharge.

Dr. Danielle Altares Sarik, a pediatric nurse practitioner and research nurse scientist at Nicklaus Children’s Hospital and Dr. Yui Matsuda, an assistant professor at the University of Miami School of Nursing and Health Studies, lead the Baby Steps program. They received a three-year grant from the Florida Blue Foundation to fund this work, which was officially launched in July 2020, as the COVID-19 pandemic began to take hold.

“Nurses are ideally positioned to respond to caregiver questions and concerns and help to guide families through the transition from the hospital to home,” says Dr. Sarik. “This period of transition, while joyful, can also be overwhelming for many caregivers. This program addresses that need by utilizing the skills of our expert NICU nurses.”

Within the first year of the program, a total of 380 infants were enrolled and a total of 432 encounters were completed. Readmissions decreased by 60 percent during this time, with decreased emergency care visits because of these visits. Surveys also indicate strong satisfaction with the quality and helpfulness of the telehealth visits.

To ensure the success of the Baby Steps Program, nurses at the Nicklaus Children’s NICU begin planning their patients’ discharge soon after their admission into the NICU. Patients are then given training and even a mock virtual call with caregivers to ensure that they know how to navigate the technology. Finally, a virtual call is scheduled within 48 hours of discharge.

Research on the Baby Steps program has been published in the Journal of Pediatric Nursing. The outcomes two years into the program have been overwhelmingly positive, with high satisfaction rates and significantly lower rates of hospital readmissions. While further research is needed, it appears to be an innovative and highly successful method for bridging the gap for patients between the hospital and home with their newborn baby.

Making Life Easier for Dialysis Patients

While dialysis is a critical and life-saving procedure for children who need it, there’s no question that it can be a time-consuming and burdensome treatment for a child and their caregivers. And if a “touch contamination,” or infection, occurs in your child after the administration of dialysis, then that incident often requires yet another hospitalization for the child.

Michelle Rippe, MSN, RN, Peritoneal Dialysis Educator, recognized this concern for patients and their families and began taking steps to improve patient outcomes and decrease hospitalizations related to touch contamination. Beginning in 2020, she began reviewing the best practices regarding dialysis touch contaminations and coming up with a set of “best practices” to help patients and their families prevent and treat them at home. Next, she developed a comprehensive education plan and protocols to use with her patients moving forward.

In 2021, Michelle and the nephrology team at Nicklaus Children’s began to use these new guidelines to educate patients and their families how to reduce these incidents, recognize them if they did occur, and then treat them. Michelle educated all her dialysis patients and families with hands-on teaching and instruction for how to prevent and treat touch contaminations in order to prevent hospitalizations. All patients and families then demonstrated their skills, so that the Nicklaus Children’s staff could be confident in their abilities to prevent, recognize and treat these issues at home should they occur.