Stories | 2022 Nursing Annual Report | Nicklaus Children's Health System

Reducing Patients Who “Left Without Being Seen”

The percentage of patients who “leave without being seen” (LWBS) is a nationwide concern for emergency departments. It’s a percentage that hospitals tend to track closely, as it has direct ties to patient quality of care, hospital revenue and other critical factors in a hospital’s business model.

Due to exceptionally high patient volumes during the pandemic, LWBS rates increased at hospitals throughout the nation.

To curb rising rates, the Nicklaus Children’s team rallied and responded to this issue in an effective way. In May 2022, leadership began meeting and devised an evidence-based plan to mitigate the situation. The proposed solution was to create a Waiting Room Registered Nurse role. This nurse’s role is to greet patients upon registration in the ED and escort them to a bed immediately if one is available. This role was fully implemented by the end of June 2022.

The success of this strategy was seen immediately. By July 2022, LWBS incidents in the Nicklaus Children’s ED dropped to 2.5%, followed by 1.4% in August. The addition of the Waiting Room Registered Nurse role was seen as highly successful, and Nicklaus Children’s leadership plans to continue to monitor this situation and continually strive to improve quality of care in this area.

Reducing Nurse Turnover Rates

Since the COVID-19 pandemic, nurse retention has been a critical concern for hospitals across the country, and Nicklaus Children’s Hospital was certainly not immune to this issue. A variety of factors in the years following the pandemic seemed to contribute to this high level of nursing turnover: Fears over COVID itself, difficulties with family demands and childcare, high salary and compensation for traveling nurses, among others.

Hospital leadership was acutely aware of this issue and openly sought strategies for how to remedy this situation. Chief Nursing Officer Shannon Odell regularly discussed this issue with nurses during her open office hours. One of the popular ideas that surfaced from these meetings was an “Internal Traveler Program.” This research-backed program has been gaining popularity nationwide as an effective method to reduce turnover and improve nurse retention rates.

On the surface, the Internal Traveler Program is fairly simple: Give nurses on your staff the ability to work extra hours at a higher pay rate, similar to what had previously been given to external traveling nurses. Through the program, Nicklaus Children’s Hospital nurses were allowed to work an extra 24 hours per pay period, not exceeding 16 extra hours per week, at a higher rate of pay.

The program went live in May 2022, and thus far the outcomes have been a success. Since its implementation, nurse turnover rates have steadily declined, from 16.2% in May 2022 all the way down to 13.5% in September 2022. Hospital leadership is optimistic that this program will continue to reduce the rate of nurse turnover and is also exploring other possibilities for further reducing the nurse turnover rate.

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

First launched in 2019, the Baby Steps program at Nicklaus Children’s Hospital was intended to provide families discharged from the NICU with access to trained NICU nurses as navigate 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 during the first two weeks after discharge to help support optimal transition. The program provides access 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 Director of Nursing Research and Evidence-Based Practice Nicklaus Children’s Hospital and Dr. Yui Matsuda, an assistant professor at the University of Miami School of Nursing and Health Studies, founded the program and gained approval for its implementation. Since its founding, Maria Miranda and Melody Hernandez were hired as Lead NICU Telehealth Registered Nurses to implement the program and provide support to patients and families as needed.

From July 2020 through October 2021, various aspects of the Baby Steps program were studied through funding from the Florida Blue Foundation. During the course of that research, 380 infants were enrolled in the program, and 432 total encounters were completed. These encounters led to an overall decrease of 57% in patient readmissions, and 100% of patients reported that they were satisfied or highly satisfied with their care. Nursing students also reported a positive experience related to their telehealth training as part of the program.

Since the study was completed, the nurses involved have presented their results in various platforms, both inside and outside the hospital. This ultimately culminated in Hernandez presenting the study’s finding through a podium presentation at the National Association of Neonatal Nurses in 2022.The Baby Steps program was a great success for Nicklaus Children’s Hospital patients, and now the dissemination of this research can ultimately help other hospital around the country create similar programs.

Enhancing Care with a Diabetes Nurse Navigator

Diabetes is a growing concern throughout the United States and the world, and the effects of this disease have certainly been felt at Nicklaus Children’s Hospital as well. In 3 Northeast, a wing of Nicklaus Children’s that specializes in children with renal, gastrointestinal, endocrinological and related issues, Maryann Duva, Manager of 3 Northeast, noted that the number of patients with diabetes rose from 127 in 2020 to 152 in 2021.

This rising number of patients with diabetes strained resources, as not all nurses were trained at providing education to patients with diabetes. This meant that Duva had to reallocate nurses with this training in order to provide education to the growing number of patients. In some cases, this education could not be provided in a timely fashion, which led to discharge delays for some patients.

In January 2022, the 3 Northeast Unit Practice Council set a goal to reduce the length of stay of patients with diabetes by 5%. To achieve that goal, Duva advocated for the addition of a new position in her department, a dedicated Diabetes Nurse Navigator. This nurse would be responsible for assisting the newly diagnosed patient with diabetes, focusing on the care and coordination of the patient, and helping reduce length of stay through proper care and education.

The new Diabetes Nurse Navigator was hired in October 2022. Since then the average length of stay for newly diagnosed patients with diabetes has decreased by 24 to 48 hours, which is a significant improvement for patients and families.

Nurses Improve Nausea and Vomiting Treatment with BARF

Postoperative nausea and vomiting (PONV) is a significant issue for children after surgery. In many cases, severe PONV can even lead to an increased length of stay in the hospital or a delayed discharge for the child, leading to further distress for the patient and other complications for the hospital. In 2022, Susan Golzbein, Recovery Room Clinical Nurse, and Cristina Meca, Observation Unit Clinical Nurse, began an exploration to determine if PONV assessment, treatment and outcomes could be improved.

One research-tested model that seemed to improve diagnosis and severity of PONV was known as the Baxter Animated Retching Faces scale, which naturally uses the acronym BARF. Despite the funny name, this scale was highly effective at determining the severity of PONV and helping nurses determine the proper follow-up steps or medication to use.

By February 2022, Susan and Cristina had presented the scale to Nicklaus Children’s leadership and gained internal approval to use it for assessing PONV after surgery. By September 2022, nurses at Nicklaus Children’s were being educated in its use and incorporating the scale and proper responses to the scale into their patient rounds post-surgery.

The BARF scale is now a system-wide tool for Nicklaus Children’s nurses when it comes to assessing and treating PONV, and it has led to a positive impact both for patients and hospital staff. Nurses now use the tool to assess PONV cases and determine the proper treatment. Data has shown that it has also led to a change in medication usage related to PONV. The BARF scale is now the standard of care when it comes to assessing and treating PONV in children after a surgery.

Improving Patient Comfort with Aromatherapy

One unfortunate but common complication of childhood surgery is post-operative nausea and vomiting, or PONV. While surgery can help a child’s medical circumstances in the long-term, a frequent short-term side effect is feelings of nausea and vomiting following the procedure. Thisis often distressing to parents and children, andcan lead to a number of unwanted developments, such as a longer length of stay in the hospital, unplanned admissions, poor recovery and complications.

In April 2019, Susan Golzbein, Clinical Coordinator for the Recovery Room, was seeking methods for alleviating the effects of PONV and increasing patient comfort after the completion of surgery. She was familiar with aromatherapy and made the suggestion to Kristina Miranda, Clinical Specialist of Ambulatory Surgery Departments. From there, the team began an exploration of aromatherapy as a possible treatment method post-surgery.

Golzbein and Miranda compiled a task force to explore the possibility further, and they found several high-quality studies that validated the use of aromatherapy for PONV. With this evidence on hand, the next step was trial use of aromatherapy in the recovery room. This, too, yielded positive results.

Based on these results, the two nurses established guidelines for proper aromatherapy use and gained approval of their plan from hospital leadership. The use of aromatherapy post-surgery for the treatment of PONV became the standard of care, and was actively used in 2022. This initiative not only shows Nicklaus Children’s Hospital’s nurses dedication to making their patients as comfortable as possible, but it has also been highly effective at helping patients cope with the impact of PONV post-procedure.

A New Award for Patient Safety

One of the most critical focuses of any healthcare team should be the safety of patients. This is certainly at the forefront for nursing professionals at Nicklaus Children’s: One of their “pillars” is Amazing Patient Care, which focuses on providing safe and high-quality care to patients and families. Director of Patient Safety, Janice Yanez, realized the organization had an opportunity to recognize and honor individuals in the organization who went above and beyond the call of duty when it comes to patient safety.

To meet that end, Yanez came up with the idea for the Interprofessional Award for Excellence in Patient Safety, to be awarded annually during Patient Safety Awareness Week. Yanez took her idea to members of the Patient Safety Committee in order to develop award criteria, processes for publicizing the award, nominate teams, and ultimately select recipients for the award. Since safety is an organization-wide effort, it was determined that this award would be given to an entire team at Nicklaus Children’s, rather than just an individual.

The new award was well-received by hospital staff, and several teams were nominated. Ultimately, the Emergency Department (ED) interprofessional team was selected as the 2022 award recipient. This team of physicians, nurses and other specialists had worked together to reduce ED response time to code blues (a medical emergency, often the result of a respiratory or cardiac arrest) by 50%. They did so with several process changes, including innovations that made it easier to bring resuscitation equipment and stretchers to a crash site.

The ED team was presented with the first annual Award for Excellence in Patient Safety in late March 2022The team was also lauded in the hospital newsletter and through other media for their accomplishment. Yanez hopes that this annual award will continue to put a top priority on patient safety for all teams throughout Nicklaus Children’s Hospital.

Promoting Breastfeeding with Lactation Pods

Nicklaus Children’s Hospital has long been an advocate and supporter of breastfeeding. Research indicates that human milk is often the best source of nutrition for infants, and providing lactation support to new mothers is key to helping these efforts be successful.

Until recently, however, Nicklaus Children’s faced a conundrum: Despite their strong support of breastfeeding, the facility itself lacked adequate private spaces for new mothers to breastfeed or pump their breast milk. Lactation Services Supervisor Grecia Ferreyra received this feedback from many families on campus. Some mothers even reported that they would go their car or the bathroom in order to have privacy while breastfeeding or lactating.

Ferreyra brought her concerns to the Breastfeeding Committee, who soon took action to solve this patient problem. The solution they ultimately arrived at was the installation of three portable lactation pods from the manufacturer Mamava. Each pod included ventilation, lighting, plug-in outlets, counterspace and easy accessibility. One pod met ADA requirements as an accessible space.

After gaining approval on her plan from hospital leadership, the three new pods were delivered and installed in February 2022. Since their installation, they have been used frequently by patients, families and Nicklaus employees. Reports indicate high satisfaction with the pods, and those who have used them consider them an excellent private area to pump or breastfeed their infants.

Nurses Volunteer to Promote Car Seat Safety

Injuries from motor vehicle crashes are the leading cause of injuries and death among children in the United States. While this fact alone is devastating, the realization that 71-82 percent of these deaths could be prevented by proper car seat use makes it even more heartbreaking. The CDC estimates that more than half of car seats are not used or installed correctly.

For years, Nicklaus Children’s Hospital has been at the forefront of this safety effort through a 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, registered nurses are supported to become trained as Child Passenger Safety Technicians. 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.

Two of the federal government’s Healthy People 2030 goals are 1) to reduce motor vehicle deaths, and 2) reduce the number of deaths to vehicle passengers who were not restrained. Nicklaus’s Child Passenger Technician Certification Course aligns directly with these goals. The course consists of four days of intensive training, and graduates can then provide guidance to parents on the use and installation of car seats.

In November 2021, Radiology Clinical Nurse Jacqueline Martinez attended the training course. Since then, she has participated in two community outreach events to provide car seat safety information to parents in the community. These included the Summer Safety Splash in May 2022 and the Joe Martinez Community Health Fair in August 2022. By offering this course to interested nurses, Nicklaus Children’s Hospital is continuing their dedication to patient and community safety, both inside and outside of the hospital.

Improving Length of Stay with ‘Discharge When Ready’

A cornerstone of the values of Nicklaus Children’s Hospital is exemplary patient care. When it comes to hospital stays, that means that patients should stay as long as needed until they are well enough to be discharged.

However, is it possible that, in some cases, patients are staying in the hospital longer than they need to? That was the conclusion of a 2022 study published in the International Journal of Health Policy and Management. The researchers found that almost 25 percent of patients in children’s hospitals stayed longer than was needed, with a mean delay of 2.1 days. This total represented 9% of overall pediatric hospital days and accounted for 8.9% of total costs.

Based on this data, Chief Nursing Office Shannon Odell and Chief Medical Officer Marcos Mestre expressed concern over the current length of stay situation at Nicklaus Children’s, as well. The current “Discharge before Noon” model was falling short of its target goal, and the length of stay was actually increasing for some patient populations, such as those with common respiratory conditions like asthma, pneumonia, or croup.

Nurse Director Amy Jones led the initiative to improve discharge efficiency in the hospital. She established a new discharge initiative called “Discharge When Ready” that was based on well-established, evidence-based clinical pathways that included discharge criteria. Rather than focusing on noon for discharge, the new initiative focused on discharging the patient at any time of day when they are ready.

Once approved, the new protocols for Discharge When Ready were implemented in March 2022, and the initiative went live by the end of April 2022. Thus far, the new standards have been successful in reducing the length of stay for patients with a diagnosis of asthma, bronchiolitis, pneumonia, or croup.

Stepping Up Against Sepsis

Sepsis is a life-threatening condition that should be treated as a medical emergency. It occurs when the body reacts to an infection in an extreme way, leading to a chain reaction that causes the body’s immune system to begin attacking itself. Every year, around 75,000 children in the US develop severe sepsis, and 7,000 die. What’s more, literature shows that as many as 8 percent of sepsis cases are not diagnosed properly, and the cost of treating sepsis is around $62 billion annually.

By December 2021, the Clinical Effectiveness Program (CEP) team had begun working on the development a Sepsis Clinical Pathway to align with the Children’s Hospital Association (CHA) Improving Pediatric Sepsis outcomes (IPSO) collaborative. By February 2022, the use of an electronic “Sepsis Huddle” was created and approved. This huddle allows team members to gather and make quick decisions for addressing sepsis when an electronic sepsis alert is fired.

In March 2022, Behar and fellow nurse Diana Gomez began the process of educating staff members and working through mock scenarios if sepsis were to occur to prepare nurses in the event of a real case of sepsis. The new program for identifying and treating sepsis went live on March 29, 2022.

Thus far, the new processes have led to improved reactions when sepsis does occur, and the Nicklaus Children’s Hospital sepsis mortality rate has remained at 0% since the development of these new protocols.

Improving Nurse Well-Being with Schwartz Rounds

The COVID-19 pandemic has been associated with an increase in mental health concerns and burnout among nurses nationally and globally. According to data from Forbes in May 2022, 30% of nurses had quit due to burnout, and overall, the healthcare industry as a whole had lost 20% of its workforce. This was due to myriad factors, including anxiety, depression, stress, helplessness, and compassion fatigue. The result is often burnout due to high emotional exhaustion and a low sense of personal accomplishment.

Unfortunately, Nicklaus Children’s Hospital was not immune to this impact. Leadership knew it was time for a change, and Amy Jones, Director of Clinical Operations, advocated for the implementation of “Schwartz Rounds” as a strategy for improving nurses’ emotional well-being.

Schwartz Rounds is a different way of delivering healthcare that provides compassion for the healthcare worker, as well as the patient. The rounds essentially give caregivers a venue for sharing their thoughts, feelings and emotions about their work. This is important, as caregivers frequently do not have another outlet for doing so. Healthcare workers who frequently participate in Schwartz Rounds report greater satisfaction with their jobs and more devotion to providing their patients with the best care possible.

To implement Schwartz Rounds, a hospital must be a member of the Schwartz Center. Jones continued to advocate for this, and ultimately her plan was approved in early 2022. The first Schwartz Rounds were held at Nicklaus Children’s in April 2022, and more than 100 hospital staff members participated. Another Schwartz Rounds was hosted in August of that year.

Ultimately, the program has already been successful, and Jones and other hospital leadership envisions further progress in this area through the future use of Schwartz Rounds.