In a hospital setting, emergencies are not unexpected. Everything is in place to respond appropriately: a crash cart, a well-rehearsed protocol, an entourage of staff to assist if need be and back-up generation in case of a power outage.
In a home setting, however, there may be only one care provider. And there's no code button to push for immediate help if something goes wrong and the child's life is in danger.
As more and more medically fragile children are discharged to the home — thanks to advances in technology and a growing realization that they will do better there than in a hospital — it's essential to ensure that their care not be compromised and that the family environment is as safe as possible.
Pediatric Home Service, a St. Paul, Minn.-based organization that provides specialized health care service to technology-supported children in their homes, has a robust education component for home caregivers, including hands-on training on equipment, supplies, medications, procedures, and emergency response and troubleshooting.
A couple of years ago, staff members began to notice an increase in the number of “panic” calls from providers who were caring for PHS patients — particularly from those caring for patients with tracheostomies — indicating they didn't fully understand equipment use and emergency protocols.
PHS staff found themselves doing more and more troubleshooting and unscheduled home visits, responding to statements such as “I've never changed the circuit on the ventilator. The day nurse does that.” Or, “I didn't think to check the oxygen because we never use it.”
As a result, the company conducted in-home assessments of caregivers' essential skills relating to equipment and supplies to determine what educational materials and interventions were needed.
Evaluating Skills
PHS created a 37-item survey that included questions aimed at assessing the caregiver's knowledge of proper equipment setup, oxygen safety and use, emergency resuscitation bag (AMBU bag) function and use and emergency response procedures.
The survey, which was administered by PHS clinicians, was targeted to patients who had a tracheostomy and also used a ventilator for respiratory support.
Eighty-five families participated in the survey. Caregivers included 17 family members, 24 RNs, 38 LPNs, one RCP and five PCAs.
The Results
Overall, caregivers were found to be skilled in routine daily care but significantly lacking in abilities to demonstrate oxygen safety and proper tank use, proper AMBU bag use, appropriate emergency response and back-up battery use and charging.
Some of the results were eye-opening: A number of caregivers didn't know how to check the function of an AMBU bag, what liter flow of oxygen to use in an emergency or what suction pressure should be utilized.
The Next Step
Based on the survey results, PHS developed drafts for various educational materials and then met with home care administrators, hospital care managers and referring physicians to discuss the results, review the materials and determine the best way to incorporate them into home care to ensure consistent use.
The result: the creation of the STAR kit, along with enhanced PHS education classes.
The STAR Kit
The PHS STAR kit is a boxed set of education materials and tools designed to enhance patient safety in the home. Used for both training and to aid in the actual care of patients, it includes DVDs, safety checklists and reminders, troubleshooting guides, equipment tags and an emergency action plan.
Even the kit name is an acronym that serves as a safety reminder:
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S: Stop, look and listen to make an effective patient assessment.
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T: Take inventory of your patient's AMBU bag and bedside supplies to make sure they are available for use.
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A: Assess your patient's emergency equipment. Make sure:
- Both AMBU bags are working properly;
- Suction pressure is set correctly;
- Emergency oxygen tanks are full; and
- Batteries are charged.
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R: Review your patient's emergency action plan to make sure you fully understand what to do.
Enhanced Patient Safety In the Home
The STAR education kit has been given free of charge to PHS families, home care providers and referring physicians and is a vital component of the company's education program.
In addition, the STAR kit has been incorporated into the training given by other providers who work with PHS patients.
Among the tools caregivers say they most appreciate:
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Safety checklist reviews;
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Laminated quick reference equipment flip cards and signs;
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Home oxygen use DVD; and
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A handy mesh bag that holds everything needed for an emergency trach change.
With the implementation of the STAR kit, PHS has seen improvement in all five of the areas assessed in the survey: equipment assessment, emergency backup equipment/batteries, oxygen safety, emergency AMBU bag and emergency patient response.
All four caregiver categories — RNs, LPNs, PCAs and family members — showed improvement.
Significant numbers of the respondents indicated that they use STAR kit and would recommend it to others. Because of the STAR campaign, nearly 12 percent of respondents wrote an emergency action plan, and another 18 percent improved their existing plans.
Additional feedback from respondents also suggests that those utilizing the STAR kit believe they are more prepared to handle any emergency.
Rebecca Nielsen, RRT-NPS, RCP, is education manager for Pediatric Home Service, St. Paul, Minn. For more information about PHS, visit www.pediatrichomeservice.com or call 651/789-3259.
Performance on Initial PHS Survey by Question Type
| % of Caregivers Correctly Answering Questions | Equipment Assessment | Oxygen Safety | Emergency Patient Response | Emergency AMBU Bag | Emergency Back-Up Equipment |
|---|---|---|---|---|---|
| % of each type of question answered correctly by 90% or more of caregivers | 2/11 (18%) | 0/6 (0%) | 3/10 (30%) | 1/5 (20%) | 0/5 (0%) |
| % of each type of question answered correctly by 80% or more of caregivers | 8/11 (73%) | 1/6 (17%) | 7/10 (70%) | 1/5 (20%) | 1/5 (20%) |
| % of total questions | 11/37 (30%) | 6/37 (16%) | 10/37 (27%) | 5/37 (14%) | 5/37 (14%) |
Pediatric Home Service
Founded in 1990, Pediatric Home Service is an independent pediatric home care company providing specialized services to technology-supported children. Based in St. Paul, Minn., the company partners with health care professionals and family caregivers to ensure that the medically fragile child receives the same quality of care at home that is delivered in a hospital setting, coordinating and managing the services, medication and equipment needed. The PHS pediatric clinical specialists, who comprise about 40 percent of the staff, care for patients throughout Minnesota and western Wisconsin. The company provides infusion therapy, respiratory therapy, in-home asthma management, medical social work, nutrition support and pharmacy and education services.
