Perfecting the Pediatric Experience

From warming to the power of touch, providers’ steps to keep little ones calm and comfortable can benefit patients of all ages.

When I was in high school, I was a highly competitive ice hockey player, fully expecting to compete in college. I also had a congenital hip condition that sent me on a wild roller-coaster ride that included endless appointments, hours of physical therapy and four surgeries. Two of those surgeries took place here at Boston Children’s Hospital. It was here that I discovered what I wanted to do with my life, and here was where I returned after nursing school to fulfill my calling as a pediatric OR nurse.

A no-nonsense surgeon, Yi-Meng Yen, MD, PhD, planted the seed of a career in surgery when he walked into the exam room where I was waiting, hoping to hear that I’d be able to get fixed up and go on to enjoy a rewarding college ice hockey career, and said: “You’re never going to skate again at this level. The question is, do you want to have a life where you can walk and run and just be a healthy, active young adult, or do you want to continue to play ice hockey? Hi, I’m Dr. Yen. Nice to meet you.”

Was his introduction a bit shocking? Of course it was, but he wasn’t wrong. And if Dr. Yen even suggested there was a minuscule chance I could play hockey at a collegiate level, that’s all I’d focus on. Instead, his blunt response forced me to ask myself, What am I going to do after high school?

As important as my interaction with Dr. Yen was, it was my time with the perioperative nurses during my surgeries that ultimately inspired me to consider a career in pediatrics, helping the most vulnerable patients when they so desperately need the compassion, care and empathy that often comes naturally to nurses. My anxiety going in for surgery was through the roof, and the nurses were so phenomenal at what they did that I decided right there: This is the type of difference I want to make for others. This is what I want to do with my life.

Universal best practices

Pediatric surgery is a highly specialized field, and though there are some marked differences in the care of children and teenagers and that of adults, there are plenty of universal best practices that apply to both populations.

We care for the most vulnerable patients in our facility, and from Day One of their training, it’s instilled in our nurses that fierce and constant patient advocacy must become automatic and second nature when providing care. New staff are taught to imagine the patient as their child or someone in their family — and they are constantly reminded to never, ever forget that imperative.

That’s not to say the mindset is unique to pediatrics, but it’s easier to keep this type of advocacy top-of-mind when caring for children. When it comes to caring for adults, I’ve heard nurses say, “If he’s nervous, he’ll tell me,” or “If she’s in pain, she’ll let me know.” Sometimes, that’s not necessarily the case. I think that’s where a pediatric mindset can benefit all facilities, whether they perform simple screening procedures such as colonoscopies or complex outpatient spine surgeries. Our nursing philosophy is rooted in a firm belief that those little extras — whether it’s taking another couple minutes to explain what’s happening and why, maintaining meaningful eye contact throughout the perioperative journey, or simply holding a patient’s hand as they go under — can make a huge difference in how patients feel during their time in your care, and how they recover afterward.

Multiple benefits of patient warming

FULL CIRCLE Victoria Hammond went from being a nervous pediatric patient at Boston Children’s Hospital to working there as an OR nurse who cares for other children and teenagers.

Although keeping kids warm and cozy is a key part of our patient experience, it’s about so much more than comfort. Comprehensive studies show that patient warming — the process of actively working to stave off hypothermia — is part of the healing process and helps prevent surgical site infections (SSIs).

Keeping pediatric patients warm during surgery also helps to prevent postoperative nausea and vomiting (PONV) and keep everything stable. By maintaining a patient’s normal body temperature, we not only reduce the chances of PONV but also help them recover faster and with less pain, which leads to better overall outcomes. This starts preoperatively, where we can use warmed blankets or forced-air warming systems to get patients’ temperatures up. During surgery, it’s essential to keep the OR at the right temperature and use devices such as forced-air warmers and warmed IV fluids. A warming mattress or underbody forced-air warming blankets also help keep the patients’ core body temperature steady.

Our philosophy is: You can never have enough warm blankets on hand. We’re always grabbing warm blankets or, if we’re scrubbed in, asking the circulator for extras — even if it’s just to lay across the patients’ chest. Staff are also trained on common issues to watch for and how to step in when necessary. For instance, surgeons regularly uncover patients when they are getting lines and doing vitals, but nurses are always right there to cover them back up at the first opportunity.

The minute we can, we begin actively warming our patients, a process in which our OR staff are trained extensively because there’s a specific way to use active or forced-air warming systems. Our vendor rep, a well-respected nurse who used to work here at Boston Children’s Hospital, will come in and do a presentation on how to use the device, along with a CEU on SSI prevention. She’s one of our staff’s favorite presenters. When it comes to education and training, vendor reps are often fantastic resources, so if you’re not taking full advantage of this aspect of your industry partnerships, it’s worth looking into further.

Temperature monitoring is another key component of our warming efforts. We use non-invasive methods like tympanic, oral or infrared skin thermometers depending on the situation and the patient’s condition. We monitor their temperature constantly during the entire surgical process, and we’re required to maintain a specific temperature range for patients from pre-op through their stay in the PACU. It’s important to keep these warming measures going even after surgery until the child’s temperature returns to normal and stabilizes. These temperature management strategies make surgery safer and more comfortable for pediatric patients.

The art of nursing

In addition to clinical competencies, pediatric nursing requires a unique set of soft skills, a high level of creativity, and the ability to tailor patient care to an array of different ages and personalities. In other words, the art of nursing is fully displayed in this field.

The power of distraction is invaluable when dealing with children, especially younger ones, and our nurses understand what a wonderful resource their cell phones are when caring for little ones. A good amount of “Baby Shark’s” billions of YouTube views probably came from our hospital.

Asking open-ended as opposed to yes/no questions is another extremely effective distraction technique. Asking patients about what they want to be when they grow up or whether they’ve picked out a dream for when they’re asleep for surgery tends to work well. The idea is to build a story and allow the patient’s imagination to run wild so they’re thinking positive, pleasant thoughts when the anesthesia kicks in. Speaking of anesthesia, the patient’s mask often serves a dual purpose as both a tool to deliver anesthetic agents and as an object of distraction. Talking to patients about the scent in their mask and asking questions about it — Can I smell it? What’s your favorite flavor? — works wonders in keeping anxiety at bay during those critical moments before the patients drift off.

BEST PRACTICES

Children Inspire Creative Solutions

FEAR FIGHTER Vicki Christensen is one of the volunteers who makes Worry Monsters for kids at Hennepin County Medical Center.

Staff at pediatric surgical facilities routinely come up with some of the most clever and inventive ways to go the extra mile for anxious little ones and their families. Outpatient Surgery Magazine’s Ideas That Work section is full of examples of this pediatric-inspired ingenuity. Here are just some of the many examples: Children who undergo procedures at Hennepin County Medical Center in Minneapolis are given Worry Monsters — adorable homemade stuffed animals, made by hospital volunteers, that help the kids deal with the stress of surgery. The pediatric patients jot down their worries on a piece of paper, put it in the monster’s mouth and zip it shut. After the monsters have gobbled up their fears, staff members pull out the pieces of paper to find out what patients are afraid of and take steps to address those fears.

Pediatric patients at St. Mary’s Regional Medical Center in Lewiston, Maine, are given teddy bears in pre-op, which they take with them to the OR for comfort — and keep to snuggle with after they’re discharged.

At Nemours Children’s Hospital in Wilmington, Del., the waiting room is filled with monitors to help worried parents track their child’s surgical journey in real time. The child’s location is color-coded and changes as their journey progresses, making it easy for family to follow along.

Children at Roxana Cannon Arsht Surgicenter in Wilmington, Del., were so stressed saying goodbye to their parents before heading to the operating room for dental procedures that the center decided to purchase child-size electric vehicles that the kids rode in from the waiting room to the OR. After adding the vehicles, only 8% of pediatric patients at the center required preoperative sedation, down from 28% who needed it previously. 

When pediatric patients at Dayton (Ohio) Children’s Hospital arrived in the PACU, classical music played until they awoke from anesthesia. Once awake, the hospital’s child life department supplied iPads loaded with movies such as Disney’s Frozen and child-appropriate games. That simple combination of classical music and iPads helped patients emerge from anesthesia more quickly. Plus, nurses weren’t administering as many doses of pain medicine.

—Outpatient Surgery Editors

The power of touch is an important aspect of care for all patients, but it’s especially pronounced in pediatric ones. Naturally, babies and toddlers need to cling to someone when they are taken away from their parents, and we welcome that protector role, telling them, “I’m here, and I’m going to hold you and protect you.” But even teenagers appreciate it when you hold their hand under the blanket or rub the spot just above the IV because the anesthetic is burning a bit.

Our nursing philosophy is rooted in a firm belief that those little extras can make a huge difference in how patients feel during their time in your care, and how they recover afterward.

Difference-making care

At its core, pediatric nursing — like all patient-facing nursing — is all about making a connection with the patients, about making them feel safe, secure and important. It’s a specialty where you can feel the difference you’re making in people’s lives. You know you’re making a connection when a crying mother thanks you and lets you know that she’d never seen her son look at someone and let them hold him the way you had before carrying him back to surgery. It’s the type of difference-making care that can turn a hockey-ending prognosis into the inspiration for a long, fulfilling career in the OR. OSM

*Editor’s Note: Throughout our interviews, both Ms. Dyer and Ms. Hammond contributed equally to the content of this article. The article was written in first person simply for clarity, consistency and cohesiveness.