The PICU

Stetho-Scoop

INFORMATION, NEWS AND SUPPORT

Join us for the

5th Annual MCHF
5K Run/Walk!

July, 2015
Issue #4

As our largest annual community

event, the MCHF5K is designed to
increase awareness of Nicklaus
Childrens Hospital and its pediatric
sub-specialties,

showcase

our

cutting-edge research, work, talent

See Alana Assing for details.

and

Join the PICU Team (Lifesavers).

physicians and staff.

the

dedication

of

our

Continues on page 5

education Corner

Announcements

By Ginel Capdevila, MSN Ed, RN, CPN

WeLCoMe To oUR neW STAFF:

suction system and vent to air.

Chest tube reminders

Leaving it connected to the suction

with the actual suction being off, acts
like a clamp

Assess and record hourly:

- Condition of dressing
- Amount and character of drainage

Nursing interventions:

WeLCoMe To oUR HIP RnS:

- Elevate head of the bed

- Keep drainage system below the

Drainage output:

level of the chest

- Note color and amount

- Place marks on drainage system to

- Not routinely milked or stripped.

Only light tapping or moving the

help keep track of level

position of the drainage tube to

facilitate gravity

Respiratory status:
- Presence of chest pain or shortness

- Encourage coughing and deep

breathing, including the use of the

of breath

incentive spirometer

Assess for the following and

Zuleny Rodriguez, Belen Baluja, Arthur

Quintero, Emily Mallon, Carolyn Ramirez,
and Sandra Amoretti

- Always keep a sterile petrolatum

Krystina Machin, Monique Nortelus,

Yesica Peraza, and Ricardo Ortega
WeLCoMe To oUR neW FeLLoWS:
Kaitlin Kobaitri, and Prithvi Raj Sendi
Keshavamurthy
CongRATULATIonS!
Soeurette Joseph for finishing her MSN!

communicate to the physician:

gauze dressing and dry sterile gauze

- Fluctuation in water seal column

at the bedside to use in the case of

UnIT CoUnSeL STRUCTURe

an accidental removal

Chairs:
Denise Collins and Rachel De Pons
Co-chairs:
Clinical Practice: Nicole Sardinas-Lago
Evidence Based Practice: Yamile Viera
Exemplary Professional Practice: Lidia Rosado
Finance: Mercedes Cosio
Quality: Mara Ceruto

(non-fluctuating may be due to

obstruction of chest tube or reexpansion of lung; large fluctuations

Chest tubes are ONLY flushed by MD,

NP, or PA when ordered. RNs do NOT

may indicate pneumothorax)

flush egardless of physician order.

- Bubbling (indicates air leak;

vigorous bubbling usually indicates
dislodgement)
- Subcutaneous emphysema (leakage
of air into subcutaneous tissues)

Transporting patients off the unit for

testing: Do not clamp chest tube (it
should be kept as ordered, either to
suction or water-seal)

A written physician's order shall be

required to disconnect the chest tube
from suction to place to water seal.

Must disconnect completely off the

Chest tubes are never to be clamped,

as this can result in a tension
pneumothorax; only if ordered
by the MD.

Drainage Chamber

Suction Control

Water Seal Chamber

5K Team Shirt!
Dri-Fit Style made comfortable for the race. Lets all represent PICU
with our team shirts on or outside the race! Deadline to order August 3rd.
Must pay in full to place order. Please see Lidia, Francesca, or Adriana

A big thank you to nicole Defauw

for completing our PICU brochure
2 The PICU Stetho-Scoop

20

From the eeP Comittee

Hey guys! Just wanted to give an update
on the status of raising money for the
gala. We have raised $130!!!! Keep up
the great work!!! Bags of candy are still
avaliable for sell for $5, they contain a
different array of candy and chocolates.
We will as well be raffling a bottle of wine
for $3. Thank you guys!!! We got this!!!

February, 2015. Issue #3

Reducing Unplanned
extubations in the
Pediatric Intensive
Care Unit (PICU)

By Pat Thorpe, BSRN, MSN Ed.

An unplanned extubation (Ue) is an accidental or unscheduled dislodgement

or removal of an artificial airway (i.e. endotracheal tube [eTT]). The eTT can
be inserted through the nose or mouth into the trachea. Ue can be medical
personnel related (accidental) or patient related (accidental or deliberate)
Risk Factors

Age related
Gender
Inadequate sedation
Patient agitation
Copious secretion
Loose and in-secure tape
Procedure related
Nurse-patient ratio

Complications

Re-intubation
Increase length of hospitalization
Bronchospasms
Arrhythmias
Airway traumas
Ventilator-associated pneumonia (VAP)
Increase in morbidity and mortality

Strategies to Prevent Ue
1:1 nurse patient ratio while weaning
off sedation

Continuous quality improvement (CQI)

Standardization for procedures and
transportation

Standardization of tube
Securement and sedation protocol
Patient and family education

Proper positioning of
intubated patients
The proper positioning of intubated
pediatric patients is very important in
preventing UE, and also ventilated

associated pneumonia (VAP). These

positions varies from supine, left and right
lateral, with head of bed up at 30 degrees
to prevent (VAP), and provide adequate air
exchange. The sniffing and prone positions
are also used.

Capnography
Capnography measures exhaled carbon
dioxide (CO2). This is measured by placing
a CO2 detector at the opening at the top
of the ETT. If the ETT is in place/patient is
intubated the color on the detector turns

yellow after five seconds. If the tube is

displaced/patient is not intubated the color
will be purple.

Method of securing eTT

The fixation of
tapes

can

an ETT is important as

become loose from oral

secretions and tongue movements. The

nurses

would

be taught

standardized

method of taping the ETT as per Niklaus

Children's Hospital policy. The tape of
choice is water proof which is placed on
The PICU Stetho-Scoop 3

the cheeks, upper lips and around the tube.

Childrens Hospital, 2014). According to

Prior to application of the tape Cavilon a

Durham and Alden (2008), human-patients

protective skin barrier and duoderm is

simulators can be used in continuing

applied to the taping area on the cheeks.

education to enhance self-confidence, in the

This procedure should be carried out by two

delivery of safe effective care to patients.

trained personnel; respiratory therapist,

registered

nurse,

or

doctor

(Miami

Conclusions
UE is an accidental dislodgement or
removal of an ETT

National benchmark of UE is 1.0 UE

per 100 ventilated days

Supplies needed
for Intubation

UE is a potential life threatening event

Early detection of risks factors can

that poses risks to patient safety and

quality of care

Laryngoscope with blade

Endotracheal tube

decrease UE

Implementation of a CQI program is

Co2 detector
Stylette, oral airway

effective in reducing UE

Increase nursing staff knowledge and

Detachol, Mastisol
Tape, cavilon, duoderm

awareness of UE can reduce this

Abu-bag, oxygen, suction

adverse event

Miami Childrens Hospital Becomes

nicklaus Childrens Hospital

e are deeply honored that our

name will be associated with a

healthcare organization that so

many know and trust throughout the

world, said Jack and Barbara Nicklaus in a
joint statement. Children are our regions
most precious and vulnerable resource. We
have heeded a call to make a difference for
all children in need and have found a
worthy partner in Miami Childrens Health
System.
The organization shares our passion and
commitment to care excellence. We are
delighted that we are further united in our
common purpose.
The name change is in recognition of a $60
million pledge from the Nicklaus Childrens

the same great nonprofit network of

facility will include provisions for three new

Health Care Foundation to the Miami

healthcare facilities for children made

family-centered intensive care units. Funds

Miami

stronger by the generous philanthropic

will also support emergency and trauma

Childrens Health Foundation, which raises

support of the Nicklaus Childrens Health

preparedness,

funds for the health system, is currently in

Care Foundation and Jack and Barbara

recognized centers for excellence at the

the midst of its Together for the Children

Nicklaus.

hospital.

Childrens

Health

System.

The

Campaign, aimed at raising $150 million by

and

enhance

globally

In addition to the pledge, the Nicklauses

We

are now the chairs of the Together for the

Barbaras

Children Campaign and will spearhead

generosity to our mission of providing

Miami Childrens Health System, said, The

fundraising

health

65th anniversary celebration presents a

enhancements for the hospital, including

2017.
Dr. Narendra Kini, President and CEO of

efforts

to

support

major

are

truly

grateful

long-term

and

Jack

and

commitment

and

happiness

for

to

children

everywhere, said Lucy Morillo, President

perfect opportunity to treasure our past

supporting construction of the planned

and

and embrace a new name and future for

212,000-square-foot Advanced Pediatric

Foundation. As chairs of the Together for

our hospital and outpatient centers. We are

Care Pavilion, now in progress. This new

The Children campaign, they will help us

4 The PICU Stetho-Scoop

CEO

of

Miami

Childrens

Health

February, 2015. Issue #3

ensure that we not only reach our $150

Miami Childrens Health System, the parent

organization for the hospital, outpatient
centers, foundation and other entities, will

(main campus near Coral Gables)

Outpatient Center

Outpatient Center (Weston)

Nicklaus Childrens Palm Beach

Gardens Outpatient Center

Nicklaus Childrens Doral

Outpatient Center

Nicklaus Childrens Palmetto Bay

Nicklaus Childrens Miami Lakes

Outpatient Center

network of facilities now embrace new

names as follows:

Nicklaus Childrens Miramar

Nicklaus Childrens Dan Marino

retain its name, as will Miami Childrens

Health Foundation. The hospital and its

Outpatient Center

Nicklaus Childrens Hospital

million goal, but hopefully exceed it.

Outpatient Center

Nicklaus Childrens West Kendall

Nicklaus Childrens Midtown

Outpatient Center

Join us for the 5th Annual MCHF 5K Run/Walk!

See Alana Assing for details. Join the PICU Team (Lifesavers).

RUnneR, WALKeR
& 5K STRoLLeR
BeneFITS:
Awards for top finishers in each
runner age group category

Official Race day medal for all

finishers

Official Race day tech t-shirt

Race or walk with a team or
individually
Access to celebration with music,
awards, food and beverages
Access to Vendor Village
Opportunity to make a difference in
the life of a child

FUn RUn BeneFITS:

$500 - Helps provide 100 meals for

$1000 - Sends a child to a week at

Custom event t-shirt

Medals for all finishers
Access to Kids Fun Zone
Access to celebration with music,
awards, food and beverages
Opportunity to make a difference in
the life of a fellow child

families with limited resources

one of the many camps available at
Nicklaus Childrens Hospital

MAKe A DIFFeRenCe:
$25 - Buys 50 preemie-sized diapers
for babies as small as your phone

$50 - Helps buy baby blankets for 10

patients in the NICU

$100 - Provides games and entertainment

for the Michael Fux Family Center

Happy Birthday
PICU Nurses!!

LIKINS, SARAH.................................1-Jul
PATINO, CRISTHIAN D.....................1-Jul
FORCINE, CHRISTINA .....................5-Jul
ESPINAL, STEPHANIE .....................9-Jul
GONZALEZ, MIRTHA......................14-Jul
HUNTER, DANIELLE ......................21-Jul
BERMUDEZ, ENRIQUE ..................23-Jul
DOBBINS, VIVETTE........................5-Aug
LOPEZ-CALLEJA, SARAH..............8-Aug
STEPHEN, SYLVIA........................14-Aug
SMITH, JULIE................................15-Aug
SCHEFLOW, ALISON....................22-Aug
ESCOBAR, VANESSA...................25-Aug

CABALLERO, KIRIAN ...................29-Aug

GRIFFITHS, SARAH .......................8-Sep

MURILLO, RUTH.............................9-Sep

DAZA-GALLEGO, EILEEN ............11-Sep

SERRANO, MARCIA .....................13-Sep

ARRAZOLA, LAURA......................17-Sep

BARLEY, ROSALYN ......................19-Sep

DIAZ, BOBBI..................................19-Sep

DIMAANO, GINA ...........................26-Sep

VALDES, JENNIFER .....................27-Sep
RODRIGUEZ, MICHELLE .............28-Sep

WALKER, PAULETTE ...................28-Sep

The PICU Stetho-Scoop 5

State Behavioral Scale (SBS)

ICU Sedation Workgroup:
PICU Intensivists: Dr. Totapally, Dr. Raszynski, Dr. Beltramo. Dr. Luis Lee, PICU
Fellow. Carolina Soto, PICU Pharmacist. PICU Nurses: Yamile Viera, Michelle
Rodriguez, Viviana Castillo, and Ming Li

THE VOICE
Get your Voice OF PICU

Heard! Fill the forms out and deposit on

drop box or contact your representatives
from day and night shift.

What is SBS: SBS is a 6-point nursing scale that describes level of sedation (state behavior).
Why: A pediatric sedation scale & protocol can significantly decrease days of
benzodiazepine & opiate administration, which may improve pediatric intensive care unit
resource utilization. Prolonged sedation has been associated with increased procedures,
acquired neuromuscular disorders, delirium and post traumatic stress disorder. Who:
Every supported mechanically ventilated (MV) patient. Where: PICU. Other critical
care areas could benefit in near future. When: Started Monday June 1, 2015. Phases:
Phase 1 (June 1- Aug 1). Hand collection of data from sedation nursing flow sheets.
Return to ICU committee with summarized collected data for review. Phase 2
(August). SBS will go live in Cerner under ICU Quick view. Nurses will chart SBS
score in PEDS. Phase 3 (January 2016). Implement nursing driven sedation
intervention as per hospital approved protocol. In pediatric patients supported on

MV, state behavior is described as a summative characteristic of the following

dimensions: 1. Respiratory Drive/Response to Ventilation 2. Coughing 3. Best
Response to Stimulation 4. Attentiveness to Care Provider 5. Tolerance to Care 6.
Consolability 7. Movement After Consoled. Scale of -3 to +2. More negative scores
reflect a sedated state. More positive scores reflect a more agitated state.
SCORE

+2

+1

-1

-2

-3

DESCRIPTION

Agitated

Restless and
difficult to calm

Awake and
able to calm

Responsive to gentle touch

or voice

Responsive to
noxious stimuli

Unresponsive

May have difficulty breathing with ventilator

Coughing spontaneously
No external stimulus required to elicit response
Spontaneously pays attention to care provider
Unsafe (biting ETT, pulling at lines, cannot be left alone)
Unable to console
Increased movement (restless, squirming or thrashing side-to-side, kicking legs)

Spontaneous effective breathing/Having difficulty breathing with ventilator

Occasional spontaneous cough
Responds to voice/No external stimulus is required to elicit response
Drifts off/Spontaneously pays attention to care provider
Intermittently unsafe
Does not consistently calm despite 5 minute attempt/unable to console
Increased movement (restless, squirming)

Spontaneous and effective breathing

Coughs when repositioned/Occasional spontaneous cough
Responds to voice/No external stimulus is required to elicit response
Spontaneously pays attention to care provider
Distresses with procedures
Able to calm with comforting touch or voice when stimulus removed
Occasional movement of extremities or shifting of position/increased movement
(restless, squirming)
Spontaneous but ineffective nonsupported breaths
Coughs with suctioning/repositioning
Responds to touch/voice
Able to pay attention but drifts off after stimulation
Distresses with procedures
Able to calm with comforting touch or voice when stimulus removed
Occasional movement of extremities or shifting of position

Spontaneous yet supported breathing

Coughs with suctioning/repositioning
Responds to noxious stimuli
Unable to pay attention to care provider
Will distress with a noxious procedure
Does not move/occasional movement of extremities or shifting of position
No spontaneous respiratory effort
No cough or coughs only with suctioning
No response to noxious stimuli
Unable to pay attention to care provider
Does not distress with any procedure (including noxious)
Does not move

Coordination, graphic design and editing: William Padron. Contributions: Ginel

Capdevila, Christianne Caceres, Karla Filosa, Mercy Cosio, Mirtha Gonzalez, Harry
Reyes, Christian Patino, Pat Thorpe, Lidia Rosado, and Mara Ceruto.
6 The PICU Stetho-Scoop

Child Life

DEFINITION

By Karla Filosa, M.A. Ed. CCLS II

How Can We Help our

Patients Cope with
Painful Procedures?:
Utilize Child Life to provide teaching,
medical play, support, and distraction.

Embrace the concepts of family

centered care

Encouraging parents presence and

participation is key

Advocate for typical analgesia

and appropriate pharmacologic

interventions when need is identified
Utilize comfort positioning
Let patient know what they can do,
not what they cant!
Make expectations clear!
Offer appropriate choices!
Offer character band-aids
Utilize stickers when appropriate