Defining the role of the pediatric critical care nurse practitioner in a tertiary care center

OBJECTIVE: To describe the development and implementation of a pediatric critical care nurse practitioner role in a tertiary academic pediatric intensive care unit. DATA SOURCES: Selected relevant articles from the literature. DATA EXTRACTION/SYNTHESIS: Over the past two decades, the role of critical care nurse practitioners in neonatal and adult settings has developed. More recently, the role has emerged in the setting of pediatric critical care. Literature to date focuses on implementation of the nurse practitioner role in neonatal and adult critical care units, with limited publications on the role in the pediatric critical care arena. In addition, information on the practice of critical care nurse practitioners in tertiary care centers is lacking. We therefore, sought to describe the design, implementation, scope of practice, and outcomes to date of a pediatric nurse practitioner program in our pediatric critical care unit. CONCLUSIONS: A pediatric critical care nurse practitioner role can be implemented successfully in a tertiary center's pediatric intensive care unit. However, before integration of the pediatric critical care nurse practitioner into the health care team, definition of entry level requirements and the overall role with respect to scope of practice, daily operations, and professional practice is essential. Future endeavors should include evaluation of the impact of the pediatric critical care nurse practitioner on patient outcomes in the tertiary care center.     

The seduction of general practice and illegitimate birth of an expanded role in population health care

To reduce health inequalities and improve quality in health care, health policy initiatives in countries including New Zealand and the United Kingdom are expecting general practice to share responsibilities for a population approach to health care. This is giving increased emphasis to preventative care, including health promotion. Reasoned debate on this policy is overdue, not least in New Zealand, where clinicians within general practice appear to have been seduced by the lack of clarity in health policy into accepting this policy without question. They appear to disregard implications of the policy for redefining the nature and scope of their discipline (and of public health), including their own role as providers of personal care. This paper suggests that a population health approach is inappropriate in general practice when this approach weakens personal care and involves health promotion activity of unknown safety and effectiveness. The example of intentional weight loss to reduce overweight is used to illustrate these issues. We argue for a restricted range of general practice services.     

Innovative approach in rehabilitation nursing: providing primary care to tertiary care patients

In 1998 health care legislation in Ontario changed and allowed Primary Health Care Nurse Practitioners the possibility to expand their practice. At a rehabilitation centre, where spinal cord injured patients would seek primary health care services, a new amalgamated role was implemented to meet those needs. This article will described the advanced practice role that was developed, define the scope of practice, and demonstrate an innovative approach to service delivery. The role serves as a concrete link between primary health care services and tertiary care patients needs.     

The role of the enrolled nursing auxiliary in a selected health care administration

The purpose of the study was to determine the contribution of nursing auxiliaries towards health care services, against their scope of practice. The sample consisted of nursing auxiliaries in the Gazankulu area, in the Northern Transvaal. The findings revealed that nursing auxiliaries are presently an essential component of nursing services rendered in Gazankulu, but that apart from their prescribed role, they are also engaged in activities which should be performed by enrolled and professional nurses, and general assistants. A need for education is apparent for all categories of nursing staff regarding the scope of practice of nursing auxiliaries.     

Occupational health nursing in Lebanon: exploring the world through international occupational health programs.

Lebanon is undergoing rapid developments. The majority of occupations (approximately two thirds) fall under services, industry makes up one fifth, and the remaining occupations are in agriculture. Primary health care is recently gaining renewed interest, with a focus on primary preventive services. Occupational health practice lags behind, despite the presence of legislation. Data related to occupational illnesses and injuries are fragmented. There is need for comprehensive multidisciplinary national studies to identify occupational health needs. Occupational health nursing is underdeveloped in Lebanon. Nevertheless, the establishment of a National Nurses' Order is hoped to promote the educational preparation and scope of nursing practice in the field.     

Health problems encountered by pediatric nurse practitioners and pediatricians in ambulatory care clinics

This study documents the health problems managed by pediatric nurse practitioners (PNPs) and pediatricians and examines the effects of setting and provider group on the distribution of health problems. Proportional samples by clinic were selected from a total of 11,968 patient visits to five ambulatory care clinics during an 18-week period in 1978. A patient encounter form was devised and the ICD-9-CM was used as the coding system. Results indicated 1) distributions of health problems differed significantly between the PNPs and the pediatricians in each clinic; 2) setting significantly effected the distributions of both types of health problems; and 3) provider group significantly affected the distribution of health problems with V codes but not frequently reported problems given a setting. The PNPs caseloads differ from pediatrician caseloads in diagnostic categories and wellness emphases. Community-based settings seem to be especially appropriate for nurse practitioner practice.     

An Introduction to Pediatric Home Health Care

purpose . To provide an overview of the delivery of home health care services to pediatric patients
population . All pediatric patients
conclusions . Institution-based nurses are integral in making referrals for home health care services and assuring home health care agencies have the needed information for providing seamless services.
practice implications . Institution-based nurses are the first line in the transition to home and are key members in making the transition happen without unnecessary difficulty for the child and family. This article presents pragmatic information about home health care agencies and how they operate so that institution-based nurses can maximize the benefit their pediatric patients receive from home health care.     

Chiropractic's functional integration into conventional health care: some implications

Australian chiropractors have achieved functional integration into a referral network within conventional health care. In order that benefits from this achievement be maximized, one issue that needs to be addressed includes the streamlining of interprofessional referrals. Most respondents indicated that their preferred interprofessional communication pattern within this network was either by telephone or written report. Delineation of chiropractic scope of practice and/or the services available within chiropractic clinics is suggested as a means of further refining the efficiency of interprofessional referrals. Another issue to be addressed is the implementation of a rational approach when chiropractic belief and traditional medical practice are in conflict. As complementary conventional health care practitioners, chiropractors are representatives of the orthodox health care system. This paper proposes a format whereby resolution of conflicts between ascribed and perceived roles may be attempted. Evolutionary progress rather than revolutionary disruption is possible within conventional health care.     

The clinical nurse specialist's role in school health.

This article explores the role of the clinical nurse specialist (CNS) in school health. School nurse roles and responsibilities are expanding from their original emphasis on providing direct care and education to children and their parents to community-oriented care. CNS roles and practice areas have expanded to fill needs in a variety of settings, with a variety of clients. The identified CNS roles of clinician, educator, consultant, researcher, and leader/manager provide a comprehensive approach to providing school health services directly to individuals and indirectly through community-oriented care. A CNS's expertise is essential to assist with providing comprehensive care to students, their families, and the community through comprehensive school health services.     

Creating Healthy Futures: an innovative nurse-managed transition clinic for adolescents and young adults with special health care needs

The Creating Healthy Futures (CHF) clinic is an innovative, nurse-managed service model that provides comprehensive transition services to youth and young adults with special health care needs. Unlike other transition service models reported in the literature that are medically based, comprehensive transition services were coordinated by a family nurse practitioner who worked in close collaboration with an interagency team of pediatric and adult service providers. The Creating Healthy Futures (CHF) service model was originally developed for use in educational settings but was adapted for use in health care settings. The components of the service model are described in detail as a model for replication in other health care settings.     

Guidelines and levels of care for pediatric intensive care units

The practice of pediatric critical care medicine has matured dramatically during the past decade. These guidelines are presented to update the existing guidelines published in 1993. Pediatric critical care services are provided in level I and level II units. Within these guidelines, the scope of pediatric critical care services is discussed, including organizational and administrative structure, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education.     

Facilitating the transition of adolescents with developmental disabilities: nursing practice issues and care

The purpose of this article is to provide an overview of salient issues that adolescents with developmental disabilities face as they approach adulthood. For nurses who provide services to this population of youth, knowledge of these significant issues is essential to developing a youth-centered transition plan that addresses their comprehensive health needs. Health care professionals, including pediatric nurses, have important roles as service coordinators, consultants, or direct service providers to ensure that the health-related transition needs of the youth are met. Transition assessment, planning, and intervention strategies that can be integrated into a comprehensive plan of care are discussed.     

A Cost-Analysis of an Interdisciplinary Pediatric Chronic Pain Clinic

Chronic pain is characterized by high rates of functional impairment, health care utilization, and associated costs. Research supports the use of comprehensive, interdisciplinary treatment approaches. However, many hospitals hesitate to offer this full range of services, especially to Medi-Cal/Medicaid patients whose services are reimbursed at low rates. This cost analysis examines the effect on hospital and insurance costs of patients' enrollment in an interdisciplinary pediatric pain clinic, which includes medication management, psychotherapy, biofeedback, acupuncture, and massage. Retrospective hospital billing data (inpatient/emergency department/outpatient visits, and associated costs/reimbursement) from 191 consecutively enrolled Medi-Cal/Medicaid pediatric patients with chronic pain were used to compare 1-year costs before initiating pain clinic services with costs 1 year after. Pain clinic patients had significantly fewer emergency department visits, fewer inpatient stays, and lower associated billing, compared with the year before without interdisciplinary pain management services. Cost savings to the hospital of $36,228 per patient per year and to insurance of $11,482 per patient per year were found even after pain clinic service billing was included. Analyses of pre-pain clinic costs indicate that these cost reductions were likely because of clinic participation. Findings provide economic support for the use of interdisciplinary care to treat pediatric chronic pain on an outpatient basis from a hospital and insurance perspective.

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale,Development, and First Steps*

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC), in the out‐of‐hospital as well as the emergency department (ED) and hospital settings, that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October 2001. PECARN is the first federally funded national network for research in EMSC. PECARN is the result of Cooperative Agreement grants funded through the Health Resources and Services Administration (HRSA) with the purpose of developing an infrastructure capable of overcoming inherent barriers to pediatric EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out‐of‐hospital care, patient transport, ED and in‐hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the Network.     

Comprehensive care from the perspective of health care workers from Belo Horizonte

The objective of this qualitative case study was to present the understanding that health care workers and administrators of Belo Horizonte have about comprehensive care. Thirty-two workers were interviewed using a semi-structured questionnaire. Data analysis showed that comprehensiveness permeates the various levels of health care, adding the concept of health promotion. Interdisciplinary work emerges as a key element for the health care practice, which is made effective by sharing feelings. On the other hand, data show that comprehensive health care is only made effective provided that basic conditions are present, and services often do not provide those conditions. In conclusion, it is necessary to eliminate the fragmentations that exist in the form of health care organization as well as in the everyday practice of health care workers at the referred services so that it is possible to offer comprehensive, problem-solving care and humanize health care practices always aiming at the quality of life of the population.     

Strengthening an academic nursing center through partnership

Nurse-managed health centers offer holistic health care and patient-centered health promotion and disease prevention. These goals are particularly well suited to the needs of children and their families. Few reports in the literature, however, have described such practices. The purpose of this paper is to describe one practice, Valencia Health Services (VHS), a nurse-managed, academic health center providing primary care to pediatric and adolescent patients. Valencia Health Services offers interdisciplinary, comprehensive health services to ethnically diverse children and their families through an inter-university partnership and provides clinical experiences and research opportunities, under the supervision of expert faculty-clinicians, to students of nursing (advanced practice, public health, and case management), social work and psychology. Valencia Health Services is the rare nurse-managed academic health center that provides comprehensive health care to children and adolescents. The multifaceted demands of such a health center, however, present both unique opportunities for quality care and service and considerable ongoing challenges.     

Use of health services by chronically ill and disabled children

Hospitalization and use of outpatient health care services during a 1-year period by 369 pediatric patients with cystic fibrosis, cerebral palsy, myelodysplasia, or multiple physical handicaps and 456 randomly selected children without congenital conditions from the Cleveland area were examined. Use of hospitalization and outpatient services by the average chronically ill or disabled child was 10 times that of the average comparison child. Physician specialists, occupational and physical therapists, and school nurses were the major outpatient categories used disproportionately by children with chronic illnesses or disabilities. The major share of health care used by children with chronic conditions was attributable to a small subset of children: All hospital care was accounted for by one third of the children, and three quarters of all outpatient care was accounted for by one quarter of that sample. Hospital care was used at similar rates by the four diagnostic groups. However, amount and type of outpatient care varied by diagnosis, level of functional impairment, race, and income. Estimated average expenditure for health services used by the chronically ill or disabled sample was 10 times that of the comparison sample. Relative distribution of estimated expenditures across types of services differed for the two samples as well as among diagnostic categories.     

A Model for Pediatric Sedation Centers Using Pharmacologic Sedation for Successful Completion of Radiologic and Procedural Studies

St. Louis Children's Hospital is a 368-bed tertiary care center for Washington University St. Louis School of Medicine. Due to increased needs for procedural sedation, in 2004 an Ambulatory Procedure Center (APC), formerly run by the department of radiology, was recreated to combine the expertise of sedation services under the guidance of pediatric anesthesia, and centralizing sedation within our treating facility to optimize patient care and improve sedation safety. The center uses sedation specialists in nursing, pediatric hospitalists, and pediatric anesthesia to care for patients. Patient population is comprised of both inpatient and outpatient referrals. The center provides sedation services to 18 different types of subspecialty physicians performing numerous diagnostic, therapeutic, and radiologic studies. In 2006, the APC successfully completed 4,276 sedations, showing consistent increases in number of patients and decreases in rates of unexpected cancellation. The collaborative efforts creating the APC have been successful in establishing a more efficient and regulated sedation center, and have further improved safety and quality assurance management regarding pediatric sedation in our hospital. On-going studies and data collection will continue to provide information regarding areas for improvement, as the center continues to grow and expand in its referral base. This article will describe the APC, the personnel involved, the training and expertise needed to create the sedation unit, the patient base, scope of services provided, and sedation provider selection based on patient characteristics. Modalities and options for providing sedation are based on procedure type, level of sedation care warranted, and previous sedation history of the patient. The article will explain the operational flow of a typical APC day, and describe the APC patient experience. We believe the APC to be a unique endeavor, which could be modeled as one solution to the growing need for directed, competent, and consistent pediatric sedation services in the health care system.     

The impact of social stressors and social networks on pediatric medical care use

Substantial differences in the use of pediatric medical resources reinforce the need for identifying and understanding factors that influence the use of medical services for children. This research assesses the simultaneous impact of sociodemographic characteristics, health attitudes and beliefs, psychologic distress, social stressors, and social networks on the use of pediatric acute care services during a 12-month period. Using a prospective longitudinal study design, data were obtained on 513 children and their families enrolled in a prepaid group practice. Linear modeling results showed that health attitudes and social networks were important predictors of acute care utilization in addition to child's age, birth order, baseline health status, and ethnic group. The authors were able to show significant effects for network size, dispersion, and tendency to use one's network members. Individuals with large nondispersed networks are more likely to use pediatric health services, apparently due to the transmission of the networks' pro-medical care health beliefs. Also the tendency to call on network members modifies an individual's propensity to seek care for minor pediatric medical problems and can make a difference by as much as 1.6 visits per year per child for acute care episodes.