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One of the most challenging aspects for nurses caring for incontinent children in spica casts is maintaining healthy skin integrity. Noting an increase in the number of phone calls from parents of discharged children in spica casts concerning diaper rash and skin breakdown, inpatient orthopedics staff nurses lead an interdisciplinary quality improvement and educational initiative. They standardized pediatric spica cast care and education by creating an intranet narrated PowerPoint presentation for staff and parents of children with spica casts. A take-home DVD of this education module is now produced and given to parents, reinforcing nursing discharge teaching and giving parents the opportunity to review these new skills at home as needed. The purpose of this article is to share this experience of improving patient outcomes and empowering other orthopedics nurses to develop creative educational solutions.
Jim, aged 7 months, was the first child in a spica cast cared for by Nurse C., one of the pediatric orthopedic nurses providing his care, after the ABC's of Spica Cast Care teaching module became available for parents via the unit's computer on wheels (COWs). The parents, although very involved with the care of their only child, had a learning barrier. Mr. and Mrs. B. both had cognitive delays. The Department of Social Services was involved for parenting support at home, even prior to Jim's surgery. Nurse C. took care of this family the day before the child's discharge. The staff nurses had already set up the COW and the parents had watched the teaching video. Jim's father demonstrated the diapering technique and positioning correctly. His mother, though hesitant with her son's care, was an interested observer.
Nurse C. was pleased that this new teaching module was completed in time to be helpful to these particular parents and would hopefully assist many other patients and families. Mr. and Mrs. B. were not able to read or write, but they were able to view and listen to the instructions with each slide. Later that shift, Jim's father pointed to the nearby supply of moleskin and asked Nurse C. to place "that tape" to a sharp edge of Jim's cast. His request validated that he understood and processed the spica care information from the teaching module. It was wonderful to see that the spica cast teaching initiative via the teaching module was of genuine help to patients, families, and others.
Spica casts immobilize a child's hip and leg joints after surgical repair or trauma. They maintain the correct position for healing by holding the hip, thigh muscles, and tendons in place. They are applied for multiple reasons including femur, pelvic, and hip fractures; tendon releases; and for stabilization after hip and leg surgeries. There are several types of spica casts and the most common are as follows: one and one-half hip spica (see Figure 1), bilateral long-leg hip spica, and short-leg hip spica. They remain in place between several weeks to several months, depending on the surgery. These body casts extend from under the child's axilla to one or both legs. An opening created in the genital area allows passage of urine and stool (Brown & Wilson, 2003).
Although they have been in use on a regular basis at this large urban pediatric teaching hospital since the 1800s according to M. B. Millis, orthopedics surgeon (personal communication, January 2, 2010), one of the most challenging aspects for healthcare professionals caring for an incontinent child in a spica cast is maintaining healthy skin integrity. Prolonged urine and stool contact with the child's skin can cause rash, discomfort and skin breakdown resulting in open skin lesions and susceptibility to infections. It may also affect the integrity of the cast itself (Brown & Wilson, 2003).
In 2003, skin breakdown was identified as an issue with incontinent children in spica casts. Several experienced staff nurses on a 36-bed orthopedics surgical inpatient unit, questioned the current diapering techniques used with the waterproof-lined spica cast patient population. These unit subject matter experts (SMEs) noted an increase in the number of phone calls from parents of discharged children in spica casts with questions concerning diaper rash, skin breakdown, and foul smelling casts. Nurses also observed in clinical practice an increase in the number of readmissions of children in spica casts for skin breakdown issues and the need for spica cast replacement. The staff who worked in the orthopedics ambulatory clinic confirmed these observations. The SMEs identified a need to review the literature, current practices, and available resources in caring for children in spica casts.
The initiative to improve care for spica cast patients required support of the unit and program leadership under a shared governance model to provide the dedicated time and resources for the staff nurses who are most uniquely qualified to identify important patient care needs, to develop evidence-based improvements in care, and to provide a broad range of new educational materials. Provision of resources required to achieve the desired outcomes of this project was possible with teamwork, a shared vision, and support from leadership thus allowing for involved staff members to utilize time creatively. Empowerment of nurses helps to effectively influence positive outcomes for patients and families and to change system-wide processes (ANCC, 2008). This framework of leadership parallels the values of magnetism which helped to support the institution's efforts toward Magnet designation in 2008.
The ability of the staff nurses to identify what support and resources were needed, and then move forward with autonomy and produce positive clinical outcomes, is a powerful and motivating force that stimulated involvement of the healthcare team. Collaboration with the surgical program nurse educators enhanced the experience and contributed to the professional growth of the nursing staff.
The SMEs performed a literature review using EBSCOhost, CINAHL database, and MEDLINE. Keywords included in the literature search were spica cast, hip spica casts, infant, pediatric, adolescent, nursing, and guidelines. Nine articles were found in the literature search. The articles excluded from the review focused on orthopedics technique, transportation, and car restraint.
The review of literature revealed minimal evidence of best practices related to spica cast toileting and diapering. Young children who are placed in spica casts present their families with increased challenges related to their change in activity, which can also lead to a disruption in the regular home environment. Parent information specific to keeping the cast clean at home, and more novel discharge programs, are needed specific to spica cast care (Smith, 2004).
With minimal published evidence, the SMEs sought out best practices taught at other pediatric institutions related to the care of the pediatric patient in a spica cast. Nine pediatric institutions had web accessible home care instructions sheets for children in spica casts. All nine of the institutions described the use of a diaper tucked into the cast with either a sanitary pad or an adult incontinence pad for extra absorption. Only one of these institutions discussed the use of plastic strips on the outside of the cast, although the use of plastic strips was in conjunction with the diaper and absorbable pad.
Only one published article described a successful program related to spica cast teaching (Shesser & King, 1986). The program described by Shesser and King (1986) instituted the use of a sound-tape presentation and verbal reinforcement describing the diapering technique with the use of a tucked diaper and absorbable sanitary pad. The authors found that parents who were taught spica cast care with these discharge materials verbalized an understanding and relative ease with the care of the spica cast. Additionally, an improvement in the condition of the cast was observed during follow-up visits (Shesser & King, 1986).
Following a review of the literature, the SMEs concluded that common practice throughout children's hospitals for spica cast diapering technique included the use of an absorbable pad and tucked diaper. Evidence also supported the use of innovative and technologically appropriate teaching tools for discharge education.
The spica cast SMEs decided that the existing nursing policy and procedure document on Care of the Patient in a Spica Cast needed revising, specifically the diapering technique. The existing procedure guided the caregiver to use a cut plastic trash bag to protect the cast. Nurses tucked the edges of the trash bag around the perineal opening and folded the rest over the exterior of the cast. After positioning a small diaper over the perineal opening, the cast was then covered with a larger diaper. The SMEs observed that the plastic lining often became undone and wet with urine. The existing procedure did not help to alleviate skin breakdown and allowed for pooling of urine. Furthermore, the plastic against skin did not allow for air movement and was a cause for skin irritation and diaper rash.
The spica cast SMEs also realized that staff taught spica care inconsistently between nursing units, that there were no formal teaching tools available for staff, and that parent-teaching materials were limited. These expert nurses also identified a lack of communication between the orthopedics inpatient nursing staff and the orthopedics ambulatory clinic nursing staff regarding spica cast care. The two patient areas were located in separate buildings, which did not foster direct daily contact. This disconnect in communication between the inpatient and outpatient staff allowed for inconsistent spica cast care techniques, education, and identification of skin issues.
The SMEs then convened an interdisciplinary team consisting of inpatient staff nurses, orthopedics ambulatory clinic staff nurses, nurse practitioners, the hospital skin-care specialist, and orthopedics physicians. Over the course of the next year, two inpatient unit SMEs and the hospital's skin-care Clinical Nurse Specialist revised the nursing policy. Use of the plastic trash bag lining was eliminated. The new guidelines integrated use of a urinary incontinent pad and small disposable diaper tucked under the edges of the perineal opening as described in the literature by Shesser and King (1986). A larger disposable diaper is then placed over the other two barriers for containment and privacy. The SMEs also revised the hospital's Family Education Sheet: Home Care Instructions for Children and Adolescents in a Spica Cast. The instructions addressed the first week at home, comfort, positioning, skin care, circulation checks, caring for the cast, diet, toileting for children who wear diapers, toileting for toilet trained children, home equipment and safety, common questions and answers, and when to call the child's physician or nurse. The SMEs created a brochure called Spica Cast Care Frequently Asked Questions. All families received a visiting nurse referral for at least one home visit after discharge.
The orthopedics unit Child Life Specialist developed two related educational brochures: Going Home in a Spica Cast, which focuses on age appropriate tips for home care of the child with a spica cast and Relaxation Breathing, which provides breathing and coping tips for pediatric patients after surgery. The SMEs made spica cast hospitality bags that staff would give to parents as part of their discharge teaching. The bags contained all of the described brochures and a sample urinary incontinence pad. The goal of these educational interventions was to provide more specific discharge instructions for this population of patients as described by Smith (2004).
With the new spica cast skin-care guidelines in place, the SMEs provided multiple in-services to all clinical areas that care for patients in a spica cast, including the surgical units, the recovery room, and the orthopedics ambulatory clinic, thus, providing a seamless system with educational information. The SMEs demonstrated diapering and skin-care techniques using a small stuffed bear. They reinforced documentation of family teaching using the Spica Cast Care: A Family/Nursing Teaching Checklist. This document ensured a standardized approach to teaching families in an easy-to-follow checklist format. It contained three check-off columns for Nurse Demonstration, Family Demonstration, and Family Understands, which addressed cast care, neurovascular checks, skin care, positioning, safety, pain medication, diet, and when to call the physician. The spica cast initiative leaders also identified nurses on the other units to serve as resource staff during implementation of this new educational program.
With the new spica case skin-care guidelines in place, and the staff education teaching completed, the SMEs evaluated the new approach to care with audits. One audit assessed the efficacy of the new guidelines regarding the parents' perceptions of the helpfulness of the spica care educational materials related to skin care. The other audit assessed the effectiveness of the education provided to staff.
In 2005, the SMEs created a tool to document skin assessments in 20 children admitted to the inpatient orthopedics surgical unit with a spica cast postoperatively (see Figure 2). Of the 20 children assessed, 15 (75%) were placed in a spica for the first time. The remaining five children (25%) were repeat spica patients. These children included scheduled elective surgeries and nonscheduled, nonelective surgeries. A staff nurse completed a skin assessment prior to discharge from the hospital. Using the telephone audit tool (see Figure 3), a spica cast SME then followed up with a phone call to the child's home within 2 weeks postdischarge to assess the parents' comfort level and proficiency with cast care. One hundred percent (n [SUPERSCRIPT EQUALS SIGN] 20) of the first time spica parents found the educational materials useful. Parents previously familiar with spica care were less likely to need the educational materials.
The follow-up phone calls revealed that only one of 20 patients (5%) returned with skin breakdown. For the one patient, the SMEs identified language barrier for the parents and a prior involvement with the Department of Social Services as potential factors increasing this child's risk of skin breakdown. The orthopedics ambulatory clinic staff also reported a decrease in the number of phone calls related to skin-care issues from parents of children with spica casts.
In summary, findings from this audit demonstrated improvement in self-reported parental comfort levels in spica cast home care, a decreased incidence of skin breakdowns and readmissions, and an improvement in collaborative care between the inpatient orthopedics unit and the orthopedics ambulatory clinic settings across the continuum of care.
Eighty percent (n [SUPERSCRIPT EQUALS SIGN] 100) of the inpatient surgical nursing staff attended spica cast education sessions offered in late 2004 through early 2005. With the assistance of the hospital's Staff Development Specialists, the SMEs created a web-based audit to assess the effectiveness of the teaching provided to staff and their understanding of spica cast care. Fifty-six of 100 staff nurses (56%) responded. Not all of the 56 total respondents answered all of the questions in the survey. Twenty-seven of 33 total respondents (82%) stated that they were comfortable with spica cast care after the in-service. Twenty-six of 34 total respondents (76%) stated that they were comfortable educating parents on spica cast care after the in-service.
After the completion of the educational series, the SMEs identified the potential barrier of training all staff, including newly hired staff, in a timely manner. They acknowledged that there could be a resource gap if SME nurses were not available. With the vast array of information and changes within the healthcare environment, a staff nurse may need to refresh his or her knowledge especially if there was a length of time between the in-service and actual patient care. Finally, the SMEs hypothesized that staff would follow a standardized skin-care and diapering guideline if there was a consistent form of education available for training and referral to at a later time.
The inpatient nurses gave positive feedback on the hands-on demonstration. However, the SMEs found it difficult to demonstrate effectively on the small stuffed bear. They needed a more user-friendly model to show the diapering and positioning techniques so they purchased a larger brightly colored rag doll. The orthopedics unit cast technician was consulted and applied a one and one-half spica cast to the rag doll. The SMEs further engaged the inpatient unit staff in this initiative by having a doll-naming contest with a prize for the winner. The new teaching tool was named Holly Hipster (see Figure 1).
Again, with nursing leadership support, the SMEs then worked on improving the method of education. They developed an intranet web-based competency for staff nurses called the ABC's of Spica Cast Care using Holly Hipster (see Figure 4). The module, created as a narrated English-speaking PowerPoint presentation, allowed for learning using three methods: visual, auditory, and the written word. For parents, they modified this slightly so to be used as an educational teaching module to supplement the written home care instructions sheets. Both modules included demonstration of diapering, proper positioning, safety guidelines, and preventative skin-care measures. The modules provided car seat information and contact referral to the hospital's Injury Prevention Program.
In 2007, all staff completed the web-based competency and in early 2008, the parent educational module was integrated into the hospital's intranet site. Both staff and parents found the educational module very helpful. The module could be brought into patient rooms and accessed on the unit's COWs at all hours of the day. This additional teaching method fulfilled the SMEs final objective of providing readily available education of standardized care across the healthcare continuum, thus, decreasing variation in practice.
Patients and families come to this large pediatric teaching center from all over the country and world. These individuals come from diverse backgrounds and speak a variety of languages. Within the hospital, there is a staff of interpreters to assist with teaching of patients and families. However, because parents learn spica cast care over a period of time, and in several sessions, allowing them time to observe, assist, and perform independently, it is sometimes difficult to schedule the interpreter at the multiple required times.
The staff on the inpatient orthopedics surgical unit is diverse, coming from numerous backgrounds and countries. When an SME presented the spica module, ABCs of Spica Cast Care, at a monthly in-service, one attendee offered to translate the module into Spanish. Another participant offered to translate into Arabic. This continuous evaluation and expansion of the spica teaching methods to include narrated videos for a diverse patient population involved several staff members' talents and time to develop. Nurses, clinical assistants, and surgical program educators have assisted in the translating and narrating the ABCs of Spica Cast Care into Spanish, Arabic, and Filipino. These non-English-speaking versions are available on the hospital's intranet. Plans for other language translations include the following: Haitian Creole, Chinese, Portuguese, Hindi, Italian, and French. The benefit of involving all the nursing staff in this translation process promoted increased unit teamwork, utilization of staff expertise in diverse languages, reinforced collaborative relationships, enriched knowledge in spica cast care and computers.
The staff on the inpatient surgical units gave positive reviews on the translated and narrated PowerPoint modules. The SMEs created two posters and presented them at national conferences. They received encouraging anecdotal feedback. A common request from the inpatient surgical nurses, as well as the participants at the conference, included the availability of the PowerPoint teaching module in the form of a take-home CD or DVD.
The SMEs researched the cost to fund the DVDs with the institution's multimedia services department and presented this information to their nurse leaders. The Director of Surgical Programs approved and provided the funding. The English-speaking DVDs are now available for families to take home from both the inpatient units and the orthopedics ambulatory clinic. Staff encourages families to share their DVD with visiting nurses to help improve spica cast care in the home environment. A feedback survey is included with the take-home DVD to assess its usefulness to parents. Parents are asked to return the DVD and feedback card at their child's follow-up outpatient visit (see Figure 5). The SMEs continually reassess and revise this program thus meeting the goal for Magnet related educational programs to provide high quality of care to their patients (Children's Hospital Boston, 2010).
The SMEs met challenges along the way. After initially meeting with interdisciplinary staff, they relied on e-mail communication for updates and consensus. They recognized the need for flexibility to allow staff to give feedback and make revisions. To maximize efficiency, a more practical time schedule would have been to correlate any revisions in the module with the hospital's calendar of policy reviews of every 3 years.
The SMEs stopped the use of the spica hospitality bags once the supply was depleted. They were unable to get donations from companies for the sample incontinence pads. Additionally, as an outcome of updating and adjusting practices, moleskin is no longer used because it contains latex. It was also found if moleskin is removed when in contact with the waterproof lining, it may tear the lining.
Over the years, all attempts were made to place patients who were in a spica cast on the orthopedics unit. This meant the surgical units other than the orthopedics unit experienced low-volume of spica patients. The nurses previously identified as spica resources on those units could not maintain their clinical competencies and expertise. However, nurses from the orthopedics unit readily visit other units to assist with teaching staff and parents.
One continual challenge to sustain this educational format is funding. It will be critical to build into the yearly budget funding to support the production and revision of DVDs, dedicated time for nurses to revise changes on the basis of new products and disseminate any new updates yearly. In addition, funding will be required to support the salaries of any translations done in other languages. If financial resources cannot be allocated, it would be appropriate to consider philanthropic donations as a next step.
The spica cast project started as an idea of several expert nurses to improve one aspect of patient care and evolved into policy practice changes with innovative educational resources. With the support of the nursing administration, unit SMEs created a standardized teaching program to achieve the highest quality of nursing care across the continuum of care whereas promoting full family participation and communication, and supporting the mission and vision of the institution. This initiative is now a model for other patient care quality improvement projects in progress such as a new ostomy creation teaching video module and materials, also developed and implemented by a group of unit nursing SMEs.
Future quality improvement, evidence-based practice, and research projects will be explored with the feedback gathered from the take-home DVDs. The inpatient surgical unit SMEs plan to continue to work collaboratively with the hospital's interdisciplinary team of staff nurses, nurse educators, nurse scientists, physicians, the hospital's skin-care specialist, and the orthopedics ambulatory clinic to assess and improve upon this patient education initiative. Nurses under a Magnet framework continue to make meaningful contributions in achieving the best clinical outcomes for patients and families using an interdisciplinary team that supports a commitment to excellence.
The authors thank Kathleen Cappucci, BSN, RN, CPN, Tamara Dalton BSN, RN, CPN, and Diane Tubman, BSN, RN, CPN, for their expertise and involvement in this initiative and John Murray, PhD, RN, CPNP, CS, FAAN, for his editorial contribution.
ANCC. (2008). Magnet Recognition Program(R) Overview Brochure. Retrieved October 9, 2011, from http://www.nursecredentialing.org/Magnet/ResourceCenters.aspx[Context Link]
Brown J., Wilson D. (2003). The child in a cast. In Wong D. L., Hockenberry-Eaton M., Wilson D., Winkelstein M. L., Ahmann E., Divito-Thomas P. A. (Eds.), Wong's nursing care of infants and children (7th ed., pp. 1784-1787). St Louis, MO: Mosby. [Context Link]
Children's Hospital Boston. (2010). Living the forces of Magnetism at Children's Hospital, Boston. Retrieved from http://www.childrenshospital.org/clinicalservices/Site1544/mainpageS1544P16suble[Context Link]
Shesser L., King T. (1986). Practical considerations in caring for a child in a hip spica cast: An evaluation using parental input. Orthopaedic Nursing, 5(3), 11-15. [Context Link]
Smith J. (2004). A literature review of the care of babies and young children in hip spicas. Journal of Orthopaedic Nursing, 8(2), 83-90. [Context Link]
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