Background and Aims

Most youths with cancer experience pain, negatively affecting health-related quality of life. To improve outcomes, barriers to pain assessment and treatment must be mitigated using effective, but also well-implemented, assessment tools. PainSquad is a valid and reliable, multidimensional app designed to support youths (8-18 years) with cancer to self-report cancer pain in real-time and in any environment. Partnering with nurse practitioners (NPs) and registered nurses (RNs), we used an evidence-based implementation toolkit and knowledge translation strategies to implement the PainSquad app into routine pediatric oncology practice. Following a 6-month implementation period, we aimed to evaluate the implementation process and effectiveness from the perspectives of our partner nurses.

Methods

Audio-recorded, semi-structured, qualitative interviews were conducted with all participating NPs and RNs. Interviews were transcribed and coded in duplicate according to the Consolidated Framework for Implementation of Research (CFIR) constructs to uncover intervention, setting, individual, and process themes impacting implementation success. Coded data were then analyzed using a template analysis approach.

Results

Two NPs and three RNs were interviewed. Four main themes were derived that each described patterns of barriers and facilitators to implementation: (1) characteristics of PainSquad (including clinical advantages of the intervention); (2) internal context and setting of the practice (including a need to improve compatibility between PainSquad and existing workflows and systems); (3) implementation partner characteristics and attitudes (including a need to optimize familiarity with PainSquad); and (4) PainSquad implementation process within the practice (including a need to engage champions and formally appointed implementation leaders to support implementation).

Conclusions

Several nurse-specified barriers and facilitators to implementing a pain assessment app for youth into routine pediatric oncology practice were identified. Future PainSquad implementation efforts will require continued partnerships with stakeholders to ensure process fit in current workflows and the engagement of a central team lead to support the project.

Background and Aims

The majority of children with cancer experience pain despite the availability of evidence-based treatment guidelines. Further, a significant proportion of pain episodes occur in environments where management options are limited (i.e., at home). Young children receiving outpatient cancer care may be particularly vulnerable to undermanaged pain because of their limited ability for pain self-report and their reliance on parents to implement pain management interventions or seek medical treatment. We aimed to understand parents’ experiences of assessing and managing their young children’s cancer pain at home, as well as the impact of children’s pain on the child, parent, and family.

Methods

We recruited parents of children (2-11 years) with cancer spending >25% of their cancer care time outside of the hospital and who experienced pain in the previous week. Parents were recruited from two pediatric tertiary care centers to participate in audio-recorded, semi-structured qualitative interviews. We conducted qualitative interviews until data saturation was reached. Audio-recordings were then transcribed, coded, and analyzed using thematic analysis.

Results

Twenty parents participated. Four themes, each comprising several subthemes, were identified: (1) the child’s pain experience at home (pain severity, frequency, type, cause); (2) currently used home-based methods to assess and treat young children’s cancer pain; (3) the emotional, care coordination, and practical impact of caring for a child with pain at home; and (4) solutions needed to better support parents in home-based pain management.

Conclusions

Parents recognized pain in their younger children and its negative impact on the child and family. Parents reported using a number of management solutions at home, however, co-developing interventions with parents to further assess and treat their child’s pain may result in better managed pain and, ultimately, improved quality of life for young children.

Background and Aims

Gram negative sepsis is the main cause of mortality in children undergoing high dose chemotherapy in India. Nursing care is paramount to decreasing mortality in this cohort. We analyzed the trends in the rates of infection over a five-year period and aim to use this data to introduce nursing interventions to combat infections

Methods

We performed a retrospective analysis of the blood culture positive infection in the recipients of high-dose chemotherapy for hematolymphoid malignancies and hematopoietic stem cell transplantation (HSCT) up to 18 years of age, from January 2016 to December 2020. Gram negative bacilli (GNB) were further classified as Extended Spectrum Beta Lactamase (ESBL) if there was resistance to cephalosporins but sensitive to carbapenem, Carbapenem Resistant Enterobacteriaceae (CRE) if there was resistance to carbapenem and sensitive to colistin and polymyxin and Pan Drug Resistance (PDR) if there was resistance to colistin and polymyxin

Results

A total of 558 children underwent conditioning chemotherapy for HSCT, and 22 for malignancies (15 acute myeloid leukemia; seven Burkitts lymphoma). Culture positive sepsis was documented in 82 HSCT recipients (14.7%) and 14 children with malignancies (63%). Across the spectrum, GNB was predominant (75.6%). Klebsiella pneumoniae was the most common isolate (46.7%), followed by E.Coli (20.9%) and Pseudomonas (12.9%). The rates of CRE were 45.1%, ESBL 9.6%. There were no isolates of PDR in our cohort. In 12.9% children, bacteria such as Acinetobacter, Ochrabacterium, Bacteroides were isolated.

Conclusions

The rates of GNB infections are alarmingly high. The trends have been stable over the last 5 years with no reduction or increase in drug resistant infections. Stringent infection control measures and adherence to central line handling protocols as per CLABSI bundle will help in prevention. We plan to present the data for nurse training sessions in our unit to make meaningful interventions and reduce morbidity and mortality in children.

Background and Aims

Children with cancer are at disproportionate risk for central line-associated bloodstream infections (CLABSIs) relative to other hospitalized children. This ongoing single-institution project evaluated changes in CLABSI rates following targeted CLABSI-reduction strategies using a practice-based evidence approach.

Methods

The setting was a 32-bed inpatient pediatric hematology/oncology/stem cell transplant unit in the United States. CLABSIs identified using National Health Safety Network (NHSN) surveillance criteria from January 1, 2006 – December 31, 2019 were included. Data were organized into four time periods:

• Pre-intervention baseline (2006-2010).

• Children’s Hospital Association (CHA) best practice bundles (2011-2012).

• Formalized supportive cares (2013-2017 3rd quarter).

• Antibacterial prophylaxis for patients with high-risk hematologic malignancies (2017 4th quarter-2019).

Conditional Poisson regression models were used to evaluate the effect of time (intervention period) on CLABSI rates with post-hoc Tukey pairwise comparisons between each of the four time periods. Clinical characteristics of patients who developed CLABSIs were compared using chi-square tests.

Results

From 2006 through 2019, 227 patients experienced 310 CLABSIs. Most (69%) occurred in patients with leukemia; however, events involving patients with leukemia decreased following implementation of antibacterial prophylaxis (Χ²=32.51; p<0.01). Clinically important decreases in CLABSI rates from baseline (4.84/1,000 line days) occurred with implementation of CHA bundles (3.29/1,000 line days); however, this difference was not significant (p=0.16). CLABSI rates decreased from baseline with the addition of formalized supportive cares [2.66/1,000 line days; incidence rate ratio (IRR)=0.60; p < 0.01], and with the use of antibacterial prophylaxis (1.66/1,000 line days; IRR=0.35; p < 0.01). Post-hoc comparisons indicated decreased CLABSI rates with the use of antibacterial prophylaxis compared with CHA bundles alone (IRR=0.49; p=0.011) and CHA bundles plus formalized supportive cares (IRR=0.58; p=0.046).

Conclusions

Results demonstrate sustained success using a practice-based evidence approach to guide CLABSI-reduction interventions. Follow-up research, applying machine learning algorithms, may identify additional risk factors and inform future interventions.

Background and Aims

The presence of a venous access device is important in the anticancer treatment for patients requiring chemotherapy or parenteral nutrition. The aim of this study is to determine the indications and the complications associated with the use of peripherally inserted central catheter (PICC) in paediatric oncology patients of a tertiary oncology care hospital of a developing nation with a PICC dedicated nursing staff.

Methods

All paediatric oncology patients, less than 18 years of age, who underwent PICC line insertion at a tertiary oncology centre from January 2018 to December 2020 were enrolled in the study. A retrospective analysis of demographic features, primary diagnosis, length of catheter stay, complications and indication for removal was done.

Results

A total of 114 PICC were inserted in 110 patients. The total catheter days were 14927 with 116.5 median catheter dwell time. Seventy-eight patients with haematolymphoid and 32 patients with solid tumor malignancies underwent PICC insertion. The overall complication rate was 44.73% with ­18.4% complications warranting removal of PICC. The most common complications were catheter related infections (19%, 1.47 per 1000 catheter days), mechanical complications (fracture and displacement) (19%, 1.47 per 1000 catheter days) and thrombosis (6%, 0.46 per 1000 catheter days). No patient had pneumo/hemothorax with PICC insertion. The most common complication causing removal of PICC was infection, accounting for 44% cases of PICC removal. It was found that in the hands of dedicated and trained nursing staff the PICC line infection rate went down from 28% in 2018 to 16.8% in 2019 to 2020.

Conclusions

Our study suggests that the PICC is an effective and easy to handle CVAD with low rates of complications if dealt by a trained and a PICC dedicated nursing staff. PICC can be successfully utilized in paediatric oncology patients as a means of safe and long-lasting venous access.

Background and Aims

Pediatric cancer patients suffer frequent deterioration requiring care in an intensive care unit (ICU). Unfortunately, in many hospitals, ICU access is limited due to lack of pediatric intensivists and shortage of ICU beds. To address these issues, three centers in Peru (INEN–Ministry of Health; Rebagliati and Almenara Hospital – Social Security ESSALUD) joined an international network for the implement of a Pediatric Early Warning System (PEWS) in their Pediatric Oncology Units (POUs). The aim of this study is to evaluate the impact of PEWS implementation on mortality during clinical deterioration in these units.

Methods

This is a prospective cohort study of all pediatric patients admitted to the POUs at the 3 collaborating hospitals. Pre-implementation data were compared to 12 months post-implementation at each center (INEN: 4/2017-4/2018 vs 2/2019-1/2020, Rebagliatti: 8/2018-6/2019 vs 12/2019-11/2020, and Almenara: 6/2018-4/2019 vs 2/2020-1/2021). Clinical deterioration events, defined as unplanned ICU transfer or floor ICU-level interventions, were identified and clinical characteristics extracted from patient charts.

Results

During the study period, 253 deterioration events were recorded among 101,716 inpatient days across the 3 centers. Comparing the period before and after PEWS implementation, the rate of clinical deterioration increased from 2.7 to 3.8/1000-inpatient-days at INEN,decrease at Rebagliati Hospital from 2.15 to 1.04 and Almenara Hospital from 2.85 to 1.38. There was a decrease in mortality from 47% to 34% of events (27% decrease) at INEN, from 47% to 42% of events (11% decrease) at Rebagliati Hospital and 82% to 60% of events (26.8% decrease) at Almenara Hospital.

Conclusions

PEWS is an effective intervention to improve quality of inpatient care in limited setting allowing for early identification of deterioration with timely ICU transfer, resulting in reduced mortality. Our experience in Peru supports the global adoption of this intervention to improve childhood cancer survival.