507130

research-article2013

CPJXXX10.1177/0009922813507130Clinical PediatricsElliott et al

Article

An Inpatient Child Passenger Safety Program

Clinical Pediatrics 52(11) 1022­–1028 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813507130 cpj.sagepub.com

Lindsey Nichole Elliott, BSN, RN, CPN1, Barbara DiGirolamo, MEd1, Maria McMahon, MS1, Frances Damian, MSN, RN1, Marcie Brostoff, MS, RN1, Herminia Shermont, MS, RN, NE-BC1, David Patrick Mooney, MD, MPH2, and Lois Kaye Lee, MD, MPH2

Abstract Background. Our institution implemented an Inpatient Child Passenger Safety (CPS) program for hospitalized children to improve knowledge and compliance with the Massachusetts CPS law, requiring children less than 8 years old or 57 inches tall to be secured in a car seat when in a motor vehicle. Methods. After the Inpatient CPS Program was piloted on 3 units in 2009, the program was expanded to all inpatient units in 2010. A computerized nursing assessment tool identifies children in need of a CPS consult for education and/or car seat. Results. With the expanded Inpatient CPS Program, 3650 children have been assessed, 598 consults initiated, and 325 families have received CPS education. Car seats were distributed to 419 children; specialty car seats were loaned to 134 families. Conclusions. With a multidisciplinary approach, we implemented an Inpatient CPS Program for hospitalized children providing CPS education and car seats to families in need. Keywords child passenger safety, car seats, injury prevention

Introduction In the United States, all 50 states have laws requiring car seats for infants and toddlers, and with the exceptions of Florida, Arizona, and South Dakota, all the other states have booster seat laws.1 Although legislation, improvements in car design, and a safer built environment have been effective in reducing deaths and injuries from motor vehicle crashes (MVCs), they still represent the leading cause of death for children and youth older than 3 years in the United States.2-6 Each year, more than 5000 children and adolescents under the age of 21 years die in MVCs, which represents approximately 15% of people of all ages killed annually in MVCs.2 Since the implementation of child passenger safety (CPS) laws, health care providers and hospitals have played a key role in providing awareness, education, and access to equipment to improve child passenger safety in the United States.5 In Massachusetts, the CPS law states, “A passenger in a motor vehicle on any way who is under the age of 8 shall be fastened and secured by a child passenger restraint, unless such passenger measures more than 57 inches in height.”7 To promote best practices around CPS and to support our patients in complying with the

Massachusetts law, we created a multidisciplinary group to develop and implement an inpatient CPS program at our institution. The objective of this Inpatient CPS Program was to ensure all children admitted to the hospital would be assessed for CPS needs and then provided with the appropriate intervention, as needed.

Methods Our institution is an urban 395-bed freestanding tertiary care children’s hospital. Prior to 2008, car seats were provided to patients and other members of the local community through CPS classes in the primary care clinics and in the Center for Families, a hospital resource for patients and their families. In conjunction with the 2008 Massachusetts enhanced child passenger safety law, which included children through age 7 years,7 a multidisciplinary 1

Boston Children’s Hospital, Boston, MA, USA Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA 2

Corresponding Author: Lois Kaye Lee, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA. Email: [email protected]

1023

Elliott et al committee interested in injury prevention at the hospital decided that CPS should be a priority issue for injury prevention initiatives at the institution. This group consisted of an injury prevention liaison, a physician leader, and representatives from nursing, case management, child life, and the hospital’s Center for Families. We conducted a literature review and interviews with other institutions that had existing CPS programs. In 2008, an online prepilot survey was created and administered to nursing staff on 3 inpatient units to establish a baseline assessment in the following areas: car seat knowledge, previous encounters with transportation difficulties at discharge, and awareness of CPS laws. A surgical, medical, and orthopedic unit, all with rapid patient turnover, participated in this survey. Based on the results of this survey, the committee created assessment sheets on paper for staff to use to screen patients for CPS needs as well as education sheets for families. From this initial groundwork, the committee determined the program needed to be organized around the following areas for successful implementation: financial, distribution, storage, education, computer charting, and staffing. Within these areas the key players were identified and partnerships were established to accomplish our goal of incorporating the program into the hospital. A state-based transportation and safety equipment grant was used to purchase car seats and needed educational materials and equipment. A financial assessment for patients was developed with the assistance of the social work staff to identify families who could not afford a car seat. A credit card collection method was also established during this time for short-term loan of specialty car seats. After discussion with the institution’s business and legal offices, it was determined that no payment would be taken for families after hours and on weekends. A location was identified within the distribution storage area of the hospital, which allowed staff to access car seats after regular business hours and on weekends. The injury prevention staff members worked with the hospital’s distribution and equipment department to establish a system of stocking car seats and tracking the delivery to the patients. The pilot CPS program was launched on the same 3 prepilot inpatient units in February 2009. Injury Prevention staff members hours were formalized, and their responsibilities included consulting on CPS consult patients in the morning. In addition, they were available to provide education, equipment, and installations to patients as needed until 4 pm. They also established a weekly car seat installation/inspection clinic for patient families by appointment. The committee worked to identify hospital staff to become certified car seat technicians to accommodate after hours/weekend needs. The

hospital’s certified technician group was created using staff from nursing, parking services, security, child life, and social work. To be able to expand this CPS program to all of the inpatient units, a computerized CPS screening tool was developed and embedded into the institution’s computerized order entry (CPOE) and electronic medical record system. This computerized CPS screening tool was placed within the discharge planning section of the nursing admission assessment. Completion of this section automatically generates a consult for the inpatient CPS team, depending on the answers provided by the caregiver. This computerized data also allowed the CPS program to track the number of hospitalized patients less than 8 years old who were screened by the nursing staff. To extend this CPS program to all the inpatient units of the hospital, it was first approved by the nursing Educational Council and each of the inpatient unit directors. Nursing leadership then created a formal policy for nurses on the inpatient units, which was included with other nursing policies in the hospital’s online e-library. The program was then introduced and implemented onto each inpatient unit through educational inservices about the CPS program presented by the injury prevention staff members, including the computerized assessment tool (see Figure 1). An educational plan for the nursing staff on these units was also created. The Inpatient CPS Program was formally launched hospital-wide on all the inpatient units on September 2010. This study protocol was approved by our hospital’s institutional review board, the Committee on Clinical Investigation.

Results The prepilot survey answers are included in Table 1. Since the hospital-wide program was instituted, 3650 children have been screened by the computerized nursing assessment, and 702 of the children screened were flagged for consults (Table 2). The total numbers of CPS-related patient interactions are shown in Figure 2 and then by age in Figure 3. CPS education alone was provided to 325 families. Car seats were provided to 419 children, and specialty seats were loaned to 134 patients (Table 3). Of these seats, 131 car seats were installed by a hospital-based CPS technician staff member. Of those installations, 31% involved specialty car seats (23 Hippo, 7 EZ-On Vest®, 1 Angel Ride, 6 Dream Ride, 3 Hope Car Bed). The admission CPS screening tool use throughout the units is currently at 37% related to the total number of admissions. One child who was provided with a car seat after a need was identified through the nursing assessment

1024

Clinical Pediatrics 52(11)

Figure 1.  Computerized nursing child passenger safety assessment in PowerChart®.

was involved in a MVC 6 months after discharge from the hospital. This crash resulted in a rollover of the car, in which the car sustained substantial damage and was no longer able to be driven. The child survived

with no injuries. The parents credited the Inpatient CPS Program for providing the car seat installation that allowed their child to come through the crash unharmed.

1025

Elliott et al Table 1.  Answers to Prepilot Nursing Staff CPS Survey. Question

Response (N = 88)

How would you describe your knowledge level regarding CPS?   Very little knowledge   Some knowledge, need assistance  Knowledgeable In the past year how often have you sent a patient home with a concern for their mode of transportation?  Never   1-2 times in the last year   3-5 times in the last year   >5 times in the last year If a family has a need for a car seat what is your method of assisting a family to acquire one?   Do not intervene   Ask family to purchase one   Arrange for ambulance   Contact Center for Families If the hospital were to implement a CPS program, what would you anticipate to be your biggest concern?a  Time  Paperwork  Education   Parental expectations   Handling the car seats How aware and familiar are you of the current Massachusetts state law (St. 2008, c.79) regarding child passenger restraints?   Not aware   Very little awareness   Somewhat aware  Aware   Very much aware

  25% 58% 16%   32% 43% 12% 8%   3% 24% 2% 70%   44% 37% 37% 49% 29%   10% 19% 32% 31% 8%

Abbreviation: CPS, child passenger safety. a Participant could check all that applied; therefore, total is greater than 100%.

Table 2.  Demographic Characteristics of Children Receiving Services From the Child Passenger Safety Program.

Age (mean, years) Gender (% male) Race (%)  White  Black  Asian  Other Ethnicity (% Hispanic) Children with special health care needs (%)

Discussion The goal of the Inpatient CPS Program is to ensure that all hospitalized patients at our institution have access to CPS education and/or a car seat at the time of discharge.

Education Only

Car Seat Provided

2.83 years 53%

2.17 years 50%   35% 28%   9% 27% 32% 26%

41% 27%  9% 23% 10% 13%

With a multidisciplinary team from different areas of the hospital and with seed funding from a state-based grant, we were able to develop and implement an Inpatient CPS Program. Use of a computerized CPS screening tool, which is completed as part of the admission nursing

1026

Clinical Pediatrics 52(11) Table 3.  Types of Car Seats Distributed (September 2010 to May 2012).

300 250

252

200

Car Seat

246 190

150 134

100 50

56

0 2009 Interacon

2010 Interacon

2011 2012 Jan-June Hippo Interacon 30th 2009-2012

Figure 2.  Total inpatient interactions by year, 2009-2012.

Figure 3.  Patient interactions by age in years, 2009-2012.

assessment under the discharge planning section, has allowed this process to begin at the time of admission to the inpatient unit. Based on this assessment, a CPS team consult can be automatically generated. With this consult, the child and family can receive CPS education, as well as have a car seat provided, at cost or gratis, as needed. In the hospital setting an inpatient CPS program is not only important to improve motor vehicle safety for pediatric patients, but may also aid in discharge planning by providing equipment that could be a transportation alternative to an ambulance ride home, which could otherwise delay discharge. An Inpatient CPS Program provides the opportunity for health care providers to provide education and equipment to prevent injuries and death to the vulnerable population of children riding in motor vehicles. For every motor vehicle–related fatality, approximately 18 children are hospitalized, and more than 400 receive medical treatment for injuries sustained in a crash.2 The current recommendations from the American Academy of Pediatrics (AAP) state that all children should ride rear facing until 2 years of age, and children should ride in a child passenger restraint until they are 8 to 12 years old and/or at least 4′9″ in height.8 Massachusetts state

Infant seat Convertible seat Combination seat Booster seat Car bed Vest-type Specialty seat for Spica cast

n (N = 419) 52 106 95 72 27 62 5

law does not specifically include the recommendations for rear-facing children, and many parents are unaware of these best-practice recommendations.7 The Inpatient CPS Program provided an opportunity for staff to educate families about these types of best-practice recommendations with the goal of keeping the child as safe as possible during transport home and afterwards. Much of the literature regarding hospital-based CPS programs has focused on programs based in the neonatal intensive care unit or in newborn nurseries.9-12 This includes the 1999 AAP policy statement recommending all hospitals establish protocols for the safe transportation of newborns to home.13 Less is known regarding hospital-based CPS programs for children outside the newborn period and in particular CPS programs focusing on hospitalized children. One program that has been described provides specialized education and/or car seats for children with special health care needs.14 This same hospital also developed a CPS program for hospitalized children without special health care needs. Car seat needs were identified during the nursing admission assessment, and then recommendations for the appropriate car seat were made. Car seats could be purchased at hospital, loaned, or obtained for free with a voucher. A teaching record was used by the nurse to document parent education.15 Another study evaluated the educational component of a hospital-based outpatient CPS class for parents and found parents surveyed