Wong Chris I, Desrochers Marie D, Conway Margaret, Stuver Sherri O, Mahan Riley M, Billett Amy L
Department of Pediatric Oncology.
Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts.
Pediatrics. 2023 Apr 1;151(4). doi: 10.1542/peds.2022-056617.
Home caregivers (eg parents) of pediatric patients with cancer with external central lines (CL) must carefully maintain this device to prevent complications. No guidelines exist to support caregiver skill development, assess CL competency, follow-up after initial CL teaching, and support progress over time. We aimed to achieve >90% caregiver independence with CL care within 1 year through a family-centered quality improvement intervention.
Drivers to achieve CL care independence were identified using surveys and interviews of patient or caregivers, a multidisciplinary team with patient or family representatives, and piloting clinic return demonstrations (teach-backs). A family-centered CL care skill-learning curriculum, with a postdischarge teach-back program, was implemented using plan-do-study-act cycles. Patients or caregivers participated until independent with CL flushing. Changes included: language iterations to maximize patient or caregiver engagement, developing standardized tools for home use and for teaching and evaluating caregiver proficiency on the basis of number of nurse prompts required during the teach-back, earlier inpatient training, and clinic redesign to incorporate teach-backs into routine visits. The proportion of eligible patients whose caregiver had achieved independence in CL flushing was the outcome measure. Teach-back program participation was a process measure. Statistical process control charts tracked change over time.
After 6 months of quality improvement intervention, >90% of eligible patients had a caregiver achieve independence with CL care. This was sustained for 30 months postintervention. Eighty-eight percent of patients (n = 181) had a caregiver participate in the teach-back program.
A family-centered hands-on teach-back program can lead to caregiver independence in CL care.
患有癌症且带有外置中心静脉导管（CL）的儿科患者的家庭照护者（如父母）必须仔细维护该装置以预防并发症。目前尚无指南来支持照护者技能培养、评估CL操作能力、初次CL教学后的随访以及随时间推移支持进展情况。我们旨在通过以家庭为中心的质量改进干预措施，在1年内使90%以上的照护者在CL护理方面实现独立。
通过对患者或照护者进行调查和访谈、由患者或家属代表组成的多学科团队以及试点门诊回示（复述）来确定实现CL护理独立的驱动因素。采用计划-实施-研究-改进循环，实施了以家庭为中心的CL护理技能学习课程以及出院后复述计划。患者或照护者持续参与直至能够独立进行CL冲洗。变更内容包括：优化语言表述以最大程度提高患者或照护者的参与度；开发家庭使用的标准化工具以及用于教学和评估照护者熟练程度的工具，该评估基于复述过程中所需护士提示的次数；更早地进行住院培训；重新设计门诊流程，将复述纳入常规就诊。以照护者在CL冲洗方面实现独立的符合条件患者的比例作为结果指标。复述计划参与情况作为过程指标。统计过程控制图跟踪随时间的变化。
经过6个月的质量改进干预，90%以上的符合条件患者的照护者在CL护理方面实现了独立。干预后30个月内这一情况持续保持。88%的患者（n = 181）的照护者参与了复述计划。
以家庭为中心的实践复述计划可使照护者在CL护理方面实现独立。
