http://doi.org/10.33698/NRF0099 -Sapna Bimal, Raman Kalia, Sunit Singhi, Sukhwinder Kaur
Abstract : Emergency care is always a bit scary, and it should be. It needs the best kind of quick and broadly based diagnostic thought and action. Nurses represent the largest group of trained professional health workers, their awareness of and preparation for emergency care of ill and injured are essential. Nursing practice no longer relies on tradition or ritual; instead, it is based on research and empirical evidence. The emphasis on evidence-based nursing, as well as standardization of nursing practice, has resulted in the production of policies, protocols and guidelines aimed at directing numerous aspects of nursing care.
The present study was undertaken to develop a nursing management protocol for pediatric emergencies. The final draft of nursing management protocol includes acute diarrhea, Anorectal malformation, fever, foreign body ingestion, poisoning, respiratory distress, seizures, snake bite and Tracheoesophageal fistula as these were common emergencies reported at PGI and on operationalizing the protocol in the unit results revealed that it was utilized for managing 39% of total children who reported at pediatric emergency. Results of Nurses opinion reveled that 48% of total nursing staff working in pediatric emergency found the Nursing Management protocol helpful in managing emergencies. Thus the present study has provided set of written guidelines for managing pediatric emergencies by nurses at their own
Key words :
Pediatric Emergencies, Nursing Management Protocol
Correspondence at : Sapna Bimal
Silver Oak College of Nursing, Abhipur, Distt. Ropar, Punjab
Introduction
An emergency is defined as any situation actual or imminent that endangers the safety and life of any person. It poses an immediate risk to health, life, proper ty or environment. Most emergencies require urgent intervention to prevent a worsening of the situation. The emergency department of each hospital is an area which is truly different each and every day and can quickly shift from the quietest to the most hectic department in literally a matter of minutes.1
Pediatric emergencies are a common problem resulting in approximately 12.5 million visits to the emergency department yearly. While only five percent of pediatric emergency department (ED) visits represent true life-threatening medical or surgical emergencies, acute illness still remains a dominant cause of mortality. Deaths in the pediatric emergency department occur within 24 hrs of admission. Many of these deaths could be prevented if very sick children are identified soon after their arrival and treatment is started immediately. 2
In many instances, these preventable pediatric deaths are the result of delayed recognition and treatment by emergency department personnel. Proper intervention by educated emergency care professionals may have prevented such deaths and disabilities.3 Emergency nurses specialize in rapid assessment and treatment when every second counts, particularly during the initial phase of acute illness and trauma. She must tackle diverse tasks with professionalism, efficiency, and above all-caring. An emergency nurse can make a life or death difference to patient by her quick action based on sound knowledge. Her practice in the emergency department is the application of nursing process to patient of all ages requiring stabilization and resuscitation of variety of illness and injuries.4
Nurse need to be prepared to meet everyday emergencies in term of first aid and lifesaving measures. Providing first line care in a pediatric emergency is first most important responsibility of nurse.5
In responding to a situation presented by the patient in an emergency the nurse uses a range of technical, initiative and personnel knowledge in deciding how to best manage the patient. Her response is based on a series of action determined by a protocol.6
Protocol is an impor tant document, which shows the competencies of emergency nurses, is a standardized protocol for nursing care. Which spells out departmental expect- ations for nursing care.@ In other words protocol is a tool which Operationalize the impl- ementation of evidence based practice and improves the quality of health care7.Studies have shown that after protocol development how nursing care interventions can and do make a difference every day in the outcomes of patients.8
In pediatric emergency department of APC sometimes children gets deprived from early management of case, which leads to complications for their lives. At present there is Lack of nursing protocol for managing pediatric emergencies at their own. And thus Nurses are not able to provide first line care to children. In view of this an attempt is being made to develop a “nursing management protocol” for common pediatric emergencies.
Objectives
To develop a “Nursing Management Protocol” for common pediatric emergencies at emergency unit of advanced pediatric center.
Material and Methods
The study was conducted at the emerg- ency unit of advanced pediatric centre, Post graduate Medical Institute of Medical Education and Research (PGIMER), Chandig- arh. PGIMER is central government owned autonomous institute. It is a ter tiary level hospital and a referral centre with bed strength of 1400 beds. Advanced Pediatric Centre (A.P.C) was attached to PGI as exclusive child care center. Pediatric emergen-cy department of A.P.C is situated at 2nd floor of B Block. It is the area which is providing emergency services to children below the age of 18 years. The unit is specialized for mana-ging all types of medical emergencies, trauma cases are not being managed here. Written permission was obtained from Head of Depar-tment of Pediatric for conducting study. Prot-ocol was developed during the months of June and August 2008. whole process of protocol development was divided into two main phases,
Phase I – Development of protocol; Part 1-Assessment of common emergencies, Part 2-Preparation of drafts of protocol.
Phase II – Operationalization of Protocol; Par t 1-Distribution of draft of protocol to nurses
Par t 2-observation of utilization of protocol
Final draft of protocol was developed under the guidance of ten panel members, from the field of Pediatric medicine, Pediatric nursing and from faculty of National Institute of Nursing Education. All the experts had a rich experience and professional expertise in their respective field’s. The final draft was organized under following headings; introduction, definition, signs and symptoms, nursing assessment, nursing action.
The final draft of protocol was named as “Nursing Management Protocol”. This final version contained 52 pages of text, content was arranged in alphabetical order an index was also prepared. Colored paper back title was provided to prevent the damage of the pages. Content of final draft of protocol included emergency medical and surgical conditions i.e. emergency drugs and equipments, care of child with acute diarrhea, care of child with Anorectal malformation, care of child with fever, care of child with foreign body, care of child with snake bite, care of child with seizures, care of child with Tracheoesophageal fistula.
Results
Table 1 depicts the distribution of total cases reported to the emergency during the Operationalization phase nurses utilized the Nursing management protocol for managing 178(39.3%) cases only. However protocol was not used by the nurses for managing 61% cases.
Total number of cases Number of cases Reported during Phase II
Table 1 : Distribution of cases as per Utilization of Nursing Management Protocol (NMP)
452 178 (39.3) 274 (60.7)
(21Days) NMP Utilized NMP not utilized n (%) n (%)
Table 2 depicts the complaint specific utilization of nursing management protocol. Out of 190 children who repor ted with complaint of fever, Nurses utilized nursing management protocol for managing 75(39.4%) children. Out of 60 children who
reported with complaint of acute diarrhea, nurses utilized nursing management protocol for managing 29(48.3%) children. Nurses have utilized nursing management protocol for 50% of total children who reported with complaints of poisoning and snake bite.
Table 2 : Complaints Specific Utilization Nursing Management Protocol (NMP)
- No Chief Complaints Children Reported NMP Utilized
| n | n | (%) | ||
| 1 | Fever | 190 | 75 | (39.4) |
| 2 | Respiratory distress | 98 | 32 | (32.6) |
| 3 | Seizure | 72 | 25 | (34.7) |
| 4 | Acute Diarrhea | 60 | 29 | (48.3) |
| 5 | ARM | 11 | 07 | (63.6) |
| 6 | Poisoning | 8 | 04 | (50.0) |
| 7 | TEF | 5 | 03 | (60.0) |
| 8 | FBI | 4 | 01 | (25.0) |
| 9 | Snake bite | 4 | 02 | (50.0) |
Table 3 reveals the opinion of nurses regarding utilization of developed nursing management protocol. Out of 23 nurses, almost half of them 11(48%) found nursing management protocol of great help for managing pediatric emergencies. Only 2(9%) nurses found protocol of no use.
Opinion of Nurses regarding Number of Nurses utilization of Nursing
Table 3 : Distribution of Nurses as per their Opinion Regarding Utilization of Nursing Management Protocol
Management protocol n (%)
Helpful for managing cases 11 (47.8)
Time Consuming 7 (30.4)
Do not want change in existing routine 3 (13.2)
Of no use 2 (08.6)
Discussion
Nursing protocols often deal with procedures that are matters of medical opinion. The use of a treatment plan for each diagnosis has improved the continuity of patient care, while also enhancing nursing autonomy. Studies have showed that after protocol development, nursing care interventions can and do make a difference every day in the outcomes of patients.8 Protocol development and evaluation is a formalized, ongoing process involving both nurses and physicians. The quality and consistency of clinical care is enhanced by the availability of clear evidence- based guidelines. Clinical protocols have also enhanced nursing efficiency, as nurses need to consult with physicians less frequently Protocol contains a comprehensive, up-to-date review of the disease process and provides the rationale for each therapeutic decision; protocols represent an important educational resource for clinical staff.
In present study nursing management protocol was developed under two main phases, during first phase of study drafts of protocol were prepared where as in 2nd phase protocol was operationalized to assess its utilization. Format was revised while developing the final draft of nursing management protocol which included- Introduction, Definition, Signs and sympto- ms, Nursing assessment, Nursing action. Emergency conditions included in final draft of nursing management protocol included were Acute diarrhea, Anorectal malformation, Fever, Foreign body ingestion, Poisoning, Respiratory distress, Seizures, Snake bite, Tracheoesophageal fistula.
The use of clinical protocols has been proven benefited for physicians, nurses, and patients by Michelle Tracy at Methodist Hospital in Houston. She found that the use of a treatment plan for each diagnosis has improved the continuity of patient care, while also enhancing nursing autonomy. Nurses are empowered to make decisions and initiate changes in patient care, and have strong physician support for their decisions. Overall, the quality and consistency of clinical care is enhanced by the availability of clear evidence- based guidelines. Interviews following protocol implementation indicate improved job satisfaction among nursing staff due to increased autonomy, higher efficiency of care, and an increased knowledge base regarding treatment options.
In present study results of protocol utilization revealed that out of 452 cases nurses have utilized the protocol for 178(39%) cases. Their opinions regarding utilization of newly developed nursing management protocol were; almost half of nurses (48%) found it as Help ful for managing cases, some of them (30%) found it time consuming, 3 of them (13%) do not want any change in existing routine of ward where as very few i.e. 2 (9%) found it of no use.
After Operationalization of newly developed nursing management protocol it was found that though most of nurses found it beneficial in terms of availability of written guidelines for managing pediatric emergencies at their own, however constrains like work over load, poor nurse patient ratio, lack of authority in deciding care and personnel interest etc were also expressed. Incorporation of nursing management protocol in existing routine of pediatric emergency unit was not found to be easy task.
Recommendations
Based on present study findings it is recommended that the study can be replicated in any other similar setting to assess the effectiveness of newly developed nursing management protocol and another study can be done to develop nursing care protocol for any other specialized area.
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