So these are our nursing actions. We're monitoring her for pain and these folks have,
yes they had a bad headache but as that blood is in their head it caused meningeal irritation so they may it neck pain and lower back pain and they don't ever quite understand and neither does their family,
"Well I thought this blood was in their head?" and then you have to kind of explain the rest of it. The photophobia is secondary to the cerebral irritation. The anxiety? Well we know she had a history of anxiety and depression. We need to make sure
that we keep these people on their meds if we can. Because they needed 'em before they're sure gonna need them afterwards right? They're a high risk for secondary brain injury related to re-bleeding and cerebral vasospasm. So we do frequent neuro checks.
We check them hourly. When you come up to get this patient from the neuro nurse you need to do a modified bedside exam so that you know what this patient looks like. I know they're in a hurry
and I know everybody's downstairs setting up the room and getting everything ready and you've got time you know time. But we need to take the time to know what they were like before the procedure. We need to know so that at the end of the procedure
if Susie doesn't wake up right that you don't go, "Oh, I can't remember. "What did they tell me?" Well it's not what they told you, it's what you saw. What was she like before?
So there's that hand-off. When you take 'em back to the floor there needs to be that hand-off communication, that hand-off exam, because if that nurse on the floor-- maybe Susie's fine when she gets back up
but there can be this secondary brain injury that happens and maybe she's a little sleepy in about an hour and maybe her blood pressure's a little low and you say, "Well, you know, "they gave her a calcium channel blocker
"during her procedure "and we gave her Nimodipine this morning "maybe her blood pressure's down because of that "maybe that's why she's sleepy." And several hours go by trying to trouble shoot what went on
and those are precious hours that her brain may not have. She may not have that kind of time. And I've seen these happen in many cases in many situations. So we'll look at
a little bit of the delayed neurological deterioration. It can be vasospasm. We tend to blame everything on vasospasm, don't we? All their sleepiness, all everything, and how many times have we brought 'em down to radiology and done an arteriogram and it wasn't vasospasm.
It was clear as a bell yet they're goofy. I had just had this happen to me a couple of weeks ago. I was relieving some nurses on the floor and I thought, "This is a subarachnoid? "Give me this, "I'll just watch this patient while you're off the floor."
And I go in and she's sleepy. Somebody decided that she was fluid overloaded. Well yeah she had COPD, she was obese, she wasn't breathing worth a darn, but in my brain I'm thinking, "Vasospasm, vasospasm." They had put her IV fluids on keep open rate.
So she wasn't getting her fluids. Well they run her down to IR and squirted her and she wasn't in vasospasm. She had enough other co-morbid issues going on she probably had some cerebral edema but it wasn't showing up as a vasospasm
so the Nimodipine was doing the right trick but sometimes it's not the head it's the other systems especially if they have a real bad COPD and things like this that she had that, kinda like Susie had too.
These are the seven steps of evidence based practice and this is directly taken out
of the Melnyk and Overholt book. I'm gonna show you this resource later. This is a great resource for nurses that want to engage in evidence based practice and these nurses right here who are pillars in our evidence based practice community and they provide blue prints, pretty much a recipe
on how to actually do this. I want to point you to this, this is the most important part of evidence based practice. They rate it a zero. They call it step zero. It's kind of reflective of what happens here.
If you have no inquiry, if nobody cares about what's actually happening in practice, then we'll never progress to step one. So you have to have some level of inquiry. So people have to be passionate about their work in order to develop and go into this process
which is going to ultimately effect patient outcomes. So everybody's familiar with this pyramid right? I think the pyramid is actually upside down, if you ask me. I think systematic reviews, meta-analysis should be at the bottom and the all these other ones
should be at the top because these are the research that's really not applicable to evidence based practice. It's when you start getting to the tip of the pyramid which is where the majority of the studies you're gonna use are that are worth anything when applying
evidence based practice.
So the actual research itself. How did I do it?
So it was a qualitative research so I interviewed six public health nurses working in the Dublin Mid Leinster Region. These areas were chosen due to their involvement in the hospital group which I discussed earlier. The majority of patients discharged from our department
with IR drains generally live in these areas, areas six and seven like we mentioned earlier. So the actual research findings themselves. So three main themes emerged very clearly throughout all of the narratives with the public health nurses. There's a knowledge gap, an information gap,
and an education gap. So it's important to note that all of these themes are interrelated and participants' experiences in any of these themes have implications and connections with other themes. So this is a figure that outlines the overall themes
and then the sub themes within them. I won't go through it here. You'll be able to catch them on the slides and throughout our discussion later on but in order to discuss the findings properly and for you to really get an insight
into the experiences of these nurses, I'm going to be reading some extracts from the participants from each theme. So as it is a qualitative study, it is quite dense so please at this point, forget about what's in front of you and just listen out.
It reads nearly like a story.
This final step of our presentation was a pretty exiting one for us as nurses because we were the first nurses to do a Columbia University IRB research study. Actually, it was my idea to do something about distractions and interruptions
during the surgical count. I know the policy says it's kept to a minimum, but that's so hard to really capture. I know we have zones of silence when it comes to nurses giving out medications, but in the OR were different,
we don't give out medications per se, it's part of the procedure. So I really wanted to look at distractions and interruptions during the count process. What I did was I applied to be the principal investigator
for this research study, which was pretty unique because always had to be an MD, and just this year, in 2017, actually they changed it. It can be a nurse as long as she's masters-prepared. Columbia University, we started the process in January 2017. We received an expedited review
because there was no direct patient care involvement. What we did was we stood in the rooms and observed the count processes. We looked at distractions and interruptions. We observed 50 cardiac cases. Looked at, again, the surgical count process.
We looked at the initial, the second wound, and the third final. And we utilized a validated tool. One of the things, if you've ever done a research project, is to always use something that's already out there. It makes your life a lot easier.
So we used a validated tool. I found this surgical flow interruptions tool by a Dr. Matthias Weigl in Germany. And believe it or not, I emailed him, and the next day, asking permission to utilize his tool. And I said I wanted to modify it.
What he did was he looked at interruptions and distractions during the entire surgical procedure. I looked at it, I just wanted to modify it and look at it during the count process. Within 24 hours, this nice man wrote me back and said, "You certainly can use it," and to him keep posted as to
what our outcomes are. So we will definitely do that. Pretty interesting that I can get an email back from someone in a foreign country in less than 24 hours, but in within my department it might take a few weeks. Looking at how we went about doing it.
I think when you start doing observations and looking at things in an OR, knowing that that's a huge, huge undertaking and you need a lot of help. So in order to get people involved, and we have over 200 staff that we have in Columbia OR,
and what I wanted to do was get these nurses involved in a research project. So the criteria would be, for the nurses would be, they'd have to be CNOR, which is nationally certified in the operating room and they would have to complete the CITI/RASCAL training,
which is all your ethical and things like that, all that type of training, in which eight nurses did absolutely do that. So they were allowed to participate in our study, which was great. We established interrater reliability
by using three pilot observations. What that means is we had to get everybody on the same page. So using the tool, we made sure that everyone was using it correctly. We shot three videos of the count process. And then we had everyone sit down in a room,
use the tool for three separate cases, and then compare notes. So that's how we established interrater reliability. We had to pull in randomization. How do we do that? We used every third scheduled case on every third weekday.
And this was strictly cardiac. So there was no add-ons, there was no emergent cases, and no hybrid cases. The take-home messages, they had to be open cases. Recruitment for the study by person to person, email. We had to get the surgeons on board,
and updates were provided at monthly cardiac meetings and during the staff huddle. In particular, the cardiac staff, just tell them how we're doing. Give them a progress report so to speak. Informational consent was needed for all patients.
Again, it was an expedited review, we weren't changing anything, we weren't interfering in anything. Obviously, if something was to go wrong in the room, we would help. But we were just standing there
and observing the count process. All data was collected on hard copy, kept in a locked office in a locked drawer. And there were no identifiers on the tool. So there was no way to trace back. So the clinical question or the PICO question was,
how do distractions or interruptions during the count process influence patient safety in adult patients undergoing surgery over a six-month period? As you can tell, distractions are prevalent and potentially contribute to patient safety risks.
Phone calls, pagers, beepers, just few of the common distractions that occur during procedures, especially during the count process. Counting is an important preventive measure that's a human process,
so that's already prone to error, especially in a busy environment where multiple things are happening simultaneously. We sought to evaluate the impact of distractions during the count process on patient safety. So this is the actual tool that was used.
I know it's a little small, I'm sorry. Looking at the left-hand corner, just the date, the room number, and the observer's initials. Not any patient identifier. So what we did was line by line was look at the surgical count interruptions and distractions.
So at 7:45 a.m., there was a procedural interruption or distraction, and was from anesthesia to anesthesia, talking about the patient or case at hand. And that was done during the first count. And the procedural level,
you'll see numbers one and three on that column next to the right, second to the right. And what that means is one, the distraction level means that the count continued despite the distraction. If there was a two, that means someone else
addressed the distraction, such as a beeper. If perfusion went and answered that beeper instead of the nurse doing the count. And if you saw a three, as you would on line, I believe, 14, as you could see, again, it was procedural anesthesia. It was to the nurse
telling her that there's a bed in heart center room six. That was during the second count or the wound. That was a complete stop. The nurse had to stop the count, go make arrangements for the bed, and then go back to doing the count.
So that was a total interruption of the count. So here is a summation. We had 50 cases, this is just to sum it up. We met with neuroscientists, we met with a statistician, which is where we're at right now.
He's taking the stats and running some numbers for us. But these are the summations of what we've done on those worksheets. So as you can see, for count number one, the first count, second count, third count. The first count, people entering and exiting.
There was three for this. CIC means communication irrelevant. So that wasn't talking about the case at hand, it was about something other than the case at hand. It can be what they were doing on the weekend to the next case.
So that was considered irrelevant communication. And then there was two procedural interruptions. So they were all distraction levels of one. So the counts continued. Was the start of the wound or final count announced? That's an interesting question.
And I put that in there because our policy says the nurse is supposed to announce the start of the wound and final count. And my next slide will attest to how many times they actually do that. And I put that in there because
a lot of times the surgical team doesn't know that the count process has started. And then I added on the end total time in and out versus procedure time. I put that in there, basically, to help the statistician. Because what I wanted to see
to look at something maybe, maybe it would be a variable, I don't know right now, to look at, "Is this surgical count prolonged "based on the interruptions and distractions?" We're not there yet. Again, he has those numbers so he's looking at that as well.
Looking at national averages, I already did look at national averages for each type of case. Whether it be a (mumbles), we do fall in the range of the national average of time. So it didn't prolong it like I would have thought initially,
but, again, it's still in the statistician's hands right now. This is our final slide, and this is a summation of this interruptions and distractions. And I thought this was pretty much an eye-opener as well. If you look at the initial count,
out of the 50 cases, people entering and exiting the room was 278 times. So that means they came in, they came out. Pagers, overhead, beepers, 40 times. And this is just during their final count. All the irrelevant communication,
whether it be started by the attending, the fellow, the anesthesia, RN, or somebody else. Those numbers aren't as high, but they're still there nonetheless. Equipment failures. Looking at procedural.
Now, obviously, in the operating room, looking at that, we always have to have some type of communication about the patient, about a need of the surgeon, so that number may not be able to be improved upon. Going all the way to the right, looking at distraction level one and two (mumbles),
it was 451 times was a distraction, meant the count kept going on, but it was still there nonetheless. Level two means number seven was the count continued. Someone else took care of it other than the nurse. And then the interruption level,
as you can see the count completely stopped. That was 57 times. And that was just during the initial count. Looking at the wound count, less people entered and (mumbles). Still 165, still a huge number.
Beepers, 52 times, or pagers or overhead pages. Radio on, seven times. Just an FYI, when we were doing this observation, we did not change anything that was going on in the room dynamics.
One doc questioned me, he goes, "Oh, you're here to do the observation. "Should I shut the radio off?" I said, "Doc, you just continue doing what you always do." And he wound up leaving it on. Again, we only interjected if there was patient harm
or an adverse event in which help was needed. We were strictly there in the observation mode. Going across on the wound count, 287 procedural interruptions. What could they be? That's pretty much a surgeon request
or an anesthesia request. They could be asking for medication, anesthesia, usually protamine or heparin, or additional antibiotics, could be for the bed where the patient's going. Procedure can be also be from
the surgeon asking for something that he hadn't asked before and it came up during the second count. The level, again, going across level one, 362. The counts continued, but it still was a distraction. Level two, 16. And interruptions was 215.
So that number was real high. If you think about it, the wound count in any operating room, I think, is one of the most important counts. I'm not minimizing other counts, but this is when the patient's chest, in these instances,
is wide open. This where you really have to focus in making sure you get everything back. And you do need a few minutes to do that and do it in my opinion without interruption or distraction. I know sometimes it can't be helped
especially if it's procedural, but maybe we can get those numbers down. Looking at the final count, the final count is when you're on skin. So you're closing pretty quickly at this stage. 91 times people entering, exiting.
This is just over 50 cases. 37 times the beeper went off. Moving all the way to the right, distraction level was 189 times. Again, it was a distraction, it did not stop the count,
but, again, it was nonetheless a distraction. Level two was a seven, someone else addressed it. And 52 times the count actually stopped. So looking at the total distractions and interruptions in that little box, initial count, 515 times.
There was either a distraction or an interruption during 50 surgeries. Wound count, 593. And final count, 248. I wanted to put that in there, "Start of wound and final count announced?"
And it is our policy that the nurse should announce when the wound and final count is starting. Unfortunately, only 33%, 33 nurses did not announce it and only 17 did. So that could be a barrier that has to be looked at as well, maybe reexamined.
We are in the process now of changing our count sheets because evidence suggests that the count sheet should not have cross outs on it, addition, subtractions, anything like that. I know it's a worksheet, but at NewYork-Presbyterian, we put our count sheets on the patient chart.
So it becomes part of the medical record. We were told to by CSM, and we responded and have done that. So now we're trying very hard to get nine campuses to see the same goal of unifying and using the same count sheet,
being that we all have so many specialties. We do cardiac, vascular cases, transplant, general surgical cases, orthopedics, ENT, eye cases, ophthalmology, urology cases, GYN. We run the full gamut,
so trying to get everybody to be comfortable in using a standardized sheet is becoming, based on evidence, is quite the challenge. We're almost there, I will say that. Within the next few months we should roll out a standardized count sheet.
I wish I had it with me. In which case, we would be able to see, the numbers are preprinted on everything so it makes life a lot easier. You also have to understand that everyone writes a little different,
some (mumbles) little neater, some people have different ways of using the count sheet, so we're trying to standardized that and make that as clear as well. Also, tying up our policy into X-ray and how important radiology is.
We partner very well with Radiology Department. Especially when it comes to lost needles, our policy is based on AORN which is our standardized nursing Association of periOperative Registered Nurses. And for needles, they make sure that needles, they recommend that no X-ray be taken for a needle
10 millimeters or smaller. Because you really can't find it. And then it becomes risk versus benefit. I will share this with you with regards to retained foreign bodies, we are looking at now
disposable items which are coming up very strongly and a lot more. We see a lot more different products. And what we're finding is that a lot of these disposable products, especially the sheets, the vascular sheets,
they'll peel apart. Pieces of them, unfortunately, get lost. And we've had four instances where they've been lost in the patient. So we are looking at the different products that we use. We try to standardize the best we can,
but based on need and necessity of the patient, surgeon, and the surgery at hand, that becomes quite the challenge. Also with finance involved, too. So we are looking at that. I will say that this project that we did, and still on doing,
it's now, as I said, in the statistician hands, it was an eye-opener. Hopefully, in the future we'll have a policy that reflects the importance of doing the count and making sure that our patients are safe.
What do we need to implement all of this? What is required? Strong and effective leadership and management.
As we all know, anything in our healthcare profession or in any profession where you're trying to push forward with a new initiative, it's really important to have strong leadership. It's absolutely pertinent. So moving on quickly as we're getting close for time here,
leadership is the most significant player in implementing clinical governance structures and processes and achieving safe patient care. Today, healthcare especially in Ireland, we're being scrutinized by the media for all errors being made in service.
So the reality is that most medical errors or adverse events are down to inappropriate systems and processes, not the individual. Leaders must analyze practices and ensure a systems approach in the deliver and improvement of quality, built around six specific aims,
to be safe, to be effective, patient-centered, timely, efficient, and equitable. Leadership, as we know over the years, has been conceptualized in a multitude of ways. However, there are four central components that are necessary.
Leadership is a process. It involves influence. It occurs in groups and involves common goals. Leaders make something happen when they notice what isn't working. They create a solution for the problem,
they gain-buy in and they implement the desired outcome. So leadership and the ideal of challenging the process. You know, everyone here is a leader and everyone has the ability to lead. But it is important to note, leaders do not challenge for the sake of challenging.
It is not about shaking things up just to keep people on their toes. Those who criticize new thoughts and ideas or point our problems without offering kind of alternate option are not challenging the process. They are simply complaining.
Leaders change for meaning's sake. So really at this point, I challenge you all to kind of stop and think about your practices within your own departments. Are there improvements that could be made to enhance the care of your patients
in the community setting. The challenges leaders raise are always accompanied by a drive to do something themselves, to resolve and improve a situation, not simply complain. Progress is not made in giant leaps. It is made incrementally.
Exemplary leaders move forward in small steps with little directories. They turn adversity into advantage, setbacks into success. They persevere with grit and determination. You know, working in healthcare, we have two jobs.
We have our job and we have our job of improving our job. We must always be open to change and we must always question the way in which we do things in order to improve. You know, I feel this is really relevant specifically to our wonderful world of radiology.
We are continuously evolving and we must adapt our practices accordingly to ensure our patients receive the highest quality of care.
Any questions? Yes.
No, so while they're going through doing the patient care orientation, the five in one area was too much, but for classes where they're kind of in a classroom setting I like more nurses. I try to work with the preceptor,
some of our preceptors are really okay with precepting. They love it, they don't care how many orientees they have and then some will tell me after just doing one for about nine weeks, can I this time around not have anyone? So I kind of know who the employees are
who really thrive with it, and I feel like, I don't want to say overburden them, but they love it so much that they're always asking me like oh, can I, and they volunteer like I'll orientate her, I'll orientate her.
Whereas some nurses are like no, I need a break right now. Let me just kind of do my own thing and then the next time around I'll take someone. So it really individually depends on the nurse. I try to keep one preceptor
for one or two, like one main one and then maybe two backup ones for the one orientee. Sometimes it works out, sometimes it doesn't because of vacations. Like I feel in the summer I have to,
they have multiple preceptors because people go on vacation and so forth, but I try to with one orientee keep them with one main one and then some filler ins if the nurse has PTO or a day off that doesn't coincide with,
I always let the orientees tell me if they need any particular day off or anything like that. So I usually try to keep one main one and then a couple filler-ins if anything happens, they get sick or anything.
And then keep them through the whole nine week process. I've found with the nurses we see, it depends on the nurse. Some orientees, they tell me, I've had a handful say I actually really liked having several preceptors because everyone
had different tips and tricks. And then I've had a couple say you know, can we really limit, they had me with Annie and then Annie got called to do something else and then they put me with so and so the next day 'cause Annie called in sick.
Can we try to keep it to a limited number because I'm getting confused, it's not helpful to me. So sometimes I have, if I don't know, if the nurse is internal I can actually, I reach out to the other educator and ask about that nurse and I can get some
good feedback on how they learn. When the nurse is external, we kind of have to guess until we meet them and really learn about how they learn best. For our external employees. Anyone internal I have a good,
I have a better knowledge base of what they know. For example, we had several nurses kind of in that summer of 2017 come from the emergency department. Well one, I have a master's student from out ED working with me, so she kind of gave me
some knowledge base of the nurses as well as I reached out to the educator of the ED and really asked them what are their strengths, what are their weaknesses, and it's easy for me to contact them and kind of see where their competencies are.
The external employees, I always give them a welcome email. But then when they come in in several of their classes, I put in some hands on training 'cause we do have particular protocols especially with our central line care,
our blood administration to really bring them up to speed on those competencies that might be different from their previous institute. So if they're an external employee, we have EPIC, that's our charting system. So our external employees, how they kind of,
their first week runs when they're external, the first day, that Monday of orientation is a hospital orientation class, so they're there eight hours with all new employees to the institution. And then on the Tuesday, Wednesday, Thursday,
we have a, it's called experienced nursing orientation, where they kind of sit in a big auditorium and then they meet all different kind of interdisciplinary through the hospital whether it be child, life, lab, so they get to know the hospital in general
and then they do some hands on competencies. And then the Friday is when I like to coordinate. It's a three hour epic training class with a specific epic trainer for medical imaging and nursing department. We have a big challenge with EPIC
and it kind of stems back from when we first moved from our old hospital to our new hospital and the medical imaging nursing team was under procedural services, the new manager is really trying to clean it up, in a way. So when they were under surgical services,
they developed the medical imaging epic really surgical service based, so it doesn't really flow as nicely for that department. So unfortunately we do have a lot of work arounds that our new manager is really trying to clean up because a lot of the charting isn't
needed for the medical imaging team. But it's something that the preceptors work with them to chart, 'cause they have the EPIC charting and then they have to go into radiant and then for GA cases they have to go into OP time, it's, I'll be honest, it is a big mess
for these nurses and I feel so bad for them. But when talking with the manager in EPIC, it's not really going to be cleaned up for our team until really they build a whole new EPIC access for the nursing team there, unfortunately. - (Woman) How long is that gonna take?
- I don't know. Sometimes I want to cry when they ask me anything about EPIC, I'm like I'm so sorry. We do have a small number of nurses who I kind of all the EPIC gurus. And I like them to sit with them,
kind of off patient care time and sit with them and just learn navigating. 'Cause unfortunately with how they're accessed, how it's built for the medical imaging nursing team, it's a bit of a cluster and a mess for them. Yeah, so a lot of our nurses who come in are
1.0 FTE so we do have them work for 10 hour night shifts. So they do about eight o'clock to 6:30 and we do four nights for them. I did just actually when I was flying here on Sunday, one of the girls who's gonna be coming off orientation in about the next four weeks or so,
I kind of followed up with her, asked her how things were going, and we're always open if anyone needs more time, we like to give them more time. Recently we've never had to give more time, but we're always open.
If you need more time in orientation, we are there to provide you more orientation time. And I asked her, I said, she had her week of resource time and I said oh I see on the schedule they left you a blank a week. Where would you like more resource time?
And she said I want another week of nights. Just 'cause sometimes we find they're on the week of nights and it is like the best week to be on nights. They see everything imaginable, every weird scenario that could happen at night, and then sometimes it's like the slowest week ever
and they're like I have seen all the 19th, our 19th floor is our neurosurgery floor, well I had every patient come for an MRV and that was it. So it just depends, so that nurse had a very low kind of calm
night week and she's like I really feel like I need another resource week a night, so we added that for her. I don't know the particular number, I would actually have to talk to the manager about that. But we have a very low turnover rate, about 2% or 3% in general.
We mainly see nurses leave because one, they graduated from school with either an FNP or PNP and they're moving on to become a nurse practitioner. Yeah, so one of our biggest reasons for nurses leaving are they graduate from NP school. That was, two nurses in October left
because they became FNPs and then found, graduated boards, got all that credentialing DEA stuff and then they found jobs as nurse practitioners. So that's one of our, probably why the leave is because they move on for career advancement. Any other questions?
- [Woman] How many staff do you have? - Oh, how many staff do we have? Right now currently we have about 40. And then in cardiac cath and interventional radiology we have a very small group of 10 nurses.
Okay. All right, we have a preschooler
needing a bone scan for leg pain. So he doesn't need to be completely still so we could certainly use distraction with him. So the preschoolers, they are very active learners. They like medical play. So how can you explain what's going to happen?
Anybody wanna take how would you explain that to a four-year-old, what a bone scan is gonna be like? Anybody wanna take a guess at that? Okay. Show him the machine ahead of time, exactly.
- [Participant] Show them on a doll or teddy bear. - Show them on a doll or teddy bear, yep. Exactly. So we have a miniature, I should have brought a picture of it. We have a wooden, someone constructed a wooden framed
CAT scan machine, and so when we have the kid that needs a CT scan, we show a picture of in slides and we show a picture of what the doll. So you can actually bring it to the child in the exam room and show them exactly what it looks like,
and it's made of wood and we just have the doll slide in. 'Cause sometimes we can get an idea of the kid's anxiety by walking in the room. So anything that you could bring to them at the bedside would be helpful to kind of show them. And there are so many videos available online.
I mean, I work at Children's Hospital of Philadelphia so we have a whole bunch of cartoon videos about having an MRI and getting things ready, but there are so many things that you could access even on YouTube just to show what they are going to expect. And some people ask, how far in advance
do I need to prepare a child to come to radiology? So obviously, for the infants, they are just whatever it's scheduled, okay? But what about for a preschooler, how soon do you think if they're gonna come in for a test? Are you gonna do it a week ahead of time?
No, because that's a century for a three or four-year-old. Correct? So maybe you're gonna do it the day before talk about what's going to happen. But thinking about not preparing too far in advance which can increase the anxiety
and also we wanna make sure that they're prepared, but not overly anxious about the weight and exactly what's going to happen. And in terms of kids with special needs, we do all kinds of things to help prepare. If you know that the child needs to,
by talking to the family in advance and finding out what they like. Do they like music? I mean, we see so many kids with special needs. Do they like music? They like certain types of videos
or certain cartoon character making sure that we can kind of get things ready for them when they come in. We've actually sent pajamas, mailed pajamas to families because if the child has to get changed into like if they're having an MRI or whatever,
sending them the pajamas so they can actually just bring them in with them because getting changed into a hospital gown can be very traumatic for kids, right? I mean, I do sedation so sometimes we actually sedate the kids
and then get them changed afterwards because that pajama is just not gonna happen. So something that you take for granted. So sending pajamas. There are there a picture cards that they'll do for kids with autism
where they'll actually have a picture of all of the steps of what's going to happen throughout the course of the day. You will meet a nurse, she will take your temperature, she will take your blood pressure, and they have pictures of what to expect
because it can be very overwhelming not just in a strange environment, but with all of these unfamiliar medical procedures being done. So picture cards are very helpful. And finding out whatever their comfort object is, okay?
Or do you have, have you established that already, the criteria, with the patient going for anesthesia or not anesthesia or something?
- [Instructor] No, I don't think we had, we really didn't address that with the project, no. - [Woman] That's a big, big, big, job, there. - [Instructor] Yes. - [Woman] Very good, then, very good. - [Instructor] All right, thank you.
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