The 8D Step-Down Unit for Pediatric Cardiology (8D SDU) is comprised of a majority of BSN and several MSN prepared nurses. The team is also committed to professional development with over 90% of nurses obtaining their Pediatric Nurse Certification and over 10% of the staff designated as RN III. The staff is highly qualified to provide both Pediatric and Adult Life Saving measures and has established a mock code team called Project Heart Start which is a program to practice low frequency, high-risk emergency situations. They have instituted a Medical Emergency Team (MET) which is a rapid response team that comes to the bedside to assess a patient with potentially worsening clinical status. The MET is also a product of Cardiac Children's Early Warning Score (C-ChEWS) which is a scoring tool that the 8D nurses initiated to help advocate for calling a rapid response team. The C-ChEWS and MET programs are the first of their kind in the MUSC children's hospital and have greatly reduced bounce-back ICU transfers and helped with increasing acuity and nursing assessment skills on the 8D SDU. 8D nursing staff is also committed to delivering high-quality patient care in a safe environment. They have been free of infection for central lines, foley catheters and have one of the lowest fall incidences of all the children's hospital units. The patient population on 8D ranges in age from newborns to older adults with congenital heart defects. The majority of the patients are recovering from surgical interventions, minimally invasive catheterization interventions, are in heart failure with or without mechanical support devices such as Ventricular Assist Devices (VAD), awaiting heart transplantation or are being medically managed for a variety of cardiac conditions. The patients on 8D are among the sickest patients in the children's hospital and have some of the most unique challenges which 8D nursing staff handle with compassion, empathy, and devotion. 8D nursing staff consistently score in the 90th percentile on patient and family satisfaction surveys and they are always finding ways to make the patient experience as atraumatic and seamless (as in the transition to home) as possible. In addition to these accomplishments, the nursing staff is cross training to the ICU to care for higher acuity patients via a voluntary program called Step Up where the 8D SDU nurse learns additional skills for patients who are not quite ready to transition to the next level of care. Lastly, but certainly not least- the 8D SDU nursing staff is working with the ICU nursing staff to create a smoother transition for families transferring out of the ICU and into the 8D SDU care environment. This transition process seeks to ease the transition to 8D SDU by allowing families to tour the unit prior to transfer, initiating routine baby care for new parents in the ICU in order to continue that teaching on 8D SDU and face-to-face handoff from 8D SDU to ICU nursing staff on the day of transfer.
On 8D SDU, patients often stay for weeks in order to optimize their nutrition, to have close monitoring and/or to ensure that families are comfortable with the care of their children. One particular toddler raised the bar and created a precedent for the patient care of high risk, high acuity patients on 8D SDU. This patient, JB, had a rough start in life. Postnatally diagnosed with a critical heart defect, JB had surgical repair as an infant and a post-operative course that included heart failure and placement of a Ventricular Assist Device known as the Berlin Heart. JB's Berlin Heart supported both pumping chambers of the heart and although it was not the first Berlin Heart for the Children's Heart Program at the Medical University of South Carolina, JB was the first Berlin Heart patient to transition to 8D SDU. JB and family were well loved on 8D SDU before the Berlin Heart because many of the symptoms of heart failure- feeding intolerance and poor weight gain- made it difficult for JB to be cared for at home. JB's parents were both working and taking care of the other children in the household. Often times, JB's grandparents would stay in the hospital, but many nights JB was alone. After Berlin Heart implantation, JB stayed in the ICU for weeks before the ICU felt comfortable transitioning care to the 8D SDU team. During those weeks of planning, 8D SDU nursing staff rotated through the ICU to care for JB and to get experience assessing the Berlin Heart. The 8D SDU staff also underwent additionally Berlin Heart training sessions- often coming in during scheduled time off or during off shifts- to learn the Berlin Heart care. When JB transitioned to 8D as a toddler, patient care was challenging. As a patient in a 1:2 nurse: patient ratio- typical for an 8D SDU higher acuity patient- the nursing staff recognized quickly that JB consumed most of their time. Nursing staff could hardly leave the room for very long because the Berlin Heart would alarm because JB would kink the cannulas by doing normal activities like sitting while playing in the crib. Because JB's family had to work and care for the other children, they could not be at the bedside to keep him safe, at least not during the weekdays. On the weekend, his family would come in waves during the day but could not stay overnight to keep him company. 8D SDU nurses advocated for making JB a 1:1 nurse-patient ratio. This kind of staffing is typically reserved for critically ill patients in the ICU but with the support of management, they were able to staff JB as a 1:1 so that the nurse caring for JB would be able to stay in the room and keep him safe, occupied and developmentally on track. No other unit in the children's hospital has 1:1 nurse-patient ratio for their patients- but 8D was able to make it happen and make the most of the patient care experience.
As a 1:1 patient, the 8D nursing staff were able to go on walks and take JB to the playroom - which took a small multidisciplinary army to move the Berlin Heart driver, IV poles, hold JB's hand and make sure the hallways were clear for strutting! Through these interactions with the team, JB learned how to say "Hi!" and "Bye!" and how to dance when a familiar song came on! JB learned to talk and had an impressive vocabulary for an under 2-year-old. JB sang nursery rhymes, the ABCs and kept to a routine which are all developmentally appropriate for toddlers at this age. Nurses kept a log of who was assigned to care for JB so that everyone could get acquainted with the device and the patient care. The patient assignment log was also useful for the nurses because caring for JB was exhausting and consumptive. Everyone loved JB but it was difficult to handle JB's toddler energy and the complex care on multiple, consecutive shifts. Adjusting to JB's care was a testament to the teamwork and dedication that the 8D SDU nursing staff had for this precious patient.
To say that JB was a challenging patient is an understatement. JB was the first Berlin Heart on 8D SDU. The care for a Berlin Heart is complex and precarious for a patient who can understand and follow directions, but an added layer of peril is the toddler with large, life-encompassing cannulas hanging out of a twenty four inch body! JB liked to move, explore, walk, ride a tricycle and jump. All of that movement was made possible because a nurse was dedicated to his care all day long. A watchful eye to avoid falling or dislodging a cannula and to ensure that he was able to explore beyond the six foot leash that tied him to a machine that pumped his sick heart. JB never had an infection or an adverse event while cannulated with a Berlin Heart. Any changes in the appearance of the blood in the cannulas or with the filling/ejecting of the pump were quickly addressed with the surgeon and the goals of care were adjusted to keep JB safe. With each day of that nine month stint, 8D SDU nursing staff grew ever more confident in caring for its first Berlin Heart patient. Dr. Minoo Kavarana, Pediatric Cardiothoracic Surgeon, commented that he was impressed with how far JB had come in his development and how extremely attentive the staff was to JB's needs. The 8D SDU staff was truly invested in JB's total care: mind, body and little toddler spirit. Not only was the Berlin Heart patient a lesson on total patient care but 8D SDU staff also remained fiscally accountable by creating a list of supplies to keep stocked at the bedside for the complex dressing changes and for the adaptable equipment needed to secure the cannulas at the insertion site. The 8D SDU nursing care was so thorough and so customized for JB that the post-Berlin Heart transplant length of stay was minimized or at the very least on target for non-Berlin Heart transplant patients. JB had optimal nutrition, remained strong and stayed safe, which helped JB's heart transplant recovery. JB was even able to hold his own cannulas during dressing changes and kept distracted so that minimal sedation was necessary to do this painful, routine procedure. JB turned 2 years old in the hospital and by discharge, he was eating by mouth (something he had not done for most of his life), running, talking and in the care of his family who was grateful for this in their absence. The 8D SDU nurse-led team caring for JB, his Berlin Heart and his family, rose to the challenge, exceeding the expectations for caring and for raising the bar for patient care on 8D SDU.