Registed Nurses' Association of Ontario

Development of Clinical Practice Guideline for the Pediatric Bone Marrow

Erica Patterson RN, MN
The Hospital For Sick Children

My overall learning goal for my RNAO advanced clinical fellowship was to increase my leadership skills through program policy development. Through this fellowship, I had the opportunity to develop a draft guideline on the nursing management and documentation on continuous bladder irrigation (CBI) for the bone marrow transplant (BMT) pediatric patient population. This project was chosen as there was not a policy currently at the Hospital for Sick Children to direct RNs how to provide care or how to document on patients receiving CBI. Patients undergoing BMT treatment are at high risk for hemorrhagic cystitis due to chemotherapy regimens and risk of BK virus (Thompson, et al., 2016). When hemorrhagic cystitis worsens, the patient develops large clots in the bladder which they cannot pass on their own. To help break down the clots CBI treatment is started, allowing a continuous flow of normal saline into the patient’s urinary tract (Thompson, et al., 2016). Nurses on the BMT unit are very familiar with this procedure, however a policy is needed to help maintain evidence based quality care. Documentation of fluid and description of clots varies from nurse to nurse, leading to inconsistent care. These inconsistencies in documentation led to inaccurate fluid balances and therefore made it challenging for the health care team to intervene or account for changes in the patient, such as clot obstruction or urinary retention. Fluid balances in patients receiving CBI treatment must be monitored closely and documented precisely in order to intervene appropriately.

By going through the process of policy development at my hospital, I was able to increase my knowledge in gathering evidence based literature as well as learning how to benchmark internally and externally. Once I started my literature review, it was evident that was very little literature on this specific topic to help guide nursing practice. This made the integration of stakeholder knowledge and input extremely valuable to help facilitate the development of this guideline. Through benchmarking, I was able to connect with key stakeholders through the hospital and externally that I otherwise would have had little to no contact with. I also got to work closely with my quality leader, nurse educator and the nurse practitioners and staff doctors on the unit. This provided me with more knowledge and insight on how policy changes occur within my department at the Hospital for Sick Children and how evidence base literature and stakeholder knowledge is synthesised to create a concrete policy for staff to follow. I have also learned a great deal on the importance of having nursing and nursing leaders present at committees to provide input in policy changes.

As a result of this project, I have increased my confidence in my ability to connect with fellow Sick Kids staff and external key stakeholders. I am also more assertive in my ability to present the knowledge that I have obtained in order to be catalyst of change and promote evidence based practice. The implementation of my guideline will help to improve the quality of care and minimize complications for patients receiving continuous bladder irrigation treatment. I am very grateful for the learning experience that the RNAO Advanced Clinical Practice Fellowship has provided me. I have learned so much about an area of nursing leadership I have always wanted to explore, but never really have been allotted the time and resources to do so. This fellowship has help to provide me with that protected time. I am also so grateful to my mentorship team, Jenny Moloney and Lisa Honeyford. Their insight to how knowledge is translated to the bedside has helped me a great deal. I also want to thank my manger and the BMT department as a whole for their support and feedback throughout the whole process. This experience has been so rewarding and has help guided me on a nursing career path to be part of policy evaluation and implementation.