Running head: BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
Broselow Cart Performance Improvement Project
Jean M. Collins RN, BSN
American Sentinel University
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BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
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Broselow Cart Performance Improvement Project
The Joint Commission’s definition of Performance Improvement is the continuous
process and functions of healthcare to increase the desired outcomes and to provide the patient
with needed services. The Joint Commission’s standardized performance measure development
methodology is considered the "gold standard" in health care today (The Joint Commission,
2014).
The Broselow Cart
The Broselow Pediatric Emergency Tape is a tool that healthcare providers can use to
quickly estimate a child’s weight, thereby allowing the quick calculations of the correct weightbased drug dosage during an emergency situation. The broselow tape is a system used by
healthcare providers in critical situations with pediatric patients. This includes paramedics,
nurses, doctors, and others who treat infant and children, and should be properly trained in its
use. The broselow tape is a color coded system to help healthcare providers make more accurate
decisions in medication administration and equipment needed in the care of a pediatric code. The
tapes recommendations are based on the infants or child’s estimated height and weight. The
color coded system is present on the actual tape along with all of the charts and other medical
material that comes in the complete system (CPR St. Louis, 2011). A critical area in providing
safety and optimal are to pediatric patients in a cardiac arrest is the resuscitation equipment. In
prior years children’s hospitals and pediatric clinics have used a standard pediatric cart in an
emergency situation. These carts are organized by the interventions needed for the patient and
not for the ease of access of the equipment. Many hospitals emergency departments and/or
pediatric units are now using the broselow cart pediatric resuscitation system based on the
broselow tape in which each cart in each drawer is color coded and organized based on the
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patients weight and length. Within each drawer they contain all necessary equipment for the
resuscitation of patients in that specific weight/length ranges (Agarwal et al., 2005).
Goal of the Project
The survival rates of a pediatric code are dismal, and the rate of 27% survival to
discharge is a dismal number for the pediatric population. Those pediatric patients that make it to
discharge after a CPA or cardio-pulmonary arrest, only 34% of those patients survive. Those that
do survive will have neurological deficits post arrest (Loyola University Health System [LUHS],
2012). The initial actions of the staff of the pediatric patient with a CPA are essential to the
survival of the patient. Delays in providing the basic ABC’s such as airway, breathing and
circulation to the pediatric population can lead to poor outcome of that pediatric patient. If the
pediatric CPA occurs within a critical care unit in a hospital, the initial actions of the staff is
critical due to the time delay in the activation and arrival of the pediatric code team. One study
found that staff nurses in a noncritical care unit focused more on the prepping of the room for the
code and not initiating the basic life support or CPR for the pediatric patient (LUHS, 2012).
Since CPA in children occurs less often than in the adult population, the medical professionals
may have limited exposure and experience with an unstable pediatric patient. In one study of a
teaching hospital, 74% of the graduating pediatricians did not lead any CPA resuscitation event
during their residency (LUHS, 2012).
The goal of this safety initiative is to cut down on the time that it takes staff to have the
right equipment available to them with no hesitation and to pull the appropriate tray that is
appropriate to the pediatric patient. This project will provide the safety initiative to the pediatric
population upon admission to the pediatric unit. On admission to the unit the pediatric patient
will be broselow banded according to the broselow tape color. This in turn will provide the staff
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the staff the appropriate color drawer to pull saving time in a code. A medication form will also
be obtained from the pharmacy for the correct dosages and placed at the head of the pediatric bed
for needed reference in the event of a code.
The measurement of the performance improvement project would be that there will not
be a time lapse in the choosing the correct color tray on the broselow cart and having the correct
dosages of the medications needed. This will be demonstrated by the nurse looking at the color
band on the pediatric patient, announcing the need for the code and the correct color of the cart
being brought to the bedside for the code. This performance project when initiated within the
pediatric unit will be maintained at 100% compliance in the banding of the patient on admission.
To further the project this will be initiated within the pediatric emergency department when the
patient presents there for care.
Research has shown that the simulation of a mock pediatric code and other crisis
scenarios have demonstrated that there is significant delays in the ABC’s of a resuscitation effort
that included the application of the oxygen during CPR and defibrillation(LUHS, 2012). This
delay is detrimental to the pediatric survival rates following the CPA (LUHS, 2012). Knowing
where the needed equipment for the patient will save time in treating that patient.
As healthcare providers we all share the common goal of providing quality care to our
patients. Measuring the performance of these measures allows us to better understand the goals
of the healthcare organizations in which we work. Measures allows healthcare workers to
analyze what changes they may need to make in order to improve the through a performance
improvement process and to improve the quality of care provided to the patients in which we
serve. Measuring the performance allows the healthcare workers the ability to understand what is
working well and what is not working within an initiative, this information then can also be
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shared with other healthcare workers who can learn from the success of the project (Health
Resources and Services Administration, 2011). The preoccupation with the potential for harm
manifests itself in a systems-based approach to patient safety, an approach that acknowledges
that human beings and their limitations must be accounted for in the design of the system. By
proactively designing a system that takes into account the strengths and limitations of individual
health care professionals, the team can improve the safety of patients and minimize the risk of
harm (Krug et al., 2007).
Intended Outcomes
The intended use of the broselow system for a pediatric unit is to decrease the time to
initialize the resuscitation equipment in the even to a pediatric code. This student feels that the
pediatric practitioners, hospitals and clinics caring for the pediatric population should consider
using a broselow system to enhance the safety for the patient and ease of use for the
practitioners. The outcomes for the pediatric patient who sustains a CPA is dismal and the
survival rates have been reported to be anywhere between 14%-36% (Hunt, Walker, Shaffner,
Miller, & Pronovost, 2008). Despite all efforts of healthcare workers to prevent a CPA and the
resuscitation care that occurs before, during and after a CPA, the survival rates are not improving
in the last 4 decades within the pediatric population (Hunt et al., 2008).
One challenge that we as healthcare practitioners are facing is the lack of research in the
area of safety within the pediatric population. Because the pediatric population is a small part of
the hospital population, this area is not focused on and is frequently placed within others areas of
focus within the safety and quality agenda of an organizations initiatives (Runy, 2009).
Promoting safety of a pediatric population will require the healthcare practitioners to
change the culture in which we practice, and to recognize the need to enhance the safety of this
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population. Teamwork and communication within a organization is needed to provide change.
The promotion of pediatric safety initiatives and to decrease the time to implementation of
initiatives should be the two major goals of the process. Safety of this population should be a
commitment in a healthcare organization to providing optimal safety and care for the pediatric
population as a goal that should be embraces and that the staff, pediatricians for the families in
which we serve.
Role of the Nurse in Pediatric Safety
Pediatric Nurses can appreciate the impact of significant socioeconomic, disease, and
disparity issues in the healthcare of children. Daily, pediatric nurses provide care to children in
hospitals and within the community setting. As pediatric nurse serve our pediatric population
they are also caregivers but also as change agents working to improve the care of the pediatric
population’s health and safety (McCarthy & Sperhac, 2011).
In any patient population, nursing care is given through the best evidence based nursing
practice. This evidence is obtained through resources such as clinical trials, observational
studies, outcomes research and case reports (Cooper, 2011).
Evidence based nursing is based on the integration of researched evidence within clinical
expertise and placing the patient’s values and nursing ethics to facilitate a clinical decision. The
concept of evidence based practice is that it provides a base to use scientifically proven research
to deliver high quality of care to patient populations. In researching for this paper on a safety
initiative for our pediatric population, this student has found little evidence of research in the
study of pediatric safety initiatives with the broselow system. In research comes change and in
change we will create a culture of safety for our littlest patients.
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Society is demanding a safer health care system. State and federal agencies (eg, Centers
for Medicare and Medicaid Services), certifying organizations (eg, the Joint Commission), and
professional societies (eg, AAP, American Board of Pediatrics) also have patient-safety
expectations. These combined forces are placing greater pressure on the health care community
to develop a culture of safety in which leaders and members understand and act on the basis of a
systems approach (Miller, Takata, Stucky, & Neuspiel, 2011).
The pediatrics nurse’s role within this student’s safety initiative involves the initiation of
the banding process with the placement of the correct drawer color band on the patient wrist. The
role of the pediatric nurse with the initiative would be the use of the broselow tape to measure
the pediatric patient on admission and then banding the patient with the correct color to increase
the chance of proper care of the patient and increase survival of that patient in the event of a
CPA. Nurses are usually the first responders of a code and are the first link in the “chain of
survival” (American Heart Association, 2011). The pediatric nurse’s ability to have the
appropriate equipment available quickly to physicians increases the chance of survival of these
patients. Pediatric nurses and organizational initiatives will decrease the time to treatment of the
pediatric patient with a CPA.
Using the weight/length specific broselow resuscitation cart will allow faster and a more
accurate access to equipment and supplies needed during the pediatric resuscitation and would
also increase the chances that healthcare providers will find the broselow cart easier to use and
would prefer it over the standard resuscitation cart.
In today’s electronic world, the broselow tape has become available to healthcare
workers on their iPhone as a reference tool. The app is called Safe Dose and is available to
decrease the common errors of medication dosing in the pediatric population. The app also
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provides the practitioner a guide for Post-Intubation Management of the patient (iMedical Apps,
2011).
Research Review
With the introduction of the broselow cart and the broselow tape, research has shown that
with the time saving use of this cart the lives of many pediatric patients are saved. The system
groups the pediatric population into a color-coded zones rather than using the child’s weight in
kilograms. This system can be accessed by using the pediatric patient’s weight or length. Even
though it can be used for length it should not be used in the case of an emergency when it is not
possible to weigh the child. The broselow system is used by accessing the proper equipment,
proper drug doses and fluids used in an emergency situation of the pediatric patient. When there
is no pediatric emergency, the broselow system can be used for more accurate and consistent
drug dosing and the practitioners have the ability to choose the proper equipment for the
appropriate age and size of the pediatric patient.
Literature Review and Support
In the February 2008 issue of Journal of Emergency Nursing, a research study was
conducted in which researcher’s surveyed 1,489 emergency room nurses and medical directors
about whether their emergency departments was compliant with the guidelines from the
American Academy of Pediatric/American College of Emergency Physicians. They found that
only 6% of the emergency rooms have all the recommended equipment, and half lacked
laryngeal mask airways used for ventilation in children (Emergency Nurse Association, 2014).
Only 12% of these emergency rooms have vascular access supplies for children, and 17% lacked
Magill forceps for removing foreign objects from a child’s airway. The study’s lead author,
Marianne Gausche-Hill MD believes that death could potentially result due to the lack of having
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the proper equipment available for the pediatric population. New research sends an urgent
message to emergency room nurses are even pediatric nurses that they must be proactive in
evaluating their equipment and policies and to pay attention to the needs of this patient
population (Emergency Nurse Association, 2014).
Access to resuscitation equipment is a critical component in delivering optimal care in
the event of a pediatric code. Children’s hospitals and clinics have used for years standard
resuscitation cards for the pediatric population in which the drawers are organized by the way
that interventions would be used in a code. This in turn causes multiple drawers to be open in the
event of a pediatric code. Many emergency rooms are now using pediatric resuscitation cars
based on the broselow system. The broselow cart has the color coded and organized by patient
length and weight ranges and contains all the necessary equipment for the resuscitation of the
pediatric population in the specific length/weight ranges (Agarwal et al., 2005). In a research
study by Stanford University, they performed a prospective, randomized, controlled, crossover
trial to compare which resuscitation cart organization (Standard verses Broselow) allowed for
faster access to the needed equipment, a more accurate selection of the appropriate sized
equipment and the users satisfaction. They took 21 pediatric healthcare providers in which they
assigned the role of obtaining the appropriate equipment during 2 standardized, mocked codes
ultimately using either a standard or broselow cart. In the study they accessed the time to and the
accuracy of the selection and the appropriate medical equipment along with a post-test
satisfaction was measured in the study. All the simulations were performed at the Center for
Advanced Pediatric Education at Stanford University Medical Center in Stanford CA. The
training facility was designed to replicate real medical situations. With the 21 subjects observed,
62% found the broselow cart “easy” or “very easy” to use verses 33% for the standardized cart.
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Of these 21 subjects, 67% preferred the broselow cart, 10% preferred the standard cart with 23%
had no preference. Intubation supplies and nasogastric tubes were found significantly faster
when using the broselow cart with fa mean time of 29.1 and 20 seconds, respectively verses the
standard cart with a mean time of 38.7 and 38.2 respectively. Finding the correct equipment was
provided in the code and statistically significant 99% of the time with the broselow cart verses
83% of the time with a standard cart. Ten percent of the subjects had prior experience with the
broselow cart verses 62% having experience with a standard cart. Some of the subjects having
less experience with the broselow cart in this study found it easier to use and preferred it over the
standard cart. In addition the healthcare practitioners located the intubation equipment and
nasogastric tubes significantly more often with the borselow cart. The data suggest that areas
caring for pediatric patients should consider modeling their resuscitation carts after the broselow
system to enhance the healthcare provider’s confidence and increase patient safety.
The outcomes of hospital pediatric CPA’s can be dismal. In recent data suggest that the
quality of basic and advanced life support delivered to adults is low and contributes to poor
outcomes, but there is fewer research and data on pediatric outcomes. This information is
limited. Reports of survival rates have been ranging from 14%-36% as stated earlier (Hunt et al.,
2008). The object of a study found in the Journal of Pediatrics by Hunt et al, measured the
median elapsed time to initiate resuscitation measures in simulated pediatric medical
emergencies via “mock codes” and identified the types and frequency of errors during pediatric
mock codes. Among the 34 mock codes performed in the study it found the median time to
assessment of the airway and breathing was 1.3 minutes to the administration of the oxygen 2
minutes, assessment of the circulation was 4 minutes, arrival of the physician was 3 minutes and
the arrival of the first member of the code team was 6 minutes. Among the cardiopulmonary
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arrest mock codes, the elapsed time to initiation of the compressions was 1.5 minutes, and to the
request for a defibrillator was 4.3 minutes. In 75% of the mock codes, the code team deviated
from the AHA’s pediatric basic life support protocol, and in 100% of these mock codes there
were communication errors (Hunt et al., 2008).
In comparison, LaPorte Hospital Indiana, a color-coded pediatric code readiness system
was implemented in their medical/surgical/orthopedic/pediatric and joint camp unit. The Chief
Nursing Officer believes that this was a step in assuring the safety of their pediatric population
within her hospital and provides a constant care for that population in an emergency situation
(Nurse.com, 2004). Bruce Garwood RN was instrumental in implementing the pediatric
resuscitation system. His approach was proactive in which the hospital considered a possible
safety problem in the pediatric population. They had noticed delays with decisions about drug
dosages and equipment used during a code at other facilities. Any delays can be life threatening
when it comes to this age population (Nurse.com, 2004). Their implementation of the system
with every pediatric patient at admission is weighed and then assigned their color category
within the system. The corresponding wristbands is then applied to the patient and changed to
their daily weight changes in kilograms. His system shows that if the patient goes into cardiac
arrest the color will quickly show the appropriate pouch to provide the treatment needed for the
patients care (Nurse.com, 2004). Their evaluation of this preventive measure will need to be
continually be evaluated to improve the process if needed.
Based on these findings the broselow resuscitation cart can decrease the time to mobilize
the needed resuscitation equipment, increase the accurate selection of the equipment, and is the
preferred approach by experienced practitioners, hospital settings or clinics caring for the
pediatric populations. These groups caring for this patient population this student leader believes
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should consider grouping their resuscitation equipment by patient size using the broselow system
in their resuscitation carts to enhance provider confidence and patient safety. This student
believes that additional up-to-date studies are necessary to confirm findings of this system in a
real clinical setting.
Key Stakeholders and Communication Points
The Agency for Healthcare Research and Quality defines a “stakeholder” as a person or
groups who have a vested interest in the clinical decisions and the evidence that supports that
decision (Agency for Healthcare Research and Quality, 2014). To ensure the relevance of the
research to those making healthcare decisions, stakeholders are kept involved in all the core
activities, at every stage of the research process. Stakeholders can be the patients, their
caregivers, clinicians, researchers, advocacy groups, professional societies, businesses and
policymakers. Each group has a unique and valuable perspective (Agency for Healthcare
Research and Quality, 2014).
Key Stakeholders for Broselow Band Project
The key stakeholders for the broselow project would be those involved with the care of
the pediatric patient, the patient themselves and administrative support for the project.
Stakeholders are the people or organizations that would be vested in the broselow initiative are
interested in the results of the safety initiative and/or have stake in what will be done with the
results of the evaluation (Center for Disease Control, n.d.). Key informants are the stakeholders
with direct experience with the topic being researched and initiated as patients or caregivers,
clinicians, policymakers, insurers or other healthcare decision makers. Key informants offer their
unique perspective that can help to refine the key questions before research can begin. They also
can provide context, as well as help to direct more specific questions for consideration such as
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possible side effects, benefits, harms and the possible quality of life issues (Agency for
Healthcare Research and Quality, 2014). Stakeholders are more likely to support a process and
act on results and recommendations if they are involved with a process. A hospitals
organizational culture can set the stage for quality improvements initiatives and the nurses’ roles
in these activities. Hospitals with supportive leadership, and also have a philosophy of providing
quality as everyone’s responsibility with individual accountability, having physician and nurse
champions, and effective feedback system to offer a great deal of successful staff engagement
within a process improvement (Draper, Felland, Liebhaber, & Melichar, 2008). This student
leader wants to create a team of safety consciousness with all stakeholders, such as the doctors,
nurses, administrators and patients. The care of the pediatric population in hospitals necessitates
the participation of both the parents and others among the safety stakeholders.
Persuasive Arguments
Engaging the staff that is taking care of the pediatric patient population is imperative in
the success of the project. It is within the content and safety strategies that will promote the
active involvement of the nurse to better prepare them to be more competent and confident
stakeholders in any safety initiative. In engaging the organizations in the work and increasing
quality and performance improvement initiatives will increase quality and healthcare workers
excellence in the clinical care of the patient.
Evidence has shown that the participation of front-line staff members in a quality
improvement decisions increases the support for the process and will increase the success in
implementation and the staff’s will continue to process (Needleman et al., 2009). Because staff
nurses are the important part in the care of a hospitalized patient, nurses are also the priority in
hospitals efforts to improve the quality of care. This student leader wants to create an
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organizational culture where patient safety is the top priority of the staff and there is an ongoing
commitment to address possible patient safety issues within the nursing culture in a hospital
setting. This student wishes to provide the staff education and training in the need for this safety
initiative within the pediatric population and involve the staff in helping to teach others in this
need for safety in other units of the hospital for this patient population.
A theory of change would not be complete without the articulation of assumptions that
stakeholders use to explain the change process represented by a change framework (Center for
Theory of Change, 2013). Assumptions explain both the connection between early, intermediate
and long term outcomes and the expectations about how and why proposed interventions will
bring about them. At times the staff’s assumptions can be supported by research strengthening
the case to be made about plausibility of theory and the likelihood that stated goals can be
accomplished (Center for Theory of Change, 2013). The stakeholder will value theories of
change as part of a program of planning and evaluation because this creates a vision for long
term goals, how they can be reached and what will be used to measure progress along the way
(Center for Theory of Change, 2013).
This student leader will need substantial nursing leadership acceptance and pediatrician
support in the involvement and commitment to the broselow band quality improvement initiative
for the safety of our pediatric population. Their help is needed to help promote the initiative to
both nursing staff and at the patient level by providing a visibility on the project in both writing
and physically within the hospital unit. These are important factors in making the significant
changes this student will need to implement the project. The resources demands associated with
this changing process will require nursing leadership to ensure this student has the financial
resources for training and purchasing the needed supplies. They must also emphasize safety as an
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organizational priority and reinforce expectations, especially when this student will need to
provide for them the evidence based practice that shows that pediatric safety is a need in
hospitals today. This student will also incorporate the need for nursing leadership to make patient
safety in the pediatrics populations a key aspect of all meetings of patient quality and risk
management strategies, to create a process for identifying patient safety goals for the
organization, and to hold themselves as well as staff accountable for patient safety concerns.
Organizational Theory
Organizational theory considers how organizations are structured in an effort to better
understanding how that structure will impact productivity, efficiencies and effectiveness
(Villanova University, n.d.). They are a collection of people working together under a defined
structure for the purpose of achieving predetermined outcomes through the use of financial,
human, and material resources (Villanova University, n.d.) Within the framework of nursing,
organizational theory is the simple views of a healthcare facility’s nursing system to determine if
it works for the benefit of the patients we serve (Swansburg, n.d.). To be able to successfully
apply the organizational theory to a nursing structure to should provide better care to patient
populations. At all levels, organizational theory should be applied to enhance patient safety and
services. At the unit level where the nurses and patients are constantly interacting; there should
be a constant interaction of information relayed between the nurses and their supervisors as well
as up and down the chain of command (Swansburg, n.d.). This theory will work to bring safety
measures to the patient and provide nurses easier access to pediatric code measures. Bringing
together through communication and sharing of information to the stakeholder is critical to the
purpose and strategies of this quality initiative. Developing an open channel of communication
across all the disciplines such as the doctors (pediatrician), all level of leadership, and the
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nursing staff, allowing the stakeholders voice concerns and observations throughout the process
of planning and implementing the initiative; this ensures that the patient and their families were
appropriately included in the planning with getting feedback from such and ensuring that
everyone involved felt that they were an integral part of the implementation process team and
was responsible for the pediatric safety initiative.
This initiatives success relies on the multidisciplinary structure team approach. This
allows each member to identify each step of the process from their own professional practice
perspective, anticipate and overcome potential barriers, allowing for different ideas to be brought
forward and provide outcome discussions, in which this student wishes to promote teambuilding,
productive work, and involvement of the staff in the broselow project.
System theories are the approach in philosophy of science, aiming at understanding and
investigating the world as sets of systems and involves two sets of concepts (Chuang & Inder,
2009). These concepts emergence/hierarchy, control and communication can be used to show the
hierarchy levels of any organizations. The safety and quality of an organization is the
responsibility of the whole not an individual system component. The broselow band initiative is
based on the unit providing a safe environment for the pediatric population and just not the
individual nurse. The hospital involvement with the initiative is imperative in its success.
Communication is imperative in leadership and for staff nurses for this initiative succeed
(Chuang & Inder, 2009). This process shows that pediatric safety and as a product for better
outcomes for a pediatric populations.
If we as healthcare workers and a hospital system as a whole provide an atmosphere
where parents and/or patients in the pediatric/adult population is able to give feedback on the
process of the broselow band initiative, this student feels that it would help with the process
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improvement aspect of the initiative. To provide these stakeholders to give feedback will help in
the possible problems. Teaching the parents on admission of the process and why we have
implemented this as a safety initiative for their children will provide reassurance to the parents of
the child that we have their best care and safety while they are in the hospital. Parents generally
expect the safety of their child in a healthcare setting. However, there are times when a parent’s
view of what is safe does not agree with that of the nurse, hospital policy and the safety and
standards they hope to enforce. For this such reason, the nurses assessment needs to be patientcentered and include the patient’s own perceptions of their risk factors, knowledge of how to find
risk and previous experiences with any accidents. This will provide the staff an overview of the
need for further education on safety factors with the hospital setting.
Anticipated Problems and Issues
The first requirement is to create a supporting structure that will enable widespread
change implementation if problems appear. This may include a temporary nursing group that
works on implementation of the plan; with the staff testing our some of the proposed changes if
needed (Ramanijam, Keyser, & Sirio, 2005). There can be possible new challenges of possible
communication problems in getting the information about changes out to the staff, physicians,
patient/parents and providing training that brings the best practice suggestions by the proposed
changes in the broselow band initiative. The teaching new staff the process in orientation will
also need to be monitored for compliance.
Even with the processes implemented successfully, there is always the risk that the
organizations or nurses may revert to bad behaviors and not initiating the band at admission
(Ramanijam et al., 2005). The possibility that supplies are not available as the organization may
no longer afford the resources that were allocated in the beginning to initiating the change, the
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organization may face new challenges such as diverting senior leaders attention to other
initiatives or problems, or there may be a turnover in employees that are the project champions.
This student’s first challenge would be to develop the organizations culture so that the change
becomes a safety feature of the organization. Secondly, the organization must also introduce
leadership changes that will reinforce the changes, for example, improving the interactions of the
multidisciplinary team which includes the nurse, physician, respiratory therapy and pharmacist.
These are the key players in a pediatric code. In the implementation phase if there are any
inconsistencies, this process may lead to possible staff non-compliance in the initiation of the
band (Ramanijam et al., 2005). It is essential that we focus on providing the best possible care
for our patients. Healthcare providers can ensure that high quality care is provided by ensuring
that a process is in place to monitor the care. It is also essential that we base our care of scientific
evidence. Forming a multidisciplinary committee whose focus is on the quality of this initiative,
but using best evidence to accomplish this goal. This initiative supports the hospital and patients
in a culture of safety (Brennan, Donnelly, & Somani, 2011).
Within the broselow system there is some experts who believe that this system needs
improvement. In a cross sectional study from September –December 2007, the rate of correctly
estimating the pediatric patients weights was 43%. This study was conducted within a tertiary
children’s hospital with an ED volume of greater than 30,000 pediatric patients a year.
Childhood obesity is on the rise with an estimated 22.6%-31% of this population as obese. The
current method used to estimate pediatric weights could become less accurate, this especially
with the broselow tape in which relies on patient weight (Rosenberg, Greenberger, Rawal,
Latimer-Pierson, & Thundiyil, 2011). The study conducted at Orlando Health in Orlando Florida
demonstrated that the broselow tape differentiated from the actual weight on average of 10.8%
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and physician estimate was 16.2%. Based on this study, the physician’s estimate was worse than
the broselow tape estimation. This study showed that the broselow tape was more accurate than
physician estimation in the pediatric weight and may justify the need for the broselow tape.
When weight estimations are needed for those that are clearly obese, may be taller or for older
children, the physician will need to make an adjustment for proper medication administration
(Rosenberg et al., 2011). Current American Heart Association (AHA) guidelines recommend that
healthcare providers make medication dose decisions based on the child’s weight, if known
(Kleinman et al., 2010). When unknown, the AHA recommends that healthcare providers use a
weight-based measuring tape with pre-calculated doses (ems1, 2012). Studies have suggested
that medication dosing in children is a particularly high-risk activity, because it requires manual
dosing. Standardized unit doses are rarely used in children; rather, each dose of medicine is
calculated by using a dosing equation based on the child's weight. The act of calculating dosing
equations has been identified as a high-error activity, and several factors compound the risk of
error when medications are given emergently. For example, the child's weight is often not known
and, therefore, must be approximated. There are limited opportunities for prescription monitoring
or double checking, and in some cases, the inherent stress of managing a life-or-death situation
can lead to errors. Indeed, a study that reviewed medical errors in academic medical centers
found the pediatric service to be the most error-prone setting and the ED to be a close second
(Krug et al., 2007).
Although helpful, the Broselow length-based tape is not ideal. Medication doses are listed
on the tape in milligrams, yet nurses must draw up medications by volume. Although this tape
provides pre-calculated medication doses for physicians to order, it does not provide the nurse
with a pre-calculated volume (milliliters) of medication to administer. There is currently no
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clinical tool universally available to ED nurses that provide them with this critical information,
and a recent study of a simulated pediatric emergency event suggests that errors may occur at
this point in the process of emergent medication administration.
Operationalization of the Broselow Band Initiative
The Academy of Pediatrics (AAP) suggests that all pediatric patients entering a hospital
have safety initiatives implemented. Efforts to improve patient safety and prevent errors should
be focused on a systems approach. The AAP recommends that identifying and learning from
errors in improving health care safety exist by research on hospital-based care revealing that
medical errors rarely represent the failure of one nurse, but that most errors in medical care are
related to equipment malfunctions, complex care processes and the lack of standardized
procedures ("Policy Statement," 2011).
This initiative’s first step will be initiated with the introduction to nursing leadership,
quality and medical/pharmacy staff during their monthly meetings. This will focus on the safety
aspects, policy and bringing forth the cost analysis of the initiative. Getting leadership, quality
and the medical/pharmacy staff on board of this initiative will increase compliance with the staff.
The next step to initiation would be to introduce the project to the staff at the monthly
staff meeting. Staff will be encouraged to provide their input into the implementation process
and initiation phase. This will gain support of the project as the staff will feel empowered to
provide for the safety of our pediatric patients. The staff will be introduced to implementation
and initiation phase. This will gain support of the project as the staff will feel empowered to
provide for the safety of our pediatric patients. The staff will be introduced to implementation
steps of this process and policy. With empowering the staff at this meeting to bring about ideas
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
21
of implementations changes, results will be communicated with leadership. Implementation
would begin the following Monday after staff meeting to allow for communication to all staff.
Staff projects champions will be designated to provide ongoing teaching to staff and off
shift staff. This student leader will provide initial teaching to the staff on use of broselow tape
and demonstrate how to pick the appropriate color associated with the patient and how to provide
the patient/parent teaching on the initiative.
Staff will on admission broselow tape the pediatric patient and assessing the proper color
of the patient. We will start out using construction paper that correlates with the drawer, placing
it over the patient’s bed with the weight in kilograms written with permanent marker on it.
Pharmacy will submit a pediatric dosage sheet to the patients chart. This will be monitored for 4
weeks for compliance before implementing the bands. Monitoring will be done by the charge
nurse with shift rounding on patients. Compliance monitoring will be communicated with
nursing leadership, quality and medical/pharmacy committee.
The staff will be introduced to the staff after the 4 week construction paper trial. The staff
will place the kilograms on the band with a permanent marker. Staff will also monitor weight
changes in the patient for need to change band colors in event of weight change and drawer
change.
Compliance will be monitored for no less than 6 months and until 100% compliance is
seen with 3 month concurrently. Monthly compliance results will be communicated to nursing
leadership who will then communicate with quality and the medical/pharmacy committee at their
regular scheduled meetings. Those nurses out of compliance will be subject to hospital policy
and/or reoriented to the process.
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
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A potential problem that this student believes that may be encountered is that we may
have pediatric patients who weigh under the first drawer and some children that may not be over
the last drawer. Solutions to the problems would be to implement a NRP protocol for these
infants under the first drawer and those over the last drawer would be adult resuscitation cart
with pharmacy calculating drug dosage sheet for the staff and placed at the patient’s head of bed.
Another potential problem would be that the construction paper or bands may not be the
same shade of color as the broselow cart drawers. Staff would have to follow a close color to the
drawer.
Healthcare organizations should demonstrate their commitment to the safety of the
pediatric population and promote safety initiatives to protect this population ("Policy Statement,"
2011).
Rough Operational Budget

Construction paper- Staples-Pastel Colors of 100 pkg
$15.00

Permanent Markers-Staples-per dozen
$ 8.29

Staffing-trained on duty, normal working hours
$ 0.00

Tyvek Wrist Bands- Company-Wristco.com
$55.60
$6.95/100
$6.95 x 8 colors No shipping fee

Broselow Pediatric Emergency Tape-currently on carts
$ 0.00

Broselow Carts-Units already supplied with
$ 0.00
Total $78.89
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
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Evaluation Parameters
Outcome based evaluations is a systematic way to determine if a project has achieved the
goals set by an organization. The organized process of developing these outcome based
evaluations will help to provide a clear out come or benefit to the project, indicators that measure
the benefits of the project, and to clarify the benefits that the project will provide for the intended
individual and/or groups. Outcome based evaluations will provide the answers to questions such
as: Who is my intended target audience, what are the resources needed, when will resources be
needed, how are the resources gotten and what is needed to complete this project, and how will
the patient population benefit from the project (Utah State Library, 2013).
Evaluating the Outcomes
In starting this patient safety initiative, this student’s goal is to cut down the time that it
takes to respond and start a code on a pediatric patient. This initiative will provide the healthcare
practitioner the ability to know the color of the drawer to pull and not have to broselow tape the
patient first, saving precious life saving time for that patient. Delay in care occurs in most of the
pediatric resuscitation efforts. Future educational and organizational interventions should focus
on improving the quality of care delivered during the first 5 minutes of an resuscitation.
Practicing of simulations of a pediatric crisis can identify targets for educational intervention to
improve pediatric cardiopulmonary resuscitation outcomes (Hunt et al., 2008).
The first step in evaluation of the compliance with the staff is their completing of the
broselow tape assessment of the patient and then banding the patient on admission with the
appropriate color. This student wants the staff to be 100% compliant with this step. If this step
were missed then the patient during a code would have to have the nurse take the time to
broselow tape the patient for the staff to know what color drawer to pull in a code.
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
24
Desired outcomes would be the staff correctly identifying on admission the color of the
band to place on the pediatric patient and properly placing the kilograms on the band of the
patient. This will be evaluated with leadership rounding on each shift and checking the patients
for the correct band. The ultimate outcome evaluation would be evaluating a code by time of
rescue compared to adult codes, and also comparing if the band saves time with just grabbing the
correct drawer compared to broselow taping the child to find the correct drawer and then
grabbing the correct drawer for the patient in the event of a code. Another desired outcome of
this initiative would be the ability of the IT department of building into the electronic
documentation system the assessment and band color during the admission assessment and also
for the shift assessment. The greatest accomplishment would be to initiate this in the emergency
room with 100% compliance in the staff. This would be the end of this student’s program
evaluation as success with the hospital with 100% compliance.
Measurement of these outcomes would be asking if this has improved the safety during
the code of a pediatric patient. Is it working as designed? Will this initiative make a difference in
the long run? This student believes that this initiative will save time and lives with this simple
safety initiative.
Why Evaluating Programs are Important
The monitoring and evaluating of any program is vital to determine whether it has
worked, and to provide the evidence to continue in the supporting of the initiative. Evaluating
will not only provide with feedback information about the effectiveness of the initiative but will
help to determine if we are able ti expand the program, if there are any problems that were found
in the implementation, if support was given by staff and leadership, and whether there are any
ongoing problems that need to be resolved in the initiative when it was implemented (Centers for
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
25
Disease Control and Prevention, 2012). Monitoring the outcomes of the pediatric code time to
response is vital to the outcome of the pediatric patient’s survival. Herlitz et al reported that
patients who receive cardiopulmonary resuscitation within 1 minute of collapse were twice as
likely to survive as those who did not. Also demonstrated was that initiation of basic life support
within 3 minutes of cardiac arrest was associated with a 25% increase in survival, when
compared to initiation of cardiopulmonary resuscitation at >3 minutes (Hunt et al., 2008).
Indicators
Indicators are the specific, observable, measurable actions or conditions that tell if the
desired changes or benefits have happened. Process indicators access what the practitioner has
done for the patient and how well that the process worked for the patient (Manz, 2003). The
indicators for this initiative would be the time that is decreased with the use of the bands in the
event of a pediatric code. If in the event that this initiative is not met then this student would put
together a nursing performance improvement council and formulate an action plan to correct the
area that is falling out of the initiative. The purpose of the nursing performance improvement
council would be to identify, review and analyze data to measure and monitor the nursing
sensitive patient outcomes, and provide any recommended actions as a result of the data
collected. The goal of the nursing performance council would be to: (University Medical Center
of Princeton, 2013)

Assess and review data, and establish priorities in the department.

Develop an action plan for improvement.

Monitor the outcomes of nursing practices.

Communicate the findings throughout the nursing department and other involved
departments, through the hospital performance improvement committee.
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT

26
Assure compliance with any Joint Commission standards and other governing
bodies.
Pediatric quality indicators were developed in 2006 by the Agency for Healthcare
Research and Quality to identify potentially preventable complications in hospitalized children.
Tracking potentially preventable complications and hospitalization has the potential to help
prioritize quality improvement efforts. It is with continued surveillance and research that we will
continue to provide quality patient care and safety.
Pediatric care is complex due to the developmental needs of patients. How these factors
impact the specific process of care area an area of science in which little is known. Throughout
health care providing safe and quality care are resources intensive and take continued
commitment by the healthcare practitioners, but also those agencies and foundations that fund
the research. Advocated for children’s health must voice these issues when they are being
discussed or start the discussion. Only then will the voice of our most vulnerable groups of
healthcare be heard ("Patient Safety," n.d.).
Conclusion
Little research has been found on this initiative and many not up-to-date. In the safety of
pediatrics populations more research needs to be done. Use of the broselow cart in the safety of
pediatric codes finds the easy access for the pediatric patient. With the use of the color coded
band with the broselow cart, time is saved in the event of a code and lives are saved. The
accuracy finding the equipment and ease of use of the cart provides healthcare practitioners an
advantage in the event of a code. Providing patient safety initiatives as this will give the pediatric
population the quality of care that is needed within the hospital setting without delays or dismal
outcomes.
BROSELOW CART PERFORMANCE IMPROVEMENT PROJECT
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