A PREVENT Case Study from Washington DC
Dr. Tanya Hinds is a pediatrician and Elaine Lamb is a pediatric nurse practitioner in the Child and Adolescent Protection Center of the Children’s National Medical Center (CNMC), the only Level 1 Pediatric Trauma Center in the metropolitan Washington DC area. They specialize in treating survivors and victims of child abuse and neglect. They perform medical assessments that care for children’s physical injuries and help ensure they are safer in the future. They connect them with the services needed to start the long road towards emotional healing. But Hinds and Lamb want to figure out how to keep at least some of those kids from showing up in the Trauma Center in the first place. In particular, they want to join forces to keep babies from suffering the devastating consequences of abusive head trauma (AHT) (also called “Shaken Baby Syndrome”).
We know that persistent infant crying often triggers shaking and/or blunt head trauma by caregivers. Probably most parents can remember a time when they were completely overwhelmed by their crying infant and could not figure out what to do. The question is how to help parents and caregivers deal safely with these screaming babies. Tanya Hinds had heard about “The Period of PURPLE Crying” (PURPLE), a program for caregivers of infants that has been shown to effectively increase parents’ knowledge about normal infant crying and how to safely respond to a baby that just won’t stop screaming. This program is designed to prevent caregivers from hurting their child when overcome by frustration with an inconsolable infant; it is designed to prevent AHT.
Tanya Hinds and Elaine Lamb joined colleagues Tara Grey, a Victims Services Associate and Heather Walsh, a Nurse Educator in deciding they wanted to use PURPLE in CNMC, but they had no idea how to go about planning and implementing this program. They applied to the PREVENT Institute with a proposal to implement PURPLE in their hospital. By the end of the first session of PREVENT, the team had identified a specific group for starting their program: parents of preterm infants. PURPLE had never been tested with caregivers of “premies”, and the Neonatal Intensive Care Unit (NICU) at the hospital has a large patient population in this unit. The team created a 5 year goal for themselves: “Implement Period of PURPLE Crying education to parents/caregivers of all NICU patients in Washington DC prior to NICU discharge.” Not surprisingly, they decided to start with a pilot of this program in the NICU in their own hospital before branching out to the 7 birthing hospitals and 1 birthing center in the District of Columbia.
The PREVENT Institute uses a public health model, focusing on population level prevention efforts. The Washington DC PREVENT team, made up of a physician, 2 advance practice nurses and a social worker used to treating individual children made a very good first step in moving towards implementing a program aimed at preventing AHT in a whole population. Still, they had some very real obstacles. How do you get the rest of the institution on board with the idea of expending precious time, human, and financial resources on prevention? Everyone will agree that preventing child abuse is a good thing to do; but how do you show that the specific issue is important and changeable in an environment that mostly treats illness? The PREVENT Institute teaches the value of using data and evidence in doing prevention work. The team realized they would need to provide data to “make their case” in the hospital. They decided that the best way to do this would be to identify how many victims of AHT had been treated in the past 4 calendar years and what the hospital costs associated with that treatment had been. For this group of clinicians, this decision represented their first foray into research! With the support of the PREVENT faculty and coaches, they designed a study in which they would review all the patient charts between 2006 and 2009 to identify AHT and suspected AHT cases. They also connected to a clinical data operations manager at CNMC to be able to cross the patient information with cost data to estimate the costs associated with the injuries. Finally they initiated the steps necessary to get permission to do research with patient information in the hospital. These data will hopefully help in making the case that AHT is costly enough in human loss and financial resources to focus caregivers and stakeholders on preventing AHT. The data will also help show the impact of PURPLE once it starts.
In the meantime, the Washington DC PREVENT team moved forward in gaining hospital wide support and momentum for their idea, even before having all the data collected and analyzed. The PREVENT Institute requires its teams to create a thorough logic model, a roadmap showing what they want to accomplish, what steps need to be taken to accomplish it, and what resources are needed to take those steps. The team found that having this clear, written plan really helped them make the case for what they wanted to do, even though creating it was hard.
The process is painful but the end result will be sound... and we get tremendous amounts of reinforcement every time we show what we think is our incomplete logic model to someone and they are so amazed that we have managed to create this thing...and they think what a phenomenal idea. (Team member interview November 2009)
Several important leaders in CNMC lent their support early on, in a large part due to the team’s ability to make a compelling case with their strong logic model. In particular, the Director of Nursing Research at CNMC was impressed with their planning process and was very helpful. The nurses with whom they engaged were very supportive; in fact they cited the PREVENT team’s plan around doing AHT education “as an important force in their recent application for Magnet Nursing status” (Team final report, October 2009). The team also used their PREVENT logic model to apply for and receive a small grant from the hospital to pilot PURPLE in the NICU.
So far the team has learned a lot about planning and implementing their idea to try to keep parents from hurting or killing their children by shaking them when they cry inconsolably. One way to help parents is to give them the information and tools they need to deal with normal infant crying. But in order to do that on a large scale, you have to get an institution to implement the education broadly. And in order to do that you have to have data, support from leadership, and some money to get started.
I think without PREVENT, I don’t know that we would have this team. I think it would just be myself and Tanya still talking―‘Maybe we should do this [implement PURPLE curriculum]; it’s a good idea. How do we do it?’ (Team member interview November 2009)
The team has looked down the road to how to sustainably spread this work widely. After getting the program going in their own hospital they plan to work on implementing it in all the other healthcare facilities with newborns in DC. They also have plans to promote legislation that would make it mandatory for all parents of newborns in the district to receive education about AHT. In addition they plan to do outreach via a media campaign specifically targeting male caregivers, the most common perpetrators of AHT.
That’s a tribute to this Institute. So we’ve moved from the individual level to how do we affect our institution and how do we affect our community. (Team member interview November 2009)
When all of these pieces are in place in their institution and in their community, the team hopes that parents across Washington DC will be much more able to avoid shaking a baby, no matter how loudly or how long s/he has been screaming, and how frustrated or overwhelmed the parent feels. And they expect that Dr. Hinds and her colleagues will see fewer cases of abused and injured infants presenting to CNMC.
PREVENT Institute 2009 Washington DC’s Children’s National Medical Center Team
- Identified issues, intervention (PURPLE curriculum), and target population (NICU caregivers) for prevention initiative
- Received organizational support
- Leadership (Chief Academic Officer, Direction of Nursing Research, Division Directors, Statistician)
- Designed study to review patient charts
- Submitted proposal to do research with human subjects
- Created medical record extraction form
- Obtained funding for NICU Pilot ($6000)
- Established plan for next steps after launch of pilot in CNMC NICU
- Implement in other Washington DC birthing facilities
- Advocate for legislation mandating AHT education across Washington DC
- Implement media campaign targeting male caregivers