In a hospital setting, emergencies are not unexpected. Everything is in place to respond appropriately: a crash cart, a well-rehearsed protocol, an entourage
by Rebecca Nielsen, RRT-NPS, RCP

In a hospital setting, emergencies are not unexpected.
Everything is in place to respond appropriately: a crash cart, a
well-rehearsed protocol, an entourage of staff to assist if need be
and back-up generation in case of a power outage.

In a home setting, however, there may be only one care provider.
And there's no code button to push for immediate help if something
goes wrong and the child's life is in danger.

As more and more medically fragile children are discharged to
the home — thanks to advances in technology and a growing
realization that they will do better there than in a hospital
— it's essential to ensure that their care not be compromised
and that the family environment is as safe as possible.

Pediatric Home Service, a St. Paul, Minn.-based organization
that provides specialized health care service to
technology-supported children in their homes, has a robust
education component for home caregivers, including hands-on
training on equipment, supplies, medications, procedures, and
emergency response and troubleshooting.

A couple of years ago, staff members began to notice an increase
in the number of “panic” calls from providers who were
caring for PHS patients — particularly from those caring for
patients with tracheostomies — indicating they didn't fully
understand equipment use and emergency protocols.

PHS staff found themselves doing more and more troubleshooting
and unscheduled home visits, responding to statements such as
“I've never changed the circuit on the ventilator. The day
nurse does that.” Or, “I didn't think to check the
oxygen because we never use it.”

As a result, the company conducted in-home assessments of
caregivers' essential skills relating to equipment and supplies to
determine what educational materials and interventions were

Evaluating Skills

PHS created a 37-item survey that included questions aimed at
assessing the caregiver's knowledge of proper equipment setup,
oxygen safety and use, emergency resuscitation bag (AMBU bag)
function and use and emergency response procedures.

The survey, which was administered by PHS clinicians, was
targeted to patients who had a tracheostomy and also used a
ventilator for respiratory support.

Eighty-five families participated in the survey. Caregivers
included 17 family members, 24 RNs, 38 LPNs, one RCP and five

The Results

Overall, caregivers were found to be skilled in routine daily
care but significantly lacking in abilities to demonstrate oxygen
safety and proper tank use, proper AMBU bag use, appropriate
emergency response and back-up battery use and charging.

Some of the results were eye-opening: A number of caregivers
didn't know how to check the function of an AMBU bag, what liter
flow of oxygen to use in an emergency or what suction pressure
should be utilized.

The Next Step

Based on the survey results, PHS developed drafts for various
educational materials and then met with home care administrators,
hospital care managers and referring physicians to discuss the
results, review the materials and determine the best way to
incorporate them into home care to ensure consistent use.

The result: the creation of the STAR kit, along with enhanced
PHS education classes.

The STAR Kit

The PHS STAR kit is a boxed set of education materials and tools
designed to enhance patient safety in the home. Used for both
training and to aid in the actual care of patients, it includes
DVDs, safety checklists and reminders, troubleshooting guides,
equipment tags and an emergency action plan.

Even the kit name is an acronym that serves as a safety

S: Stop, look and listen to make an effective patient

  • T: Take inventory of your patient's AMBU bag and bedside
    supplies to make sure they are available for use.

  • A: Assess your patient's emergency equipment. Make

    • Both AMBU bags are working properly;
    • Suction pressure is set correctly;
    • Emergency oxygen tanks are full; and
    • Batteries are charged.
  • R: Review your patient's emergency action plan to make
    sure you fully understand what to do.

    Enhanced Patient Safety In the Home

    The STAR education kit has been given free of charge to PHS
    families, home care providers and referring physicians and is a
    vital component of the company's education program.

    In addition, the STAR kit has been incorporated into the
    training given by other providers who work with PHS patients.

    Among the tools caregivers say they most appreciate:

    Safety checklist reviews;

  • Laminated quick reference equipment flip cards and signs;

  • Home oxygen use DVD; and

  • A handy mesh bag that holds everything needed for an emergency
    trach change.

    With the implementation of the STAR kit, PHS has seen
    improvement in all five of the areas assessed in the survey:
    equipment assessment, emergency backup equipment/batteries, oxygen
    safety, emergency AMBU bag and emergency patient response.

    All four caregiver categories — RNs, LPNs, PCAs and family
    members — showed improvement.

    Significant numbers of the respondents indicated that they use
    STAR kit and would recommend it to others. Because of the STAR
    campaign, nearly 12 percent of respondents wrote an emergency
    action plan, and another 18 percent improved their existing

    Additional feedback from respondents also suggests that those
    utilizing the STAR kit believe they are more prepared to handle any

    Rebecca Nielsen, RRT-NPS, RCP, is education manager for
    Pediatric Home Service, St. Paul, Minn. For more information about
    PHS, visit
    or call 651/789-3259.

    Performance on Initial PHS Survey by Question Type

    % of Caregivers Correctly Answering Questions Equipment Assessment Oxygen Safety Emergency Patient Response Emergency AMBU Bag Emergency Back-Up Equipment
    % of each type of question answered correctly by 90% or more
    of caregivers
    2/11 (18%) 0/6 (0%) 3/10 (30%) 1/5 (20%) 0/5 (0%)
    % of each type of question answered correctly by 80% or more
    of caregivers
    8/11 (73%) 1/6 (17%) 7/10 (70%) 1/5 (20%) 1/5 (20%)
    % of total questions 11/37 (30%) 6/37 (16%) 10/37 (27%) 5/37 (14%) 5/37 (14%)

    Pediatric Home Service

    Founded in 1990, Pediatric Home Service is an independent
    pediatric home care company providing specialized services to
    technology-supported children. Based in St. Paul, Minn., the
    company partners with health care professionals and family
    caregivers to ensure that the medically fragile child receives the
    same quality of care at home that is delivered in a hospital
    setting, coordinating and managing the services, medication and
    equipment needed. The PHS pediatric clinical specialists, who
    comprise about 40 percent of the staff, care for patients
    throughout Minnesota and western Wisconsin. The company provides
    infusion therapy, respiratory therapy, in-home asthma management,
    medical social work, nutrition support and pharmacy and education