Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study.

BACKGROUND: Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge. OBJECTIVES: To compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour "hand hygiene during patient care in the PICU". METHODS: A before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses. RESULTS: The hand hygiene compliance rate increased significantly from 27.3% in the "pre-intervention phase" to 33.1% in "phase 1-post-intervention," to 37.0% in "phase 2-post-intervention" (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour. CONCLUSIONS: Hand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour "hand hygiene during patient care in the PICU", reinforcing the need for behaviour determinants analysis when designing promotional interventions.

Pediatric Critical Care Nursing Research Priorities-Initiating International Dialogue.

OBJECTIVE: To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. DESIGN: One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. SETTING: Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. PARTICIPANTS: Pediatric critical care nurses and nurse scientists attending the open consensus meeting. INTERVENTIONS: Systematic review, gap analysis, and interactive multivoting. MEASUREMENTS AND MAIN RESULTS: The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. CONCLUSIONS: The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.

Endothelial, renal and hepatic variables in Wistar rats treated with Vancomycin.

Vancomycin (VCM) is indicated in combat against Gram-positive infections, but it is not considered a first-choice drug because of its adverse effects. It is believed that oxidative stress is the primary mechanism of endothelial injury and the consequent VCM toxicity, which varies from phlebitis to nephrotoxicity. Moreover, dose recommendations, dilution, rates and types of infusion are still controversial. The aim of this study was to determine the effect of different VCM dilutions in endothelial, liver and kidney injuries by biochemical parameters and histopathological analysis. Wistar rats were randomly divided into six groups and subjected to femoral vein cannulation for drug administration. Control groups received 0.9 ml of saline and the others received VCM (10mg/Kg/day) at dilutions of 5.0 and 10.0 mg/mL for 3 and 7 days. Homocysteine, hs-CRP, AST, ALT, GGT, urea, creatinine, lycopene, alpha-tocopherol, beta-carotene and retinol were analyzed. Kidney, liver and cannulated femoral vein fragments were collected.This study showed alterations in ALT which featured hepatotoxicity. However, drug dilutions were not able to show changes in other biochemical parameters. In contrast, kidney and endothelium pathological changes were observed. More studies are needed to characterize VCM induced kidney and endothelium toxicity and biochemical markers able to show such morphological modifications.

Influence of transport conditions on infusion pumps performance and triggering alarms: A simulation-based research.

BACKGROUND: Critical care transport is an essential component of care system. Inadequacies in equipment, during the interhospital transport can lead to adverse event. OBJECTIVES: To verify the influence of physical transport conditions in the infusion pumps (IPs) performance and alarm activation. METHODS: Simulation-based study about IPs use during interhospital ground transportation. There were 54 simulations (18 flowmetric, 18 volumetric, 18 syringe IPs). The equipment were tested at 01, 05 and 50mL/h infusion flow. Descriptive and inferential statistical analysis, with a 5% significance level was performed. RESULTS: The effectively infused volume was lower than the expected volume for the 3 IPs types. Vibration was the variable with highest correlation in volume difference. Flowmetric IPs showed higher alarm frequency (50.0%), followed by syringe IPs (27.8%). Free flow predominated in flowmetric IP and airline and occlusion alarms in volumetric and syringe IP. Error percentage of delivered fluid ranged from 2.8% to 25.9% being more evident in flowmeter IPs. CONCLUSION: The infusion pumps showed infusion misfunctioning when subjected to physical transport conditions. Syringe IPs were more accurate for low flow administration, while for the administration of solutions at higher flow rate, the volumetric IP showed the highest accuracy.

Peripheral vascular catheter use in Latin America (the vascular study): A multinational cross-sectional study.

Background: Peripheral intravenous catheter (PIVC) insertion is one of the most common clinical procedures worldwide, yet little data are available from Latin America. Our aim was to describe processes and practices regarding PIVC use in hospitalized patients related to hospital guidelines, characteristics of PIVC inserters, prevalence of PIVC complications, and idle PIVCs. Methods: In 2019 we conducted a multinational, cross-sectional study of adult and pediatric patients with a PIVC in hospitals from five Latin American countries: Argentina, Brazil, Chile, Colombia, and Mexico. We used two data collection tools to collect hospital guidelines and patient-specific data on the day of the study. The vessel health and preservation (VHP) model guided synthesis of the study aims/questions and suggested opportunities for improvement. Results: A total of 9,620 PIVCs in adult (86%) and pediatric inpatients in 132 hospitals were assessed. Routine replacement 8-72 hourly was recommended for adults in 22% of hospitals, rather than evidence-based clinical assessment-based durations, and 69% of hospitals allowed the use of non-sterile tape rather than the international standard of a sterile dressing. The majority (52%) of PIVCs were inserted by registered nurses (RNs), followed by nursing assistants/technicians (41%). Eight percent of PIVCs had pain, hyperemia, or edema, 6% had blood in the extension tubing/connector, and 3% had dried blood around the device. Most PIVCs had been inserted for intravenous medications (81%) or fluids (59%) in the previous 24 h, but 9% were redundant. Conclusion: Given the variation in policies, processes and practices across countries and participating hospitals, clinical guidelines should be available in languages other than English to support clinician skills and knowledge to improve PIVC safety and quality. Existing and successful vascular access societies should be encouraged to expand their reach and encourage other countries to join in multinational communities of practice.

Safety and structural integrity of N95/PFF2 respirators decontamination.

BACKGROUND: COVID-19 is caused by the SARS-CoV-2 virus, an emerging respiratory pathogen. The work environment represents a high-risk factor for health professionals. Given the scarcity of protective personal equipment due to global demand, decontamination and reuse studies should be carried out. Thus, the aim of this study was to evaluate the safety of a method of decontamination of N95/PFF2 respirators, especially regarding structural integrity. METHODS: N95/PFF2 respirators were subjected to hydrogen peroxide decontamination and analyzed using scanning electron microscopy and thermogravimetric analysis. Seven respirators of the same brand and lot were used, one being a control and the other six subjected to decontamination process. As for the sealing, a qualitative test was applied, in order to identify the changes in the structure that could damage the sealing of respirators. RESULTS: Indicated that the fiber morphology in all layers was not affected by the six decontamination cycles. Also, the thermal stability in the different layers was very similar. Fit testing showed that the respiradors submitted to all cycles of decontamination were approved. CONCLUSIONS: Thus, it is possible to conclude that the hydrogen peroxide decontamination method is effective, since it does not alter the physical properties of the respirators.

Oral care interventions and oropharyngeal colonization in children receiving mechanical ventilation.

BACKGROUND: Recent progress in identification of oral microorganisms has shown that the oropharynx can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs. OBJECTIVE: To compare the oropharyngeal microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit of children receiving mechanical ventilation who had pharmacological or nonpharmacological oral care. METHODS: A randomized and controlled study was performed in a pediatric intensive unit in São Paulo, Brazil. A total of 56 children were randomly assigned to an experimental group (n=27, 48%) that received oral care with use of 0.12% chlorhexidine digluconate or a control group (n=29, 52%) that received oral care without an antiseptic. Oropharyngeal secretions were collected and cultured on days 0, 2, and 4, and at discharge. RESULTS: The 2 groups had similar demographic characteristics, preexisting underlying diseases, and pharmacological, nutritional, and ventilatory support. Gram-negative bacteria were the predominant pathogens: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enter-obacter species. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22). CONCLUSION: Use of chlorhexidine combined with nonpharmacological oral care did not decrease the colonization profile, duration of mechanical ventilation, or length of stay in critically ill children receiving mechanical ventilation.

[Redesigning nursing activities to reduce medication errors in pediatrics]. / Redesenho de atividades da enfermagem para redução de erros de medicação em pediatria.

Quasi-experimental study which aimed to verify the influence of nursing activities redesign in the reduction of medication errors in three pediatrics wards of a university hospital. Types and frequencies of medication errors identified in a study carried through the wards guided the redesign and exerted the function of dependent variable in the assessment of the intervention. To errs identification 556 documents on 77 children's medical charts were analyzed. In 8550 medication doses analyzed, in 1498 (17,5%) errors were evidenced, an inferior ratio (21,1%) of the control study. Globally the intervention generated small changes in medication errors ratio and type, being effective to reduce dose omission (p< 0.0001), medication suspended by physicians and not registered as suspended for the nurses (p<0.0001) and wrong hour (p= 0,0002).

Subjective assessment of backrest elevation: magnitude of error.

BACKGROUND: Backrest elevation, defined as the angle of the backrest height above the horizontal position, is a common nursing intervention that is often used by subjective visual estimation in critically ill patients. OBJECTIVES: The aim of the study was to describe the magnitude of error during the subjective assessment of backrest elevation. METHODS: This prospective study was conducted in a sample of 160 subjects: 97 registered nurses, 48 undergraduate nursing students, and 15 nursing assistants. Data were collected by recording the degrees of backrest elevation identified by the subjects through an individual random presentation of the selected study angles of 20 degrees, 30 degrees, 35 degrees, 40 degrees, and 45 degrees. A measurement instrument was developed for determination of the angles. RESULTS: Of the 800 investigated angles, 14.9% were estimated accurately, 61.6% were overestimated, and 23.5% were underestimated, with an error average of 8 degrees (+/-13.5 degrees). It was determined that the larger the angle estimated, the greater the average error. A statically significant difference (P

Variability in the establishment of an external reference point for central venous pressure measurement in children.

OBJECTIVE: To investigate the variability in the establishment of the midaxillary line as external reference point (ERP), by different healthcare workers, for the measurement of central venous pressure in children. METHODS: Descriptive and correlational study carried out in a pediatric intensive care unit of a teaching hospital. During the establishment of the midaxillary line as ERP for central venous pressure measurement, five assessments of the same patient made by healthcare workers and one assessment made by a trained evaluator were compared. A total of 120 assessments were made by 44 healthcare workers, 17 (38.6%) by nursing assistants and nursing technicians, 16 (36.3%) by nurses and 11 (25.1%) by physicians, in addition to 24 assessments made by the trained evaluator. The data were analyzed using the chi-square test, ANOVA, Kruskal-Wallis test and t test. Significance level was set at 5%. RESULTS: There was statistically significant difference between the assessments made by healthcare workers and by the evaluator (p < 0.001). The comparison of the variability in the measurements made by healthcare workers revealed that 56 (46.7%) measurements were lower than those obtained by the evaluator (range from -0.5 to -9), 44 (36.7%) were higher (range from 0.5 to 4) and 20 (16.7%) were concordant (zero variability). Professional category did not influence the concordance between the ERPs (p = 0.899), or the variability observed (p = 0.778). However, the measurements made by professionals with greater experience in intensive care tended to differ more sharply from those made by the evaluators. CONCLUSION: The indications of the midaxillary line as ERP presented variations when measured by the healthcare team and by the trained evaluator. Variability was not influenced by professional category, and the more experienced the healthcare worker, the greater the probability for underestimation of the ERP. According to the results of this study, such situations may compromise both the efficacy of this procedure and patient safety.

Retrospective analysis of renal transplantation outcomes in children admitted to a paediatric intensive care unit in Brazil.

Renal transplantation has been described as the main treatment for children with end-stage renal disease. Traditionally, infants and small children represented a high-risk group with poor allograft survival. However, studies conducted mainly in developed countries have been demonstrated improvements in allograft survival rates. The aim of this study was to identify demographic characteristics of recipients and kidney donors and to analyse the outcomes of children who received postoperative care following renal transplantation in one Paediatric Intensive Care Unit (PICU). This retrospective study was carried out in a university hospital in Brazil. The data were collected through reviewing the follow up of medical records of recipients and kidney donors between 1988 and 2002. Chi-square or Fisher exact tests were used to analyse differences in outcome between living and donor transplants, whereas Mann-Whitney and Kruskal-Wallis tests were used to compare differences in outcome by age groups and by the number of complications affecting recipients. A total of 44 children were admitted for renal transplantation. Within this group, the median age was 10.1(+/-3.2) years, 63.6% were men and 38% were non-Caucasians. In contrast, the donor group had a median age of 17.5(+/-12.5) years, of which 51.3% were male, 56.8% were Caucasian and 70.5% were cadaver donors. The average length of PICU stay was 31.4 h, with complications being identified in the majority of the transplanted children. The occurrence of four or more complications was significantly associated with acute rejection (p= 0.009). In conclusion, the main outcomes of this study were similar to those observed in developed countries, in terms of acute rejections (52.3%), dialysis resumption (31.8%), graft loss (29.5%), chronic rejections (9.1%) and death (4.5%). Complications during PICU stay were significantly linked to the occurrence of acute rejection.

Noise level in a pediatric intensive care unit.

OBJECTIVE: The purpose of this study was to verify the noise level at a PICU. METHODS: This prospective observational study was performed in a 10 bed PICU at a teaching hospital located in a densely populated district within the city of São Paulo, Brazil. Sound pressure levels (dBA) were measured 24 hours during a 6-day period. Noise recording equipment was placed in the PICU access corridor, nursing station, two open wards with three and five beds, and in isolation rooms. The resulting curves were analyzed. RESULTS: A basal noise level variation between 60 and 70 dBA was identified, with a maximum level of 120 dBA. The most significant noise levels were recorded during the day and were produced by the staff. CONCLUSION: The basal noise level identified exceeds International Noise Council recommendations. Education regarding the effects of noise on human hearing and its relation to stress is the essential basis for the development of a noise reduction program.

[Prospective, randomized and controlled trial on the dwell time of peripheral intravenous catheters in children, according to three dressing regimens]. / Estudo prospectivo, randomizado e controlado sobre o tempo de permanência de cateteres venosos periféricos em crianças, segundo três tipos de curativos.

This prospective, randomized and controlled study verified the influence of three dressing regimens on the dwell time of peripheral intravenous catheters (PIC) in children. The study groups were composed of dressings with sterile gauze (EG 1), with sterile transparent film (EG 2) and with hypoallergenic adhesive tape (CG). Variables were selected to control for variables related to children, professionals and intravenous therapy characteristics. The 150 PIC that composed the sample were inserted in 68 children, predominantly of preschool age, male, with brown skin color, eutrophic and with gastrointestinal system diseases. The majority of the PIC was installed by nursing auxiliaries in veins of the dorsal arch of the hand. The type of dressing exerted a significant influence (p = 0.022) on the average dwell time of the studied PIC: EG 1 (46.12 hours), EG 2 (29.53 hours) and CG (38.18 hours), concluding that the dressing with sterile gauze maintained the catheter inserted for a longer time.

Surgical Safety in Pediatrics: practical application of the Pediatric Surgical Safety Checklist.

OBJECTIVES: To assess the practical application of the Pediatric Surgical Safety Checklist on the preoperative period and to verify family satisfaction regarding the use of the material. METHOD: Exploratory study that aimed to analyze the use of the checklist by children who underwent surgical interventions. The sample was constituted by 60 children (from preschoolers to teens) and 60 family members. The variables related to demographic characterization, filling out the checklist, and family satisfaction, being evaluated through inferential and descriptive statistical analysis. RESULTS: Most children (71.7%) were male, with a median age of 7.5 years. We identified the achievement of 65.3% of the checklist items, 30.0% were not filled due to non-performance of the team and 4.7% for children and family reasons. In the association analysis, we found that the removal of accessories item (p = 0.008) was the most checked by older children. Regarding satisfaction, the family members evaluated the material as great (63.3%) and good (36.7%) and believed that there was a reduction of the child's anxiety (83.3%). CONCLUSION: The use of the checklist in clinical practice can change health services regarding safety culture and promote customer satisfaction.

Information technology and patient safety in nursing practice: an international perspective.

When people become patients, they place their trust in their health care providers. As providers assume responsibility for their diagnosis and treatment, patients have a right to expect that this will include responsibility for their safety during all aspects of care. However, increasing epidemiological data make it clear that patient safety is a global problem. Improved nursing care may prevent many adverse events, and nursing must take a stronger leadership role in this area. Although errors are almost inevitable, safety can be improved, and health care institutions are increasingly making safety a top priority. Information technology provides safety benefits by enhancing communication and delivering decision-support; its use will likely be a cornerstone for improving safety. This paper will discuss the status of patient safety from an international viewpoint, provide case studies from different countries, and discuss information technology solutions from a nursing perspective.

Predisposing factors for infiltration in children submitted to peripheral venous catheterization.

AIMS: The aims were to compare characteristics of children with peripheral intravenous catheters who developed infiltration and those who did not and to identify risk factors for developing this complication. METHOD: A retrospective cohort study carried out at a university hospital, with 338 children with peripheral intravenous catheters. Variables related to the children and therapies were investigated. RESULTS: Researchers identified infiltration in 54 children (16%). Characteristics statistically different in those who developed infiltration were the following: intravenous therapy for more than 5 days, presence of predisposing factors to peripheral venipuncture failure, history of previous infiltration, catheter readjustment to vein insertion, use of infusion pump, intermittent administrations, and shorter dwell time. CONCLUSION: Only intravenous therapy variables showed a significant relation with the occurrence of infiltration and represented risk factors for its occurrence.

Medication errors reported in a pediatric intensive care unit for oncologic patients.

BACKGROUND: Considering all sources of errors that may occur during healthcare, medication errors are the most common and also the most frequent cause of adverse events. OBJECTIVE: The objective of the study was to describe the medication errors reported in a pediatric intensive care unit for oncologic patients. METHODS: This is a descriptive and exploratory study. The errors were reported by the professionals involved in the medication system in a medication error report form developed for the study. RESULTS: The sample consisted of 110 medication errors reported on 71 forms. The omission error was the most common error type reported (22.7%), followed by administration error (18.2%). No harm to patients was reported in 83.1% of the notifications. CONCLUSION: The analysis of the110 medication errors provides evidence of the context of their occurrence and the need to implement measures that can prevent or intercept these errors. IMPLICATIONS FOR PRACTICE: In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.

Surgical Safety in Pediatrics: practical application of the Pediatric Surgical Safety Checklist / Cirurgia segura em pediatria: aplicação na prática doChecklist Pediátrico para Cirurgia Segura / Cirugía segura en pediatría: aplicación en la práctica delChecklist Pediátrico para Cirugía Segura

Objectives: to assess the practical application of the Pediatric Surgical Safety Checklist on the preoperative period and to verify family satisfaction regarding the use of the material. Method: exploratory study that aimed to analyze the use of the checklist by children who underwent surgical interventions. The sample was constituted by 60 children (from preschoolers to teens) and 60 family members. The variables related to demographic characterization, filling out the checklist, and family satisfaction, being evaluated through inferential and descriptive statistical analysis. Results: most children (71.7%) were male, with a median age of 7.5 years. We identified the achievement of 65.3% of the checklist items, 30.0% were not filled due to non-performance of the team and 4.7% for children and family reasons. In the association analysis, we found that the removal of accessories item (p = 0.008) was the most checked by older children. Regarding satisfaction, the family members evaluated the material as great (63.3%) and good (36.7%) and believed that there was a reduction of the child's anxiety (83.3%). Conclusion: the use of the checklist in clinical practice can change health services regarding safety culture and promote customer satisfaction.

Objetivos: avaliar a aplicação na prática do Checklist Pediátrico para Cirurgia Segura no período pré-operatório e verificar a satisfação da família quanto ao uso do material. Método: estudo exploratório, no qual se visou analisar o uso dochecklist por crianças que seriam submetidas a intervenções cirúrgicas, sendo a amostra constituída por 60 crianças pré-escolares a adolescentes e 60 familiares. As variáveis relacionaram-se à caracterização demográfica, preenchimento do checklist e satisfação dos familiares, sendo avaliadas por meio da análise estatística descritiva e inferencial. Resultados: a maioria (71,7%) das crianças era do sexo masculino, com mediana de idade de 7,5 anos. Identificou-se consecução do checklist em 65,3% dos itens, 30,0% não foram preenchidos devido à não execução da equipe e 4,7% por motivos das crianças e familiares. Na análise de associação, verificou-se que o item da retirada de adornos (p=0,008) foi mais checado por crianças com maior média de idade. Quanto à satisfação, os familiares avaliaram o material como ótimo (63,3%) e bom (36,7%) e acreditaram que houve redução de ansiedade na criança (83,3%). Conclusão: o uso do checklist na prática clínica pode colaborar para mudanças nos serviços de saúde com relação à cultura de segurança e promover satisfação dos clientes.

Objetivos : evaluar la aplicación en la práctica del ChecklistPediátrico para la Cirugía Segura en el periodo preoperatorio y verificar la satisfacción de la familia con respecto al uso del material. Método : estudio exploratorio, cuyo objetivo fue analizar el uso delchecklist por niños que serían sometidos a intervenciones quirúrgicas, siendo la muestra compuesta por 60 niños en edad preescolar a adolescentes y 60 familiares. Las variables se relacionaron con la caracterización demográfica, llenado del checklist y satisfacción de los familiares, siendo evaluadas por medio del análisis estadístico descriptivo e inferencial. Resultados : la mayoría (71,7%) de los niños eran varones, con una edad media de 7,5 años. Se identificó el cumplimiento del checklist en el 65,3% de los ítems, el 30,0% no ha sido rellenado debido a la falta de ejecución por parte del equipo y el 4,7% por causa de los niños y familiares. En el análisis de asociación, se constató que el ítem de retirada de joyas (p =0,008) fue el más marcado por los niños con una edad media más alta. En cuanto a la satisfacción, los familiares evaluaron el material como óptimo (63,3%) y bueno (36,7%) y acreditaron que hubo una reducción de la ansiedad en los niños (83,3%). Conclusión : el uso del checklist en la práctica clínica puede contribuir a cambios en los servicios de salud con respecto a la cultura de seguridad y promover la satisfacción de los clientes.