Tidal volume and mortality in mechanically ventilated children: a systematic review and meta-analysis of observational studies*.

OBJECTIVE: To determine whether tidal volume is associated with mortality in critically ill, mechanically ventilated children. DATA SOURCES: MEDLINE, EMBASE, and CINAHL databases from inception until July 2013 and bibliographies of included studies without language restrictions. STUDY SELECTION: Randomized clinical trials and observational studies reporting mortality in mechanically ventilated PICU patients. DATA EXTRACTION: Two authors independently selected studies and extracted data on study methodology, quality, and patient outcomes. Meta-analyses were performed using the Mantel-Haenszel random-effects model. Heterogeneity was quantified using I. Study quality was assessed using the Newcastle-Ottawa Score for cohort studies. DATA SYNTHESIS: Out of 142 citations, seven studies met the inclusion criteria, and additional two articles were identified from references of the found articles. One was excluded. These eight studies included 1,756 patients. Mortality rates ranged from 13% to 42%. There was no association between tidal volume and mortality when tidal volume was dichotomized at 7, 8, 10, or 12 mL/kg. Comparing patients ventilated with tidal volume less than 7 mL/kg and greater than 10 mL/kg or greater than 12 mL/kg and tidal volume less than 8 mL/kg and greater than 10 mL/kg or greater than 12 mL/kg also showed no association between tidal volume and mortality. Limiting the analysis to patients with acute lung injury/acute respiratory distress syndrome did not change these results. Heterogeneity was observed in all pooled analyses. CONCLUSIONS: A relationship between tidal volume and mortality in mechanically ventilated children could not be identified, irrespective of the severity of disease. The significant heterogeneity observed in the pooled analyses necessitates future studies in well-defined patient populations to understand the effects of tidal volume on patient outcome.

Infants with severe respiratory syncytial virus needed less ventilator time with nasal continuous airways pressure then invasive mechanical ventilation.

AIM: Nasal continuous positive airway pressure (NCPAP) has been proposed as an early first-line support for infants with severe respiratory syncytial virus (RSV) infection. We hypothesised that infants <6 months with severe RSV would require shorter ventilator support on NCPAP than invasive mechanical ventilation (IMV). METHODS: Retrospective cohort analysis of infants admitted to two paediatric intensive care units, one primarily using NCPAP and one exclusively using IMV, between January 2008 and February 2010. RESULTS: We studied 133 (NCPAP n = 89, IMV n = 46) consecutively admitted infants. On admission, disease severity [i.e. Paediatric RISk of Mortality (PRISM) II score (NCPAP 5.1 ± 2.8 vs. IMV 12.2 ± 6.0, p < 0.001) and SpO2 /Fi O2 ratio (NCPAP 309 ± 81 vs. IMV 135 ± 98, p < 0.001)] was higher in the IMV group. NCPAP remained independently associated with shorter ventilatory support (hazard ratio 2.3, 95% CI 1.1-4.7, p = 0.022) after adjusting for PRISM II score, PCO2 , SpO2 /Fi O2 ratio, bronchopulmonary dysplasia and occurrence of clinically suspected secondary bacterial pneumonia. CONCLUSION: Nasal continuous positive airway pressure was independently associated with a shorter duration of ventilatory support. Differences in baseline disease severity mandate a randomised trial before the routine use of NCPAP can be recommended.

Transfusion of leukocyte-depleted RBCs is independently associated with increased morbidity after pediatric cardiac surgery.

OBJECTIVE: To test the hypothesis that transfusion of leukocyte-depleted RBC preparations within the first 48 hours of PICU stay was independently associated with prolonged duration of mechanical ventilation, irrespective of surgery type and disease severity. DESIGN: Retrospective, observational study. SETTING: Single-center PICU in The Netherlands. PATIENTS: Children less than 18 years consecutively admitted after pediatric cardiac surgery between February 2007 and February 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from 335 patients were used for analysis of whom 86 (25.7%) were transfused during the first 48 hours of PICU stay. Duration of mechanical ventilation (115 ± 19 hours vs. 25 ± 4 hours, p < 0.001) was longer among transfused patients. Ventilator-associated pneumonia (10.5% vs. 1.6%, odds ratio 7.2; 95% confidence interval 1.92-32.47; p < 0.001) was more frequent among transfused patients. New acute kidney injury after 48 hours of PICU admission (23.9% vs. 15.4%, p = 0.18) and mortality were comparable (2.3% vs. 4%, p = 0.16). The number of discrete transfusion events was significantly correlated with the duration of mechanical ventilation (Spearman's rho 0.617, p < 0.001). Transfusion remained independently associated with prolonged duration of mechanical ventilation after adjusting for confounders using Cox proportional hazards regression analysis. CONCLUSIONS: Transfusion of leukocyte-depleted RBCs within the first 48 hours of PICU stay after cardiac surgery is independently associated with prolonged duration of mechanical ventilation.

Children as donors: a national study to assess procurement of organs and tissues in pediatric intensive care units.

A shortage of size-matched organs and tissues is the key factor limiting transplantation in children. Empirical data on procurement from pediatric donors is sparse. This study investigated donor identification, parental consent, and effectuation rates, as well as adherence to the national protocol. A national retrospective cohort study was conducted in all eight Dutch pediatric intensive care units. Records of deceased children were analyzed by an independent donation officer. Seventy-four (11%) of 683 deceased children were found to be suitable for organ donation and 132 (19%) for tissue donation. Sixty-two (84%) potential organ donors had been correctly identified; the parental consent and effectuation rate was 42%. Sixty-three (48%) potential tissue donors had been correctly identified; the parental consent and effectuation rate was 27%. Correct identification increased with age (logistic regression, organs: P = .024; tissues: P = .011). Although an overall identification rate of 84% of potential organ donors may seem acceptable, the variation observed suggests room for improvement, as does the overall low rate of identification of pediatric tissue donors. Efforts to address the shortage of organs and tissues for transplantation in children should focus on identifying potential donors and on the reasons why parents do not consent.

Key factors in paediatric organ and tissue donation: an overview of literature in a chronological working model.

There is a growing shortage of size-matched organs and tissues for children. Although examples of substandard care are reported in the literature, there is no overview of the paediatric donation process. The aim of the study is to gain insight into the chain of events, practices and procedures in paediatric donation. Method; a survey of the 1990-2010 literature on paediatric organ and tissue donation and categorization into a coherent chronological working model of key events and procedures. Studies on paediatric donation are rare. Twelve empirical studies were found, without any level I or level II-1 evidence. Seventy-five per cent of the studies describe the situation in the United States. Literature suggests that the identification of potential donors and the way in which parental consent is requested may be substandard. We found no literature discussing best practices. Notwithstanding the importance of looking at donation care as an integrated process, most studies discuss only a few isolated topics or sub-processes. To improve paediatric donation, more research is required on substandard factors and their interactions. A chronological working model, as presented here, starting with the identification of potential donors and ending with aftercare, could serve as a practical tool to optimize paediatric donation.

Children's opinions about organ donation: a first step to assent?

BACKGROUND: Parents have to decide about organ donation after the death of their child. Although most parents probably would like to respect their child's intentions, parents often are not aware of their child's wishes. This requires insight into children's opinions about donation. METHODS: An internet survey that investigated whether Dutch children in the age range of 12 through 15 years had heard about organ donation, what their opinions were on donation and whether the topic had been discussed at home. Questionnaire response rate 38%. RESULTS: Around 99% of 2016 responders had heard about organ donation and about the possibility of becoming a donor, 75% preferred to decide for themselves about donation, 43% had discussed organ donation more than once at home, 66% were willing to donate. The willingness to donate was positively associated with age and socio-economic status. CONCLUSION: This survey indicates that these children at 12 through 15 years of age are capable and willing to think about organ donation. Thought should be given about how to raise awareness and how to enable parents and children to develop some sort of health literacy concerning the concept of organ donation. Children and their parents should be given adequate opportunities to receive appropriate information, suited to their psychological and moral developmental status.

Differences in the perceptions of parents and healthcare professionals on pediatric intensive care practices.

OBJECTIVE: To explore similarities and differences in perceptions on pediatric intensive care practices between parents and staff by using data from two studies. DESIGN: A two-round Delphi method among nurses and physicians followed by an empiric survey among parents. SETTINGS: Pediatric intensive care units at eight university medical centers. SUBJECTS: Parents whose child has been admitted to a pediatric intensive care unit, nurses, and physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcome measures were 74 satisfaction-with-care items divided into five domains: 1) information; 2) care and cure; 3) organization; 4) parental participation; and 5) professional attitude. The Delphi study was completed by 218 nurses and 46 physicians and the survey by 559 of 1042 (54%) parents. Parents rated 31 items more important than the professionals based on the standardized mean difference (Cohen's d, 0.21-1.18, p < .003). Ten of these were related to information provision. Information on the effects of medication had the largest effect size (Cohen's d 1.18, p = .001). Correct medication administration by professionals was also rated significantly more important by parents (Cohen's d 0.64, p = .001). The professionals rated 12 items more important than the parents (Cohen's d -0.23 to -0.73, p < .005), including three about multicultural care. Significant differences remained on two of the three multicultural care items when the Dutch (n = 483) and non-Dutch parents (n = 76) were separately compared with professionals. On the domain level, parents rated the domains information and parental participation more important than the professionals (Cohen's d 0.36 and 0.26, p = .001). CONCLUSIONS: Compared with the parents' perceptions, nurses and physicians undervalued a substantial number of pediatric intensive care unit care items. This finding may reflect a gap in the understanding of parental experiences as well as incongruity in recognizing the needs of parents.

Pandemic influenza and pediatric intensive care.

OBJECTIVE: To assess the adequacy of preparedness planning for an influenza pandemic by modeling the pediatric surge capacity of healthcare facility and pediatric intensive care unit (PICU) requirements over time. Governments and Public Health authorities have planned preparedness activities and training for a flu pandemic. PICU facilities will be the limiting factor in healthcare provision for children but detailed analyses for needs and demands in PICU care have not been published. DESIGN: Based on the Center for Disease Control and Prevention and World Health Organization estimates and published models of the expected evolution of pandemic flu, we modeled the pediatric surge capacity of healthcare facility and PICU requirements over time. Various scenarios with different assumptions were explored. We compared these demands with estimates of maximal PICU capacity factoring in healthcare worker absenteeism as well as reported and more realistic estimates derived from semistructured telephone interviews with key stakeholders in ICUs in the study area. SETTING: All hospitals and intensive care facilities in the Northern Region in The Netherlands with near 1.7 million inhabitants, of whom approximately 25% is <18 yrs. MEASUREMENTS AND MAIN RESULTS: Using well-established modeling techniques, evidence-based medicine, and incorporating estimates from the Centers for Disease Control and Prevention and World Health Organization, we show that PICU capacity may suffice during an influenza pandemic. Even during the peak of the pandemic, most children requiring PICU admission may be served, even those who have nonflu-related conditions, provided that robust indications and decision rules are maintained, both for admission, as well as continuation (or discontinuation) of life support. CONCLUSIONS: We recommend that a model, with assumptions that can be adapted with new information obtained during early stages of the pandemic that is evolving, be an integral part of a preparedness plan for a pandemic influenza with new human transmissible agent like influenza A virus.

Education on organ donation and transplantation in primary school; teachers' support and the first results of a teaching module.

Organ and tissue donation can also involve children. Because of its sensitivity, this topic requires careful decision making. Children have the ability to carefully reflect on this subject and enjoy participating in family discussions about it. Therefore, what children need is proper information. When schools are used to educate children about this subject, information about teacher support for this type of lesson along with its effects on the depth of family discussions is important. METHODS: A questionnaire was sent to all 7,542 primary schools in the Netherlands. The goal was to gather information on teachers' perspectives about a neutral lesson devoted to organ and tissue donation, and also on the best age to start giving such a lesson. The second part of our study examined the effects of a newly developed lesson among 269 primary school pupils. The school response was 23%. Of these, 70% were positive towards a lesson; best age to start was 10-11 years. Pupils reported 20% more family discussions after school education and enjoyed learning more about this topic. There is significant support in primary schools for a school lesson on organ and tissue donation. Educational programs in schools support family discussions.

Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure.

BACKGROUND: Neuromuscular blockade (NMB) has been shown to improve outcome in acute respiratory distress syndrome (ARDS) in adults, challenging maintaining spontaneous breathing when there is severe lung injury. We tested in a prospective physiological study the hypothesis that continuous administration of NMB agents in mechanically ventilated children with severe acute hypoxemic respiratory failure (AHRF) improves the oxygenation index without a redistribution of tidal volume V T toward non-dependent lung zones. METHODS: Oxygenation index, PaO2/FiO2 ratio, lung mechanics (plateau pressure, mean airway pressure, respiratory system compliance and resistance), hemodynamics (heart rate, central venous and arterial blood pressures), oxygenation [oxygenation index (OI), PaO2/FiO2 and SpO2/FiO2], ventilation (physiological dead space-to-V T ratio) and electrical impedance tomography measured changes in end-expiratory lung volume (EELV), and V T distribution was measured before and 15 min after the start of continuous infusion of rocuronium 1 mg/kg. Patients were ventilated in a time-cycled, pressure-limited mode with pre-set V T. All ventilator settings were not changed during the study. RESULTS: Twenty-two patients were studied (N = 18 met the criteria for pediatric ARDS). Median age (25-75 interquartile range) was 15 (7.8-77.5) weeks. Pulmonary pathology was present in 77.3%. The median lung injury score was 9 (8-10). The overall median CoV and regional lung filling characteristics were not affected by NMB, indicating no ventilation shift toward the non-dependent lung zones. Regional analysis showed a homogeneous time course of lung inflation during inspiration, indicating no tendency to atelectasis after the introduction of NMB. NMB decreased the mean airway pressure (p = 0.039) and OI (p = 0.039) in all patients. There were no significant changes in lung mechanics, hemodynamics and EELV. Subgroup analysis showed that OI decreased (p = 0.01) and PaO2/FiO2 increased (p = 0.02) in patients with moderate or severe PARDS. CONCLUSIONS: NMB resulted in an improved oxygenation index in pediatric patients with AHRF. Distribution of V T and regional lung filling characteristics were not affected.

Routine enteral nutrition in neonates on extracorporeal membrane oxygenation.

OBJECTIVES: To evaluate over a 5-yr period the feasibility and tolerance of a protocol of routine enteral nutrition in neonates requiring extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective medical chart review. SETTING: Level III children's hospital, pediatric surgical intensive care unit. PATIENTS: Neonates treated with venoarterial ECMO (VA-ECMO) between January 1997 and January 2002. Patients with congenital diaphragmatic hernia were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Charts of all neonates treated with VA-ECMO were reviewed. Feasibility was evaluated by recording the time period needed for enteral nutrition to reach 40% of total fluid intake; tolerance was evaluated by reviewing data on enteral nutrition related morbidity. Sixty-seven of the 77 eligible patients received enteral feeding during ECMO. Thirty-six of these patients (54%) received 40% of total fluid intake as enteral nutrition within a median of 3 (range, 2-4) days. Over the years there was a trend toward an increasing usage of enteral nutrition from 71% to 94% (p = .07). Enteral nutrition was temporarily discontinued in 16 patients, with 14 showing gastric retentions, one showing discomfort, and one showing aspiration. Symptoms of bilious vomiting, blood-stained stool, or abdominal distention were not present. CONCLUSION: Neonates on ECMO in this series tolerated enteral feeding well and did not show serious adverse effects. Overall, it is our experience that routine use of enteral feeding in critically ill neonates on VA-ECMO is feasible.

Male sex predisposes the newborn surgical patient to parenteral nutrition-associated cholestasis and to sepsis.

HYPOTHESIS: Sepsis is an epiphenomenon of parenteral nutrition-associated cholestasis (PNAC) and not a causative factor, and the incidence of sepsis is not affected by the presence or absence of PNAC. DESIGN: Observational cohort study. SETTING: Pediatric surgery department in a tertiary referral children's hospital. PATIENTS: Newborns receiving PN for at least 7 days following intestinal surgery. MAIN OUTCOME MEASURES: The criteria for PNAC were as follows: PN for at least 14 consecutive days, conjugated bilirubin level greater than 1.5 mg/dL (>26 micromol/L), conjugated bilirubin fraction greater than 50%, and absence of another identifiable cause of cholestasis. The identification of septic events was based on Centers for Disease Control and Prevention criteria. RESULTS: The patients (26 with PNAC and 72 without PNAC) were well comparable for underlying disease, gestational age, birth weight, and age at the start of PN. Time receiving PN and length of hospital stay were significantly (P<.001) longer in patients with PNAC. Parenteral nutrition-associated cholestasis was associated with male sex (P =.03; odds ratio, 2.8; 95% confidence interval, 1.1-7.1). The overall sepsis incidence was low (9 per 1000 hospital days). The sepsis incidence tended to be higher in patients with PNAC than in patients without PNAC (11.8 vs 7.1 per 1000 days; P =.08), but was significantly higher in male than in female patients (12.2 vs 5.6 per 1000 days; P =.01). Most septic events were caused by coagulase-negative staphylococci. CONCLUSIONS: Sepsis is an epiphenomenon of PNAC rather than a causative factor. Moreover, male sex predisposes the newborn surgical patient to PNAC and to sepsis.

The effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population.

BACKGROUND AND AIMS: Nutritional support is essential in the care of critically ill children since inadequate feeding increases morbidity and negatively affects growth. We aimed to compare cumulative energy and protein intakes with recommended dietary intakes (RDA) and examine relationships between accumulated balances and anthropometric parameters. METHODS: Prospective, observational study. Total daily energy and protein intakes were determined during a maximum of 14 days in 261 children admitted to our multidisciplinary tertiary pediatric ICU. Actual intakes were subtracted from RDA and cumulative balances were calculated. Relations between cumulative balances, various clinical factors and changes in anthropometry (weight, arm and calf circumference) were analyzed using regression analysis. RESULTS: At 14 days after admission children showed significant cumulative nutritional deficits compared to RDA. These deficits were on average 27, 20, 12 kcal/kg and 0.6, 0.3, and 0.2 g protein/kg per day for preterm neonates (n = 103), term neonates (n = 91) and older children (n = 67), respectively. Age at admission, length of ICU-stay and days on mechanical ventilation were negatively related to cumulative balances. Cumulative energy and protein deficits were associated with declines in SD-scores for weight and arm circumference. CONCLUSIONS: Children admitted to the ICU accumulate substantial energy and protein deficits when compared to RDA. These deficits are related to decreases in anthropometric parameters.

Clinical relevancy of nonurinary nitrogen excretion in newborns and infants after digestive tract surgery.

BACKGROUND: Whether the contribution of nonurinary nitrogen excretion (N2nu) to total nitrogen excretion (N2tot) is clinically relevant has not been tested in children in an intensive care unit. Particularly after digestive tract surgery, fecal nitrogen losses, and losses via nasogastric tubes, enterostomies and wound drains may be large. METHODS: We prospectively measured urinary nitrogen excretion (N2u) and N2nu 4 to 6 days after digestive tract surgery in 78 newborns and infants who were given total parenteral nutrition. RESULTS: Two hundred seven collections of excreta, each representing one 24-hour period, were obtained. Median N2nu was 15 mg/kg/24 hours (range, 0.4-153), median N2u 153 mg/kg/24 hours (range, 57-558), median N2tot 179 mg/kg/24 hours (range, 72-577), and the median ratio of N2nu and N2u 9.9% (range, 0.2-110). The observed variations could not be attributed to differences in the severity of the underlying disease or the surgical stress. The mean difference between N2tot and N2u was 21 mg/kg/24 hours (95% prediction interval -20 to +63). Use of a linear regression equation that predicts N2tot according to N2u and the weights of other excreta eliminated bias and improved precision (95% prediction interval -34 to +34 mg/kg/24 hours). For individual measurements, however, considerable imprecision remained. CONCLUSIONS: In newborns and infants, receiving parenteral nutrition 4 to 6 days after digestive tract surgery, N2nu is variable and not to be neglected. The only way to accurately assess N2tot in individual patients is by measuring the nitrogen content of all excreta.

An online explorative study towards parents' opinions about organ donation: from individual decisions to family discussions.

BACKGROUND: Parental decisions about organ donation by their child are influenced by many factors. One of these factors may be a previous discussion under non-crisis circumstances. The question then arises whether parents have thought about this topic for themselves and discussed it with each other or with their child. METHODS: An initial exploratory Internet survey to explore these discussions, parental opinions about school lessons on donation, the age threshold for a child to decide about donation, and determinants that influence these aspects. Questionnaire was sent to 14,000 panel members. We selected respondents with children younger than 16 years old. RESULTS: Questionnaire response rate was 35%. Of all 1146 respondents with children, 84% had discussed the topic with their partner and, on average, 46.5% had discussed this with their child aged 10-16 years old. Religion and educational level of the parents were not related. Sixty-nine percent of parents were positive towards school lessons. Most of the children were allowed to decide for themselves at the age of 15/16 years old. CONCLUSION: Family discussions between spouses about donation do occur frequently, however, discussion with children can be improved. If desired, triggers for beginning these conversations could be provided through public information and school education, which would also contribute to health literacy on this subject.

Mortality prediction models for pediatric intensive care: comparison of overall and subgroup specific performance.

AIM: To validate paediatric index of mortality (PIM) and pediatric risk of mortality (PRISM) models within the overall population as well as in specific subgroups in pediatric intensive care units (PICUs). METHODS: Variants of PIM and PRISM prediction models were compared with respect to calibration (agreement between predicted risks and observed mortality) and discrimination (area under the receiver operating characteristic curve, AUC). We considered performance in the overall study population and in subgroups, defined by diagnoses, age and urgency at admission, and length of stay (LoS) at the PICU. We analyzed data from consecutive patients younger than 16 years admitted to the eight PICUs in the Netherlands between February 2006 and October 2009. Patients referred to another ICU or deceased within 2 h after admission were excluded. RESULTS: A total of 12,040 admissions were included, with 412 deaths. Variants of PIM2 were best calibrated. All models discriminated well, also in patients <28 days of age (neonates), with overall higher AUC for PRISM variants (PIM = 0.83, PIM2 = 0.85, PIM2-ANZ06 = 0.86, PIM2-ANZ08 = 0.85, PRISM = 0.88, PRISM3-24 = 0.90). Best discrimination for PRISM3-24 was confirmed in 13 out of 14 subgroup categories. After recalibration PRISM3-24 predicted accurately in most (12 out of 14) categories. Discrimination was poorer for all models (AUC < 0.73) after LoS of >6 days at the PICU. CONCLUSION: All models discriminated well, also in most subgroups including neonates, but had difficulties predicting mortality for patients >6 days at the PICU. In a western European setting both the PIM2(-ANZ06) or a recalibrated version of PRISM3-24 are suited for overall individualized risk prediction.

Implantable continuous Doppler monitoring device for detection of hepatic artery thrombosis after liver transplantation.

BACKGROUND: Early hepatic artery thrombosis (eHAT) after liver transplantation occurs in 3% of adults and 8% of children and often results in retransplantation. eHAT is initially asymptomatic and arterial patency is monitored with percutaneous Doppler ultrasound screening (pDUS). The aim of the study is to analyze the diagnostic accuracy of "continuous" Doppler registration (CONDOR) using an implantable miniature Doppler. METHODS: This prospective observational study was conducted in 102 liver transplant recipients. Hepatic arterial signal is checked by CONDOR at least six times per day for the first 10 days after transplantation with comparison of diagnostic accuracy of CONDOR versus pDUS. RESULTS: Extra investigations were performed after 48 (11%) regular pDUS where arterial patency was questioned: 32 extra pDUS, 14 computed tomography (CT) angiographies, and 2 reoperations. CT scan confirmed eHAT in 4 cases. In 10 cases of pDUS-suspected eHAT, where subsequent CT showed an open artery, the CONDOR signal was clearly pulsatile. In 2 of 4 patients with five eHATs, a weak arterial signal was inadvertently interpreted as an open artery (sensitivity of 60%). The accuracy for detection of eHAT increased from 93% (pDUS) to 99% (CONDOR). Using CONDOR, additional CT angiographies may be prevented in 10% of cases. CONCLUSION: CONDOR is a useful adjunct to pDUS because it reduces the false-positive rate of pDUS. Further development of the technique and analysis of the signal generated by CONDOR are needed to improve the sensitivity before CONDOR can replace pDUS as a reliable screening method for detection of eHAT.

A qualitative study exploring the experiences of parents of children admitted to seven Dutch pediatric intensive care units.

PURPOSE: To explore parents' experiences during the admission of their children to a pediatric intensive care unit (PICU). METHOD: Qualitative method using in-depth interviews. Thematic analysis was applied to capture parents' experiences. Thirty-nine mothers and 25 fathers of 41 children admitted to seven of the eight PICUs in university medical centers in The Netherlands were interviewed. RESULTS: Parents were interviewed within 1 month after their child's discharge from a PICU. Thematic analysis identified 1,514 quotations that were coded into 63 subthemes. The subthemes were categorized into six major themes: attitude of the professionals; coordination of care; emotional intensity; information management; environmental factors; parent participation. Most themes had an overarching relationship representing the array of experiences encountered by parents when their child was staying in a PICU. The theme of emotional intensity was in particular associated with all the other themes. CONCLUSIONS: The findings provided a range of themes and subthemes describing the complexity of the parental experiences of a PICU admission. The subthemes present a systematic and thematic basis for the development of a quantitative instrument to measure parental experiences and satisfaction with care. The findings of this study have important clinical implications related to the deeper understanding of parental experiences and improving family-centered care.

Construction and psychometric testing of the EMPATHIC questionnaire measuring parent satisfaction in the pediatric intensive care unit.

PURPOSE: To construct and test the reliability and validity of the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire measuring parent satisfaction in the pediatric intensive care unit (PICU). METHODS: Structured development and psychometric testing of a parent satisfaction-with-care instrument with the results of two cohorts of parents (n = 2,046) from eight PICUs in the Netherlands. RESULTS: In the first cohort, 667/1,055 (63%) parents participated followed by 551/991 (56%) parents in the second cohort. The empirical structure of the instrument was established by confirmatory factor analysis with the first sample of parents confirming 65 statements within five theoretically conceptualized domains: information, care and cure, organization, parental participation, and professional attitude. The standardized factor loadings were greater than 0.40 in 63 statements. Cronbach's α, a measure of reliability, per domain ranged from 0.73 to 0.93 in both cohorts with no significant difference documenting the reliability over time. Beside rigorous content and face validity, the congruent validity of the instrument showed adequate correlation with four gold standard questions measuring overall satisfaction. The non-differential validity was confirmed with no significant differences between the population characteristics and the domains, except that parents with a child for a surgical admission were more satisfied on information issues. CONCLUSIONS: The final EMPATHIC questionnaire incorporates 65 statements. The empirical structure of the satisfaction statements and domains was satisfactory. The reliability and validity proved to be adequate. The EMPATHIC questionnaire is a valid quality performance indicator to measure quality of care as perceived by parents.

Off-hours admission and mortality in two pediatric intensive care units without 24-h in-house senior staff attendance.

PURPOSE: To compare risk-adjusted mortality of children non-electively admitted during off-hours with risk-adjusted mortality of children admitted during office hours to two pediatric intensive care units (PICUs) without 24-h in-house attendance of senior staff. DESIGN: Prospective observational study, performed between January 2003 and December 2007, in two PICUs without 24-h in-house attendance of senior staff, located in tertiary referral children's hospitals in the Netherlands. METHODS: Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Index of Mortality (PIM1) and Pediatric Risk of Mortality (PRISM2) scores. Office hours were defined as week days between 8:00 a.m. and 6:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 6:00 p.m. and 8:00 a.m., Saturdays, Sundays and public holidays, with one resident covering the PICU and senior staff directly available on-call. RESULTS: Of 3,212 non-elective patients admitted to the PICUs, 2,122 (66%) were admitted during off-hours. SMRs calculated according to PIM1 and PRISM2 did not show a significant difference with those of patients admitted during office hours. There was no significant effect of admission time on mortality in multivariate logistic regression with odds ratios of death in off-hours of 0.95 (PIM1, 95% CI 0.71-1.27, p = 0.73) and 1.03 (PRISM2, 95% CI 0.76-1.39, p = 0.82). CONCLUSION: Off-hours admission to our PICUs without 24-h in-house attendance of senior staff was not associated with higher SMRs than admission during office hours when senior staff were available in-house.